Research ArticleAssessment of Healthcare Waste Management Paradigms and ItsSuitable Treatment Alternative A Case Study

MohammadMehedi Hasan 1 and M Habibur Rahman2

1Hydraulic Research Directorate River Research Institute (RRI) Faridpur 7800 Bangladesh2Department of Civil Engineering Bangladesh University of Engineering and Technology (BUET) Dhaka 1000 Bangladesh

Correspondence should be addressed to Mohammad Mehedi Hasan mmhasanrrigovbd

Received 11 June 2017 Revised 15 November 2017 Accepted 11 January 2018 Published 29 July 2018

Academic Editor Riccardo Buccolieri

Copyright copy 2018 MohammadMehediHasan andMHabibur RahmanThis is an open access article distributed under theCreativeCommons Attribution License which permits unrestricted use distribution and reproduction in any medium provided theoriginal work is properly cited

The management and treatment of healthcare waste (HCW) are of great concern owing to its potential hazard to human healthand the environment particularly in developing countries Nowadays various technological alternatives are gaining momentumas efficient and favorable waste management options across the world However selecting a suitable technology as well as aneffective waste management approach for the treatment of HCW is still a challenging task for the municipal authoritiesThis studyrenders a comprehensive analysis of healthcare waste management (HCWM) practices and the technological options for its bettermanagement through a case study in Khulna the southwestern division of Bangladesh A number of healthcare establishments(HCEs) in the study area were selected and a questionnaire survey as well as field investigations was performed to find out thepresent status of HCWM and its limitations An assessment of different technological alternatives was also carried out usingSustainability Assessment of Technologies (SAT) methodology which could pave the way for treating hazardous waste moreefficiently in the Khulna metropolitan area The study revealed that the overall HCW generation rate and hazardous HCWgeneration rate in Khulna city were 090 kg bedminus1 dayminus1 and 018 kg bedminus1 dayminus1 respectively Assessment of management systemrevealed that 56 (119899 = 38) of workers did not receive any form of training in the handling of hazardous waste Around 54(119899 = 47) of them did not use any safety equipment or clothing It has been found from the study that among different technologicalalternatives based on the final score incineration was the most suitable option for the treatment of hazardous waste in KhulnaFinally some guidelines have been put forward to improve its existing management practices

1 Introduction

Healthcare waste has been a growing concern across theworld over the last few years [1] HCW is defined as all typesof waste generated from HCEs whether it is infectious ornoninfectious in nature chemicals and hazardous as well asnonhazardous materials [2] In developing countries HCWposes a serious threat due to its potential for causing environ-mental and public health hazards A lack of awareness amonghealth professionals as well as general population regardingimproper handling of HCW the absence of an effective reg-ulatory framework and national policy and financial strainsare the major impediments of adequate HCWM and allincrease the potential risk of environment and public healthhazards Bangladesh a developing country also experiences

the same obstructions which exerts a tremendous impact onthe environment and public health Mushrooming growthof healthcare facilities (HCFs) in urban areas accentuatesthe problem to a large extent About 85 of the wastegenerated by healthcare activities is general nonhazardousin nature and the remaining 15 is considered hazardousmaterials which may be infectious toxic or radioactive [3]This small portion of HCWmay pose various environmentaland health risks if not managed or disposed of properly Forthe treatment and disposal of HCW a range of technologieshave been developed so far However identification of anappropriate waste treatment technology for the selected site isstill a challenging task for the planners and decision-makersespecially in developing countries To this end a numberof factors are involved These include the quantification and

HindawiJournal of Environmental and Public HealthVolume 2018 Article ID 6879751 14 pageshttpsdoiorg10115520186879751

2 Journal of Environmental and Public Health

characterization of local waste degrees of safety technologi-cal suitability and the cost and impact on the environment

Khulna the third largest metropolitan city of Bangladeshis presently encountering the impacts of inadequate manage-ment of HCW [4] In many cases in these cities most of thehospitals and clinics in both the public and private sectorshave either a nonexistent or an outdated HCWM systemWastes produced from the HCEs in the city are not treatedor smashed properly Instead they are thrown into dustbinsconsequently causing health hazards These waste productsmingled with general solid waste from different householdscontaminated the air and water as well as the wider envi-ronment Moreover bacteria such as Pseudomonas Staphy-lococcus Streptococcus and so on are produced from theseproducts [5] Infections whichmay result from these bacteriaincludemeningitis AIDS hemorrhagic diarrhea tuberculo-sis and various skin diseases [6] Comprehending the inten-sity of the problem a nongovernmental organization (NGO)has already extended its assistance to Khulna City Corpora-tion (KCC) for better management of HCW However thepresentmanagement system is dangerous to the environmentand human health [4] HCWM is one of the most ignoredparts of the white-collar process in Bangladesh Impropermanagement of HCW exposes health workers waste han-dlers and the community to infections toxic effects anda higher potential risk of injury [7] It was observed thatconsciousness regarding health hazards of HCW among pro-fessional as well as general people is very low With the rapidadvancement of urbanization the environment as well as thehealth conditions of city dwellers will be an unpleasant one

Considering the consequences of environmental andpotential health risks a number of studies have investigatedvarious aspects of wastemanagement inKhulna city Rahmanet al [8] analyzed the suitability of solid waste disposal sitesusing a GIS approach in Khulna city Moniruzzaman et al[9] disclosed the recycling practices of solid waste in Khulnacity Bari et al [10] revealed the scenario of solid wastereuse in Khulna city Another study conducted by Ahsan etal [11] evaluated the role of private organizations in wastemanagement Therefore most of the studies in this area havebeen focused on solid waste management However muchless attention has been paid to HCWM issues specificallyalthough HCW pose a significant threat to the environmentand public health in Khulna [4]This study was conducted toinvestigate the existing HCWMpatterns and their downsidesin the KCC area An effort was also made to explore thepossibility of developing an efficient waste management sys-tem for the metropolis Therefore an assessment of the dif-ferent technological alternatives was also accomplished usingSATmethodology in order to comprehend their applicabilityin Khulna for the betterment of the present situation Forthe technology selection in the environmental arena variousdecision-making tools and approaches have been developedincluding AHP Matrix method ANP Fuzzy and VIKORwhere each method has its own criteria in finding the bestalternatives SAT is an apposite approach for incorporatingtechnical environmental economic and social considera-tions with the primary emphasis on developmental aspectsand environmental issues [12] Examples of investigations

carried out using SAT methodology includes those of Sutha-panich [13] and Rafiee et al [14] where assessment andselection of best waste treatment technologies were exploredFurthermore quantification and analysis of the physical com-position of HCW were performed since quantitative assess-ment of HCW generation is usually the main basis for anywaste management plan [15]

2 An Overview of Various HCWTreatment Technologies

TheHCWtreatment options include incinerationmicrowav-ing autoclaving hydropulping and compaction Incinera-tion is a perfect method for all types of HCW both hazard-ous and nonhazardous Combustion temperature is morethan 1800∘F [16] All hazardous and toxic elements can bedestroyed effectively The method significantly reduces thevolume of waste by up to 95 of its original volume [17 18]which is highest among all themethodsHowever investmentcost for incineration is very high and it may emit unwantedpollutants Conversely microwaving has less impact on theenvironment compared to incineration because there areno combustion emissions produced by the system It canreduce thewaste volumeby approximately 80Microwavingis not suitable for pathological waste and requires a strictmonitoring system [17 19]

Autoclaving is suitable for sterilizing hazardous wasteHowever the volume of waste cannot be reduced in this pro-cess It is not suitable for recognized body parts [19] On theother hand the hydropulping an oxidation technique hasthe required water content of approximately 80 as a result ofan increase in weight however the resultant volume can be aslittle as 30 of the original volume The use of a pulping sys-tem is highly controversial for clinical waste treatment [18]The compaction system can reduce the waste volume up to60 However sterilization is not possible in this method[17]Athoroughdescription of technologywith their strengthsand weaknesses as well as some key factors for technologyselection has been presented in preceding publications [20ndash22]

3 Sustainability Assessment of Technologies(SAT) Methodology in Brief [12]

The SAT methodology was introduced by the InternationalEnvironmental Technology Centre (IETC) of the UnitedNations Environment Program (UNEP) Sustainability is amajor concern in this methodology which incorporates tech-nical suitability environmental aspects social acceptabilityand economic feasibility The SAT methodology addressesfirst strategic and then operational level assessments

Strategic-Level Assessment A situational analysis is under-taken by planners elected representatives and decision-makers in this level of assessment encompassing the col-lection of baseline data preliminary information relevantstakeholder consultations andmapping Afterward themea-surable target is defined for a particular issue selected in the

Journal of Environmental and Public Health 3

course of stakeholder discussions A ldquotargetrdquo specifies bywhatmeans an identified single issue can be mollified

Operational Level Assessment The methodology continuesto an operational level assessment next to the macrolevel orstrategic-level assessment in which technical staff expertsengineers and so on assess available technology options

The subsequent three-phased approach is used in thislevel of assessment

Phase 1 Screening Available technological options are scru-tinized against finalized technical and environmental criteriawhich are usually in the form of logical operators (ieYesNo types) Scrutinizing can be performed by a suitablestakeholder group with or without the help of expert opinion

Phase 2 Scoping Eligible technological alternatives from thepreceding step are then subjected to go through the extensivescoping step Scoping criteria may be developed under fourbroad categories including technical environmental eco-nomic and social aspects The weightage for each criterion isascribed based on how the stakeholders gave an importanceon it The score was assigned on the scale of 1 to 10 in thedescending order It is to be noted that several quantificationtechniques can be applied in the scoping phase based on theintricacy as well as sensitivity of the decision to be madeMoreover competency and the capabilities of stakeholdergroups can influence the choice of aggregation method Theweighted sum matrix method is likely said to be the simplestone

Phase 3 Detail Assessment Technological options with bestoverall scores from the scoping phase are then subjected tofurther methodical assessment in this phaseThis assessmentis situation-specific and requires comprehensive and quan-titative information for each criteria topic to assist decision-making At this stage a composite star diagram can be used tosummarize and present data about various traits fact relatedto each topic

The steps criteria and indicators defined in SATmethod-ology should be followed as a general guide They shouldbe revised and adapted through consultative meetings tomeet local conditions An inclusive interpretation of SATmethodology can be obtained from UNEP [12]

4 Methodology

41 Study Site Khulna one of the major divisions inBangladesh with an area of about 60 km2 stands on the banksof River Rupsha and Bhairab It is located in the southwesternpart of the country at 22∘4810158401015840N to 22∘5410158401015840N Latitude and89∘3110158401015840E to 89∘3410158401015840E Longitude The present population ofKhulna city is about 07 million The city has experienceda high rate of population growth in the last few decadesprincipally due to migration from the adjacent city as itis the administrative headquarters of Khulna division andthe regional center for higher education better treatmentfacilities business and so on Tomeet the demand of its large

and ever-increasing population a good number ofHCFs havebeen developed in the city The nearby small districts alsodepend onKhulna for better treatment facilitiesThis regionalimportance has also accelerated the growth of the healthsector in Khulna metropolis

42 Study Design This study is a cross-sectional survey andof explorative nature HCEs in the KCC area that allowed usto collect relevant HCW data were selected for this studyFinally 20 different HCEs (Table 1) including diagnosticcenters residing in KCC area were selected to carry outthis investigation The purpose of such selection was toobtain representative features of the existing HCWM statusof Khulna municipality as well as to determine the type andrate of HCW At the outset of the comprehensive fieldwork areconnaissance survey was carried out to identify the overallmanagement status and physical composition of HCW inthe study area Due to time constraints primary data werecollected from selected HCEs during July to August 2015 soas to quantify the generation of waste Congregated wasteswere then segregated and characterized following its classi-fication and finally weighted in the separate room Pruss etal [23] classified HCW in nine categories (infectious sharpspathological pharmaceutical genotoxic and chemical wastewastewith high content of heavymetals and pressurized con-tainers and radioactive waste) However the reconnaissancesurvey unveiled that all these wastes were not available inthe study area or produced in a very insignificant amountwhich have not been included in the present investigation Inthis study the infectious pathological chemical sharps andplastic-type waste have been considered as hazardous wasteand general waste as nonhazardous

Waste sampling was performed once per day and thequantity of the HCW generated was then recorded accordingto its classification Questionnaire surveys and in-depthinterviews were adopted to acquire qualitative informa-tion Questionnaires were designed from studying previousresearch on this topic so that they would cover all basicrequirements needed for HCWM in Khulna city It is notedhere that four (4) sets of questionnaires were prepared fordifferent categories of respondents including patients doc-tors nurses technicians cleaners administrative officers andmanagement authorities Collected data were then analyzedto yield findings (see Section 52) Hazardous waste treatmentalternatives were assessed using Sustainability Assessment ofTechnologies (SAT) methodology The SAT outcomes there-fore assisted in informative decision-making for choosingthemost suitable waste treatment technology Secondary datawere gathered from various public and private organizationsdifferent workers officials some journals publications web-sites and so on

43 Employing SAT Methodology In the strategic level thepresent status of HCWM in the Khulna metropolitan areawas analyzed involving the collection of baseline data andstakeholder consultations Then the target was set to managethe HCW efficiently using suitable treatment technologyAfterward the methodology wasmoved on to an operationallevel assessment where common incineration microwave

4 Journal of Environmental and Public Health

Table 1 Overall HCW (hazardous and nonhazardous) generation rate from different HCEs in Khulna city

Name of the HCE Number ofbeds Category

Total generatedwaste kg bedminus1

dayminus1 orkgDCminus1 dayminus1

Mean kg bedminus1dayminus1 or

kgDCminus1 dayminus1

Haz waste kgbedminus1 dayminus1 orkgDCminus1 dayminus1

Mean kg bedminus1dayminus1 or

kgDCminus1 dayminus1

KGH 250 Public 098

090

020

018

KMCH 500 Public 115 025SANSH 75 Public 089 019IDH 20 Public 087 017CDH 100 Public 090 019MCWC 20 Public 088 017GMCH 500 Private 100 020GNCDC 50 Private 088 015AAMCH 20 Private 080 017KSH 218 Private 092 019KDH 100 Private 090 018KSMH 50 Private 087 016DBC 30 Private 085 015IBH 100 Private 091 017FHC 15 Private 077 012KC 25 Private 083 014DDC ndash DC 310

442

119

171MDC ndash DC 590 211SDC ndash DC 450 180PDC ndash DC 420 174Notes DC Diagnostic Center or Dental Clinic KGH Khulna General Hospital KMCH Khulna Medical College Hospital SANSH Sheikh Abu NaserSpecializedHospital IDH InfectiousDiseasesHospital CDHCheastDiseaseHospitalMCWCMotheramp ChildWelfareCenterGMCHGaziMedical CollegeHospital GNCDC Garib Newaz Clinic and Diagnostic Center AAMCH Ad-din Akij Medical College Hospital KSH Khulna Shishu Hospital KDH KhulnaDiabetic Hospital KSMH Khulna Surgical and Medical Hospital DBC Dabs Clinic IBH Islami Bank Hospital FHC Fair Health Clinic KC KhalishpurClinic DDC Decent Dental Clinic MDC Mahanagar Diagnostic Center SDC Setu Diagnostic Center and PDC Padma Diagnostic Center

autoclave waste treatment alternatives and so on werescreened by using modified screening criteria through con-sultative meetings to meet local situations Waste treatmenttechnologies that passed through the screening step werethen subjected to the comprehensive scoping tier Scopingcriteria were developed under four broad criteria topics astechnical financial social and environmental It is noted herethat therewere 10 technical 18 environmental 4 financial and

5 social criteria under each criteria topicWeight was given bythe stakeholders for each criterion from 0 to 10 depending onthe importance and significance (0 for not important 1 to 3for low 4 to 6 formedium 7 to 9 for high and 10 for essential)For each waste treatment technology under considerationthe score was given for each criterion from 0 to 9 (1 to 3 forlow 4 to 6 formedium and 7 to 9 for high) For each criterionmultiplying factors were calculated as follows [12]

MF = 119882 times RCTMSCT

MSCT = 9 times (algebraic sum of all weightage given under each criteria topic) (1)

where119882 is weight of each criterion RCT is ranking for eachcriteria topic and MSCT is maximum score for each criteriatopic

It can be mentioned here that the ranking of each criteriatopic (RCT) is established by a factor from 0 to 100 to eachtopic such that the sum of all the ranking factors adds up to100 In this study 25 was assigned to each topic since they

are all of equal importance according to the local conditionsThe technologies with best overall ratings from the scopingstep were selected for further assessment in this step Amongvarious multicriteria decision-making (MCDM) the simpleweighted sum matrix method was employed in this studyfor quantitative assessment With the aim of selecting themost preferred HCW treatment technology a number of

Journal of Environmental and Public Health 5

experts and stakeholders in the study area participated in theSAT process For detailed assessment outcomes readers aresuggested to see Section 55

5 Results and Discussions

51 Generation of HCW in the Studied HCEs The studyrevealed that waste generation rate is slightly higher (119901 lt005) in Public HCEs (095 kg bedminus1 dayminus1) than the privatehealth centers (088 kg bedminus1 dayminus1) Public HCFs producedmore wastes than that of the Private HCEs due to morenumbers of beds departments andwards in comparisonwithprivate hospitals [24] The amount of HCW generated in theHCEs was positively correlated with the number of beds (119903s =079 119901 lt 0001) The average waste generation per bed perday in Khulna city has been found to be 090 kg (Table 1)which ismuch lower than that of the developed countries likethe United States (45 kg bedminus1 dayminus1) the United Kingdom(33 kg bedminus1 dayminus1) and Spain (44 kg bedminus1 dayminus1) [25 26]In high-income countries HCW generation is usually higherthan that in the middle and low-income countries [27] Therate of waste generation mainly depends upon geographicallocation living standard healthcare facilities waste collec-tion services and so on In Latin American countries likeChile Brazil Argentina and Venezuela this figure variesfrom 1 to 45 kg bedminus1 dayminus1 [28] Therefore it can be men-tioned that the waste generation rate of Khulna city is closeto the figure of the developing countries of Latin AmericaHowever this figure is very close to the generation rate of093 kg bedminus1 dayminus1 in Sylhet city and 12 kg bedminus1 dayminus1 inDhaka [29 30]

The rate of generation of hazardous waste per bed perday from selected HCEs in Khulna city has been found tobe 018 kg (Table 1) This rate is close to the rate of 021 kgbedminus1 dayminus1 in Sylhet and Bangladesh [29] and much lowerthan that of 057 kg bedminus1 dayminus1 in Brazil and 047 kg bedminus1dayminus1 in Japan reported byDa Silva et al [31] andMohee [32]respectively About 80 of waste generated is nonhazardousand the other 20 is hazardous (Figure 1) which is muchlower than reported in Denmark (25) and the United States(28) [33] Among hazardous waste 8 is infectious 5pathological 4 plastic 2 sharps and 1 is chemical waste(Figure 1)

About 3 tons of HCW were generated daily from 120registered HCEs in Khulna city (Table 2) Most of them werecontributed by private HCFs (60) as the aggregated numberof beds is higher in Private HCEs Public HCFs cover 35and the other 5 were generated by the diagnostic centersand dental clinics In Khulna city about 235 kg of infectiouswaste 116 kg of plastic 24 kg of chemicals and 69 kg of sharpsare generated daily fromdifferent HCEs (Table 2)These largeamounts of unorthodox wastes deserved extra attention

The importance for the proper management of HCWcan be sensed from the aforementioned statistics whichrevealed that roughly 212 metric tons of hazardous waste isgenerated in Khulna each year This ever-increasing amountof hazardous waste if not managed properly will cause severehealth hazards and environmental problems

80

8

54 2 1

GeneralInfectiousPathological

PlasticSharpsChemical

Figure 1 Composition of HCW in Khulna city

52 Survey Findings Depicting HCWM Practices in KhulnaCity The materials presented here are aimed at showingrespondents view on the existing HCWM practices in dif-ferent HCEs in the KCC area Using a random samplingprocedure a questionnaire survey was carried out among 87respondents from different occupations including patientsdoctors nurses cleaners administrators and general peoplein different HCFs Most of them were educated with the ageranging from 30 to 50 years and average service length of 10years However a few of them were illiterate Their opinionsare displayed herein (Table 3)

In the studied HCEs the frequency of on-site wastehandling was categorized as once per day twice per day andirregular Most of the respondents in Private HCEs opine thatthe on-site waste handling (patientrsquos bed to storage place) isirregular while in Public HCEs most of them said that itis once per day In the case of on-site waste handling fromstorage place tomunicipal dustbin or NGOs van the majorityfrom thePrivateHCEs reported ononce per daywhich can beevident fromTable 3More than 40 respondents reported thatwaste collection from the secondary source to final disposalwas at noon while a good number of respondents enunciatedon morning

In the case of an existing level of awareness on using safetyequipment to prevent the spreading of infectious diseasesa great number of respondents (54 119899 = 47) from HCEsreported that they were not using any safety equipment(Table 3) It also investigated from the field survey thatalmost all the respondents from surveyed HCEs focused theiropinion in favor of training concerning the waste manage-ment In connection with the training methods the main-stream showed their interest in video and lecture

It was observed from the study that 75 (119899 = 65) of thetotal respondents preferred to dispose of their wastes in theNGOrsquos covered bins 17 (119899 = 15) of respondents indicatedthe municipal open dustbin for their waste disposal andvery few respondents reported on another disposal system(Figure 2)

6 Journal of Environmental and Public Health

Table 2 Total amount of HCW generated in Khulna city

Types of HCEsNonhazardous

waste(Kg dayminus1)

Infectious waste(Kg dayminus1)

Pathologicalwaste

(Kg dayminus1)

Chemical waste(Kg dayminus1)

Plastic waste(Kg dayminus1)

Sharp waste(Kg dayminus1)

Total(Kg dayminus1)

Public 793 86 47 8 41 23 998Private 1399 135 83 11 56 32 1716DC 96 14 7 5 19 14 155Grand Total 2288 235 137 24 116 69 2869Note This figure was calculated only from 120 registered HCEs (Total number of beds 3000) It can be mentioned that there were more than 50 nonregisteredHCEs existing in Khulna city These HCFs produced relatively small portion of the overall amount of waste in the studied area

Table 3 Scenarios of waste handling and management practices in Khulna metropolis

Variables Frequency () Total respondents ()GH PH DC

On-site handling (patientrsquos bed to storage place)Once per day 12 (14) 10 (11) 4 (5) 30Twice per day 4 (5) 13 (15) 5 (6) 25Irregular 8 (9) 19 (22) 12 (14) 45On-site handling (storage place to final disposal)Once per day 14 (16) 34 (39) 15 (17) 73Twice per day 6 (7) 5 (6) 4 (5) 17Irregular 4 (5) 3 (3) 2 (2) 10Time of waste collection (secondary source to final disposal)Morning 10 (12) 18 (21) 4 (5) 37Noon 24 (28) 14 (16) 5 (6) 49Random 9 (10) 2 (2) 1 (1) 14Systematic issues of waste collectionSystematic 21 (24) 7 (8) 5 (6) 38Nonsystematic 3 (3) 35 (40) 16 (18) 62Safety equipment scenarioFollowed 7 (8) 23 (26) 10 (12) 46Not followed 17 (20) 18 (21) 12 (14) 54Training issuesGot training 5 (7) 19 (28) 6 (9) 44Did not get training 14 (21) 15 (22) 9 (13) 56Opinion on training methodologyLecture amp video 16 (24) 28 (41) 12 (18) 82Video 2 (3) 3 (4) 2 (3) 10Lecture 1 (1) 3 (4) 1 (1) 7Opinion on existing HCWMSatisfactory 2 (2) 25 (29) 10 (11) 42Unsatisfactory 25 (29) 16 (18) 9 (10) 58Notes GH public HCEs PH private HCEs DC diagnostic center or dental clinic

A large number of respondents (58 119899 = 50) expressedtheir dissatisfaction with existing HCWM practices inKhulna city The problems they faced are no environment-friendly dustbin for waste disposal no separate dustbin forHCW collection dustbin is not in a suitable location wastecollection system is unhygienic irregular collection systemand hazardous waste is spreading all over the place due tolack of on-site treatment facility Although the chart showsthat satisfaction rates are quite high this is due to the better

management of Private HCEs They also mentioned someprobable steps that could overcome the problems and theseare as follows

(i) Use of an apronmask and gloves during handling thepatients and segregation as well as disposal of wastesuse of WHO-guided color-coded bins for segregatedwaste

(ii) Training for awareness could be a great help regardingthis issue

Journal of Environmental and Public Health 7

7517

8

NGOrsquos covered binsMunicipalrsquos open dustbinsOthers

Figure 2 Graphical presentation of preferable waste collection sys-tem

(iii) Formulating amending and imposing the relevantlaws could prevent the improper management ofHCW

53 Institutional Arrangements for HCWM in Khulna Cityand Their Limitations At the local level only KCC a publicorganization and Prodipan anNGO are involved inHCWMin Khulna city KCC does not have any special arrangementfor the collection and disposal of HCW separately as theyare not obliged to do according to their ordinance Theconservancy department of KCC identifies the lack of trainedmanpower and resources as the principal reasons for nothaving any arrangement to handle the HCW KCC does nothave any research facility to identify the extent of differentproblems and to provide guidelines to mitigate that Around47 of the money spent on waste management goes for themaintenance purpose of the vehicle and the remaining 53is spent on providing remuneration of the staff engaged insolid waste management in KCC KCC collected the HCW inthe same vehicle together with other wastes from the publicdustbin twice a day and dumped it together in the dumpinggroundnear Rajbandh about 7 km south of the city KCCalsodumped wastes for landfilling purpose at different locationsof the city It increased the risk of health hazards to theadjacent community

On the other hand Prodipan started their journey inMay 2000 with the financial aid from the Swiss DevelopmentCooperation UNDP and the World Bank Initially theystarted their project with 20 HCEs which increased to100 in 2013 Prodipan segregated wastes at the source ofsegregation They provided a set of four covered drums todispose of four types of waste separately An autocoveredvan of 10-ton capacity was used for transportation of HCWfrom different HCEs Generally collection took place in themorning every day Prodipan took service charge from theHCEs they served and the charge was determined dependingon the size (number of bed) and earnings of the HCEs Thestudy revealed that 44 of monthly expenditure is spent onproviding wages for the staff Vehicle maintenance cost is

46 and the remaining 10 is for purchasing the requiredmaterials Prodipan burnt infectious waste in a locally madeburning pit at a comparatively low temperature (about 400∘Cor below) It may in some cases cause unfinished burningand in the case of the presence of any type of plastic materialin the waste experts opine that ldquothis is more harmful as ithelps in producing dioxin gasrdquo They disposed of the needlesand all other sharp materials in a concrete pit This could beviable at a small scale however in the case of the entire citywhere the yearly generation of sharpswaste is about 25metrictons the volume reduction is crucial The present HCWMsystem of Prodipan is not a very structured and cost-effectiveone The project is not internally balanced and continuity ofthe project is totally dependent on the availability of foreignaid

54 Existing HCWMPractices in Khulna City and Its ImpactsWith the upward trend of population and mushroominggrowth of HCEs together with lack of operational wastedisposal mechanism the environmental condition of Khulnacity is gradually becoming more alarming The existingHCWM status in the KCC area is unsatisfactory and unsafefor health Most of the HCEs in Khulna had no appositewaste management system and they did not use any sort ofprotective clothing like gloves a mask and so on Hospitalauthorities were found to be less concerned regarding properdisposal of clinical waste Although proper segregation andtreatment of infectious waste before dumping are very crucialto minimizing health risks to the community [34] they hadnot been exercised in any of theHCEs studied It was revealedfrom the study that more than 80 of HCW is nonhazardouswhichmay be considered as general wasteThis huge amountof nonhazardous waste is excessively contaminated withhazardous waste due to a lack of proper waste separationpractices Moreover there are no distinct color-coded collec-tion bins for HCWM and all categories of waste from HCEscomprising reusable and sharp waste are dumped in com-mon places like public garbage disposal bins side of roadsdumping grounds or municipal waste collection containersThis malpractice elucidated the inefficiency of HCWM inKhulna as well as increasing the chances of contamination ofan entire mass of solid waste tainting it with infectious HCW

HCW comprises biodegradable and nonbiodegradablepolymers [29] Biodegradable polymers are easily decom-posed by the action of microorganisms while nonbiodegrad-ables are very difficult to decay The change in biologicalcharacter of HCW disinfects it which reduces the infectiousbiohazardous properties of the waste [35] The microorgan-isms may create a cyst to stay alive in adverse conditionand contaminate the environment [29] Chemical effluentsproduced from several HCEs were released straight intothe municipal cesspool and may have toxic effects on thenatural ecosystems of receiving waters Most landfills arenot constructed properly which may contaminate drinkingwater Surface overflow directly from deposited waste canpollute surface water easily Direct ejection of blood bodyparts feces and urine of contagious patients in a public sewersystem may cause a spate of communicable diseases Lack ofawareness regarding the damaging effects of HCW was also

8 Journal of Environmental and Public Health

found among the workers involved in the total managementprocess as well as general people in the studied area

Most of the disposal site is open and thereby emitsunpleasant odors and an unaesthetic view causing a hugepublic nuisance While grazing ready access of domestic ani-mals in open dumps may create the possibilities of introduc-ing microbes and pathogens into the food chain Indiscrimi-nate junking of HCWmay create the chances of adulterationof food supplies soil surface water groundwater and airThemajority of the municipal waste receptacles are not designedappropriately and are open without a cover or lid Thereforevectors like insects rodents worms birds and so on can eas-ily enter the collection containers and can take a place on theexposed piles of rotting trash causing the spread of contagiousbugs These also stimulate the mechanical transmission ofdeadly waterborne diseases like diarrhea typhoid dysenteryhepatitis and cholera [29] Moreover mosquitoes promotebiological transmission ofmany types of diseases likemalariadengue and yellow fever under humid environment Rubberand plastic trash being burnt in the open air releases fumescontaining carbonmonoxide dioxins furans and so on [36]When these toxic components are inhaled through smokethey may cause cancer respiratory diseases and many otherdeadly results to humans

Informal waste collectors (known as scavengers) engagedin collecting refuse from HCEs are suffering from variousintestinal parasitic and skin diseases Waste pickers collectused medical equipment particularly syringes from thegarbage and sell them at a low price Many drug addictsmay suffer from cholera typhoid hepatitis AIDS and otherhazardous and contagious diseases as they are reusing thesesyringes Scavengers are scooping out waste from the dust-bins roads and garbage lots for the recyclables with barehands without taking any safety measures therefore facing ahigh risk of salient epidemics of infectious diseasesThewastepickers involved in the recycling process are extremely poorhaving no proper education and incautious of detrimentalconsequences of exposure to contaminated and harmfulwaste

The inadequate disposal of HCWmay be catastrophic tohealth and the environment as well as thewellbeing of societyIf the HCW in Khulna city is not handled in a proper way itwill undoubtedly pose a danger to the workforce employed inthe HCEs as well as to the neighboring people

55 Assessment of Different Technological Options for ProperTreatment of HCW Using SAT Methodology in the Context ofKhulna City In general treatment options may be availableeither on- or off-site A central treatment facility is proposedas the generation of hazardous waste from individual HCEsis not high enough to run a treatment facility solely Assess-ment outcomes of different technological choices for HCWtreatment including technical suitability environmental eco-nomic and social aspects using SATmethodology for Khulnaare narrated herein chronologically

Strategic-Level Assessment(i) Issue all HCEs in the Khulna metropolitan area do

not have proper treatment facilities to treat their haz-ardous waste efficiently

1 2 3 45

67

891011

1213

1415

16171819202122

2324

2526

27282930

3132

3334

35 36 37

IncinerationMicrowaveAutoclave

Figure 3 Distribution of acquired scores of all criteria of HCWtreatment options

(ii) Target implementation of a large-scale central treat-ment technology to handle the hazardous waste fromall HCEs in the area Furthermore proclamation ofpolicies to be needed for the treatment of all haz-ardous waste

Operational Level Assessment VariousHCW treatment alter-natives for instance incineration microwaving and auto-claving were screened (Table 4) in this step using differ-ent modified screening criteria Short-listed technologicaloptions passed through the screening step were then sub-jected to going through the comprehensive scoping tier(Table 5)

Detailed Assessment The final scores obtained by differ-ent treatment alternatives for the technical suitability andeconomic social and environmental criteria are shown inTable 6 Final weightage of all criteria (37 numbers) undereach criteria topic for HCW treatment options is presented ina composite star diagram (Figure 3)

It is observed from Table 6 that all three technologiesare fairly close although incineration is the highest rankedtreatment option followed by microwave technology Amongdifferent criteria technical suitability and social aspect varyto some extent In the technical suitability aspect the mostimportant criteria considered by the experts judgment werethe ability to treat a wide range of hazardous wastes capacityrequirement and adaptability to the future situation Regard-ing the social aspect experts contemplated communityacceptance of the technology Although incineration attainedthe highest score in technical suitability and social aspect thecapital cost of the treatment technology as well as mainte-nance expenditure is one of the drawbacks of this treatmentoption Ozkan [22] indicated that off-site incineration is the

Journal of Environmental and Public Health 9

Table 4 Screening of different HCW treatment alternatives for Khulna municipality

CriteriaIncineration withpollution control

deviceMicrowave Autoclave Hydropulping Compaction

Compliance with nationalenvironmental laws radic radic radic X X

Compliance with multilateralenvironmental agreements radic radic radic radic radic

Consistency with WHO policies radic radic radic radic radic

Flexibility in accepting variouswaste radic radic radic X X

Volume reduction radic radic X radic radic

Technology economically Viable radic radic radic radic radic

Acceptability of technology inKhulna radic radic radic X X

Outcome (selectednot selected) radic radic radic X XNoteradic yes and X no

best method out of the five assessed HCW treatment alter-natives Another research using the multicriteria decision-making (MCDM) approach carried out by Antonopoulos etal [37] also corroborated the same facts

Based on assessment outcomes utilizing SAT methodol-ogy characterization of waste and local conditions inciner-ation is likely said to be the suitable method for treatmentof all types of HCW in Khulna city The majority of thewastes produced fromHCEs are nonhazardous which can bedisposed of in ways similar to the domestic waste Only thehazardous portion needs to be treated In Khulna city thepresent generation of the waste is about 3 ton dayminus1 and thehazardous waste is nearly 06 ton dayminus1Therefore a mediumsize incinerator (destruction capacity 025 ton hrminus1) will begood enough to comply with the situation Unwanted pol-lutants can be significantly reduced with the addition of airpollution control devices of the system Many air pollutantsin emissions from incinerators can be lessened substantiallyby modern air pollution control mechanisms if appropriatelydesigned and operated [2 38] Since the investment cost isvery high for new plant several HCEs may converge to set upa plant centrallyThese types of plants are now being observedin many countries of the world

6 Conclusions and Recommendations

Thepresent study has mainly focused on the existing HCWMparadigms of Khulna metropolis and on the question of howit can be made a more efficient and acceptable one Theexisting HCWM pattern in Khulna city has many drawbacksand is in dire need of immediate attention and improvementIt was observed from the investigation that the hazardouswaste was not treated separately in almost all of the HCEsin Khulna city Intervention is required at all stages ofwastemanagement from the formulation of appropriate lawssegregation and transportation of waste to the final disposalmethodThe process and method adopted for waste manage-ment should be technically and financially sustainable in the

long run It has to also be ensured that there are no adversehealth and environmental consequences of waste handlingtreatment and disposal activities

National legislation is the basis for improving HCWpractices in any country Therefore a national managementplan will be required which will permit HCWM options tobe optimized on a national scale The law should be comple-mented by a policy document and technical guidelines devel-oped for implementation This legal document should specifyregulations on treatment for different waste categories segre-gation collection storage handling disposal transporta-tion responsibilities and training requirements Training ofhealthcare personnel as well as general people regardinghygiene and HCWM is needed to create awareness and fosterresponsibility among them which will prevent exposure torelated health hazards

Among different waste treatment options it has beenfound from the study that the incineration system is the mostsuitable one for Khulna city based on the final score con-sidering technical suitability and environmental economicand social aspect However the system should be maintainedproperly with an appropriate air pollution control deviceTheranking order of the second technological choice was micro-waving followed by autoclaving considering all aspects Theassessment of treatment alternatives in this investigation issubjected to the selection as well as weighting of the criteriaand strongly dependent on the reliability to the response ofthe expertsrsquo personal judgment Besides the waste genera-tion rate that was calculated in this investigation was ex-cluding seasonal variation A further detailed study is re-quired incorporating more HCEs with an extended periodof collected data as well as seasonal variation to explore thesustainability of such management option Furthermore it isrecommended to develop a great variety of MCDMmethodsto evaluate such HCW treatment alternatives Overall thestudy will give an insight promulgating guidelines for thefuture planning and design of HCWM strategies in Khulnacity as well as other municipalities in developing countries

10 Journal of Environmental and Public Health

Table5Scop

ingof

SATmetho

dology

forthe

assessmento

fHCW

treatmento

ptions

forK

hulnam

etropo

lis

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Technicalsuitability

Com

patib

ilitywith

local

surrou

ndings

andnatural

cond

ition

s1198821=1

Rank

ingforT

echn

ical

SuitabilityRT

25

Maxim

umscorefor

TechnicalSuitability

(MST

)9times(1198821+1198822+

sdotsdotsdot+11988210)=531

MF1

=004

77

0329

60282

50235

Preference

forlocally

manufacturedtechno

logies1198822=7

MF2

=0329

516

454

1316

30987

Availabilityof

sparep

arts

andusageo

flocalmaterials1198823=5

MF3

=0235

614

105

1175

51175

Availabilityof

local

expertise

1198824=3

MF4

=0141

60846

50705

40564

Trackrecord

onperfo

rmance

1198825=10

MF5

=0470

73290

62820

62820

Com

patib

ilitywith

existing

techno

logy

ormanagem

ent

syste

m1198826=1

MF6

=004

75

0235

40188

40188

Meetscapacityrequ

irement1198827=10

MF7

=0470

83760

62820

62820

Adaptabilityto

future

situatio

ns1198828=5

MF8

=0235

818

806

1410

51175

Abilityto

treataw

idethe

rangeo

fhealth

care

wastes1198829=10

MF9

=0470

94230

62820

62820

Levelof

automationsoph

istication11988210=7

MF10=0329

413

166

1974

619

74

Journal of Environmental and Public Health 11

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Environm

ent

Efficacy

ofmicrobial

inactiv

ation

11988211=10

Rank

ingfor

environm

ent

(resou

rces

and

emissions)RE

n25

Maxim

umscorefor

environm

ent

(MSE

n)

9times(11988211+11988212+

sdotsdotsdot+11988228)=1161

MF11=

0215

919

357

1505

612

90

Risk

levelsforw

orkers

11988212=10

MF12=0215

40860

510

755

1075

Risk

levelsforc

ommun

ities11988213=10

MF13=

0215

40860

510

755

1075

Risk

tothee

nviro

nment11988214=10

MF14=0215

20430

612

907

1505

Airem

issions

11988215=10

MF15=

0215

10215

612

906

1290

Liqu

ideffl

uents

11988216=5

MF16=0107

6064

22

0214

20214

Solid

resid

ues

11988217=5

MF17=

0107

70749

40428

40428

Volumer

eductio

n11988218=10

MF18=0215

919

356

1290

20430

Massreductio

n11988219=3

MF19=0065

80520

30195

10065

Odo

r11988220=10

MF2

0=0215

40860

40860

40860

Noise

11988221=5

MF2

1=0107

40428

30321

50535

Energy

consum

ptionperk

gof

waste

11988222=10

MF2

2=0215

612

906

1290

510

75

Extent

ofuseo

frenew

able

energy

11988223=8

MF2

3=0172

50860

712

047

1204

Waterconsum

ptionperk

gof

waste

11988224=5

MF24=0107

70749

30321

30321

Materialcon

sumption

11988225=5

MF2

5=0107

6064

26

064

26

064

2Ex

tent

ofuseo

fhazardo

usmaterials

11988226=5

MF2

6=0107

80865

70749

70749

Spacer

equirement

11988227=3

MF2

7=0065

60390

50325

50325

Resource

recovery

capabilities

11988228=5

MF2

8=0107

20214

50535

6064

2

12 Journal of Environmental and Public Health

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Fina

ncialeconomica

lEstim

ated

capitalcosto

fthetreatmenttechn

olog

y11988229=10

Rank

ingfore

cono

mic

aspectsRE

c25

Maxim

umscorefor

econ

omic(M

SEn)

9times(11988229+11988230+

sdotsdotsdot+11988232)=270

MF2

9=0926

874

086

5556

54630

Estim

ated

capitalcostsof

allaccessorie

sand

related

equipm

ent

11988230=5

MF3

0=0463

313

894

1852

418

52

Estim

ated

operationand

maintenance

costs

11988231=10

MF31=

0926

54630

43704

32778

Insta

llatio

nrequ

irements11988232=5

MF32=

0463

418

525

2315

52315

Socia

lcultural

Com

mun

ityacceptance

ofthetechn

olog

y11988233=10

Rank

ingforsocial

aspectsRS

25

Maxim

umscorefor

SocialCultural

(MSS)

9times(11988233+11988234+

sdotsdotsdot+11988237)=315

MF33=

0794

75558

53970

43176

Incomeg

eneration

potential

11988234=5

MF3

4=0397

62382

20794

20794

Acceptabilityof

treatment

resid

uesb

ythelocalland

fill11988235=10

MF35=

0794

64764

43176

43176

Extent

ofnecessary

resettlem

ento

fpeople

11988236=5

MF3

6=0397

31191

62382

62382

Visib

leor

aesth

eticim

pact11988237=5

MF37=0397

519

854

1588

31191

Total

645

554

512

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

Journal of Environmental and Public Health 3

course of stakeholder discussions A ldquotargetrdquo specifies bywhatmeans an identified single issue can be mollified

Operational Level Assessment The methodology continuesto an operational level assessment next to the macrolevel orstrategic-level assessment in which technical staff expertsengineers and so on assess available technology options

The subsequent three-phased approach is used in thislevel of assessment

Phase 1 Screening Available technological options are scru-tinized against finalized technical and environmental criteriawhich are usually in the form of logical operators (ieYesNo types) Scrutinizing can be performed by a suitablestakeholder group with or without the help of expert opinion

Phase 2 Scoping Eligible technological alternatives from thepreceding step are then subjected to go through the extensivescoping step Scoping criteria may be developed under fourbroad categories including technical environmental eco-nomic and social aspects The weightage for each criterion isascribed based on how the stakeholders gave an importanceon it The score was assigned on the scale of 1 to 10 in thedescending order It is to be noted that several quantificationtechniques can be applied in the scoping phase based on theintricacy as well as sensitivity of the decision to be madeMoreover competency and the capabilities of stakeholdergroups can influence the choice of aggregation method Theweighted sum matrix method is likely said to be the simplestone

Phase 3 Detail Assessment Technological options with bestoverall scores from the scoping phase are then subjected tofurther methodical assessment in this phaseThis assessmentis situation-specific and requires comprehensive and quan-titative information for each criteria topic to assist decision-making At this stage a composite star diagram can be used tosummarize and present data about various traits fact relatedto each topic

The steps criteria and indicators defined in SATmethod-ology should be followed as a general guide They shouldbe revised and adapted through consultative meetings tomeet local conditions An inclusive interpretation of SATmethodology can be obtained from UNEP [12]

4 Methodology

41 Study Site Khulna one of the major divisions inBangladesh with an area of about 60 km2 stands on the banksof River Rupsha and Bhairab It is located in the southwesternpart of the country at 22∘4810158401015840N to 22∘5410158401015840N Latitude and89∘3110158401015840E to 89∘3410158401015840E Longitude The present population ofKhulna city is about 07 million The city has experienceda high rate of population growth in the last few decadesprincipally due to migration from the adjacent city as itis the administrative headquarters of Khulna division andthe regional center for higher education better treatmentfacilities business and so on Tomeet the demand of its large

and ever-increasing population a good number ofHCFs havebeen developed in the city The nearby small districts alsodepend onKhulna for better treatment facilitiesThis regionalimportance has also accelerated the growth of the healthsector in Khulna metropolis

42 Study Design This study is a cross-sectional survey andof explorative nature HCEs in the KCC area that allowed usto collect relevant HCW data were selected for this studyFinally 20 different HCEs (Table 1) including diagnosticcenters residing in KCC area were selected to carry outthis investigation The purpose of such selection was toobtain representative features of the existing HCWM statusof Khulna municipality as well as to determine the type andrate of HCW At the outset of the comprehensive fieldwork areconnaissance survey was carried out to identify the overallmanagement status and physical composition of HCW inthe study area Due to time constraints primary data werecollected from selected HCEs during July to August 2015 soas to quantify the generation of waste Congregated wasteswere then segregated and characterized following its classi-fication and finally weighted in the separate room Pruss etal [23] classified HCW in nine categories (infectious sharpspathological pharmaceutical genotoxic and chemical wastewastewith high content of heavymetals and pressurized con-tainers and radioactive waste) However the reconnaissancesurvey unveiled that all these wastes were not available inthe study area or produced in a very insignificant amountwhich have not been included in the present investigation Inthis study the infectious pathological chemical sharps andplastic-type waste have been considered as hazardous wasteand general waste as nonhazardous

Waste sampling was performed once per day and thequantity of the HCW generated was then recorded accordingto its classification Questionnaire surveys and in-depthinterviews were adopted to acquire qualitative informa-tion Questionnaires were designed from studying previousresearch on this topic so that they would cover all basicrequirements needed for HCWM in Khulna city It is notedhere that four (4) sets of questionnaires were prepared fordifferent categories of respondents including patients doc-tors nurses technicians cleaners administrative officers andmanagement authorities Collected data were then analyzedto yield findings (see Section 52) Hazardous waste treatmentalternatives were assessed using Sustainability Assessment ofTechnologies (SAT) methodology The SAT outcomes there-fore assisted in informative decision-making for choosingthemost suitable waste treatment technology Secondary datawere gathered from various public and private organizationsdifferent workers officials some journals publications web-sites and so on

43 Employing SAT Methodology In the strategic level thepresent status of HCWM in the Khulna metropolitan areawas analyzed involving the collection of baseline data andstakeholder consultations Then the target was set to managethe HCW efficiently using suitable treatment technologyAfterward the methodology wasmoved on to an operationallevel assessment where common incineration microwave

4 Journal of Environmental and Public Health

Table 1 Overall HCW (hazardous and nonhazardous) generation rate from different HCEs in Khulna city

Name of the HCE Number ofbeds Category

Total generatedwaste kg bedminus1

dayminus1 orkgDCminus1 dayminus1

Mean kg bedminus1dayminus1 or

kgDCminus1 dayminus1

Haz waste kgbedminus1 dayminus1 orkgDCminus1 dayminus1

Mean kg bedminus1dayminus1 or

kgDCminus1 dayminus1

KGH 250 Public 098

090

020

018

KMCH 500 Public 115 025SANSH 75 Public 089 019IDH 20 Public 087 017CDH 100 Public 090 019MCWC 20 Public 088 017GMCH 500 Private 100 020GNCDC 50 Private 088 015AAMCH 20 Private 080 017KSH 218 Private 092 019KDH 100 Private 090 018KSMH 50 Private 087 016DBC 30 Private 085 015IBH 100 Private 091 017FHC 15 Private 077 012KC 25 Private 083 014DDC ndash DC 310

442

119

171MDC ndash DC 590 211SDC ndash DC 450 180PDC ndash DC 420 174Notes DC Diagnostic Center or Dental Clinic KGH Khulna General Hospital KMCH Khulna Medical College Hospital SANSH Sheikh Abu NaserSpecializedHospital IDH InfectiousDiseasesHospital CDHCheastDiseaseHospitalMCWCMotheramp ChildWelfareCenterGMCHGaziMedical CollegeHospital GNCDC Garib Newaz Clinic and Diagnostic Center AAMCH Ad-din Akij Medical College Hospital KSH Khulna Shishu Hospital KDH KhulnaDiabetic Hospital KSMH Khulna Surgical and Medical Hospital DBC Dabs Clinic IBH Islami Bank Hospital FHC Fair Health Clinic KC KhalishpurClinic DDC Decent Dental Clinic MDC Mahanagar Diagnostic Center SDC Setu Diagnostic Center and PDC Padma Diagnostic Center

autoclave waste treatment alternatives and so on werescreened by using modified screening criteria through con-sultative meetings to meet local situations Waste treatmenttechnologies that passed through the screening step werethen subjected to the comprehensive scoping tier Scopingcriteria were developed under four broad criteria topics astechnical financial social and environmental It is noted herethat therewere 10 technical 18 environmental 4 financial and

5 social criteria under each criteria topicWeight was given bythe stakeholders for each criterion from 0 to 10 depending onthe importance and significance (0 for not important 1 to 3for low 4 to 6 formedium 7 to 9 for high and 10 for essential)For each waste treatment technology under considerationthe score was given for each criterion from 0 to 9 (1 to 3 forlow 4 to 6 formedium and 7 to 9 for high) For each criterionmultiplying factors were calculated as follows [12]

MF = 119882 times RCTMSCT

MSCT = 9 times (algebraic sum of all weightage given under each criteria topic) (1)

where119882 is weight of each criterion RCT is ranking for eachcriteria topic and MSCT is maximum score for each criteriatopic

It can be mentioned here that the ranking of each criteriatopic (RCT) is established by a factor from 0 to 100 to eachtopic such that the sum of all the ranking factors adds up to100 In this study 25 was assigned to each topic since they

are all of equal importance according to the local conditionsThe technologies with best overall ratings from the scopingstep were selected for further assessment in this step Amongvarious multicriteria decision-making (MCDM) the simpleweighted sum matrix method was employed in this studyfor quantitative assessment With the aim of selecting themost preferred HCW treatment technology a number of

Journal of Environmental and Public Health 5

experts and stakeholders in the study area participated in theSAT process For detailed assessment outcomes readers aresuggested to see Section 55

5 Results and Discussions

51 Generation of HCW in the Studied HCEs The studyrevealed that waste generation rate is slightly higher (119901 lt005) in Public HCEs (095 kg bedminus1 dayminus1) than the privatehealth centers (088 kg bedminus1 dayminus1) Public HCFs producedmore wastes than that of the Private HCEs due to morenumbers of beds departments andwards in comparisonwithprivate hospitals [24] The amount of HCW generated in theHCEs was positively correlated with the number of beds (119903s =079 119901 lt 0001) The average waste generation per bed perday in Khulna city has been found to be 090 kg (Table 1)which ismuch lower than that of the developed countries likethe United States (45 kg bedminus1 dayminus1) the United Kingdom(33 kg bedminus1 dayminus1) and Spain (44 kg bedminus1 dayminus1) [25 26]In high-income countries HCW generation is usually higherthan that in the middle and low-income countries [27] Therate of waste generation mainly depends upon geographicallocation living standard healthcare facilities waste collec-tion services and so on In Latin American countries likeChile Brazil Argentina and Venezuela this figure variesfrom 1 to 45 kg bedminus1 dayminus1 [28] Therefore it can be men-tioned that the waste generation rate of Khulna city is closeto the figure of the developing countries of Latin AmericaHowever this figure is very close to the generation rate of093 kg bedminus1 dayminus1 in Sylhet city and 12 kg bedminus1 dayminus1 inDhaka [29 30]

The rate of generation of hazardous waste per bed perday from selected HCEs in Khulna city has been found tobe 018 kg (Table 1) This rate is close to the rate of 021 kgbedminus1 dayminus1 in Sylhet and Bangladesh [29] and much lowerthan that of 057 kg bedminus1 dayminus1 in Brazil and 047 kg bedminus1dayminus1 in Japan reported byDa Silva et al [31] andMohee [32]respectively About 80 of waste generated is nonhazardousand the other 20 is hazardous (Figure 1) which is muchlower than reported in Denmark (25) and the United States(28) [33] Among hazardous waste 8 is infectious 5pathological 4 plastic 2 sharps and 1 is chemical waste(Figure 1)

About 3 tons of HCW were generated daily from 120registered HCEs in Khulna city (Table 2) Most of them werecontributed by private HCFs (60) as the aggregated numberof beds is higher in Private HCEs Public HCFs cover 35and the other 5 were generated by the diagnostic centersand dental clinics In Khulna city about 235 kg of infectiouswaste 116 kg of plastic 24 kg of chemicals and 69 kg of sharpsare generated daily fromdifferent HCEs (Table 2)These largeamounts of unorthodox wastes deserved extra attention

The importance for the proper management of HCWcan be sensed from the aforementioned statistics whichrevealed that roughly 212 metric tons of hazardous waste isgenerated in Khulna each year This ever-increasing amountof hazardous waste if not managed properly will cause severehealth hazards and environmental problems

80

8

54 2 1

GeneralInfectiousPathological

PlasticSharpsChemical

Figure 1 Composition of HCW in Khulna city

52 Survey Findings Depicting HCWM Practices in KhulnaCity The materials presented here are aimed at showingrespondents view on the existing HCWM practices in dif-ferent HCEs in the KCC area Using a random samplingprocedure a questionnaire survey was carried out among 87respondents from different occupations including patientsdoctors nurses cleaners administrators and general peoplein different HCFs Most of them were educated with the ageranging from 30 to 50 years and average service length of 10years However a few of them were illiterate Their opinionsare displayed herein (Table 3)

In the studied HCEs the frequency of on-site wastehandling was categorized as once per day twice per day andirregular Most of the respondents in Private HCEs opine thatthe on-site waste handling (patientrsquos bed to storage place) isirregular while in Public HCEs most of them said that itis once per day In the case of on-site waste handling fromstorage place tomunicipal dustbin or NGOs van the majorityfrom thePrivateHCEs reported ononce per daywhich can beevident fromTable 3More than 40 respondents reported thatwaste collection from the secondary source to final disposalwas at noon while a good number of respondents enunciatedon morning

In the case of an existing level of awareness on using safetyequipment to prevent the spreading of infectious diseasesa great number of respondents (54 119899 = 47) from HCEsreported that they were not using any safety equipment(Table 3) It also investigated from the field survey thatalmost all the respondents from surveyed HCEs focused theiropinion in favor of training concerning the waste manage-ment In connection with the training methods the main-stream showed their interest in video and lecture

It was observed from the study that 75 (119899 = 65) of thetotal respondents preferred to dispose of their wastes in theNGOrsquos covered bins 17 (119899 = 15) of respondents indicatedthe municipal open dustbin for their waste disposal andvery few respondents reported on another disposal system(Figure 2)

6 Journal of Environmental and Public Health

Table 2 Total amount of HCW generated in Khulna city

Types of HCEsNonhazardous

waste(Kg dayminus1)

Infectious waste(Kg dayminus1)

Pathologicalwaste

(Kg dayminus1)

Chemical waste(Kg dayminus1)

Plastic waste(Kg dayminus1)

Sharp waste(Kg dayminus1)

Total(Kg dayminus1)

Public 793 86 47 8 41 23 998Private 1399 135 83 11 56 32 1716DC 96 14 7 5 19 14 155Grand Total 2288 235 137 24 116 69 2869Note This figure was calculated only from 120 registered HCEs (Total number of beds 3000) It can be mentioned that there were more than 50 nonregisteredHCEs existing in Khulna city These HCFs produced relatively small portion of the overall amount of waste in the studied area

Table 3 Scenarios of waste handling and management practices in Khulna metropolis

Variables Frequency () Total respondents ()GH PH DC

On-site handling (patientrsquos bed to storage place)Once per day 12 (14) 10 (11) 4 (5) 30Twice per day 4 (5) 13 (15) 5 (6) 25Irregular 8 (9) 19 (22) 12 (14) 45On-site handling (storage place to final disposal)Once per day 14 (16) 34 (39) 15 (17) 73Twice per day 6 (7) 5 (6) 4 (5) 17Irregular 4 (5) 3 (3) 2 (2) 10Time of waste collection (secondary source to final disposal)Morning 10 (12) 18 (21) 4 (5) 37Noon 24 (28) 14 (16) 5 (6) 49Random 9 (10) 2 (2) 1 (1) 14Systematic issues of waste collectionSystematic 21 (24) 7 (8) 5 (6) 38Nonsystematic 3 (3) 35 (40) 16 (18) 62Safety equipment scenarioFollowed 7 (8) 23 (26) 10 (12) 46Not followed 17 (20) 18 (21) 12 (14) 54Training issuesGot training 5 (7) 19 (28) 6 (9) 44Did not get training 14 (21) 15 (22) 9 (13) 56Opinion on training methodologyLecture amp video 16 (24) 28 (41) 12 (18) 82Video 2 (3) 3 (4) 2 (3) 10Lecture 1 (1) 3 (4) 1 (1) 7Opinion on existing HCWMSatisfactory 2 (2) 25 (29) 10 (11) 42Unsatisfactory 25 (29) 16 (18) 9 (10) 58Notes GH public HCEs PH private HCEs DC diagnostic center or dental clinic

A large number of respondents (58 119899 = 50) expressedtheir dissatisfaction with existing HCWM practices inKhulna city The problems they faced are no environment-friendly dustbin for waste disposal no separate dustbin forHCW collection dustbin is not in a suitable location wastecollection system is unhygienic irregular collection systemand hazardous waste is spreading all over the place due tolack of on-site treatment facility Although the chart showsthat satisfaction rates are quite high this is due to the better

management of Private HCEs They also mentioned someprobable steps that could overcome the problems and theseare as follows

(i) Use of an apronmask and gloves during handling thepatients and segregation as well as disposal of wastesuse of WHO-guided color-coded bins for segregatedwaste

(ii) Training for awareness could be a great help regardingthis issue

Journal of Environmental and Public Health 7

7517

8

NGOrsquos covered binsMunicipalrsquos open dustbinsOthers

Figure 2 Graphical presentation of preferable waste collection sys-tem

(iii) Formulating amending and imposing the relevantlaws could prevent the improper management ofHCW

53 Institutional Arrangements for HCWM in Khulna Cityand Their Limitations At the local level only KCC a publicorganization and Prodipan anNGO are involved inHCWMin Khulna city KCC does not have any special arrangementfor the collection and disposal of HCW separately as theyare not obliged to do according to their ordinance Theconservancy department of KCC identifies the lack of trainedmanpower and resources as the principal reasons for nothaving any arrangement to handle the HCW KCC does nothave any research facility to identify the extent of differentproblems and to provide guidelines to mitigate that Around47 of the money spent on waste management goes for themaintenance purpose of the vehicle and the remaining 53is spent on providing remuneration of the staff engaged insolid waste management in KCC KCC collected the HCW inthe same vehicle together with other wastes from the publicdustbin twice a day and dumped it together in the dumpinggroundnear Rajbandh about 7 km south of the city KCCalsodumped wastes for landfilling purpose at different locationsof the city It increased the risk of health hazards to theadjacent community

On the other hand Prodipan started their journey inMay 2000 with the financial aid from the Swiss DevelopmentCooperation UNDP and the World Bank Initially theystarted their project with 20 HCEs which increased to100 in 2013 Prodipan segregated wastes at the source ofsegregation They provided a set of four covered drums todispose of four types of waste separately An autocoveredvan of 10-ton capacity was used for transportation of HCWfrom different HCEs Generally collection took place in themorning every day Prodipan took service charge from theHCEs they served and the charge was determined dependingon the size (number of bed) and earnings of the HCEs Thestudy revealed that 44 of monthly expenditure is spent onproviding wages for the staff Vehicle maintenance cost is

46 and the remaining 10 is for purchasing the requiredmaterials Prodipan burnt infectious waste in a locally madeburning pit at a comparatively low temperature (about 400∘Cor below) It may in some cases cause unfinished burningand in the case of the presence of any type of plastic materialin the waste experts opine that ldquothis is more harmful as ithelps in producing dioxin gasrdquo They disposed of the needlesand all other sharp materials in a concrete pit This could beviable at a small scale however in the case of the entire citywhere the yearly generation of sharpswaste is about 25metrictons the volume reduction is crucial The present HCWMsystem of Prodipan is not a very structured and cost-effectiveone The project is not internally balanced and continuity ofthe project is totally dependent on the availability of foreignaid

54 Existing HCWMPractices in Khulna City and Its ImpactsWith the upward trend of population and mushroominggrowth of HCEs together with lack of operational wastedisposal mechanism the environmental condition of Khulnacity is gradually becoming more alarming The existingHCWM status in the KCC area is unsatisfactory and unsafefor health Most of the HCEs in Khulna had no appositewaste management system and they did not use any sort ofprotective clothing like gloves a mask and so on Hospitalauthorities were found to be less concerned regarding properdisposal of clinical waste Although proper segregation andtreatment of infectious waste before dumping are very crucialto minimizing health risks to the community [34] they hadnot been exercised in any of theHCEs studied It was revealedfrom the study that more than 80 of HCW is nonhazardouswhichmay be considered as general wasteThis huge amountof nonhazardous waste is excessively contaminated withhazardous waste due to a lack of proper waste separationpractices Moreover there are no distinct color-coded collec-tion bins for HCWM and all categories of waste from HCEscomprising reusable and sharp waste are dumped in com-mon places like public garbage disposal bins side of roadsdumping grounds or municipal waste collection containersThis malpractice elucidated the inefficiency of HCWM inKhulna as well as increasing the chances of contamination ofan entire mass of solid waste tainting it with infectious HCW

HCW comprises biodegradable and nonbiodegradablepolymers [29] Biodegradable polymers are easily decom-posed by the action of microorganisms while nonbiodegrad-ables are very difficult to decay The change in biologicalcharacter of HCW disinfects it which reduces the infectiousbiohazardous properties of the waste [35] The microorgan-isms may create a cyst to stay alive in adverse conditionand contaminate the environment [29] Chemical effluentsproduced from several HCEs were released straight intothe municipal cesspool and may have toxic effects on thenatural ecosystems of receiving waters Most landfills arenot constructed properly which may contaminate drinkingwater Surface overflow directly from deposited waste canpollute surface water easily Direct ejection of blood bodyparts feces and urine of contagious patients in a public sewersystem may cause a spate of communicable diseases Lack ofawareness regarding the damaging effects of HCW was also

8 Journal of Environmental and Public Health

found among the workers involved in the total managementprocess as well as general people in the studied area

Most of the disposal site is open and thereby emitsunpleasant odors and an unaesthetic view causing a hugepublic nuisance While grazing ready access of domestic ani-mals in open dumps may create the possibilities of introduc-ing microbes and pathogens into the food chain Indiscrimi-nate junking of HCWmay create the chances of adulterationof food supplies soil surface water groundwater and airThemajority of the municipal waste receptacles are not designedappropriately and are open without a cover or lid Thereforevectors like insects rodents worms birds and so on can eas-ily enter the collection containers and can take a place on theexposed piles of rotting trash causing the spread of contagiousbugs These also stimulate the mechanical transmission ofdeadly waterborne diseases like diarrhea typhoid dysenteryhepatitis and cholera [29] Moreover mosquitoes promotebiological transmission ofmany types of diseases likemalariadengue and yellow fever under humid environment Rubberand plastic trash being burnt in the open air releases fumescontaining carbonmonoxide dioxins furans and so on [36]When these toxic components are inhaled through smokethey may cause cancer respiratory diseases and many otherdeadly results to humans

Informal waste collectors (known as scavengers) engagedin collecting refuse from HCEs are suffering from variousintestinal parasitic and skin diseases Waste pickers collectused medical equipment particularly syringes from thegarbage and sell them at a low price Many drug addictsmay suffer from cholera typhoid hepatitis AIDS and otherhazardous and contagious diseases as they are reusing thesesyringes Scavengers are scooping out waste from the dust-bins roads and garbage lots for the recyclables with barehands without taking any safety measures therefore facing ahigh risk of salient epidemics of infectious diseasesThewastepickers involved in the recycling process are extremely poorhaving no proper education and incautious of detrimentalconsequences of exposure to contaminated and harmfulwaste

The inadequate disposal of HCWmay be catastrophic tohealth and the environment as well as thewellbeing of societyIf the HCW in Khulna city is not handled in a proper way itwill undoubtedly pose a danger to the workforce employed inthe HCEs as well as to the neighboring people

55 Assessment of Different Technological Options for ProperTreatment of HCW Using SAT Methodology in the Context ofKhulna City In general treatment options may be availableeither on- or off-site A central treatment facility is proposedas the generation of hazardous waste from individual HCEsis not high enough to run a treatment facility solely Assess-ment outcomes of different technological choices for HCWtreatment including technical suitability environmental eco-nomic and social aspects using SATmethodology for Khulnaare narrated herein chronologically

Strategic-Level Assessment(i) Issue all HCEs in the Khulna metropolitan area do

not have proper treatment facilities to treat their haz-ardous waste efficiently

1 2 3 45

67

891011

1213

1415

16171819202122

2324

2526

27282930

3132

3334

35 36 37

IncinerationMicrowaveAutoclave

Figure 3 Distribution of acquired scores of all criteria of HCWtreatment options

(ii) Target implementation of a large-scale central treat-ment technology to handle the hazardous waste fromall HCEs in the area Furthermore proclamation ofpolicies to be needed for the treatment of all haz-ardous waste

Operational Level Assessment VariousHCW treatment alter-natives for instance incineration microwaving and auto-claving were screened (Table 4) in this step using differ-ent modified screening criteria Short-listed technologicaloptions passed through the screening step were then sub-jected to going through the comprehensive scoping tier(Table 5)

Detailed Assessment The final scores obtained by differ-ent treatment alternatives for the technical suitability andeconomic social and environmental criteria are shown inTable 6 Final weightage of all criteria (37 numbers) undereach criteria topic for HCW treatment options is presented ina composite star diagram (Figure 3)

It is observed from Table 6 that all three technologiesare fairly close although incineration is the highest rankedtreatment option followed by microwave technology Amongdifferent criteria technical suitability and social aspect varyto some extent In the technical suitability aspect the mostimportant criteria considered by the experts judgment werethe ability to treat a wide range of hazardous wastes capacityrequirement and adaptability to the future situation Regard-ing the social aspect experts contemplated communityacceptance of the technology Although incineration attainedthe highest score in technical suitability and social aspect thecapital cost of the treatment technology as well as mainte-nance expenditure is one of the drawbacks of this treatmentoption Ozkan [22] indicated that off-site incineration is the

Journal of Environmental and Public Health 9

Table 4 Screening of different HCW treatment alternatives for Khulna municipality

CriteriaIncineration withpollution control

deviceMicrowave Autoclave Hydropulping Compaction

Compliance with nationalenvironmental laws radic radic radic X X

Compliance with multilateralenvironmental agreements radic radic radic radic radic

Consistency with WHO policies radic radic radic radic radic

Flexibility in accepting variouswaste radic radic radic X X

Volume reduction radic radic X radic radic

Technology economically Viable radic radic radic radic radic

Acceptability of technology inKhulna radic radic radic X X

Outcome (selectednot selected) radic radic radic X XNoteradic yes and X no

best method out of the five assessed HCW treatment alter-natives Another research using the multicriteria decision-making (MCDM) approach carried out by Antonopoulos etal [37] also corroborated the same facts

Based on assessment outcomes utilizing SAT methodol-ogy characterization of waste and local conditions inciner-ation is likely said to be the suitable method for treatmentof all types of HCW in Khulna city The majority of thewastes produced fromHCEs are nonhazardous which can bedisposed of in ways similar to the domestic waste Only thehazardous portion needs to be treated In Khulna city thepresent generation of the waste is about 3 ton dayminus1 and thehazardous waste is nearly 06 ton dayminus1Therefore a mediumsize incinerator (destruction capacity 025 ton hrminus1) will begood enough to comply with the situation Unwanted pol-lutants can be significantly reduced with the addition of airpollution control devices of the system Many air pollutantsin emissions from incinerators can be lessened substantiallyby modern air pollution control mechanisms if appropriatelydesigned and operated [2 38] Since the investment cost isvery high for new plant several HCEs may converge to set upa plant centrallyThese types of plants are now being observedin many countries of the world

6 Conclusions and Recommendations

Thepresent study has mainly focused on the existing HCWMparadigms of Khulna metropolis and on the question of howit can be made a more efficient and acceptable one Theexisting HCWM pattern in Khulna city has many drawbacksand is in dire need of immediate attention and improvementIt was observed from the investigation that the hazardouswaste was not treated separately in almost all of the HCEsin Khulna city Intervention is required at all stages ofwastemanagement from the formulation of appropriate lawssegregation and transportation of waste to the final disposalmethodThe process and method adopted for waste manage-ment should be technically and financially sustainable in the

long run It has to also be ensured that there are no adversehealth and environmental consequences of waste handlingtreatment and disposal activities

National legislation is the basis for improving HCWpractices in any country Therefore a national managementplan will be required which will permit HCWM options tobe optimized on a national scale The law should be comple-mented by a policy document and technical guidelines devel-oped for implementation This legal document should specifyregulations on treatment for different waste categories segre-gation collection storage handling disposal transporta-tion responsibilities and training requirements Training ofhealthcare personnel as well as general people regardinghygiene and HCWM is needed to create awareness and fosterresponsibility among them which will prevent exposure torelated health hazards

Among different waste treatment options it has beenfound from the study that the incineration system is the mostsuitable one for Khulna city based on the final score con-sidering technical suitability and environmental economicand social aspect However the system should be maintainedproperly with an appropriate air pollution control deviceTheranking order of the second technological choice was micro-waving followed by autoclaving considering all aspects Theassessment of treatment alternatives in this investigation issubjected to the selection as well as weighting of the criteriaand strongly dependent on the reliability to the response ofthe expertsrsquo personal judgment Besides the waste genera-tion rate that was calculated in this investigation was ex-cluding seasonal variation A further detailed study is re-quired incorporating more HCEs with an extended periodof collected data as well as seasonal variation to explore thesustainability of such management option Furthermore it isrecommended to develop a great variety of MCDMmethodsto evaluate such HCW treatment alternatives Overall thestudy will give an insight promulgating guidelines for thefuture planning and design of HCWM strategies in Khulnacity as well as other municipalities in developing countries

10 Journal of Environmental and Public Health

Table5Scop

ingof

SATmetho

dology

forthe

assessmento

fHCW

treatmento

ptions

forK

hulnam

etropo

lis

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Technicalsuitability

Com

patib

ilitywith

local

surrou

ndings

andnatural

cond

ition

s1198821=1

Rank

ingforT

echn

ical

SuitabilityRT

25

Maxim

umscorefor

TechnicalSuitability

(MST

)9times(1198821+1198822+

sdotsdotsdot+11988210)=531

MF1

=004

77

0329

60282

50235

Preference

forlocally

manufacturedtechno

logies1198822=7

MF2

=0329

516

454

1316

30987

Availabilityof

sparep

arts

andusageo

flocalmaterials1198823=5

MF3

=0235

614

105

1175

51175

Availabilityof

local

expertise

1198824=3

MF4

=0141

60846

50705

40564

Trackrecord

onperfo

rmance

1198825=10

MF5

=0470

73290

62820

62820

Com

patib

ilitywith

existing

techno

logy

ormanagem

ent

syste

m1198826=1

MF6

=004

75

0235

40188

40188

Meetscapacityrequ

irement1198827=10

MF7

=0470

83760

62820

62820

Adaptabilityto

future

situatio

ns1198828=5

MF8

=0235

818

806

1410

51175

Abilityto

treataw

idethe

rangeo

fhealth

care

wastes1198829=10

MF9

=0470

94230

62820

62820

Levelof

automationsoph

istication11988210=7

MF10=0329

413

166

1974

619

74

Journal of Environmental and Public Health 11

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Environm

ent

Efficacy

ofmicrobial

inactiv

ation

11988211=10

Rank

ingfor

environm

ent

(resou

rces

and

emissions)RE

n25

Maxim

umscorefor

environm

ent

(MSE

n)

9times(11988211+11988212+

sdotsdotsdot+11988228)=1161

MF11=

0215

919

357

1505

612

90

Risk

levelsforw

orkers

11988212=10

MF12=0215

40860

510

755

1075

Risk

levelsforc

ommun

ities11988213=10

MF13=

0215

40860

510

755

1075

Risk

tothee

nviro

nment11988214=10

MF14=0215

20430

612

907

1505

Airem

issions

11988215=10

MF15=

0215

10215

612

906

1290

Liqu

ideffl

uents

11988216=5

MF16=0107

6064

22

0214

20214

Solid

resid

ues

11988217=5

MF17=

0107

70749

40428

40428

Volumer

eductio

n11988218=10

MF18=0215

919

356

1290

20430

Massreductio

n11988219=3

MF19=0065

80520

30195

10065

Odo

r11988220=10

MF2

0=0215

40860

40860

40860

Noise

11988221=5

MF2

1=0107

40428

30321

50535

Energy

consum

ptionperk

gof

waste

11988222=10

MF2

2=0215

612

906

1290

510

75

Extent

ofuseo

frenew

able

energy

11988223=8

MF2

3=0172

50860

712

047

1204

Waterconsum

ptionperk

gof

waste

11988224=5

MF24=0107

70749

30321

30321

Materialcon

sumption

11988225=5

MF2

5=0107

6064

26

064

26

064

2Ex

tent

ofuseo

fhazardo

usmaterials

11988226=5

MF2

6=0107

80865

70749

70749

Spacer

equirement

11988227=3

MF2

7=0065

60390

50325

50325

Resource

recovery

capabilities

11988228=5

MF2

8=0107

20214

50535

6064

2

12 Journal of Environmental and Public Health

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Fina

ncialeconomica

lEstim

ated

capitalcosto

fthetreatmenttechn

olog

y11988229=10

Rank

ingfore

cono

mic

aspectsRE

c25

Maxim

umscorefor

econ

omic(M

SEn)

9times(11988229+11988230+

sdotsdotsdot+11988232)=270

MF2

9=0926

874

086

5556

54630

Estim

ated

capitalcostsof

allaccessorie

sand

related

equipm

ent

11988230=5

MF3

0=0463

313

894

1852

418

52

Estim

ated

operationand

maintenance

costs

11988231=10

MF31=

0926

54630

43704

32778

Insta

llatio

nrequ

irements11988232=5

MF32=

0463

418

525

2315

52315

Socia

lcultural

Com

mun

ityacceptance

ofthetechn

olog

y11988233=10

Rank

ingforsocial

aspectsRS

25

Maxim

umscorefor

SocialCultural

(MSS)

9times(11988233+11988234+

sdotsdotsdot+11988237)=315

MF33=

0794

75558

53970

43176

Incomeg

eneration

potential

11988234=5

MF3

4=0397

62382

20794

20794

Acceptabilityof

treatment

resid

uesb

ythelocalland

fill11988235=10

MF35=

0794

64764

43176

43176

Extent

ofnecessary

resettlem

ento

fpeople

11988236=5

MF3

6=0397

31191

62382

62382

Visib

leor

aesth

eticim

pact11988237=5

MF37=0397

519

854

1588

31191

Total

645

554

512

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

4 Journal of Environmental and Public Health

Table 1 Overall HCW (hazardous and nonhazardous) generation rate from different HCEs in Khulna city

Name of the HCE Number ofbeds Category

Total generatedwaste kg bedminus1

dayminus1 orkgDCminus1 dayminus1

Mean kg bedminus1dayminus1 or

kgDCminus1 dayminus1

Haz waste kgbedminus1 dayminus1 orkgDCminus1 dayminus1

Mean kg bedminus1dayminus1 or

kgDCminus1 dayminus1

KGH 250 Public 098

090

020

018

KMCH 500 Public 115 025SANSH 75 Public 089 019IDH 20 Public 087 017CDH 100 Public 090 019MCWC 20 Public 088 017GMCH 500 Private 100 020GNCDC 50 Private 088 015AAMCH 20 Private 080 017KSH 218 Private 092 019KDH 100 Private 090 018KSMH 50 Private 087 016DBC 30 Private 085 015IBH 100 Private 091 017FHC 15 Private 077 012KC 25 Private 083 014DDC ndash DC 310

442

119

171MDC ndash DC 590 211SDC ndash DC 450 180PDC ndash DC 420 174Notes DC Diagnostic Center or Dental Clinic KGH Khulna General Hospital KMCH Khulna Medical College Hospital SANSH Sheikh Abu NaserSpecializedHospital IDH InfectiousDiseasesHospital CDHCheastDiseaseHospitalMCWCMotheramp ChildWelfareCenterGMCHGaziMedical CollegeHospital GNCDC Garib Newaz Clinic and Diagnostic Center AAMCH Ad-din Akij Medical College Hospital KSH Khulna Shishu Hospital KDH KhulnaDiabetic Hospital KSMH Khulna Surgical and Medical Hospital DBC Dabs Clinic IBH Islami Bank Hospital FHC Fair Health Clinic KC KhalishpurClinic DDC Decent Dental Clinic MDC Mahanagar Diagnostic Center SDC Setu Diagnostic Center and PDC Padma Diagnostic Center

autoclave waste treatment alternatives and so on werescreened by using modified screening criteria through con-sultative meetings to meet local situations Waste treatmenttechnologies that passed through the screening step werethen subjected to the comprehensive scoping tier Scopingcriteria were developed under four broad criteria topics astechnical financial social and environmental It is noted herethat therewere 10 technical 18 environmental 4 financial and

5 social criteria under each criteria topicWeight was given bythe stakeholders for each criterion from 0 to 10 depending onthe importance and significance (0 for not important 1 to 3for low 4 to 6 formedium 7 to 9 for high and 10 for essential)For each waste treatment technology under considerationthe score was given for each criterion from 0 to 9 (1 to 3 forlow 4 to 6 formedium and 7 to 9 for high) For each criterionmultiplying factors were calculated as follows [12]

MF = 119882 times RCTMSCT

MSCT = 9 times (algebraic sum of all weightage given under each criteria topic) (1)

where119882 is weight of each criterion RCT is ranking for eachcriteria topic and MSCT is maximum score for each criteriatopic

It can be mentioned here that the ranking of each criteriatopic (RCT) is established by a factor from 0 to 100 to eachtopic such that the sum of all the ranking factors adds up to100 In this study 25 was assigned to each topic since they

are all of equal importance according to the local conditionsThe technologies with best overall ratings from the scopingstep were selected for further assessment in this step Amongvarious multicriteria decision-making (MCDM) the simpleweighted sum matrix method was employed in this studyfor quantitative assessment With the aim of selecting themost preferred HCW treatment technology a number of

Journal of Environmental and Public Health 5

experts and stakeholders in the study area participated in theSAT process For detailed assessment outcomes readers aresuggested to see Section 55

5 Results and Discussions

51 Generation of HCW in the Studied HCEs The studyrevealed that waste generation rate is slightly higher (119901 lt005) in Public HCEs (095 kg bedminus1 dayminus1) than the privatehealth centers (088 kg bedminus1 dayminus1) Public HCFs producedmore wastes than that of the Private HCEs due to morenumbers of beds departments andwards in comparisonwithprivate hospitals [24] The amount of HCW generated in theHCEs was positively correlated with the number of beds (119903s =079 119901 lt 0001) The average waste generation per bed perday in Khulna city has been found to be 090 kg (Table 1)which ismuch lower than that of the developed countries likethe United States (45 kg bedminus1 dayminus1) the United Kingdom(33 kg bedminus1 dayminus1) and Spain (44 kg bedminus1 dayminus1) [25 26]In high-income countries HCW generation is usually higherthan that in the middle and low-income countries [27] Therate of waste generation mainly depends upon geographicallocation living standard healthcare facilities waste collec-tion services and so on In Latin American countries likeChile Brazil Argentina and Venezuela this figure variesfrom 1 to 45 kg bedminus1 dayminus1 [28] Therefore it can be men-tioned that the waste generation rate of Khulna city is closeto the figure of the developing countries of Latin AmericaHowever this figure is very close to the generation rate of093 kg bedminus1 dayminus1 in Sylhet city and 12 kg bedminus1 dayminus1 inDhaka [29 30]

The rate of generation of hazardous waste per bed perday from selected HCEs in Khulna city has been found tobe 018 kg (Table 1) This rate is close to the rate of 021 kgbedminus1 dayminus1 in Sylhet and Bangladesh [29] and much lowerthan that of 057 kg bedminus1 dayminus1 in Brazil and 047 kg bedminus1dayminus1 in Japan reported byDa Silva et al [31] andMohee [32]respectively About 80 of waste generated is nonhazardousand the other 20 is hazardous (Figure 1) which is muchlower than reported in Denmark (25) and the United States(28) [33] Among hazardous waste 8 is infectious 5pathological 4 plastic 2 sharps and 1 is chemical waste(Figure 1)

About 3 tons of HCW were generated daily from 120registered HCEs in Khulna city (Table 2) Most of them werecontributed by private HCFs (60) as the aggregated numberof beds is higher in Private HCEs Public HCFs cover 35and the other 5 were generated by the diagnostic centersand dental clinics In Khulna city about 235 kg of infectiouswaste 116 kg of plastic 24 kg of chemicals and 69 kg of sharpsare generated daily fromdifferent HCEs (Table 2)These largeamounts of unorthodox wastes deserved extra attention

The importance for the proper management of HCWcan be sensed from the aforementioned statistics whichrevealed that roughly 212 metric tons of hazardous waste isgenerated in Khulna each year This ever-increasing amountof hazardous waste if not managed properly will cause severehealth hazards and environmental problems

80

8

54 2 1

GeneralInfectiousPathological

PlasticSharpsChemical

Figure 1 Composition of HCW in Khulna city

52 Survey Findings Depicting HCWM Practices in KhulnaCity The materials presented here are aimed at showingrespondents view on the existing HCWM practices in dif-ferent HCEs in the KCC area Using a random samplingprocedure a questionnaire survey was carried out among 87respondents from different occupations including patientsdoctors nurses cleaners administrators and general peoplein different HCFs Most of them were educated with the ageranging from 30 to 50 years and average service length of 10years However a few of them were illiterate Their opinionsare displayed herein (Table 3)

In the studied HCEs the frequency of on-site wastehandling was categorized as once per day twice per day andirregular Most of the respondents in Private HCEs opine thatthe on-site waste handling (patientrsquos bed to storage place) isirregular while in Public HCEs most of them said that itis once per day In the case of on-site waste handling fromstorage place tomunicipal dustbin or NGOs van the majorityfrom thePrivateHCEs reported ononce per daywhich can beevident fromTable 3More than 40 respondents reported thatwaste collection from the secondary source to final disposalwas at noon while a good number of respondents enunciatedon morning

In the case of an existing level of awareness on using safetyequipment to prevent the spreading of infectious diseasesa great number of respondents (54 119899 = 47) from HCEsreported that they were not using any safety equipment(Table 3) It also investigated from the field survey thatalmost all the respondents from surveyed HCEs focused theiropinion in favor of training concerning the waste manage-ment In connection with the training methods the main-stream showed their interest in video and lecture

It was observed from the study that 75 (119899 = 65) of thetotal respondents preferred to dispose of their wastes in theNGOrsquos covered bins 17 (119899 = 15) of respondents indicatedthe municipal open dustbin for their waste disposal andvery few respondents reported on another disposal system(Figure 2)

6 Journal of Environmental and Public Health

Table 2 Total amount of HCW generated in Khulna city

Types of HCEsNonhazardous

waste(Kg dayminus1)

Infectious waste(Kg dayminus1)

Pathologicalwaste

(Kg dayminus1)

Chemical waste(Kg dayminus1)

Plastic waste(Kg dayminus1)

Sharp waste(Kg dayminus1)

Total(Kg dayminus1)

Public 793 86 47 8 41 23 998Private 1399 135 83 11 56 32 1716DC 96 14 7 5 19 14 155Grand Total 2288 235 137 24 116 69 2869Note This figure was calculated only from 120 registered HCEs (Total number of beds 3000) It can be mentioned that there were more than 50 nonregisteredHCEs existing in Khulna city These HCFs produced relatively small portion of the overall amount of waste in the studied area

Table 3 Scenarios of waste handling and management practices in Khulna metropolis

Variables Frequency () Total respondents ()GH PH DC

On-site handling (patientrsquos bed to storage place)Once per day 12 (14) 10 (11) 4 (5) 30Twice per day 4 (5) 13 (15) 5 (6) 25Irregular 8 (9) 19 (22) 12 (14) 45On-site handling (storage place to final disposal)Once per day 14 (16) 34 (39) 15 (17) 73Twice per day 6 (7) 5 (6) 4 (5) 17Irregular 4 (5) 3 (3) 2 (2) 10Time of waste collection (secondary source to final disposal)Morning 10 (12) 18 (21) 4 (5) 37Noon 24 (28) 14 (16) 5 (6) 49Random 9 (10) 2 (2) 1 (1) 14Systematic issues of waste collectionSystematic 21 (24) 7 (8) 5 (6) 38Nonsystematic 3 (3) 35 (40) 16 (18) 62Safety equipment scenarioFollowed 7 (8) 23 (26) 10 (12) 46Not followed 17 (20) 18 (21) 12 (14) 54Training issuesGot training 5 (7) 19 (28) 6 (9) 44Did not get training 14 (21) 15 (22) 9 (13) 56Opinion on training methodologyLecture amp video 16 (24) 28 (41) 12 (18) 82Video 2 (3) 3 (4) 2 (3) 10Lecture 1 (1) 3 (4) 1 (1) 7Opinion on existing HCWMSatisfactory 2 (2) 25 (29) 10 (11) 42Unsatisfactory 25 (29) 16 (18) 9 (10) 58Notes GH public HCEs PH private HCEs DC diagnostic center or dental clinic

A large number of respondents (58 119899 = 50) expressedtheir dissatisfaction with existing HCWM practices inKhulna city The problems they faced are no environment-friendly dustbin for waste disposal no separate dustbin forHCW collection dustbin is not in a suitable location wastecollection system is unhygienic irregular collection systemand hazardous waste is spreading all over the place due tolack of on-site treatment facility Although the chart showsthat satisfaction rates are quite high this is due to the better

management of Private HCEs They also mentioned someprobable steps that could overcome the problems and theseare as follows

(i) Use of an apronmask and gloves during handling thepatients and segregation as well as disposal of wastesuse of WHO-guided color-coded bins for segregatedwaste

(ii) Training for awareness could be a great help regardingthis issue

Journal of Environmental and Public Health 7

7517

8

NGOrsquos covered binsMunicipalrsquos open dustbinsOthers

Figure 2 Graphical presentation of preferable waste collection sys-tem

(iii) Formulating amending and imposing the relevantlaws could prevent the improper management ofHCW

53 Institutional Arrangements for HCWM in Khulna Cityand Their Limitations At the local level only KCC a publicorganization and Prodipan anNGO are involved inHCWMin Khulna city KCC does not have any special arrangementfor the collection and disposal of HCW separately as theyare not obliged to do according to their ordinance Theconservancy department of KCC identifies the lack of trainedmanpower and resources as the principal reasons for nothaving any arrangement to handle the HCW KCC does nothave any research facility to identify the extent of differentproblems and to provide guidelines to mitigate that Around47 of the money spent on waste management goes for themaintenance purpose of the vehicle and the remaining 53is spent on providing remuneration of the staff engaged insolid waste management in KCC KCC collected the HCW inthe same vehicle together with other wastes from the publicdustbin twice a day and dumped it together in the dumpinggroundnear Rajbandh about 7 km south of the city KCCalsodumped wastes for landfilling purpose at different locationsof the city It increased the risk of health hazards to theadjacent community

On the other hand Prodipan started their journey inMay 2000 with the financial aid from the Swiss DevelopmentCooperation UNDP and the World Bank Initially theystarted their project with 20 HCEs which increased to100 in 2013 Prodipan segregated wastes at the source ofsegregation They provided a set of four covered drums todispose of four types of waste separately An autocoveredvan of 10-ton capacity was used for transportation of HCWfrom different HCEs Generally collection took place in themorning every day Prodipan took service charge from theHCEs they served and the charge was determined dependingon the size (number of bed) and earnings of the HCEs Thestudy revealed that 44 of monthly expenditure is spent onproviding wages for the staff Vehicle maintenance cost is

46 and the remaining 10 is for purchasing the requiredmaterials Prodipan burnt infectious waste in a locally madeburning pit at a comparatively low temperature (about 400∘Cor below) It may in some cases cause unfinished burningand in the case of the presence of any type of plastic materialin the waste experts opine that ldquothis is more harmful as ithelps in producing dioxin gasrdquo They disposed of the needlesand all other sharp materials in a concrete pit This could beviable at a small scale however in the case of the entire citywhere the yearly generation of sharpswaste is about 25metrictons the volume reduction is crucial The present HCWMsystem of Prodipan is not a very structured and cost-effectiveone The project is not internally balanced and continuity ofthe project is totally dependent on the availability of foreignaid

54 Existing HCWMPractices in Khulna City and Its ImpactsWith the upward trend of population and mushroominggrowth of HCEs together with lack of operational wastedisposal mechanism the environmental condition of Khulnacity is gradually becoming more alarming The existingHCWM status in the KCC area is unsatisfactory and unsafefor health Most of the HCEs in Khulna had no appositewaste management system and they did not use any sort ofprotective clothing like gloves a mask and so on Hospitalauthorities were found to be less concerned regarding properdisposal of clinical waste Although proper segregation andtreatment of infectious waste before dumping are very crucialto minimizing health risks to the community [34] they hadnot been exercised in any of theHCEs studied It was revealedfrom the study that more than 80 of HCW is nonhazardouswhichmay be considered as general wasteThis huge amountof nonhazardous waste is excessively contaminated withhazardous waste due to a lack of proper waste separationpractices Moreover there are no distinct color-coded collec-tion bins for HCWM and all categories of waste from HCEscomprising reusable and sharp waste are dumped in com-mon places like public garbage disposal bins side of roadsdumping grounds or municipal waste collection containersThis malpractice elucidated the inefficiency of HCWM inKhulna as well as increasing the chances of contamination ofan entire mass of solid waste tainting it with infectious HCW

HCW comprises biodegradable and nonbiodegradablepolymers [29] Biodegradable polymers are easily decom-posed by the action of microorganisms while nonbiodegrad-ables are very difficult to decay The change in biologicalcharacter of HCW disinfects it which reduces the infectiousbiohazardous properties of the waste [35] The microorgan-isms may create a cyst to stay alive in adverse conditionand contaminate the environment [29] Chemical effluentsproduced from several HCEs were released straight intothe municipal cesspool and may have toxic effects on thenatural ecosystems of receiving waters Most landfills arenot constructed properly which may contaminate drinkingwater Surface overflow directly from deposited waste canpollute surface water easily Direct ejection of blood bodyparts feces and urine of contagious patients in a public sewersystem may cause a spate of communicable diseases Lack ofawareness regarding the damaging effects of HCW was also

8 Journal of Environmental and Public Health

found among the workers involved in the total managementprocess as well as general people in the studied area

Most of the disposal site is open and thereby emitsunpleasant odors and an unaesthetic view causing a hugepublic nuisance While grazing ready access of domestic ani-mals in open dumps may create the possibilities of introduc-ing microbes and pathogens into the food chain Indiscrimi-nate junking of HCWmay create the chances of adulterationof food supplies soil surface water groundwater and airThemajority of the municipal waste receptacles are not designedappropriately and are open without a cover or lid Thereforevectors like insects rodents worms birds and so on can eas-ily enter the collection containers and can take a place on theexposed piles of rotting trash causing the spread of contagiousbugs These also stimulate the mechanical transmission ofdeadly waterborne diseases like diarrhea typhoid dysenteryhepatitis and cholera [29] Moreover mosquitoes promotebiological transmission ofmany types of diseases likemalariadengue and yellow fever under humid environment Rubberand plastic trash being burnt in the open air releases fumescontaining carbonmonoxide dioxins furans and so on [36]When these toxic components are inhaled through smokethey may cause cancer respiratory diseases and many otherdeadly results to humans

Informal waste collectors (known as scavengers) engagedin collecting refuse from HCEs are suffering from variousintestinal parasitic and skin diseases Waste pickers collectused medical equipment particularly syringes from thegarbage and sell them at a low price Many drug addictsmay suffer from cholera typhoid hepatitis AIDS and otherhazardous and contagious diseases as they are reusing thesesyringes Scavengers are scooping out waste from the dust-bins roads and garbage lots for the recyclables with barehands without taking any safety measures therefore facing ahigh risk of salient epidemics of infectious diseasesThewastepickers involved in the recycling process are extremely poorhaving no proper education and incautious of detrimentalconsequences of exposure to contaminated and harmfulwaste

The inadequate disposal of HCWmay be catastrophic tohealth and the environment as well as thewellbeing of societyIf the HCW in Khulna city is not handled in a proper way itwill undoubtedly pose a danger to the workforce employed inthe HCEs as well as to the neighboring people

55 Assessment of Different Technological Options for ProperTreatment of HCW Using SAT Methodology in the Context ofKhulna City In general treatment options may be availableeither on- or off-site A central treatment facility is proposedas the generation of hazardous waste from individual HCEsis not high enough to run a treatment facility solely Assess-ment outcomes of different technological choices for HCWtreatment including technical suitability environmental eco-nomic and social aspects using SATmethodology for Khulnaare narrated herein chronologically

Strategic-Level Assessment(i) Issue all HCEs in the Khulna metropolitan area do

not have proper treatment facilities to treat their haz-ardous waste efficiently

1 2 3 45

67

891011

1213

1415

16171819202122

2324

2526

27282930

3132

3334

35 36 37

IncinerationMicrowaveAutoclave

Figure 3 Distribution of acquired scores of all criteria of HCWtreatment options

(ii) Target implementation of a large-scale central treat-ment technology to handle the hazardous waste fromall HCEs in the area Furthermore proclamation ofpolicies to be needed for the treatment of all haz-ardous waste

Operational Level Assessment VariousHCW treatment alter-natives for instance incineration microwaving and auto-claving were screened (Table 4) in this step using differ-ent modified screening criteria Short-listed technologicaloptions passed through the screening step were then sub-jected to going through the comprehensive scoping tier(Table 5)

Detailed Assessment The final scores obtained by differ-ent treatment alternatives for the technical suitability andeconomic social and environmental criteria are shown inTable 6 Final weightage of all criteria (37 numbers) undereach criteria topic for HCW treatment options is presented ina composite star diagram (Figure 3)

It is observed from Table 6 that all three technologiesare fairly close although incineration is the highest rankedtreatment option followed by microwave technology Amongdifferent criteria technical suitability and social aspect varyto some extent In the technical suitability aspect the mostimportant criteria considered by the experts judgment werethe ability to treat a wide range of hazardous wastes capacityrequirement and adaptability to the future situation Regard-ing the social aspect experts contemplated communityacceptance of the technology Although incineration attainedthe highest score in technical suitability and social aspect thecapital cost of the treatment technology as well as mainte-nance expenditure is one of the drawbacks of this treatmentoption Ozkan [22] indicated that off-site incineration is the

Journal of Environmental and Public Health 9

Table 4 Screening of different HCW treatment alternatives for Khulna municipality

CriteriaIncineration withpollution control

deviceMicrowave Autoclave Hydropulping Compaction

Compliance with nationalenvironmental laws radic radic radic X X

Compliance with multilateralenvironmental agreements radic radic radic radic radic

Consistency with WHO policies radic radic radic radic radic

Flexibility in accepting variouswaste radic radic radic X X

Volume reduction radic radic X radic radic

Technology economically Viable radic radic radic radic radic

Acceptability of technology inKhulna radic radic radic X X

Outcome (selectednot selected) radic radic radic X XNoteradic yes and X no

best method out of the five assessed HCW treatment alter-natives Another research using the multicriteria decision-making (MCDM) approach carried out by Antonopoulos etal [37] also corroborated the same facts

Based on assessment outcomes utilizing SAT methodol-ogy characterization of waste and local conditions inciner-ation is likely said to be the suitable method for treatmentof all types of HCW in Khulna city The majority of thewastes produced fromHCEs are nonhazardous which can bedisposed of in ways similar to the domestic waste Only thehazardous portion needs to be treated In Khulna city thepresent generation of the waste is about 3 ton dayminus1 and thehazardous waste is nearly 06 ton dayminus1Therefore a mediumsize incinerator (destruction capacity 025 ton hrminus1) will begood enough to comply with the situation Unwanted pol-lutants can be significantly reduced with the addition of airpollution control devices of the system Many air pollutantsin emissions from incinerators can be lessened substantiallyby modern air pollution control mechanisms if appropriatelydesigned and operated [2 38] Since the investment cost isvery high for new plant several HCEs may converge to set upa plant centrallyThese types of plants are now being observedin many countries of the world

6 Conclusions and Recommendations

Thepresent study has mainly focused on the existing HCWMparadigms of Khulna metropolis and on the question of howit can be made a more efficient and acceptable one Theexisting HCWM pattern in Khulna city has many drawbacksand is in dire need of immediate attention and improvementIt was observed from the investigation that the hazardouswaste was not treated separately in almost all of the HCEsin Khulna city Intervention is required at all stages ofwastemanagement from the formulation of appropriate lawssegregation and transportation of waste to the final disposalmethodThe process and method adopted for waste manage-ment should be technically and financially sustainable in the

long run It has to also be ensured that there are no adversehealth and environmental consequences of waste handlingtreatment and disposal activities

National legislation is the basis for improving HCWpractices in any country Therefore a national managementplan will be required which will permit HCWM options tobe optimized on a national scale The law should be comple-mented by a policy document and technical guidelines devel-oped for implementation This legal document should specifyregulations on treatment for different waste categories segre-gation collection storage handling disposal transporta-tion responsibilities and training requirements Training ofhealthcare personnel as well as general people regardinghygiene and HCWM is needed to create awareness and fosterresponsibility among them which will prevent exposure torelated health hazards

Among different waste treatment options it has beenfound from the study that the incineration system is the mostsuitable one for Khulna city based on the final score con-sidering technical suitability and environmental economicand social aspect However the system should be maintainedproperly with an appropriate air pollution control deviceTheranking order of the second technological choice was micro-waving followed by autoclaving considering all aspects Theassessment of treatment alternatives in this investigation issubjected to the selection as well as weighting of the criteriaand strongly dependent on the reliability to the response ofthe expertsrsquo personal judgment Besides the waste genera-tion rate that was calculated in this investigation was ex-cluding seasonal variation A further detailed study is re-quired incorporating more HCEs with an extended periodof collected data as well as seasonal variation to explore thesustainability of such management option Furthermore it isrecommended to develop a great variety of MCDMmethodsto evaluate such HCW treatment alternatives Overall thestudy will give an insight promulgating guidelines for thefuture planning and design of HCWM strategies in Khulnacity as well as other municipalities in developing countries

10 Journal of Environmental and Public Health

Table5Scop

ingof

SATmetho

dology

forthe

assessmento

fHCW

treatmento

ptions

forK

hulnam

etropo

lis

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Technicalsuitability

Com

patib

ilitywith

local

surrou

ndings

andnatural

cond

ition

s1198821=1

Rank

ingforT

echn

ical

SuitabilityRT

25

Maxim

umscorefor

TechnicalSuitability

(MST

)9times(1198821+1198822+

sdotsdotsdot+11988210)=531

MF1

=004

77

0329

60282

50235

Preference

forlocally

manufacturedtechno

logies1198822=7

MF2

=0329

516

454

1316

30987

Availabilityof

sparep

arts

andusageo

flocalmaterials1198823=5

MF3

=0235

614

105

1175

51175

Availabilityof

local

expertise

1198824=3

MF4

=0141

60846

50705

40564

Trackrecord

onperfo

rmance

1198825=10

MF5

=0470

73290

62820

62820

Com

patib

ilitywith

existing

techno

logy

ormanagem

ent

syste

m1198826=1

MF6

=004

75

0235

40188

40188

Meetscapacityrequ

irement1198827=10

MF7

=0470

83760

62820

62820

Adaptabilityto

future

situatio

ns1198828=5

MF8

=0235

818

806

1410

51175

Abilityto

treataw

idethe

rangeo

fhealth

care

wastes1198829=10

MF9

=0470

94230

62820

62820

Levelof

automationsoph

istication11988210=7

MF10=0329

413

166

1974

619

74

Journal of Environmental and Public Health 11

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Environm

ent

Efficacy

ofmicrobial

inactiv

ation

11988211=10

Rank

ingfor

environm

ent

(resou

rces

and

emissions)RE

n25

Maxim

umscorefor

environm

ent

(MSE

n)

9times(11988211+11988212+

sdotsdotsdot+11988228)=1161

MF11=

0215

919

357

1505

612

90

Risk

levelsforw

orkers

11988212=10

MF12=0215

40860

510

755

1075

Risk

levelsforc

ommun

ities11988213=10

MF13=

0215

40860

510

755

1075

Risk

tothee

nviro

nment11988214=10

MF14=0215

20430

612

907

1505

Airem

issions

11988215=10

MF15=

0215

10215

612

906

1290

Liqu

ideffl

uents

11988216=5

MF16=0107

6064

22

0214

20214

Solid

resid

ues

11988217=5

MF17=

0107

70749

40428

40428

Volumer

eductio

n11988218=10

MF18=0215

919

356

1290

20430

Massreductio

n11988219=3

MF19=0065

80520

30195

10065

Odo

r11988220=10

MF2

0=0215

40860

40860

40860

Noise

11988221=5

MF2

1=0107

40428

30321

50535

Energy

consum

ptionperk

gof

waste

11988222=10

MF2

2=0215

612

906

1290

510

75

Extent

ofuseo

frenew

able

energy

11988223=8

MF2

3=0172

50860

712

047

1204

Waterconsum

ptionperk

gof

waste

11988224=5

MF24=0107

70749

30321

30321

Materialcon

sumption

11988225=5

MF2

5=0107

6064

26

064

26

064

2Ex

tent

ofuseo

fhazardo

usmaterials

11988226=5

MF2

6=0107

80865

70749

70749

Spacer

equirement

11988227=3

MF2

7=0065

60390

50325

50325

Resource

recovery

capabilities

11988228=5

MF2

8=0107

20214

50535

6064

2

12 Journal of Environmental and Public Health

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Fina

ncialeconomica

lEstim

ated

capitalcosto

fthetreatmenttechn

olog

y11988229=10

Rank

ingfore

cono

mic

aspectsRE

c25

Maxim

umscorefor

econ

omic(M

SEn)

9times(11988229+11988230+

sdotsdotsdot+11988232)=270

MF2

9=0926

874

086

5556

54630

Estim

ated

capitalcostsof

allaccessorie

sand

related

equipm

ent

11988230=5

MF3

0=0463

313

894

1852

418

52

Estim

ated

operationand

maintenance

costs

11988231=10

MF31=

0926

54630

43704

32778

Insta

llatio

nrequ

irements11988232=5

MF32=

0463

418

525

2315

52315

Socia

lcultural

Com

mun

ityacceptance

ofthetechn

olog

y11988233=10

Rank

ingforsocial

aspectsRS

25

Maxim

umscorefor

SocialCultural

(MSS)

9times(11988233+11988234+

sdotsdotsdot+11988237)=315

MF33=

0794

75558

53970

43176

Incomeg

eneration

potential

11988234=5

MF3

4=0397

62382

20794

20794

Acceptabilityof

treatment

resid

uesb

ythelocalland

fill11988235=10

MF35=

0794

64764

43176

43176

Extent

ofnecessary

resettlem

ento

fpeople

11988236=5

MF3

6=0397

31191

62382

62382

Visib

leor

aesth

eticim

pact11988237=5

MF37=0397

519

854

1588

31191

Total

645

554

512

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

Journal of Environmental and Public Health 5

experts and stakeholders in the study area participated in theSAT process For detailed assessment outcomes readers aresuggested to see Section 55

5 Results and Discussions

51 Generation of HCW in the Studied HCEs The studyrevealed that waste generation rate is slightly higher (119901 lt005) in Public HCEs (095 kg bedminus1 dayminus1) than the privatehealth centers (088 kg bedminus1 dayminus1) Public HCFs producedmore wastes than that of the Private HCEs due to morenumbers of beds departments andwards in comparisonwithprivate hospitals [24] The amount of HCW generated in theHCEs was positively correlated with the number of beds (119903s =079 119901 lt 0001) The average waste generation per bed perday in Khulna city has been found to be 090 kg (Table 1)which ismuch lower than that of the developed countries likethe United States (45 kg bedminus1 dayminus1) the United Kingdom(33 kg bedminus1 dayminus1) and Spain (44 kg bedminus1 dayminus1) [25 26]In high-income countries HCW generation is usually higherthan that in the middle and low-income countries [27] Therate of waste generation mainly depends upon geographicallocation living standard healthcare facilities waste collec-tion services and so on In Latin American countries likeChile Brazil Argentina and Venezuela this figure variesfrom 1 to 45 kg bedminus1 dayminus1 [28] Therefore it can be men-tioned that the waste generation rate of Khulna city is closeto the figure of the developing countries of Latin AmericaHowever this figure is very close to the generation rate of093 kg bedminus1 dayminus1 in Sylhet city and 12 kg bedminus1 dayminus1 inDhaka [29 30]

The rate of generation of hazardous waste per bed perday from selected HCEs in Khulna city has been found tobe 018 kg (Table 1) This rate is close to the rate of 021 kgbedminus1 dayminus1 in Sylhet and Bangladesh [29] and much lowerthan that of 057 kg bedminus1 dayminus1 in Brazil and 047 kg bedminus1dayminus1 in Japan reported byDa Silva et al [31] andMohee [32]respectively About 80 of waste generated is nonhazardousand the other 20 is hazardous (Figure 1) which is muchlower than reported in Denmark (25) and the United States(28) [33] Among hazardous waste 8 is infectious 5pathological 4 plastic 2 sharps and 1 is chemical waste(Figure 1)

About 3 tons of HCW were generated daily from 120registered HCEs in Khulna city (Table 2) Most of them werecontributed by private HCFs (60) as the aggregated numberof beds is higher in Private HCEs Public HCFs cover 35and the other 5 were generated by the diagnostic centersand dental clinics In Khulna city about 235 kg of infectiouswaste 116 kg of plastic 24 kg of chemicals and 69 kg of sharpsare generated daily fromdifferent HCEs (Table 2)These largeamounts of unorthodox wastes deserved extra attention

The importance for the proper management of HCWcan be sensed from the aforementioned statistics whichrevealed that roughly 212 metric tons of hazardous waste isgenerated in Khulna each year This ever-increasing amountof hazardous waste if not managed properly will cause severehealth hazards and environmental problems

80

8

54 2 1

GeneralInfectiousPathological

PlasticSharpsChemical

Figure 1 Composition of HCW in Khulna city

52 Survey Findings Depicting HCWM Practices in KhulnaCity The materials presented here are aimed at showingrespondents view on the existing HCWM practices in dif-ferent HCEs in the KCC area Using a random samplingprocedure a questionnaire survey was carried out among 87respondents from different occupations including patientsdoctors nurses cleaners administrators and general peoplein different HCFs Most of them were educated with the ageranging from 30 to 50 years and average service length of 10years However a few of them were illiterate Their opinionsare displayed herein (Table 3)

In the studied HCEs the frequency of on-site wastehandling was categorized as once per day twice per day andirregular Most of the respondents in Private HCEs opine thatthe on-site waste handling (patientrsquos bed to storage place) isirregular while in Public HCEs most of them said that itis once per day In the case of on-site waste handling fromstorage place tomunicipal dustbin or NGOs van the majorityfrom thePrivateHCEs reported ononce per daywhich can beevident fromTable 3More than 40 respondents reported thatwaste collection from the secondary source to final disposalwas at noon while a good number of respondents enunciatedon morning

In the case of an existing level of awareness on using safetyequipment to prevent the spreading of infectious diseasesa great number of respondents (54 119899 = 47) from HCEsreported that they were not using any safety equipment(Table 3) It also investigated from the field survey thatalmost all the respondents from surveyed HCEs focused theiropinion in favor of training concerning the waste manage-ment In connection with the training methods the main-stream showed their interest in video and lecture

It was observed from the study that 75 (119899 = 65) of thetotal respondents preferred to dispose of their wastes in theNGOrsquos covered bins 17 (119899 = 15) of respondents indicatedthe municipal open dustbin for their waste disposal andvery few respondents reported on another disposal system(Figure 2)

6 Journal of Environmental and Public Health

Table 2 Total amount of HCW generated in Khulna city

Types of HCEsNonhazardous

waste(Kg dayminus1)

Infectious waste(Kg dayminus1)

Pathologicalwaste

(Kg dayminus1)

Chemical waste(Kg dayminus1)

Plastic waste(Kg dayminus1)

Sharp waste(Kg dayminus1)

Total(Kg dayminus1)

Public 793 86 47 8 41 23 998Private 1399 135 83 11 56 32 1716DC 96 14 7 5 19 14 155Grand Total 2288 235 137 24 116 69 2869Note This figure was calculated only from 120 registered HCEs (Total number of beds 3000) It can be mentioned that there were more than 50 nonregisteredHCEs existing in Khulna city These HCFs produced relatively small portion of the overall amount of waste in the studied area

Table 3 Scenarios of waste handling and management practices in Khulna metropolis

Variables Frequency () Total respondents ()GH PH DC

On-site handling (patientrsquos bed to storage place)Once per day 12 (14) 10 (11) 4 (5) 30Twice per day 4 (5) 13 (15) 5 (6) 25Irregular 8 (9) 19 (22) 12 (14) 45On-site handling (storage place to final disposal)Once per day 14 (16) 34 (39) 15 (17) 73Twice per day 6 (7) 5 (6) 4 (5) 17Irregular 4 (5) 3 (3) 2 (2) 10Time of waste collection (secondary source to final disposal)Morning 10 (12) 18 (21) 4 (5) 37Noon 24 (28) 14 (16) 5 (6) 49Random 9 (10) 2 (2) 1 (1) 14Systematic issues of waste collectionSystematic 21 (24) 7 (8) 5 (6) 38Nonsystematic 3 (3) 35 (40) 16 (18) 62Safety equipment scenarioFollowed 7 (8) 23 (26) 10 (12) 46Not followed 17 (20) 18 (21) 12 (14) 54Training issuesGot training 5 (7) 19 (28) 6 (9) 44Did not get training 14 (21) 15 (22) 9 (13) 56Opinion on training methodologyLecture amp video 16 (24) 28 (41) 12 (18) 82Video 2 (3) 3 (4) 2 (3) 10Lecture 1 (1) 3 (4) 1 (1) 7Opinion on existing HCWMSatisfactory 2 (2) 25 (29) 10 (11) 42Unsatisfactory 25 (29) 16 (18) 9 (10) 58Notes GH public HCEs PH private HCEs DC diagnostic center or dental clinic

A large number of respondents (58 119899 = 50) expressedtheir dissatisfaction with existing HCWM practices inKhulna city The problems they faced are no environment-friendly dustbin for waste disposal no separate dustbin forHCW collection dustbin is not in a suitable location wastecollection system is unhygienic irregular collection systemand hazardous waste is spreading all over the place due tolack of on-site treatment facility Although the chart showsthat satisfaction rates are quite high this is due to the better

management of Private HCEs They also mentioned someprobable steps that could overcome the problems and theseare as follows

(i) Use of an apronmask and gloves during handling thepatients and segregation as well as disposal of wastesuse of WHO-guided color-coded bins for segregatedwaste

(ii) Training for awareness could be a great help regardingthis issue

Journal of Environmental and Public Health 7

7517

8

NGOrsquos covered binsMunicipalrsquos open dustbinsOthers

Figure 2 Graphical presentation of preferable waste collection sys-tem

(iii) Formulating amending and imposing the relevantlaws could prevent the improper management ofHCW

53 Institutional Arrangements for HCWM in Khulna Cityand Their Limitations At the local level only KCC a publicorganization and Prodipan anNGO are involved inHCWMin Khulna city KCC does not have any special arrangementfor the collection and disposal of HCW separately as theyare not obliged to do according to their ordinance Theconservancy department of KCC identifies the lack of trainedmanpower and resources as the principal reasons for nothaving any arrangement to handle the HCW KCC does nothave any research facility to identify the extent of differentproblems and to provide guidelines to mitigate that Around47 of the money spent on waste management goes for themaintenance purpose of the vehicle and the remaining 53is spent on providing remuneration of the staff engaged insolid waste management in KCC KCC collected the HCW inthe same vehicle together with other wastes from the publicdustbin twice a day and dumped it together in the dumpinggroundnear Rajbandh about 7 km south of the city KCCalsodumped wastes for landfilling purpose at different locationsof the city It increased the risk of health hazards to theadjacent community

On the other hand Prodipan started their journey inMay 2000 with the financial aid from the Swiss DevelopmentCooperation UNDP and the World Bank Initially theystarted their project with 20 HCEs which increased to100 in 2013 Prodipan segregated wastes at the source ofsegregation They provided a set of four covered drums todispose of four types of waste separately An autocoveredvan of 10-ton capacity was used for transportation of HCWfrom different HCEs Generally collection took place in themorning every day Prodipan took service charge from theHCEs they served and the charge was determined dependingon the size (number of bed) and earnings of the HCEs Thestudy revealed that 44 of monthly expenditure is spent onproviding wages for the staff Vehicle maintenance cost is

46 and the remaining 10 is for purchasing the requiredmaterials Prodipan burnt infectious waste in a locally madeburning pit at a comparatively low temperature (about 400∘Cor below) It may in some cases cause unfinished burningand in the case of the presence of any type of plastic materialin the waste experts opine that ldquothis is more harmful as ithelps in producing dioxin gasrdquo They disposed of the needlesand all other sharp materials in a concrete pit This could beviable at a small scale however in the case of the entire citywhere the yearly generation of sharpswaste is about 25metrictons the volume reduction is crucial The present HCWMsystem of Prodipan is not a very structured and cost-effectiveone The project is not internally balanced and continuity ofthe project is totally dependent on the availability of foreignaid

54 Existing HCWMPractices in Khulna City and Its ImpactsWith the upward trend of population and mushroominggrowth of HCEs together with lack of operational wastedisposal mechanism the environmental condition of Khulnacity is gradually becoming more alarming The existingHCWM status in the KCC area is unsatisfactory and unsafefor health Most of the HCEs in Khulna had no appositewaste management system and they did not use any sort ofprotective clothing like gloves a mask and so on Hospitalauthorities were found to be less concerned regarding properdisposal of clinical waste Although proper segregation andtreatment of infectious waste before dumping are very crucialto minimizing health risks to the community [34] they hadnot been exercised in any of theHCEs studied It was revealedfrom the study that more than 80 of HCW is nonhazardouswhichmay be considered as general wasteThis huge amountof nonhazardous waste is excessively contaminated withhazardous waste due to a lack of proper waste separationpractices Moreover there are no distinct color-coded collec-tion bins for HCWM and all categories of waste from HCEscomprising reusable and sharp waste are dumped in com-mon places like public garbage disposal bins side of roadsdumping grounds or municipal waste collection containersThis malpractice elucidated the inefficiency of HCWM inKhulna as well as increasing the chances of contamination ofan entire mass of solid waste tainting it with infectious HCW

HCW comprises biodegradable and nonbiodegradablepolymers [29] Biodegradable polymers are easily decom-posed by the action of microorganisms while nonbiodegrad-ables are very difficult to decay The change in biologicalcharacter of HCW disinfects it which reduces the infectiousbiohazardous properties of the waste [35] The microorgan-isms may create a cyst to stay alive in adverse conditionand contaminate the environment [29] Chemical effluentsproduced from several HCEs were released straight intothe municipal cesspool and may have toxic effects on thenatural ecosystems of receiving waters Most landfills arenot constructed properly which may contaminate drinkingwater Surface overflow directly from deposited waste canpollute surface water easily Direct ejection of blood bodyparts feces and urine of contagious patients in a public sewersystem may cause a spate of communicable diseases Lack ofawareness regarding the damaging effects of HCW was also

8 Journal of Environmental and Public Health

found among the workers involved in the total managementprocess as well as general people in the studied area

Most of the disposal site is open and thereby emitsunpleasant odors and an unaesthetic view causing a hugepublic nuisance While grazing ready access of domestic ani-mals in open dumps may create the possibilities of introduc-ing microbes and pathogens into the food chain Indiscrimi-nate junking of HCWmay create the chances of adulterationof food supplies soil surface water groundwater and airThemajority of the municipal waste receptacles are not designedappropriately and are open without a cover or lid Thereforevectors like insects rodents worms birds and so on can eas-ily enter the collection containers and can take a place on theexposed piles of rotting trash causing the spread of contagiousbugs These also stimulate the mechanical transmission ofdeadly waterborne diseases like diarrhea typhoid dysenteryhepatitis and cholera [29] Moreover mosquitoes promotebiological transmission ofmany types of diseases likemalariadengue and yellow fever under humid environment Rubberand plastic trash being burnt in the open air releases fumescontaining carbonmonoxide dioxins furans and so on [36]When these toxic components are inhaled through smokethey may cause cancer respiratory diseases and many otherdeadly results to humans

Informal waste collectors (known as scavengers) engagedin collecting refuse from HCEs are suffering from variousintestinal parasitic and skin diseases Waste pickers collectused medical equipment particularly syringes from thegarbage and sell them at a low price Many drug addictsmay suffer from cholera typhoid hepatitis AIDS and otherhazardous and contagious diseases as they are reusing thesesyringes Scavengers are scooping out waste from the dust-bins roads and garbage lots for the recyclables with barehands without taking any safety measures therefore facing ahigh risk of salient epidemics of infectious diseasesThewastepickers involved in the recycling process are extremely poorhaving no proper education and incautious of detrimentalconsequences of exposure to contaminated and harmfulwaste

The inadequate disposal of HCWmay be catastrophic tohealth and the environment as well as thewellbeing of societyIf the HCW in Khulna city is not handled in a proper way itwill undoubtedly pose a danger to the workforce employed inthe HCEs as well as to the neighboring people

55 Assessment of Different Technological Options for ProperTreatment of HCW Using SAT Methodology in the Context ofKhulna City In general treatment options may be availableeither on- or off-site A central treatment facility is proposedas the generation of hazardous waste from individual HCEsis not high enough to run a treatment facility solely Assess-ment outcomes of different technological choices for HCWtreatment including technical suitability environmental eco-nomic and social aspects using SATmethodology for Khulnaare narrated herein chronologically

Strategic-Level Assessment(i) Issue all HCEs in the Khulna metropolitan area do

not have proper treatment facilities to treat their haz-ardous waste efficiently

1 2 3 45

67

891011

1213

1415

16171819202122

2324

2526

27282930

3132

3334

35 36 37

IncinerationMicrowaveAutoclave

Figure 3 Distribution of acquired scores of all criteria of HCWtreatment options

(ii) Target implementation of a large-scale central treat-ment technology to handle the hazardous waste fromall HCEs in the area Furthermore proclamation ofpolicies to be needed for the treatment of all haz-ardous waste

Operational Level Assessment VariousHCW treatment alter-natives for instance incineration microwaving and auto-claving were screened (Table 4) in this step using differ-ent modified screening criteria Short-listed technologicaloptions passed through the screening step were then sub-jected to going through the comprehensive scoping tier(Table 5)

Detailed Assessment The final scores obtained by differ-ent treatment alternatives for the technical suitability andeconomic social and environmental criteria are shown inTable 6 Final weightage of all criteria (37 numbers) undereach criteria topic for HCW treatment options is presented ina composite star diagram (Figure 3)

It is observed from Table 6 that all three technologiesare fairly close although incineration is the highest rankedtreatment option followed by microwave technology Amongdifferent criteria technical suitability and social aspect varyto some extent In the technical suitability aspect the mostimportant criteria considered by the experts judgment werethe ability to treat a wide range of hazardous wastes capacityrequirement and adaptability to the future situation Regard-ing the social aspect experts contemplated communityacceptance of the technology Although incineration attainedthe highest score in technical suitability and social aspect thecapital cost of the treatment technology as well as mainte-nance expenditure is one of the drawbacks of this treatmentoption Ozkan [22] indicated that off-site incineration is the

Journal of Environmental and Public Health 9

Table 4 Screening of different HCW treatment alternatives for Khulna municipality

CriteriaIncineration withpollution control

deviceMicrowave Autoclave Hydropulping Compaction

Compliance with nationalenvironmental laws radic radic radic X X

Compliance with multilateralenvironmental agreements radic radic radic radic radic

Consistency with WHO policies radic radic radic radic radic

Flexibility in accepting variouswaste radic radic radic X X

Volume reduction radic radic X radic radic

Technology economically Viable radic radic radic radic radic

Acceptability of technology inKhulna radic radic radic X X

Outcome (selectednot selected) radic radic radic X XNoteradic yes and X no

best method out of the five assessed HCW treatment alter-natives Another research using the multicriteria decision-making (MCDM) approach carried out by Antonopoulos etal [37] also corroborated the same facts

Based on assessment outcomes utilizing SAT methodol-ogy characterization of waste and local conditions inciner-ation is likely said to be the suitable method for treatmentof all types of HCW in Khulna city The majority of thewastes produced fromHCEs are nonhazardous which can bedisposed of in ways similar to the domestic waste Only thehazardous portion needs to be treated In Khulna city thepresent generation of the waste is about 3 ton dayminus1 and thehazardous waste is nearly 06 ton dayminus1Therefore a mediumsize incinerator (destruction capacity 025 ton hrminus1) will begood enough to comply with the situation Unwanted pol-lutants can be significantly reduced with the addition of airpollution control devices of the system Many air pollutantsin emissions from incinerators can be lessened substantiallyby modern air pollution control mechanisms if appropriatelydesigned and operated [2 38] Since the investment cost isvery high for new plant several HCEs may converge to set upa plant centrallyThese types of plants are now being observedin many countries of the world

6 Conclusions and Recommendations

Thepresent study has mainly focused on the existing HCWMparadigms of Khulna metropolis and on the question of howit can be made a more efficient and acceptable one Theexisting HCWM pattern in Khulna city has many drawbacksand is in dire need of immediate attention and improvementIt was observed from the investigation that the hazardouswaste was not treated separately in almost all of the HCEsin Khulna city Intervention is required at all stages ofwastemanagement from the formulation of appropriate lawssegregation and transportation of waste to the final disposalmethodThe process and method adopted for waste manage-ment should be technically and financially sustainable in the

long run It has to also be ensured that there are no adversehealth and environmental consequences of waste handlingtreatment and disposal activities

National legislation is the basis for improving HCWpractices in any country Therefore a national managementplan will be required which will permit HCWM options tobe optimized on a national scale The law should be comple-mented by a policy document and technical guidelines devel-oped for implementation This legal document should specifyregulations on treatment for different waste categories segre-gation collection storage handling disposal transporta-tion responsibilities and training requirements Training ofhealthcare personnel as well as general people regardinghygiene and HCWM is needed to create awareness and fosterresponsibility among them which will prevent exposure torelated health hazards

Among different waste treatment options it has beenfound from the study that the incineration system is the mostsuitable one for Khulna city based on the final score con-sidering technical suitability and environmental economicand social aspect However the system should be maintainedproperly with an appropriate air pollution control deviceTheranking order of the second technological choice was micro-waving followed by autoclaving considering all aspects Theassessment of treatment alternatives in this investigation issubjected to the selection as well as weighting of the criteriaand strongly dependent on the reliability to the response ofthe expertsrsquo personal judgment Besides the waste genera-tion rate that was calculated in this investigation was ex-cluding seasonal variation A further detailed study is re-quired incorporating more HCEs with an extended periodof collected data as well as seasonal variation to explore thesustainability of such management option Furthermore it isrecommended to develop a great variety of MCDMmethodsto evaluate such HCW treatment alternatives Overall thestudy will give an insight promulgating guidelines for thefuture planning and design of HCWM strategies in Khulnacity as well as other municipalities in developing countries

10 Journal of Environmental and Public Health

Table5Scop

ingof

SATmetho

dology

forthe

assessmento

fHCW

treatmento

ptions

forK

hulnam

etropo

lis

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Technicalsuitability

Com

patib

ilitywith

local

surrou

ndings

andnatural

cond

ition

s1198821=1

Rank

ingforT

echn

ical

SuitabilityRT

25

Maxim

umscorefor

TechnicalSuitability

(MST

)9times(1198821+1198822+

sdotsdotsdot+11988210)=531

MF1

=004

77

0329

60282

50235

Preference

forlocally

manufacturedtechno

logies1198822=7

MF2

=0329

516

454

1316

30987

Availabilityof

sparep

arts

andusageo

flocalmaterials1198823=5

MF3

=0235

614

105

1175

51175

Availabilityof

local

expertise

1198824=3

MF4

=0141

60846

50705

40564

Trackrecord

onperfo

rmance

1198825=10

MF5

=0470

73290

62820

62820

Com

patib

ilitywith

existing

techno

logy

ormanagem

ent

syste

m1198826=1

MF6

=004

75

0235

40188

40188

Meetscapacityrequ

irement1198827=10

MF7

=0470

83760

62820

62820

Adaptabilityto

future

situatio

ns1198828=5

MF8

=0235

818

806

1410

51175

Abilityto

treataw

idethe

rangeo

fhealth

care

wastes1198829=10

MF9

=0470

94230

62820

62820

Levelof

automationsoph

istication11988210=7

MF10=0329

413

166

1974

619

74

Journal of Environmental and Public Health 11

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Environm

ent

Efficacy

ofmicrobial

inactiv

ation

11988211=10

Rank

ingfor

environm

ent

(resou

rces

and

emissions)RE

n25

Maxim

umscorefor

environm

ent

(MSE

n)

9times(11988211+11988212+

sdotsdotsdot+11988228)=1161

MF11=

0215

919

357

1505

612

90

Risk

levelsforw

orkers

11988212=10

MF12=0215

40860

510

755

1075

Risk

levelsforc

ommun

ities11988213=10

MF13=

0215

40860

510

755

1075

Risk

tothee

nviro

nment11988214=10

MF14=0215

20430

612

907

1505

Airem

issions

11988215=10

MF15=

0215

10215

612

906

1290

Liqu

ideffl

uents

11988216=5

MF16=0107

6064

22

0214

20214

Solid

resid

ues

11988217=5

MF17=

0107

70749

40428

40428

Volumer

eductio

n11988218=10

MF18=0215

919

356

1290

20430

Massreductio

n11988219=3

MF19=0065

80520

30195

10065

Odo

r11988220=10

MF2

0=0215

40860

40860

40860

Noise

11988221=5

MF2

1=0107

40428

30321

50535

Energy

consum

ptionperk

gof

waste

11988222=10

MF2

2=0215

612

906

1290

510

75

Extent

ofuseo

frenew

able

energy

11988223=8

MF2

3=0172

50860

712

047

1204

Waterconsum

ptionperk

gof

waste

11988224=5

MF24=0107

70749

30321

30321

Materialcon

sumption

11988225=5

MF2

5=0107

6064

26

064

26

064

2Ex

tent

ofuseo

fhazardo

usmaterials

11988226=5

MF2

6=0107

80865

70749

70749

Spacer

equirement

11988227=3

MF2

7=0065

60390

50325

50325

Resource

recovery

capabilities

11988228=5

MF2

8=0107

20214

50535

6064

2

12 Journal of Environmental and Public Health

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Fina

ncialeconomica

lEstim

ated

capitalcosto

fthetreatmenttechn

olog

y11988229=10

Rank

ingfore

cono

mic

aspectsRE

c25

Maxim

umscorefor

econ

omic(M

SEn)

9times(11988229+11988230+

sdotsdotsdot+11988232)=270

MF2

9=0926

874

086

5556

54630

Estim

ated

capitalcostsof

allaccessorie

sand

related

equipm

ent

11988230=5

MF3

0=0463

313

894

1852

418

52

Estim

ated

operationand

maintenance

costs

11988231=10

MF31=

0926

54630

43704

32778

Insta

llatio

nrequ

irements11988232=5

MF32=

0463

418

525

2315

52315

Socia

lcultural

Com

mun

ityacceptance

ofthetechn

olog

y11988233=10

Rank

ingforsocial

aspectsRS

25

Maxim

umscorefor

SocialCultural

(MSS)

9times(11988233+11988234+

sdotsdotsdot+11988237)=315

MF33=

0794

75558

53970

43176

Incomeg

eneration

potential

11988234=5

MF3

4=0397

62382

20794

20794

Acceptabilityof

treatment

resid

uesb

ythelocalland

fill11988235=10

MF35=

0794

64764

43176

43176

Extent

ofnecessary

resettlem

ento

fpeople

11988236=5

MF3

6=0397

31191

62382

62382

Visib

leor

aesth

eticim

pact11988237=5

MF37=0397

519

854

1588

31191

Total

645

554

512

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

6 Journal of Environmental and Public Health

Table 2 Total amount of HCW generated in Khulna city

Types of HCEsNonhazardous

waste(Kg dayminus1)

Infectious waste(Kg dayminus1)

Pathologicalwaste

(Kg dayminus1)

Chemical waste(Kg dayminus1)

Plastic waste(Kg dayminus1)

Sharp waste(Kg dayminus1)

Total(Kg dayminus1)

Public 793 86 47 8 41 23 998Private 1399 135 83 11 56 32 1716DC 96 14 7 5 19 14 155Grand Total 2288 235 137 24 116 69 2869Note This figure was calculated only from 120 registered HCEs (Total number of beds 3000) It can be mentioned that there were more than 50 nonregisteredHCEs existing in Khulna city These HCFs produced relatively small portion of the overall amount of waste in the studied area

Table 3 Scenarios of waste handling and management practices in Khulna metropolis

Variables Frequency () Total respondents ()GH PH DC

On-site handling (patientrsquos bed to storage place)Once per day 12 (14) 10 (11) 4 (5) 30Twice per day 4 (5) 13 (15) 5 (6) 25Irregular 8 (9) 19 (22) 12 (14) 45On-site handling (storage place to final disposal)Once per day 14 (16) 34 (39) 15 (17) 73Twice per day 6 (7) 5 (6) 4 (5) 17Irregular 4 (5) 3 (3) 2 (2) 10Time of waste collection (secondary source to final disposal)Morning 10 (12) 18 (21) 4 (5) 37Noon 24 (28) 14 (16) 5 (6) 49Random 9 (10) 2 (2) 1 (1) 14Systematic issues of waste collectionSystematic 21 (24) 7 (8) 5 (6) 38Nonsystematic 3 (3) 35 (40) 16 (18) 62Safety equipment scenarioFollowed 7 (8) 23 (26) 10 (12) 46Not followed 17 (20) 18 (21) 12 (14) 54Training issuesGot training 5 (7) 19 (28) 6 (9) 44Did not get training 14 (21) 15 (22) 9 (13) 56Opinion on training methodologyLecture amp video 16 (24) 28 (41) 12 (18) 82Video 2 (3) 3 (4) 2 (3) 10Lecture 1 (1) 3 (4) 1 (1) 7Opinion on existing HCWMSatisfactory 2 (2) 25 (29) 10 (11) 42Unsatisfactory 25 (29) 16 (18) 9 (10) 58Notes GH public HCEs PH private HCEs DC diagnostic center or dental clinic

A large number of respondents (58 119899 = 50) expressedtheir dissatisfaction with existing HCWM practices inKhulna city The problems they faced are no environment-friendly dustbin for waste disposal no separate dustbin forHCW collection dustbin is not in a suitable location wastecollection system is unhygienic irregular collection systemand hazardous waste is spreading all over the place due tolack of on-site treatment facility Although the chart showsthat satisfaction rates are quite high this is due to the better

management of Private HCEs They also mentioned someprobable steps that could overcome the problems and theseare as follows

(i) Use of an apronmask and gloves during handling thepatients and segregation as well as disposal of wastesuse of WHO-guided color-coded bins for segregatedwaste

(ii) Training for awareness could be a great help regardingthis issue

Journal of Environmental and Public Health 7

7517

8

NGOrsquos covered binsMunicipalrsquos open dustbinsOthers

Figure 2 Graphical presentation of preferable waste collection sys-tem

(iii) Formulating amending and imposing the relevantlaws could prevent the improper management ofHCW

53 Institutional Arrangements for HCWM in Khulna Cityand Their Limitations At the local level only KCC a publicorganization and Prodipan anNGO are involved inHCWMin Khulna city KCC does not have any special arrangementfor the collection and disposal of HCW separately as theyare not obliged to do according to their ordinance Theconservancy department of KCC identifies the lack of trainedmanpower and resources as the principal reasons for nothaving any arrangement to handle the HCW KCC does nothave any research facility to identify the extent of differentproblems and to provide guidelines to mitigate that Around47 of the money spent on waste management goes for themaintenance purpose of the vehicle and the remaining 53is spent on providing remuneration of the staff engaged insolid waste management in KCC KCC collected the HCW inthe same vehicle together with other wastes from the publicdustbin twice a day and dumped it together in the dumpinggroundnear Rajbandh about 7 km south of the city KCCalsodumped wastes for landfilling purpose at different locationsof the city It increased the risk of health hazards to theadjacent community

On the other hand Prodipan started their journey inMay 2000 with the financial aid from the Swiss DevelopmentCooperation UNDP and the World Bank Initially theystarted their project with 20 HCEs which increased to100 in 2013 Prodipan segregated wastes at the source ofsegregation They provided a set of four covered drums todispose of four types of waste separately An autocoveredvan of 10-ton capacity was used for transportation of HCWfrom different HCEs Generally collection took place in themorning every day Prodipan took service charge from theHCEs they served and the charge was determined dependingon the size (number of bed) and earnings of the HCEs Thestudy revealed that 44 of monthly expenditure is spent onproviding wages for the staff Vehicle maintenance cost is

46 and the remaining 10 is for purchasing the requiredmaterials Prodipan burnt infectious waste in a locally madeburning pit at a comparatively low temperature (about 400∘Cor below) It may in some cases cause unfinished burningand in the case of the presence of any type of plastic materialin the waste experts opine that ldquothis is more harmful as ithelps in producing dioxin gasrdquo They disposed of the needlesand all other sharp materials in a concrete pit This could beviable at a small scale however in the case of the entire citywhere the yearly generation of sharpswaste is about 25metrictons the volume reduction is crucial The present HCWMsystem of Prodipan is not a very structured and cost-effectiveone The project is not internally balanced and continuity ofthe project is totally dependent on the availability of foreignaid

54 Existing HCWMPractices in Khulna City and Its ImpactsWith the upward trend of population and mushroominggrowth of HCEs together with lack of operational wastedisposal mechanism the environmental condition of Khulnacity is gradually becoming more alarming The existingHCWM status in the KCC area is unsatisfactory and unsafefor health Most of the HCEs in Khulna had no appositewaste management system and they did not use any sort ofprotective clothing like gloves a mask and so on Hospitalauthorities were found to be less concerned regarding properdisposal of clinical waste Although proper segregation andtreatment of infectious waste before dumping are very crucialto minimizing health risks to the community [34] they hadnot been exercised in any of theHCEs studied It was revealedfrom the study that more than 80 of HCW is nonhazardouswhichmay be considered as general wasteThis huge amountof nonhazardous waste is excessively contaminated withhazardous waste due to a lack of proper waste separationpractices Moreover there are no distinct color-coded collec-tion bins for HCWM and all categories of waste from HCEscomprising reusable and sharp waste are dumped in com-mon places like public garbage disposal bins side of roadsdumping grounds or municipal waste collection containersThis malpractice elucidated the inefficiency of HCWM inKhulna as well as increasing the chances of contamination ofan entire mass of solid waste tainting it with infectious HCW

HCW comprises biodegradable and nonbiodegradablepolymers [29] Biodegradable polymers are easily decom-posed by the action of microorganisms while nonbiodegrad-ables are very difficult to decay The change in biologicalcharacter of HCW disinfects it which reduces the infectiousbiohazardous properties of the waste [35] The microorgan-isms may create a cyst to stay alive in adverse conditionand contaminate the environment [29] Chemical effluentsproduced from several HCEs were released straight intothe municipal cesspool and may have toxic effects on thenatural ecosystems of receiving waters Most landfills arenot constructed properly which may contaminate drinkingwater Surface overflow directly from deposited waste canpollute surface water easily Direct ejection of blood bodyparts feces and urine of contagious patients in a public sewersystem may cause a spate of communicable diseases Lack ofawareness regarding the damaging effects of HCW was also

8 Journal of Environmental and Public Health

found among the workers involved in the total managementprocess as well as general people in the studied area

Most of the disposal site is open and thereby emitsunpleasant odors and an unaesthetic view causing a hugepublic nuisance While grazing ready access of domestic ani-mals in open dumps may create the possibilities of introduc-ing microbes and pathogens into the food chain Indiscrimi-nate junking of HCWmay create the chances of adulterationof food supplies soil surface water groundwater and airThemajority of the municipal waste receptacles are not designedappropriately and are open without a cover or lid Thereforevectors like insects rodents worms birds and so on can eas-ily enter the collection containers and can take a place on theexposed piles of rotting trash causing the spread of contagiousbugs These also stimulate the mechanical transmission ofdeadly waterborne diseases like diarrhea typhoid dysenteryhepatitis and cholera [29] Moreover mosquitoes promotebiological transmission ofmany types of diseases likemalariadengue and yellow fever under humid environment Rubberand plastic trash being burnt in the open air releases fumescontaining carbonmonoxide dioxins furans and so on [36]When these toxic components are inhaled through smokethey may cause cancer respiratory diseases and many otherdeadly results to humans

Informal waste collectors (known as scavengers) engagedin collecting refuse from HCEs are suffering from variousintestinal parasitic and skin diseases Waste pickers collectused medical equipment particularly syringes from thegarbage and sell them at a low price Many drug addictsmay suffer from cholera typhoid hepatitis AIDS and otherhazardous and contagious diseases as they are reusing thesesyringes Scavengers are scooping out waste from the dust-bins roads and garbage lots for the recyclables with barehands without taking any safety measures therefore facing ahigh risk of salient epidemics of infectious diseasesThewastepickers involved in the recycling process are extremely poorhaving no proper education and incautious of detrimentalconsequences of exposure to contaminated and harmfulwaste

The inadequate disposal of HCWmay be catastrophic tohealth and the environment as well as thewellbeing of societyIf the HCW in Khulna city is not handled in a proper way itwill undoubtedly pose a danger to the workforce employed inthe HCEs as well as to the neighboring people

55 Assessment of Different Technological Options for ProperTreatment of HCW Using SAT Methodology in the Context ofKhulna City In general treatment options may be availableeither on- or off-site A central treatment facility is proposedas the generation of hazardous waste from individual HCEsis not high enough to run a treatment facility solely Assess-ment outcomes of different technological choices for HCWtreatment including technical suitability environmental eco-nomic and social aspects using SATmethodology for Khulnaare narrated herein chronologically

Strategic-Level Assessment(i) Issue all HCEs in the Khulna metropolitan area do

not have proper treatment facilities to treat their haz-ardous waste efficiently

1 2 3 45

67

891011

1213

1415

16171819202122

2324

2526

27282930

3132

3334

35 36 37

IncinerationMicrowaveAutoclave

Figure 3 Distribution of acquired scores of all criteria of HCWtreatment options

(ii) Target implementation of a large-scale central treat-ment technology to handle the hazardous waste fromall HCEs in the area Furthermore proclamation ofpolicies to be needed for the treatment of all haz-ardous waste

Operational Level Assessment VariousHCW treatment alter-natives for instance incineration microwaving and auto-claving were screened (Table 4) in this step using differ-ent modified screening criteria Short-listed technologicaloptions passed through the screening step were then sub-jected to going through the comprehensive scoping tier(Table 5)

Detailed Assessment The final scores obtained by differ-ent treatment alternatives for the technical suitability andeconomic social and environmental criteria are shown inTable 6 Final weightage of all criteria (37 numbers) undereach criteria topic for HCW treatment options is presented ina composite star diagram (Figure 3)

It is observed from Table 6 that all three technologiesare fairly close although incineration is the highest rankedtreatment option followed by microwave technology Amongdifferent criteria technical suitability and social aspect varyto some extent In the technical suitability aspect the mostimportant criteria considered by the experts judgment werethe ability to treat a wide range of hazardous wastes capacityrequirement and adaptability to the future situation Regard-ing the social aspect experts contemplated communityacceptance of the technology Although incineration attainedthe highest score in technical suitability and social aspect thecapital cost of the treatment technology as well as mainte-nance expenditure is one of the drawbacks of this treatmentoption Ozkan [22] indicated that off-site incineration is the

Journal of Environmental and Public Health 9

Table 4 Screening of different HCW treatment alternatives for Khulna municipality

CriteriaIncineration withpollution control

deviceMicrowave Autoclave Hydropulping Compaction

Compliance with nationalenvironmental laws radic radic radic X X

Compliance with multilateralenvironmental agreements radic radic radic radic radic

Consistency with WHO policies radic radic radic radic radic

Flexibility in accepting variouswaste radic radic radic X X

Volume reduction radic radic X radic radic

Technology economically Viable radic radic radic radic radic

Acceptability of technology inKhulna radic radic radic X X

Outcome (selectednot selected) radic radic radic X XNoteradic yes and X no

best method out of the five assessed HCW treatment alter-natives Another research using the multicriteria decision-making (MCDM) approach carried out by Antonopoulos etal [37] also corroborated the same facts

Based on assessment outcomes utilizing SAT methodol-ogy characterization of waste and local conditions inciner-ation is likely said to be the suitable method for treatmentof all types of HCW in Khulna city The majority of thewastes produced fromHCEs are nonhazardous which can bedisposed of in ways similar to the domestic waste Only thehazardous portion needs to be treated In Khulna city thepresent generation of the waste is about 3 ton dayminus1 and thehazardous waste is nearly 06 ton dayminus1Therefore a mediumsize incinerator (destruction capacity 025 ton hrminus1) will begood enough to comply with the situation Unwanted pol-lutants can be significantly reduced with the addition of airpollution control devices of the system Many air pollutantsin emissions from incinerators can be lessened substantiallyby modern air pollution control mechanisms if appropriatelydesigned and operated [2 38] Since the investment cost isvery high for new plant several HCEs may converge to set upa plant centrallyThese types of plants are now being observedin many countries of the world

6 Conclusions and Recommendations

Thepresent study has mainly focused on the existing HCWMparadigms of Khulna metropolis and on the question of howit can be made a more efficient and acceptable one Theexisting HCWM pattern in Khulna city has many drawbacksand is in dire need of immediate attention and improvementIt was observed from the investigation that the hazardouswaste was not treated separately in almost all of the HCEsin Khulna city Intervention is required at all stages ofwastemanagement from the formulation of appropriate lawssegregation and transportation of waste to the final disposalmethodThe process and method adopted for waste manage-ment should be technically and financially sustainable in the

long run It has to also be ensured that there are no adversehealth and environmental consequences of waste handlingtreatment and disposal activities

National legislation is the basis for improving HCWpractices in any country Therefore a national managementplan will be required which will permit HCWM options tobe optimized on a national scale The law should be comple-mented by a policy document and technical guidelines devel-oped for implementation This legal document should specifyregulations on treatment for different waste categories segre-gation collection storage handling disposal transporta-tion responsibilities and training requirements Training ofhealthcare personnel as well as general people regardinghygiene and HCWM is needed to create awareness and fosterresponsibility among them which will prevent exposure torelated health hazards

Among different waste treatment options it has beenfound from the study that the incineration system is the mostsuitable one for Khulna city based on the final score con-sidering technical suitability and environmental economicand social aspect However the system should be maintainedproperly with an appropriate air pollution control deviceTheranking order of the second technological choice was micro-waving followed by autoclaving considering all aspects Theassessment of treatment alternatives in this investigation issubjected to the selection as well as weighting of the criteriaand strongly dependent on the reliability to the response ofthe expertsrsquo personal judgment Besides the waste genera-tion rate that was calculated in this investigation was ex-cluding seasonal variation A further detailed study is re-quired incorporating more HCEs with an extended periodof collected data as well as seasonal variation to explore thesustainability of such management option Furthermore it isrecommended to develop a great variety of MCDMmethodsto evaluate such HCW treatment alternatives Overall thestudy will give an insight promulgating guidelines for thefuture planning and design of HCWM strategies in Khulnacity as well as other municipalities in developing countries

10 Journal of Environmental and Public Health

Table5Scop

ingof

SATmetho

dology

forthe

assessmento

fHCW

treatmento

ptions

forK

hulnam

etropo

lis

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Technicalsuitability

Com

patib

ilitywith

local

surrou

ndings

andnatural

cond

ition

s1198821=1

Rank

ingforT

echn

ical

SuitabilityRT

25

Maxim

umscorefor

TechnicalSuitability

(MST

)9times(1198821+1198822+

sdotsdotsdot+11988210)=531

MF1

=004

77

0329

60282

50235

Preference

forlocally

manufacturedtechno

logies1198822=7

MF2

=0329

516

454

1316

30987

Availabilityof

sparep

arts

andusageo

flocalmaterials1198823=5

MF3

=0235

614

105

1175

51175

Availabilityof

local

expertise

1198824=3

MF4

=0141

60846

50705

40564

Trackrecord

onperfo

rmance

1198825=10

MF5

=0470

73290

62820

62820

Com

patib

ilitywith

existing

techno

logy

ormanagem

ent

syste

m1198826=1

MF6

=004

75

0235

40188

40188

Meetscapacityrequ

irement1198827=10

MF7

=0470

83760

62820

62820

Adaptabilityto

future

situatio

ns1198828=5

MF8

=0235

818

806

1410

51175

Abilityto

treataw

idethe

rangeo

fhealth

care

wastes1198829=10

MF9

=0470

94230

62820

62820

Levelof

automationsoph

istication11988210=7

MF10=0329

413

166

1974

619

74

Journal of Environmental and Public Health 11

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Environm

ent

Efficacy

ofmicrobial

inactiv

ation

11988211=10

Rank

ingfor

environm

ent

(resou

rces

and

emissions)RE

n25

Maxim

umscorefor

environm

ent

(MSE

n)

9times(11988211+11988212+

sdotsdotsdot+11988228)=1161

MF11=

0215

919

357

1505

612

90

Risk

levelsforw

orkers

11988212=10

MF12=0215

40860

510

755

1075

Risk

levelsforc

ommun

ities11988213=10

MF13=

0215

40860

510

755

1075

Risk

tothee

nviro

nment11988214=10

MF14=0215

20430

612

907

1505

Airem

issions

11988215=10

MF15=

0215

10215

612

906

1290

Liqu

ideffl

uents

11988216=5

MF16=0107

6064

22

0214

20214

Solid

resid

ues

11988217=5

MF17=

0107

70749

40428

40428

Volumer

eductio

n11988218=10

MF18=0215

919

356

1290

20430

Massreductio

n11988219=3

MF19=0065

80520

30195

10065

Odo

r11988220=10

MF2

0=0215

40860

40860

40860

Noise

11988221=5

MF2

1=0107

40428

30321

50535

Energy

consum

ptionperk

gof

waste

11988222=10

MF2

2=0215

612

906

1290

510

75

Extent

ofuseo

frenew

able

energy

11988223=8

MF2

3=0172

50860

712

047

1204

Waterconsum

ptionperk

gof

waste

11988224=5

MF24=0107

70749

30321

30321

Materialcon

sumption

11988225=5

MF2

5=0107

6064

26

064

26

064

2Ex

tent

ofuseo

fhazardo

usmaterials

11988226=5

MF2

6=0107

80865

70749

70749

Spacer

equirement

11988227=3

MF2

7=0065

60390

50325

50325

Resource

recovery

capabilities

11988228=5

MF2

8=0107

20214

50535

6064

2

12 Journal of Environmental and Public Health

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Fina

ncialeconomica

lEstim

ated

capitalcosto

fthetreatmenttechn

olog

y11988229=10

Rank

ingfore

cono

mic

aspectsRE

c25

Maxim

umscorefor

econ

omic(M

SEn)

9times(11988229+11988230+

sdotsdotsdot+11988232)=270

MF2

9=0926

874

086

5556

54630

Estim

ated

capitalcostsof

allaccessorie

sand

related

equipm

ent

11988230=5

MF3

0=0463

313

894

1852

418

52

Estim

ated

operationand

maintenance

costs

11988231=10

MF31=

0926

54630

43704

32778

Insta

llatio

nrequ

irements11988232=5

MF32=

0463

418

525

2315

52315

Socia

lcultural

Com

mun

ityacceptance

ofthetechn

olog

y11988233=10

Rank

ingforsocial

aspectsRS

25

Maxim

umscorefor

SocialCultural

(MSS)

9times(11988233+11988234+

sdotsdotsdot+11988237)=315

MF33=

0794

75558

53970

43176

Incomeg

eneration

potential

11988234=5

MF3

4=0397

62382

20794

20794

Acceptabilityof

treatment

resid

uesb

ythelocalland

fill11988235=10

MF35=

0794

64764

43176

43176

Extent

ofnecessary

resettlem

ento

fpeople

11988236=5

MF3

6=0397

31191

62382

62382

Visib

leor

aesth

eticim

pact11988237=5

MF37=0397

519

854

1588

31191

Total

645

554

512

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

Journal of Environmental and Public Health 7

7517

8

NGOrsquos covered binsMunicipalrsquos open dustbinsOthers

Figure 2 Graphical presentation of preferable waste collection sys-tem

(iii) Formulating amending and imposing the relevantlaws could prevent the improper management ofHCW

53 Institutional Arrangements for HCWM in Khulna Cityand Their Limitations At the local level only KCC a publicorganization and Prodipan anNGO are involved inHCWMin Khulna city KCC does not have any special arrangementfor the collection and disposal of HCW separately as theyare not obliged to do according to their ordinance Theconservancy department of KCC identifies the lack of trainedmanpower and resources as the principal reasons for nothaving any arrangement to handle the HCW KCC does nothave any research facility to identify the extent of differentproblems and to provide guidelines to mitigate that Around47 of the money spent on waste management goes for themaintenance purpose of the vehicle and the remaining 53is spent on providing remuneration of the staff engaged insolid waste management in KCC KCC collected the HCW inthe same vehicle together with other wastes from the publicdustbin twice a day and dumped it together in the dumpinggroundnear Rajbandh about 7 km south of the city KCCalsodumped wastes for landfilling purpose at different locationsof the city It increased the risk of health hazards to theadjacent community

On the other hand Prodipan started their journey inMay 2000 with the financial aid from the Swiss DevelopmentCooperation UNDP and the World Bank Initially theystarted their project with 20 HCEs which increased to100 in 2013 Prodipan segregated wastes at the source ofsegregation They provided a set of four covered drums todispose of four types of waste separately An autocoveredvan of 10-ton capacity was used for transportation of HCWfrom different HCEs Generally collection took place in themorning every day Prodipan took service charge from theHCEs they served and the charge was determined dependingon the size (number of bed) and earnings of the HCEs Thestudy revealed that 44 of monthly expenditure is spent onproviding wages for the staff Vehicle maintenance cost is

46 and the remaining 10 is for purchasing the requiredmaterials Prodipan burnt infectious waste in a locally madeburning pit at a comparatively low temperature (about 400∘Cor below) It may in some cases cause unfinished burningand in the case of the presence of any type of plastic materialin the waste experts opine that ldquothis is more harmful as ithelps in producing dioxin gasrdquo They disposed of the needlesand all other sharp materials in a concrete pit This could beviable at a small scale however in the case of the entire citywhere the yearly generation of sharpswaste is about 25metrictons the volume reduction is crucial The present HCWMsystem of Prodipan is not a very structured and cost-effectiveone The project is not internally balanced and continuity ofthe project is totally dependent on the availability of foreignaid

54 Existing HCWMPractices in Khulna City and Its ImpactsWith the upward trend of population and mushroominggrowth of HCEs together with lack of operational wastedisposal mechanism the environmental condition of Khulnacity is gradually becoming more alarming The existingHCWM status in the KCC area is unsatisfactory and unsafefor health Most of the HCEs in Khulna had no appositewaste management system and they did not use any sort ofprotective clothing like gloves a mask and so on Hospitalauthorities were found to be less concerned regarding properdisposal of clinical waste Although proper segregation andtreatment of infectious waste before dumping are very crucialto minimizing health risks to the community [34] they hadnot been exercised in any of theHCEs studied It was revealedfrom the study that more than 80 of HCW is nonhazardouswhichmay be considered as general wasteThis huge amountof nonhazardous waste is excessively contaminated withhazardous waste due to a lack of proper waste separationpractices Moreover there are no distinct color-coded collec-tion bins for HCWM and all categories of waste from HCEscomprising reusable and sharp waste are dumped in com-mon places like public garbage disposal bins side of roadsdumping grounds or municipal waste collection containersThis malpractice elucidated the inefficiency of HCWM inKhulna as well as increasing the chances of contamination ofan entire mass of solid waste tainting it with infectious HCW

HCW comprises biodegradable and nonbiodegradablepolymers [29] Biodegradable polymers are easily decom-posed by the action of microorganisms while nonbiodegrad-ables are very difficult to decay The change in biologicalcharacter of HCW disinfects it which reduces the infectiousbiohazardous properties of the waste [35] The microorgan-isms may create a cyst to stay alive in adverse conditionand contaminate the environment [29] Chemical effluentsproduced from several HCEs were released straight intothe municipal cesspool and may have toxic effects on thenatural ecosystems of receiving waters Most landfills arenot constructed properly which may contaminate drinkingwater Surface overflow directly from deposited waste canpollute surface water easily Direct ejection of blood bodyparts feces and urine of contagious patients in a public sewersystem may cause a spate of communicable diseases Lack ofawareness regarding the damaging effects of HCW was also

8 Journal of Environmental and Public Health

found among the workers involved in the total managementprocess as well as general people in the studied area

Most of the disposal site is open and thereby emitsunpleasant odors and an unaesthetic view causing a hugepublic nuisance While grazing ready access of domestic ani-mals in open dumps may create the possibilities of introduc-ing microbes and pathogens into the food chain Indiscrimi-nate junking of HCWmay create the chances of adulterationof food supplies soil surface water groundwater and airThemajority of the municipal waste receptacles are not designedappropriately and are open without a cover or lid Thereforevectors like insects rodents worms birds and so on can eas-ily enter the collection containers and can take a place on theexposed piles of rotting trash causing the spread of contagiousbugs These also stimulate the mechanical transmission ofdeadly waterborne diseases like diarrhea typhoid dysenteryhepatitis and cholera [29] Moreover mosquitoes promotebiological transmission ofmany types of diseases likemalariadengue and yellow fever under humid environment Rubberand plastic trash being burnt in the open air releases fumescontaining carbonmonoxide dioxins furans and so on [36]When these toxic components are inhaled through smokethey may cause cancer respiratory diseases and many otherdeadly results to humans

Informal waste collectors (known as scavengers) engagedin collecting refuse from HCEs are suffering from variousintestinal parasitic and skin diseases Waste pickers collectused medical equipment particularly syringes from thegarbage and sell them at a low price Many drug addictsmay suffer from cholera typhoid hepatitis AIDS and otherhazardous and contagious diseases as they are reusing thesesyringes Scavengers are scooping out waste from the dust-bins roads and garbage lots for the recyclables with barehands without taking any safety measures therefore facing ahigh risk of salient epidemics of infectious diseasesThewastepickers involved in the recycling process are extremely poorhaving no proper education and incautious of detrimentalconsequences of exposure to contaminated and harmfulwaste

The inadequate disposal of HCWmay be catastrophic tohealth and the environment as well as thewellbeing of societyIf the HCW in Khulna city is not handled in a proper way itwill undoubtedly pose a danger to the workforce employed inthe HCEs as well as to the neighboring people

55 Assessment of Different Technological Options for ProperTreatment of HCW Using SAT Methodology in the Context ofKhulna City In general treatment options may be availableeither on- or off-site A central treatment facility is proposedas the generation of hazardous waste from individual HCEsis not high enough to run a treatment facility solely Assess-ment outcomes of different technological choices for HCWtreatment including technical suitability environmental eco-nomic and social aspects using SATmethodology for Khulnaare narrated herein chronologically

Strategic-Level Assessment(i) Issue all HCEs in the Khulna metropolitan area do

not have proper treatment facilities to treat their haz-ardous waste efficiently

1 2 3 45

67

891011

1213

1415

16171819202122

2324

2526

27282930

3132

3334

35 36 37

IncinerationMicrowaveAutoclave

Figure 3 Distribution of acquired scores of all criteria of HCWtreatment options

(ii) Target implementation of a large-scale central treat-ment technology to handle the hazardous waste fromall HCEs in the area Furthermore proclamation ofpolicies to be needed for the treatment of all haz-ardous waste

Operational Level Assessment VariousHCW treatment alter-natives for instance incineration microwaving and auto-claving were screened (Table 4) in this step using differ-ent modified screening criteria Short-listed technologicaloptions passed through the screening step were then sub-jected to going through the comprehensive scoping tier(Table 5)

Detailed Assessment The final scores obtained by differ-ent treatment alternatives for the technical suitability andeconomic social and environmental criteria are shown inTable 6 Final weightage of all criteria (37 numbers) undereach criteria topic for HCW treatment options is presented ina composite star diagram (Figure 3)

It is observed from Table 6 that all three technologiesare fairly close although incineration is the highest rankedtreatment option followed by microwave technology Amongdifferent criteria technical suitability and social aspect varyto some extent In the technical suitability aspect the mostimportant criteria considered by the experts judgment werethe ability to treat a wide range of hazardous wastes capacityrequirement and adaptability to the future situation Regard-ing the social aspect experts contemplated communityacceptance of the technology Although incineration attainedthe highest score in technical suitability and social aspect thecapital cost of the treatment technology as well as mainte-nance expenditure is one of the drawbacks of this treatmentoption Ozkan [22] indicated that off-site incineration is the

Journal of Environmental and Public Health 9

Table 4 Screening of different HCW treatment alternatives for Khulna municipality

CriteriaIncineration withpollution control

deviceMicrowave Autoclave Hydropulping Compaction

Compliance with nationalenvironmental laws radic radic radic X X

Compliance with multilateralenvironmental agreements radic radic radic radic radic

Consistency with WHO policies radic radic radic radic radic

Flexibility in accepting variouswaste radic radic radic X X

Volume reduction radic radic X radic radic

Technology economically Viable radic radic radic radic radic

Acceptability of technology inKhulna radic radic radic X X

Outcome (selectednot selected) radic radic radic X XNoteradic yes and X no

best method out of the five assessed HCW treatment alter-natives Another research using the multicriteria decision-making (MCDM) approach carried out by Antonopoulos etal [37] also corroborated the same facts

Based on assessment outcomes utilizing SAT methodol-ogy characterization of waste and local conditions inciner-ation is likely said to be the suitable method for treatmentof all types of HCW in Khulna city The majority of thewastes produced fromHCEs are nonhazardous which can bedisposed of in ways similar to the domestic waste Only thehazardous portion needs to be treated In Khulna city thepresent generation of the waste is about 3 ton dayminus1 and thehazardous waste is nearly 06 ton dayminus1Therefore a mediumsize incinerator (destruction capacity 025 ton hrminus1) will begood enough to comply with the situation Unwanted pol-lutants can be significantly reduced with the addition of airpollution control devices of the system Many air pollutantsin emissions from incinerators can be lessened substantiallyby modern air pollution control mechanisms if appropriatelydesigned and operated [2 38] Since the investment cost isvery high for new plant several HCEs may converge to set upa plant centrallyThese types of plants are now being observedin many countries of the world

6 Conclusions and Recommendations

Thepresent study has mainly focused on the existing HCWMparadigms of Khulna metropolis and on the question of howit can be made a more efficient and acceptable one Theexisting HCWM pattern in Khulna city has many drawbacksand is in dire need of immediate attention and improvementIt was observed from the investigation that the hazardouswaste was not treated separately in almost all of the HCEsin Khulna city Intervention is required at all stages ofwastemanagement from the formulation of appropriate lawssegregation and transportation of waste to the final disposalmethodThe process and method adopted for waste manage-ment should be technically and financially sustainable in the

long run It has to also be ensured that there are no adversehealth and environmental consequences of waste handlingtreatment and disposal activities

National legislation is the basis for improving HCWpractices in any country Therefore a national managementplan will be required which will permit HCWM options tobe optimized on a national scale The law should be comple-mented by a policy document and technical guidelines devel-oped for implementation This legal document should specifyregulations on treatment for different waste categories segre-gation collection storage handling disposal transporta-tion responsibilities and training requirements Training ofhealthcare personnel as well as general people regardinghygiene and HCWM is needed to create awareness and fosterresponsibility among them which will prevent exposure torelated health hazards

Among different waste treatment options it has beenfound from the study that the incineration system is the mostsuitable one for Khulna city based on the final score con-sidering technical suitability and environmental economicand social aspect However the system should be maintainedproperly with an appropriate air pollution control deviceTheranking order of the second technological choice was micro-waving followed by autoclaving considering all aspects Theassessment of treatment alternatives in this investigation issubjected to the selection as well as weighting of the criteriaand strongly dependent on the reliability to the response ofthe expertsrsquo personal judgment Besides the waste genera-tion rate that was calculated in this investigation was ex-cluding seasonal variation A further detailed study is re-quired incorporating more HCEs with an extended periodof collected data as well as seasonal variation to explore thesustainability of such management option Furthermore it isrecommended to develop a great variety of MCDMmethodsto evaluate such HCW treatment alternatives Overall thestudy will give an insight promulgating guidelines for thefuture planning and design of HCWM strategies in Khulnacity as well as other municipalities in developing countries

10 Journal of Environmental and Public Health

Table5Scop

ingof

SATmetho

dology

forthe

assessmento

fHCW

treatmento

ptions

forK

hulnam

etropo

lis

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Technicalsuitability

Com

patib

ilitywith

local

surrou

ndings

andnatural

cond

ition

s1198821=1

Rank

ingforT

echn

ical

SuitabilityRT

25

Maxim

umscorefor

TechnicalSuitability

(MST

)9times(1198821+1198822+

sdotsdotsdot+11988210)=531

MF1

=004

77

0329

60282

50235

Preference

forlocally

manufacturedtechno

logies1198822=7

MF2

=0329

516

454

1316

30987

Availabilityof

sparep

arts

andusageo

flocalmaterials1198823=5

MF3

=0235

614

105

1175

51175

Availabilityof

local

expertise

1198824=3

MF4

=0141

60846

50705

40564

Trackrecord

onperfo

rmance

1198825=10

MF5

=0470

73290

62820

62820

Com

patib

ilitywith

existing

techno

logy

ormanagem

ent

syste

m1198826=1

MF6

=004

75

0235

40188

40188

Meetscapacityrequ

irement1198827=10

MF7

=0470

83760

62820

62820

Adaptabilityto

future

situatio

ns1198828=5

MF8

=0235

818

806

1410

51175

Abilityto

treataw

idethe

rangeo

fhealth

care

wastes1198829=10

MF9

=0470

94230

62820

62820

Levelof

automationsoph

istication11988210=7

MF10=0329

413

166

1974

619

74

Journal of Environmental and Public Health 11

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Environm

ent

Efficacy

ofmicrobial

inactiv

ation

11988211=10

Rank

ingfor

environm

ent

(resou

rces

and

emissions)RE

n25

Maxim

umscorefor

environm

ent

(MSE

n)

9times(11988211+11988212+

sdotsdotsdot+11988228)=1161

MF11=

0215

919

357

1505

612

90

Risk

levelsforw

orkers

11988212=10

MF12=0215

40860

510

755

1075

Risk

levelsforc

ommun

ities11988213=10

MF13=

0215

40860

510

755

1075

Risk

tothee

nviro

nment11988214=10

MF14=0215

20430

612

907

1505

Airem

issions

11988215=10

MF15=

0215

10215

612

906

1290

Liqu

ideffl

uents

11988216=5

MF16=0107

6064

22

0214

20214

Solid

resid

ues

11988217=5

MF17=

0107

70749

40428

40428

Volumer

eductio

n11988218=10

MF18=0215

919

356

1290

20430

Massreductio

n11988219=3

MF19=0065

80520

30195

10065

Odo

r11988220=10

MF2

0=0215

40860

40860

40860

Noise

11988221=5

MF2

1=0107

40428

30321

50535

Energy

consum

ptionperk

gof

waste

11988222=10

MF2

2=0215

612

906

1290

510

75

Extent

ofuseo

frenew

able

energy

11988223=8

MF2

3=0172

50860

712

047

1204

Waterconsum

ptionperk

gof

waste

11988224=5

MF24=0107

70749

30321

30321

Materialcon

sumption

11988225=5

MF2

5=0107

6064

26

064

26

064

2Ex

tent

ofuseo

fhazardo

usmaterials

11988226=5

MF2

6=0107

80865

70749

70749

Spacer

equirement

11988227=3

MF2

7=0065

60390

50325

50325

Resource

recovery

capabilities

11988228=5

MF2

8=0107

20214

50535

6064

2

12 Journal of Environmental and Public Health

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Fina

ncialeconomica

lEstim

ated

capitalcosto

fthetreatmenttechn

olog

y11988229=10

Rank

ingfore

cono

mic

aspectsRE

c25

Maxim

umscorefor

econ

omic(M

SEn)

9times(11988229+11988230+

sdotsdotsdot+11988232)=270

MF2

9=0926

874

086

5556

54630

Estim

ated

capitalcostsof

allaccessorie

sand

related

equipm

ent

11988230=5

MF3

0=0463

313

894

1852

418

52

Estim

ated

operationand

maintenance

costs

11988231=10

MF31=

0926

54630

43704

32778

Insta

llatio

nrequ

irements11988232=5

MF32=

0463

418

525

2315

52315

Socia

lcultural

Com

mun

ityacceptance

ofthetechn

olog

y11988233=10

Rank

ingforsocial

aspectsRS

25

Maxim

umscorefor

SocialCultural

(MSS)

9times(11988233+11988234+

sdotsdotsdot+11988237)=315

MF33=

0794

75558

53970

43176

Incomeg

eneration

potential

11988234=5

MF3

4=0397

62382

20794

20794

Acceptabilityof

treatment

resid

uesb

ythelocalland

fill11988235=10

MF35=

0794

64764

43176

43176

Extent

ofnecessary

resettlem

ento

fpeople

11988236=5

MF3

6=0397

31191

62382

62382

Visib

leor

aesth

eticim

pact11988237=5

MF37=0397

519

854

1588

31191

Total

645

554

512

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

8 Journal of Environmental and Public Health

found among the workers involved in the total managementprocess as well as general people in the studied area

Most of the disposal site is open and thereby emitsunpleasant odors and an unaesthetic view causing a hugepublic nuisance While grazing ready access of domestic ani-mals in open dumps may create the possibilities of introduc-ing microbes and pathogens into the food chain Indiscrimi-nate junking of HCWmay create the chances of adulterationof food supplies soil surface water groundwater and airThemajority of the municipal waste receptacles are not designedappropriately and are open without a cover or lid Thereforevectors like insects rodents worms birds and so on can eas-ily enter the collection containers and can take a place on theexposed piles of rotting trash causing the spread of contagiousbugs These also stimulate the mechanical transmission ofdeadly waterborne diseases like diarrhea typhoid dysenteryhepatitis and cholera [29] Moreover mosquitoes promotebiological transmission ofmany types of diseases likemalariadengue and yellow fever under humid environment Rubberand plastic trash being burnt in the open air releases fumescontaining carbonmonoxide dioxins furans and so on [36]When these toxic components are inhaled through smokethey may cause cancer respiratory diseases and many otherdeadly results to humans

Informal waste collectors (known as scavengers) engagedin collecting refuse from HCEs are suffering from variousintestinal parasitic and skin diseases Waste pickers collectused medical equipment particularly syringes from thegarbage and sell them at a low price Many drug addictsmay suffer from cholera typhoid hepatitis AIDS and otherhazardous and contagious diseases as they are reusing thesesyringes Scavengers are scooping out waste from the dust-bins roads and garbage lots for the recyclables with barehands without taking any safety measures therefore facing ahigh risk of salient epidemics of infectious diseasesThewastepickers involved in the recycling process are extremely poorhaving no proper education and incautious of detrimentalconsequences of exposure to contaminated and harmfulwaste

The inadequate disposal of HCWmay be catastrophic tohealth and the environment as well as thewellbeing of societyIf the HCW in Khulna city is not handled in a proper way itwill undoubtedly pose a danger to the workforce employed inthe HCEs as well as to the neighboring people

55 Assessment of Different Technological Options for ProperTreatment of HCW Using SAT Methodology in the Context ofKhulna City In general treatment options may be availableeither on- or off-site A central treatment facility is proposedas the generation of hazardous waste from individual HCEsis not high enough to run a treatment facility solely Assess-ment outcomes of different technological choices for HCWtreatment including technical suitability environmental eco-nomic and social aspects using SATmethodology for Khulnaare narrated herein chronologically

Strategic-Level Assessment(i) Issue all HCEs in the Khulna metropolitan area do

not have proper treatment facilities to treat their haz-ardous waste efficiently

1 2 3 45

67

891011

1213

1415

16171819202122

2324

2526

27282930

3132

3334

35 36 37

IncinerationMicrowaveAutoclave

Figure 3 Distribution of acquired scores of all criteria of HCWtreatment options

(ii) Target implementation of a large-scale central treat-ment technology to handle the hazardous waste fromall HCEs in the area Furthermore proclamation ofpolicies to be needed for the treatment of all haz-ardous waste

Operational Level Assessment VariousHCW treatment alter-natives for instance incineration microwaving and auto-claving were screened (Table 4) in this step using differ-ent modified screening criteria Short-listed technologicaloptions passed through the screening step were then sub-jected to going through the comprehensive scoping tier(Table 5)

Detailed Assessment The final scores obtained by differ-ent treatment alternatives for the technical suitability andeconomic social and environmental criteria are shown inTable 6 Final weightage of all criteria (37 numbers) undereach criteria topic for HCW treatment options is presented ina composite star diagram (Figure 3)

It is observed from Table 6 that all three technologiesare fairly close although incineration is the highest rankedtreatment option followed by microwave technology Amongdifferent criteria technical suitability and social aspect varyto some extent In the technical suitability aspect the mostimportant criteria considered by the experts judgment werethe ability to treat a wide range of hazardous wastes capacityrequirement and adaptability to the future situation Regard-ing the social aspect experts contemplated communityacceptance of the technology Although incineration attainedthe highest score in technical suitability and social aspect thecapital cost of the treatment technology as well as mainte-nance expenditure is one of the drawbacks of this treatmentoption Ozkan [22] indicated that off-site incineration is the

Journal of Environmental and Public Health 9

Table 4 Screening of different HCW treatment alternatives for Khulna municipality

CriteriaIncineration withpollution control

deviceMicrowave Autoclave Hydropulping Compaction

Compliance with nationalenvironmental laws radic radic radic X X

Compliance with multilateralenvironmental agreements radic radic radic radic radic

Consistency with WHO policies radic radic radic radic radic

Flexibility in accepting variouswaste radic radic radic X X

Volume reduction radic radic X radic radic

Technology economically Viable radic radic radic radic radic

Acceptability of technology inKhulna radic radic radic X X

Outcome (selectednot selected) radic radic radic X XNoteradic yes and X no

best method out of the five assessed HCW treatment alter-natives Another research using the multicriteria decision-making (MCDM) approach carried out by Antonopoulos etal [37] also corroborated the same facts

Based on assessment outcomes utilizing SAT methodol-ogy characterization of waste and local conditions inciner-ation is likely said to be the suitable method for treatmentof all types of HCW in Khulna city The majority of thewastes produced fromHCEs are nonhazardous which can bedisposed of in ways similar to the domestic waste Only thehazardous portion needs to be treated In Khulna city thepresent generation of the waste is about 3 ton dayminus1 and thehazardous waste is nearly 06 ton dayminus1Therefore a mediumsize incinerator (destruction capacity 025 ton hrminus1) will begood enough to comply with the situation Unwanted pol-lutants can be significantly reduced with the addition of airpollution control devices of the system Many air pollutantsin emissions from incinerators can be lessened substantiallyby modern air pollution control mechanisms if appropriatelydesigned and operated [2 38] Since the investment cost isvery high for new plant several HCEs may converge to set upa plant centrallyThese types of plants are now being observedin many countries of the world

6 Conclusions and Recommendations

Thepresent study has mainly focused on the existing HCWMparadigms of Khulna metropolis and on the question of howit can be made a more efficient and acceptable one Theexisting HCWM pattern in Khulna city has many drawbacksand is in dire need of immediate attention and improvementIt was observed from the investigation that the hazardouswaste was not treated separately in almost all of the HCEsin Khulna city Intervention is required at all stages ofwastemanagement from the formulation of appropriate lawssegregation and transportation of waste to the final disposalmethodThe process and method adopted for waste manage-ment should be technically and financially sustainable in the

long run It has to also be ensured that there are no adversehealth and environmental consequences of waste handlingtreatment and disposal activities

National legislation is the basis for improving HCWpractices in any country Therefore a national managementplan will be required which will permit HCWM options tobe optimized on a national scale The law should be comple-mented by a policy document and technical guidelines devel-oped for implementation This legal document should specifyregulations on treatment for different waste categories segre-gation collection storage handling disposal transporta-tion responsibilities and training requirements Training ofhealthcare personnel as well as general people regardinghygiene and HCWM is needed to create awareness and fosterresponsibility among them which will prevent exposure torelated health hazards

Among different waste treatment options it has beenfound from the study that the incineration system is the mostsuitable one for Khulna city based on the final score con-sidering technical suitability and environmental economicand social aspect However the system should be maintainedproperly with an appropriate air pollution control deviceTheranking order of the second technological choice was micro-waving followed by autoclaving considering all aspects Theassessment of treatment alternatives in this investigation issubjected to the selection as well as weighting of the criteriaand strongly dependent on the reliability to the response ofthe expertsrsquo personal judgment Besides the waste genera-tion rate that was calculated in this investigation was ex-cluding seasonal variation A further detailed study is re-quired incorporating more HCEs with an extended periodof collected data as well as seasonal variation to explore thesustainability of such management option Furthermore it isrecommended to develop a great variety of MCDMmethodsto evaluate such HCW treatment alternatives Overall thestudy will give an insight promulgating guidelines for thefuture planning and design of HCWM strategies in Khulnacity as well as other municipalities in developing countries

10 Journal of Environmental and Public Health

Table5Scop

ingof

SATmetho

dology

forthe

assessmento

fHCW

treatmento

ptions

forK

hulnam

etropo

lis

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Technicalsuitability

Com

patib

ilitywith

local

surrou

ndings

andnatural

cond

ition

s1198821=1

Rank

ingforT

echn

ical

SuitabilityRT

25

Maxim

umscorefor

TechnicalSuitability

(MST

)9times(1198821+1198822+

sdotsdotsdot+11988210)=531

MF1

=004

77

0329

60282

50235

Preference

forlocally

manufacturedtechno

logies1198822=7

MF2

=0329

516

454

1316

30987

Availabilityof

sparep

arts

andusageo

flocalmaterials1198823=5

MF3

=0235

614

105

1175

51175

Availabilityof

local

expertise

1198824=3

MF4

=0141

60846

50705

40564

Trackrecord

onperfo

rmance

1198825=10

MF5

=0470

73290

62820

62820

Com

patib

ilitywith

existing

techno

logy

ormanagem

ent

syste

m1198826=1

MF6

=004

75

0235

40188

40188

Meetscapacityrequ

irement1198827=10

MF7

=0470

83760

62820

62820

Adaptabilityto

future

situatio

ns1198828=5

MF8

=0235

818

806

1410

51175

Abilityto

treataw

idethe

rangeo

fhealth

care

wastes1198829=10

MF9

=0470

94230

62820

62820

Levelof

automationsoph

istication11988210=7

MF10=0329

413

166

1974

619

74

Journal of Environmental and Public Health 11

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Environm

ent

Efficacy

ofmicrobial

inactiv

ation

11988211=10

Rank

ingfor

environm

ent

(resou

rces

and

emissions)RE

n25

Maxim

umscorefor

environm

ent

(MSE

n)

9times(11988211+11988212+

sdotsdotsdot+11988228)=1161

MF11=

0215

919

357

1505

612

90

Risk

levelsforw

orkers

11988212=10

MF12=0215

40860

510

755

1075

Risk

levelsforc

ommun

ities11988213=10

MF13=

0215

40860

510

755

1075

Risk

tothee

nviro

nment11988214=10

MF14=0215

20430

612

907

1505

Airem

issions

11988215=10

MF15=

0215

10215

612

906

1290

Liqu

ideffl

uents

11988216=5

MF16=0107

6064

22

0214

20214

Solid

resid

ues

11988217=5

MF17=

0107

70749

40428

40428

Volumer

eductio

n11988218=10

MF18=0215

919

356

1290

20430

Massreductio

n11988219=3

MF19=0065

80520

30195

10065

Odo

r11988220=10

MF2

0=0215

40860

40860

40860

Noise

11988221=5

MF2

1=0107

40428

30321

50535

Energy

consum

ptionperk

gof

waste

11988222=10

MF2

2=0215

612

906

1290

510

75

Extent

ofuseo

frenew

able

energy

11988223=8

MF2

3=0172

50860

712

047

1204

Waterconsum

ptionperk

gof

waste

11988224=5

MF24=0107

70749

30321

30321

Materialcon

sumption

11988225=5

MF2

5=0107

6064

26

064

26

064

2Ex

tent

ofuseo

fhazardo

usmaterials

11988226=5

MF2

6=0107

80865

70749

70749

Spacer

equirement

11988227=3

MF2

7=0065

60390

50325

50325

Resource

recovery

capabilities

11988228=5

MF2

8=0107

20214

50535

6064

2

12 Journal of Environmental and Public Health

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Fina

ncialeconomica

lEstim

ated

capitalcosto

fthetreatmenttechn

olog

y11988229=10

Rank

ingfore

cono

mic

aspectsRE

c25

Maxim

umscorefor

econ

omic(M

SEn)

9times(11988229+11988230+

sdotsdotsdot+11988232)=270

MF2

9=0926

874

086

5556

54630

Estim

ated

capitalcostsof

allaccessorie

sand

related

equipm

ent

11988230=5

MF3

0=0463

313

894

1852

418

52

Estim

ated

operationand

maintenance

costs

11988231=10

MF31=

0926

54630

43704

32778

Insta

llatio

nrequ

irements11988232=5

MF32=

0463

418

525

2315

52315

Socia

lcultural

Com

mun

ityacceptance

ofthetechn

olog

y11988233=10

Rank

ingforsocial

aspectsRS

25

Maxim

umscorefor

SocialCultural

(MSS)

9times(11988233+11988234+

sdotsdotsdot+11988237)=315

MF33=

0794

75558

53970

43176

Incomeg

eneration

potential

11988234=5

MF3

4=0397

62382

20794

20794

Acceptabilityof

treatment

resid

uesb

ythelocalland

fill11988235=10

MF35=

0794

64764

43176

43176

Extent

ofnecessary

resettlem

ento

fpeople

11988236=5

MF3

6=0397

31191

62382

62382

Visib

leor

aesth

eticim

pact11988237=5

MF37=0397

519

854

1588

31191

Total

645

554

512

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

Journal of Environmental and Public Health 9

Table 4 Screening of different HCW treatment alternatives for Khulna municipality

CriteriaIncineration withpollution control

deviceMicrowave Autoclave Hydropulping Compaction

Compliance with nationalenvironmental laws radic radic radic X X

Compliance with multilateralenvironmental agreements radic radic radic radic radic

Consistency with WHO policies radic radic radic radic radic

Flexibility in accepting variouswaste radic radic radic X X

Volume reduction radic radic X radic radic

Technology economically Viable radic radic radic radic radic

Acceptability of technology inKhulna radic radic radic X X

Outcome (selectednot selected) radic radic radic X XNoteradic yes and X no

best method out of the five assessed HCW treatment alter-natives Another research using the multicriteria decision-making (MCDM) approach carried out by Antonopoulos etal [37] also corroborated the same facts

Based on assessment outcomes utilizing SAT methodol-ogy characterization of waste and local conditions inciner-ation is likely said to be the suitable method for treatmentof all types of HCW in Khulna city The majority of thewastes produced fromHCEs are nonhazardous which can bedisposed of in ways similar to the domestic waste Only thehazardous portion needs to be treated In Khulna city thepresent generation of the waste is about 3 ton dayminus1 and thehazardous waste is nearly 06 ton dayminus1Therefore a mediumsize incinerator (destruction capacity 025 ton hrminus1) will begood enough to comply with the situation Unwanted pol-lutants can be significantly reduced with the addition of airpollution control devices of the system Many air pollutantsin emissions from incinerators can be lessened substantiallyby modern air pollution control mechanisms if appropriatelydesigned and operated [2 38] Since the investment cost isvery high for new plant several HCEs may converge to set upa plant centrallyThese types of plants are now being observedin many countries of the world

6 Conclusions and Recommendations

Thepresent study has mainly focused on the existing HCWMparadigms of Khulna metropolis and on the question of howit can be made a more efficient and acceptable one Theexisting HCWM pattern in Khulna city has many drawbacksand is in dire need of immediate attention and improvementIt was observed from the investigation that the hazardouswaste was not treated separately in almost all of the HCEsin Khulna city Intervention is required at all stages ofwastemanagement from the formulation of appropriate lawssegregation and transportation of waste to the final disposalmethodThe process and method adopted for waste manage-ment should be technically and financially sustainable in the

long run It has to also be ensured that there are no adversehealth and environmental consequences of waste handlingtreatment and disposal activities

National legislation is the basis for improving HCWpractices in any country Therefore a national managementplan will be required which will permit HCWM options tobe optimized on a national scale The law should be comple-mented by a policy document and technical guidelines devel-oped for implementation This legal document should specifyregulations on treatment for different waste categories segre-gation collection storage handling disposal transporta-tion responsibilities and training requirements Training ofhealthcare personnel as well as general people regardinghygiene and HCWM is needed to create awareness and fosterresponsibility among them which will prevent exposure torelated health hazards

Among different waste treatment options it has beenfound from the study that the incineration system is the mostsuitable one for Khulna city based on the final score con-sidering technical suitability and environmental economicand social aspect However the system should be maintainedproperly with an appropriate air pollution control deviceTheranking order of the second technological choice was micro-waving followed by autoclaving considering all aspects Theassessment of treatment alternatives in this investigation issubjected to the selection as well as weighting of the criteriaand strongly dependent on the reliability to the response ofthe expertsrsquo personal judgment Besides the waste genera-tion rate that was calculated in this investigation was ex-cluding seasonal variation A further detailed study is re-quired incorporating more HCEs with an extended periodof collected data as well as seasonal variation to explore thesustainability of such management option Furthermore it isrecommended to develop a great variety of MCDMmethodsto evaluate such HCW treatment alternatives Overall thestudy will give an insight promulgating guidelines for thefuture planning and design of HCWM strategies in Khulnacity as well as other municipalities in developing countries

10 Journal of Environmental and Public Health

Table5Scop

ingof

SATmetho

dology

forthe

assessmento

fHCW

treatmento

ptions

forK

hulnam

etropo

lis

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Technicalsuitability

Com

patib

ilitywith

local

surrou

ndings

andnatural

cond

ition

s1198821=1

Rank

ingforT

echn

ical

SuitabilityRT

25

Maxim

umscorefor

TechnicalSuitability

(MST

)9times(1198821+1198822+

sdotsdotsdot+11988210)=531

MF1

=004

77

0329

60282

50235

Preference

forlocally

manufacturedtechno

logies1198822=7

MF2

=0329

516

454

1316

30987

Availabilityof

sparep

arts

andusageo

flocalmaterials1198823=5

MF3

=0235

614

105

1175

51175

Availabilityof

local

expertise

1198824=3

MF4

=0141

60846

50705

40564

Trackrecord

onperfo

rmance

1198825=10

MF5

=0470

73290

62820

62820

Com

patib

ilitywith

existing

techno

logy

ormanagem

ent

syste

m1198826=1

MF6

=004

75

0235

40188

40188

Meetscapacityrequ

irement1198827=10

MF7

=0470

83760

62820

62820

Adaptabilityto

future

situatio

ns1198828=5

MF8

=0235

818

806

1410

51175

Abilityto

treataw

idethe

rangeo

fhealth

care

wastes1198829=10

MF9

=0470

94230

62820

62820

Levelof

automationsoph

istication11988210=7

MF10=0329

413

166

1974

619

74

Journal of Environmental and Public Health 11

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Environm

ent

Efficacy

ofmicrobial

inactiv

ation

11988211=10

Rank

ingfor

environm

ent

(resou

rces

and

emissions)RE

n25

Maxim

umscorefor

environm

ent

(MSE

n)

9times(11988211+11988212+

sdotsdotsdot+11988228)=1161

MF11=

0215

919

357

1505

612

90

Risk

levelsforw

orkers

11988212=10

MF12=0215

40860

510

755

1075

Risk

levelsforc

ommun

ities11988213=10

MF13=

0215

40860

510

755

1075

Risk

tothee

nviro

nment11988214=10

MF14=0215

20430

612

907

1505

Airem

issions

11988215=10

MF15=

0215

10215

612

906

1290

Liqu

ideffl

uents

11988216=5

MF16=0107

6064

22

0214

20214

Solid

resid

ues

11988217=5

MF17=

0107

70749

40428

40428

Volumer

eductio

n11988218=10

MF18=0215

919

356

1290

20430

Massreductio

n11988219=3

MF19=0065

80520

30195

10065

Odo

r11988220=10

MF2

0=0215

40860

40860

40860

Noise

11988221=5

MF2

1=0107

40428

30321

50535

Energy

consum

ptionperk

gof

waste

11988222=10

MF2

2=0215

612

906

1290

510

75

Extent

ofuseo

frenew

able

energy

11988223=8

MF2

3=0172

50860

712

047

1204

Waterconsum

ptionperk

gof

waste

11988224=5

MF24=0107

70749

30321

30321

Materialcon

sumption

11988225=5

MF2

5=0107

6064

26

064

26

064

2Ex

tent

ofuseo

fhazardo

usmaterials

11988226=5

MF2

6=0107

80865

70749

70749

Spacer

equirement

11988227=3

MF2

7=0065

60390

50325

50325

Resource

recovery

capabilities

11988228=5

MF2

8=0107

20214

50535

6064

2

12 Journal of Environmental and Public Health

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Fina

ncialeconomica

lEstim

ated

capitalcosto

fthetreatmenttechn

olog

y11988229=10

Rank

ingfore

cono

mic

aspectsRE

c25

Maxim

umscorefor

econ

omic(M

SEn)

9times(11988229+11988230+

sdotsdotsdot+11988232)=270

MF2

9=0926

874

086

5556

54630

Estim

ated

capitalcostsof

allaccessorie

sand

related

equipm

ent

11988230=5

MF3

0=0463

313

894

1852

418

52

Estim

ated

operationand

maintenance

costs

11988231=10

MF31=

0926

54630

43704

32778

Insta

llatio

nrequ

irements11988232=5

MF32=

0463

418

525

2315

52315

Socia

lcultural

Com

mun

ityacceptance

ofthetechn

olog

y11988233=10

Rank

ingforsocial

aspectsRS

25

Maxim

umscorefor

SocialCultural

(MSS)

9times(11988233+11988234+

sdotsdotsdot+11988237)=315

MF33=

0794

75558

53970

43176

Incomeg

eneration

potential

11988234=5

MF3

4=0397

62382

20794

20794

Acceptabilityof

treatment

resid

uesb

ythelocalland

fill11988235=10

MF35=

0794

64764

43176

43176

Extent

ofnecessary

resettlem

ento

fpeople

11988236=5

MF3

6=0397

31191

62382

62382

Visib

leor

aesth

eticim

pact11988237=5

MF37=0397

519

854

1588

31191

Total

645

554

512

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

10 Journal of Environmental and Public Health

Table5Scop

ingof

SATmetho

dology

forthe

assessmento

fHCW

treatmento

ptions

forK

hulnam

etropo

lis

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Technicalsuitability

Com

patib

ilitywith

local

surrou

ndings

andnatural

cond

ition

s1198821=1

Rank

ingforT

echn

ical

SuitabilityRT

25

Maxim

umscorefor

TechnicalSuitability

(MST

)9times(1198821+1198822+

sdotsdotsdot+11988210)=531

MF1

=004

77

0329

60282

50235

Preference

forlocally

manufacturedtechno

logies1198822=7

MF2

=0329

516

454

1316

30987

Availabilityof

sparep

arts

andusageo

flocalmaterials1198823=5

MF3

=0235

614

105

1175

51175

Availabilityof

local

expertise

1198824=3

MF4

=0141

60846

50705

40564

Trackrecord

onperfo

rmance

1198825=10

MF5

=0470

73290

62820

62820

Com

patib

ilitywith

existing

techno

logy

ormanagem

ent

syste

m1198826=1

MF6

=004

75

0235

40188

40188

Meetscapacityrequ

irement1198827=10

MF7

=0470

83760

62820

62820

Adaptabilityto

future

situatio

ns1198828=5

MF8

=0235

818

806

1410

51175

Abilityto

treataw

idethe

rangeo

fhealth

care

wastes1198829=10

MF9

=0470

94230

62820

62820

Levelof

automationsoph

istication11988210=7

MF10=0329

413

166

1974

619

74

Journal of Environmental and Public Health 11

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Environm

ent

Efficacy

ofmicrobial

inactiv

ation

11988211=10

Rank

ingfor

environm

ent

(resou

rces

and

emissions)RE

n25

Maxim

umscorefor

environm

ent

(MSE

n)

9times(11988211+11988212+

sdotsdotsdot+11988228)=1161

MF11=

0215

919

357

1505

612

90

Risk

levelsforw

orkers

11988212=10

MF12=0215

40860

510

755

1075

Risk

levelsforc

ommun

ities11988213=10

MF13=

0215

40860

510

755

1075

Risk

tothee

nviro

nment11988214=10

MF14=0215

20430

612

907

1505

Airem

issions

11988215=10

MF15=

0215

10215

612

906

1290

Liqu

ideffl

uents

11988216=5

MF16=0107

6064

22

0214

20214

Solid

resid

ues

11988217=5

MF17=

0107

70749

40428

40428

Volumer

eductio

n11988218=10

MF18=0215

919

356

1290

20430

Massreductio

n11988219=3

MF19=0065

80520

30195

10065

Odo

r11988220=10

MF2

0=0215

40860

40860

40860

Noise

11988221=5

MF2

1=0107

40428

30321

50535

Energy

consum

ptionperk

gof

waste

11988222=10

MF2

2=0215

612

906

1290

510

75

Extent

ofuseo

frenew

able

energy

11988223=8

MF2

3=0172

50860

712

047

1204

Waterconsum

ptionperk

gof

waste

11988224=5

MF24=0107

70749

30321

30321

Materialcon

sumption

11988225=5

MF2

5=0107

6064

26

064

26

064

2Ex

tent

ofuseo

fhazardo

usmaterials

11988226=5

MF2

6=0107

80865

70749

70749

Spacer

equirement

11988227=3

MF2

7=0065

60390

50325

50325

Resource

recovery

capabilities

11988228=5

MF2

8=0107

20214

50535

6064

2

12 Journal of Environmental and Public Health

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Fina

ncialeconomica

lEstim

ated

capitalcosto

fthetreatmenttechn

olog

y11988229=10

Rank

ingfore

cono

mic

aspectsRE

c25

Maxim

umscorefor

econ

omic(M

SEn)

9times(11988229+11988230+

sdotsdotsdot+11988232)=270

MF2

9=0926

874

086

5556

54630

Estim

ated

capitalcostsof

allaccessorie

sand

related

equipm

ent

11988230=5

MF3

0=0463

313

894

1852

418

52

Estim

ated

operationand

maintenance

costs

11988231=10

MF31=

0926

54630

43704

32778

Insta

llatio

nrequ

irements11988232=5

MF32=

0463

418

525

2315

52315

Socia

lcultural

Com

mun

ityacceptance

ofthetechn

olog

y11988233=10

Rank

ingforsocial

aspectsRS

25

Maxim

umscorefor

SocialCultural

(MSS)

9times(11988233+11988234+

sdotsdotsdot+11988237)=315

MF33=

0794

75558

53970

43176

Incomeg

eneration

potential

11988234=5

MF3

4=0397

62382

20794

20794

Acceptabilityof

treatment

resid

uesb

ythelocalland

fill11988235=10

MF35=

0794

64764

43176

43176

Extent

ofnecessary

resettlem

ento

fpeople

11988236=5

MF3

6=0397

31191

62382

62382

Visib

leor

aesth

eticim

pact11988237=5

MF37=0397

519

854

1588

31191

Total

645

554

512

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

Journal of Environmental and Public Health 11

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Environm

ent

Efficacy

ofmicrobial

inactiv

ation

11988211=10

Rank

ingfor

environm

ent

(resou

rces

and

emissions)RE

n25

Maxim

umscorefor

environm

ent

(MSE

n)

9times(11988211+11988212+

sdotsdotsdot+11988228)=1161

MF11=

0215

919

357

1505

612

90

Risk

levelsforw

orkers

11988212=10

MF12=0215

40860

510

755

1075

Risk

levelsforc

ommun

ities11988213=10

MF13=

0215

40860

510

755

1075

Risk

tothee

nviro

nment11988214=10

MF14=0215

20430

612

907

1505

Airem

issions

11988215=10

MF15=

0215

10215

612

906

1290

Liqu

ideffl

uents

11988216=5

MF16=0107

6064

22

0214

20214

Solid

resid

ues

11988217=5

MF17=

0107

70749

40428

40428

Volumer

eductio

n11988218=10

MF18=0215

919

356

1290

20430

Massreductio

n11988219=3

MF19=0065

80520

30195

10065

Odo

r11988220=10

MF2

0=0215

40860

40860

40860

Noise

11988221=5

MF2

1=0107

40428

30321

50535

Energy

consum

ptionperk

gof

waste

11988222=10

MF2

2=0215

612

906

1290

510

75

Extent

ofuseo

frenew

able

energy

11988223=8

MF2

3=0172

50860

712

047

1204

Waterconsum

ptionperk

gof

waste

11988224=5

MF24=0107

70749

30321

30321

Materialcon

sumption

11988225=5

MF2

5=0107

6064

26

064

26

064

2Ex

tent

ofuseo

fhazardo

usmaterials

11988226=5

MF2

6=0107

80865

70749

70749

Spacer

equirement

11988227=3

MF2

7=0065

60390

50325

50325

Resource

recovery

capabilities

11988228=5

MF2

8=0107

20214

50535

6064

2

12 Journal of Environmental and Public Health

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Fina

ncialeconomica

lEstim

ated

capitalcosto

fthetreatmenttechn

olog

y11988229=10

Rank

ingfore

cono

mic

aspectsRE

c25

Maxim

umscorefor

econ

omic(M

SEn)

9times(11988229+11988230+

sdotsdotsdot+11988232)=270

MF2

9=0926

874

086

5556

54630

Estim

ated

capitalcostsof

allaccessorie

sand

related

equipm

ent

11988230=5

MF3

0=0463

313

894

1852

418

52

Estim

ated

operationand

maintenance

costs

11988231=10

MF31=

0926

54630

43704

32778

Insta

llatio

nrequ

irements11988232=5

MF32=

0463

418

525

2315

52315

Socia

lcultural

Com

mun

ityacceptance

ofthetechn

olog

y11988233=10

Rank

ingforsocial

aspectsRS

25

Maxim

umscorefor

SocialCultural

(MSS)

9times(11988233+11988234+

sdotsdotsdot+11988237)=315

MF33=

0794

75558

53970

43176

Incomeg

eneration

potential

11988234=5

MF3

4=0397

62382

20794

20794

Acceptabilityof

treatment

resid

uesb

ythelocalland

fill11988235=10

MF35=

0794

64764

43176

43176

Extent

ofnecessary

resettlem

ento

fpeople

11988236=5

MF3

6=0397

31191

62382

62382

Visib

leor

aesth

eticim

pact11988237=5

MF37=0397

519

854

1588

31191

Total

645

554

512

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

12 Journal of Environmental and Public Health

Table5Con

tinued

Criteria

Weigh

t(119882)

Rank

ingforc

riteria

topic(RC

T)

Maxim

umscorefor

criteria

topic

(MSC

T)

Multip

lyingFactors

(MF)

=119882timesRC

TMSC

T

Incinerator

Microwave

Autoclave

Score

Scoretimes

MF

Score

Scoretimes

MF

Score

Scoretimes

MF

Fina

ncialeconomica

lEstim

ated

capitalcosto

fthetreatmenttechn

olog

y11988229=10

Rank

ingfore

cono

mic

aspectsRE

c25

Maxim

umscorefor

econ

omic(M

SEn)

9times(11988229+11988230+

sdotsdotsdot+11988232)=270

MF2

9=0926

874

086

5556

54630

Estim

ated

capitalcostsof

allaccessorie

sand

related

equipm

ent

11988230=5

MF3

0=0463

313

894

1852

418

52

Estim

ated

operationand

maintenance

costs

11988231=10

MF31=

0926

54630

43704

32778

Insta

llatio

nrequ

irements11988232=5

MF32=

0463

418

525

2315

52315

Socia

lcultural

Com

mun

ityacceptance

ofthetechn

olog

y11988233=10

Rank

ingforsocial

aspectsRS

25

Maxim

umscorefor

SocialCultural

(MSS)

9times(11988233+11988234+

sdotsdotsdot+11988237)=315

MF33=

0794

75558

53970

43176

Incomeg

eneration

potential

11988234=5

MF3

4=0397

62382

20794

20794

Acceptabilityof

treatment

resid

uesb

ythelocalland

fill11988235=10

MF35=

0794

64764

43176

43176

Extent

ofnecessary

resettlem

ento

fpeople

11988236=5

MF3

6=0397

31191

62382

62382

Visib

leor

aesth

eticim

pact11988237=5

MF37=0397

519

854

1588

31191

Total

645

554

512

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

Journal of Environmental and Public Health 13

Table 6 Ranking of different HCW treatment options based on final scores

Technological options Technical suitability Environmental Economic Social Total RankIncineration 189 144 153 159 645 1Microwave 155 146 134 119 554 2Autoclave 148 137 119 107 512 3

Abbreviations

HCEs Healthcare establishmentsHCFs Healthcare facilitiesHCW Healthcare wasteHCWM Healthcare waste managementIETC International Environmental Technology CentreKCC Khulna City CorporationMCDM Multicriteria decision-makingNGO Nongovernmental organizationSAT Sustainability Assessment of TechnologyUNDP United Nations Development ProgramUNEP United Nations Environment ProgramWHO World Health Organization

Conflicts of Interest

The authors declare they have no potential conflicts of inter-est

Acknowledgments

Theauthors gratefully acknowledge Bangladesh University ofEngineering and Technology (BUET) Dhaka for providingpartial financial support to carry out this study They wouldalso like to thank KCC and Prodipan for their kind assistancein this research venture

References

[1] E Shinee E Gombojav ANishimuraNHamajima andK ItoldquoHealthcare waste management in the capital city of MongoliardquoWaste Management vol 28 no 2 pp 435ndash441 2008

[2] Y Jang C Lee O Yoon and H Kim ldquoMedical waste manage-ment in Koreardquo Journal of Environmental Management vol 80no 2 pp 107ndash115 2006

[3] WHO Healthcare Waste Fact Sheet World Health Organiza-tionGeneva Switzerland 2018 httpwwwwhointnews-roomfact-sheetsdetailhealth-care-waste

[4] G MoniruzzamanMedical Wastes Pose Threat to Public Healthin Khulna The Daily Independent 2015 httpwwwtheinde-pendentbdcomarcprintdetails263942015-12-12

[5] M Sohrab Hossain N NN Ab Rahman V Balakrishnan V RPuvanesuaranM Zaidul Islam Sarker andMO AbKadir ldquoIn-fectious risk assessment of unsafe handling practices and man-agement of clinical solid wasterdquo International Journal of Envi-ronmental Research and Public Health vol 10 no 2 pp 556ndash5672013

[6] N Akter and J Trankler ldquoAn analysis of possible scenarios ofmedical wastemanagement in BangladeshrdquoManagement of En-vironmental Quality vol 14 no 2 pp 242ndash255 2003

[7] WHO ldquoSafe management of wastes from health-care activitiesa summary World Health Organizationrdquo Geneva Switzerland

2017 httpwwwwhointwater sanitation healthpublicationssafe-management-of-waste-summaryen

[8] M M Rahman K R Sultana and M A Hoque ldquoSuitable sitesfor urban solid waste disposal using GIS approach in KhulnacityrdquoProceedings of the PakistanAcademyofSciences 2008 httpagrisfaoorgagris-searchsearchdorecordID=PK2009001080

[9] S M Moniruzzaman Q H Bari and T Fukuhara ldquoRecyclingpractices of solidwaste inKhulnaCity BangladeshrdquoThe Journalof Solid Waste Technology andManagement vol 37 no 1 pp 1ndash15 2011

[10] QH Bari K MahbubHassan and R Haque ldquoScenario of solidwaste reuse in Khulna city of BangladeshrdquoWaste Managementvol 32 no 12 pp 2526ndash2534 2012

[11] A Ahsan M Alamgir M Imteaz N N Daud and R IslamldquoRole of NGOs and CBOs in waste managementrdquo Iranian jour-nal of public health vol 41 no 6 pp 27ndash38 2012

[12] UNEP Compendium of Technologies for TreatmentDestructionof HealthcareWaste Division of Technology Industry and Eco-nomics International Environmental Technology Centre Unit-ed Nations Environment Programme 2012

[13] W Suthapanich Characterization and assessment of municipalsolid waste for energy recovery options in Phetchaburi Thailand[MS thesis] Asian Institute ofTechnologyThailand 2014httpfacultyaitacthvisupublicuploadsimagespdf2014wiratcha-panpdf

[14] A Rafiee K Yaghmaeian M Hoseini et al ldquoAssessment andselection of the best treatment alternative for infectious wasteby modified sustainability assessment of technologies method-ologyrdquo Journal of Environmental Health Science and Engineeringvol 14 no 1 article no 10 2016

[15] M Karamouz B Zahraie R Kerachian N Jaafarzadeh and NMahjouri ldquoDeveloping a master plan for hospital solid wastemanagement a case studyrdquo Waste Management vol 27 no 5pp 626ndash638 2007

[16] J Bujak ldquoExperimental study of the lower heating value ofmedical wasterdquo Polish Journal of Environmental Studies vol 19no 6 pp 1151ndash1158 2010

[17] L F Cross E H Hesketh and K P Rykowski Infectious WasteManagement Technomic 1990

[18] BKrishnamoorthyEnvironmentalManagement Text AndCasesPHI Learning Pvt Ltd 2017

[19] J Emmanuel C Hrdinka P Gluszynski et alNon-IncinerationMedical Waste Treatment Technologies in Europe Health CareWithout Harm Europe Prague Czech Republic 2004

[20] HCWH Non-Incineration Medical Waste Treatment Technolo-gies A Resource for Hospital Administrators Facility Man-agers Health Care Professionals Environmental Advocates AndCommunity Member Health Care Without Harm (HCWH)Washington Wash USA 2001 httpsnoharmorg

[21] C Yang L Peijun C Lupi et al ldquoSustainable managementmeasures for healthcare waste in Chinardquo Waste Managementvol 29 no 6 pp 1996ndash2004 2009

14 Journal of Environmental and Public Health

[22] A Ozkan ldquoEvaluation of healthcare waste treatmentdisposalalternatives by using multi-criteria decision-making tech-niquesrdquo Waste Management amp Research vol 31 no 2 pp 141ndash149 2013

[23] A Pruss E Giroult and P Rushbrook Safe Management ofWastes fromHealth-Care Activities WorldHealth OrganizationGeneva 1999 httpappswhointirisbitstream106654217519241545259pdf

[24] P A Abor ldquoManaging healthcarewaste inGhana a comparativestudy of public and private hospitalsrdquo International Journal ofHealth Care Quality Assurance vol 26 no 4 pp 375ndash386 2013

[25] J M Alhumoud and H M Alhumoud ldquoAn analysis of trendsrelated to hospital solid wastes management in Kuwaitrdquo Man-agement of Environmental Quality vol 18 no 5 pp 502ndash5132007

[26] USEPA ldquoMunicipal solid waste in the United Statesrdquo EPA530R-02001 USEPA (Environmental Protection Agency) Wash-ington Wash USA 2002 httpsarchiveepagovepawastenonhazmunicipalwebpdfreport-00pdf

[27] S Khan S Mohammad AMMasoodi et al ldquoCurrent practiceof bio-medical waste management in government medicalcollege associated SMHSHospital Srinagarrdquo JK Practitione vol11 no 3 pp 206ndash209 2004 httpmedindnicinjabt04i3jabt04i3p206gpdf

[28] J Monreal Considerations on The Management of HospitalWastes in Latin America Environmental Health ProgramPAHOWorld Health Organization 1991

[29] A S K Sarkar A M Haque and A T Khan ldquoHospital wastemanagement in Sylhet cityrdquo ARPN Journal of Engineering andApplied Sciences vol 1 no 2 pp 32ndash40 2006

[30] M A Patwary W T OrsquoHare G Street K Maudood Elahi S SHossain andM H Sarker ldquoQuantitative assessment of medicalwaste generation in the capital city of Bangladeshrdquo WasteManagement vol 29 no 8 pp 2392ndash2397 2009

[31] C E Da Silva A E Hoppe M M Ravanello and N MelloldquoMedical wastes management in the south of Brazilrdquo WasteManagement vol 25 no 6 pp 600ndash605 2005

[32] R Mohee ldquoMedical wastes characterisation in healthcare insti-tutions inMauritiusrdquoWasteManagement vol 25 no 6 pp 575ndash581 2005

[33] HM Rahman S Ahmed and S MUllah ldquoA study on hospitalwaste management in Dhaka Cityrdquo in Proceedings of the 25thWEDCConference vol 25 pp 342ndash345 Addis Ababa Ethiopia1999

[34] M ChaerulM Tanaka and A V Shekdar ldquoA system dynamicsapproach for hospital waste managementrdquoWaste Managementvol 28 no 2 pp 442ndash449 2008

[35] K W Townend D J Donaldson and M S Grimes Review ofClinical Waste Treatment Technologies Government of ChinaEnvironmental Protection Department Hong Kong China2000

[36] DoE Environmental Guideline for the Burning and Incinerationof Solid Waste Department of Environment Government ofNunavut Canada 2012 httpwwwgovnucasitesdefaultfilesguideline - burning and incineration of solid waste 2012pdf

[37] I S AntonopoulosG Perkoulidis D Logothetis andC Karka-nias ldquoRanking municipal solid waste treatment alternativesconsidering sustainability criteria using the analytical hierarchi-cal process toolrdquo Resources Conservation amp Recycling vol 86pp 149ndash159 2014

[38] R Xie W Li J Li B Wu and J Yi ldquoEmissions investigationfor a novel medical waste incineratorrdquo Journal of HazardousMaterials vol 166 no 1 pp 365ndash371 2009

Stem Cells International

Hindawiwwwhindawicom Volume 2018

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of

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Disease Markers

Hindawiwwwhindawicom Volume 2018

BioMed Research International

OncologyJournal of

Hindawiwwwhindawicom Volume 2013

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Oxidative Medicine and Cellular Longevity

Hindawiwwwhindawicom Volume 2018

PPAR Research

Hindawi Publishing Corporation httpwwwhindawicom Volume 2013Hindawiwwwhindawicom

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Volume 2018

Immunology ResearchHindawiwwwhindawicom Volume 2018

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ObesityJournal of

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Computational and Mathematical Methods in Medicine

Hindawiwwwhindawicom Volume 2018

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Hindawiwwwhindawicom Volume 2018

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Evidence-Based Complementary andAlternative Medicine

Volume 2018Hindawiwwwhindawicom

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