review of literature on biomedical waste management 2016

• DOI: 10.7759/cureus.34589
• Corpus ID: 256591284

Biomedical Waste Management and Its Importance: A Systematic Review

• Himani S Bansod , Prasad Deshmukh
• Published in Cureus 1 February 2023
• Medicine, Environmental Science

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Biomedical waste management in India: Critical appraisal

Affiliation.

• 1 Department of Microbiology, Government Medical College Hospital, Chandigarh, India.
• PMID: 29403196
• PMCID: PMC5784295
• DOI: 10.4103/JLP.JLP_89_17

The safe and sustainable management of biomedical waste (BMW) is social and legal responsibility of all people supporting and financing health-care activities. Effective BMW management (BMWM) is mandatory for healthy humans and cleaner environment. This article reviews the recent 2016 BMWM rules, practical problems for its effective implementation, the major drawback of conventional techniques, and the latest eco-friendly methods for BMW disposal. The new rules are meant to improve the segregation, transportation, and disposal methods, to decrease environmental pollution so as to change the dynamic of BMW disposal and treatment in India. For effective disposal of BMWM, there should be a collective teamwork with committed government support in terms of finance and infrastructure development, dedicated health-care workers and health-care facilities, continuous monitoring of BMW practices, tough legislature, and strong regulatory bodies. The basic principle of BMWM is segregation at source and waste reduction. Besides, a lot of research and development need to be in the field of developing environmental friendly medical devices and BMW disposal systems for a greener and cleaner environment.

Keywords: 2016; Biomedical waste; India; changes.

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• WHO. Review of Health Impacts from Microbiological Hazards in Health-Care Wastes. Geneva: World Health Organization; 2004.
• Technical Guidelines on Environmentally Sound Management of Wastes Consisting of Elemental Mercury and Wastes Containing or Contaminated with Mercury 31 October, 2011. Geneva: Basel Convention and United Nations Environment Programme; 2011. Secretariat of the Basel Convention.
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Volume 11, Issue 01 (January 2022)

Review on bio-medical waste management.

• Article Download / Views: 6,549
• Authors : Sahil Sanjeev Salvi , Shubhangi Waghmare , Vikas Thombare, Sagar Mandlik , Saurabh Veer, Prajwal Walke, Prathamesh Zambare
• Paper ID : IJERTV11IS010038
• Volume & Issue : Volume 11, Issue 01 (January 2022)
• Published (First Online): 17-01-2022
• ISSN (Online) : 2278-0181
• Publisher Name : IJERT

Mr. Sahil Sanjeev Salvi1, Shubhangi Waghmare2, Vikas Thombare3, Sagar Mandlik4, Saurabh Veer5 , Prajwal Walke6, Prathamesh Zambare7

Assistant Professor1, Student234567 Department of Civil Engineering,

Pimpri Chinchwad Collage of Engineering and Research, Pune, India

AbstractThis review study aims at discussing the between COVID-19 and biomedical waste management. The ongoing COVID-19 pandemic has already turned healthy places around the world into a living hell with massive death tolls because of its fastest-spreading nature, and continuously leading to lockdowns in almost every part of the world. Amid all the problems so far it created, one significant problem that can create major havoc in this already devastating and contagious atmosphere in a densely populated city is, not handling medical waste properly. It was a systemic review study regarding the relationship between COVID-19 and biomedical waste management. We have gathered total 16 articles and newsletters related to COVID-19 and biomedical waste management using different search portal. After proper literature review only 10 articles and newsletters which were related to this study were taken for this systemic review purpose. If the massive number of medical wastages cannot be managed through maintaining proper and adequate guidelines, chances of community-based spreading of COVID-19 can exceed the limit and take more lives in the upcoming days. In simple term the preferred technique for the bio medical waste management is incineration. It is Adequate for all infectious waste, most chemical waste, and pharmaceutical waste.

KeywordsBio-medical waste management , pandamic covid –

INTRODUCTION

Many waste are produced as a result of human activities. Such waste may be dangerous and therefore need safe disposal. Industrial waste, sewage and agricultural waste pollute water, soil and air and it can also be dangerous to human beings and environment. Solid waste can be classified into different types depending on their source [1]. It includes

(a) House hold waste (b) Industrial waste (c) Biomedical waste or hospital waste or infectious waste. Hospital waste is considered as hazardous because they contain toxic substances. This waste is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities in these fields. Liquid waste can be divided into two components (a) Liquid reagents/ chemicals discarded and (b) the cleaning and washing water channel ed into the drain [2]. Until recently, medical waste management was not generally considered an issue. In the 1980s and 1990s, concerns about exposure to human immunodeficiency virus (HIV) and hepatitis B virus (HBV) led to questions about potential risks inherent in medical waste. Thus, hospital waste generation has become a prime concern due to its multidimensional ramifications as a risk factor to the health of patients, hospital staff and extending beyond the boundaries of the medical establishment to the general population [3]. Hospital waste refers to all waste, biologic or non-biologic that is discarded and not intended for further use. Medical waste is a subset of hospital waste; it refers to

the material generated as a result of diagnosis, treatment or immunization of patients and associated biomedical research. Biomedical waste (BMW) is generated in hospitals, research institutions, health care teaching institutes, clinics, laboratories, blood banks, animal houses and veterinary institutes Biomedical waste, also known as infectious waste or medical waste is defined as waste generated during the diagnosis, testing,

treatment, research or production of biological products for humans or animals. Biomedical

waste includes syringes, live vaccines, laboratory samples, body parts, bodily fluids and waste,

According to the Medical Waste (Management and Processing) Rules 2008, "medical wastes could not be mixed with other wastes at any stage while producing inside hospitals, while collecting from hospitals, while transporting, and would be processed separately based on classification". The ongoing COVID-19 pandemic has already turned healthy places around the world into a living hell with massive death tolls because of its fastest spreading nature, and continuously leading to lockdowns in almost every part of the world. Amid all the problems so far it created, one significant problem that can create major havoc in this already devastating and contagious atmosphere in a densely populated city is not handling medical waste properly. Chinas Wuhan, the first of the cities that got viciously brutalized by the pandemic, is home to 11 million people. Its hospitals produced more than

240 tons of medical waste daily during the peak of the outbreak compared with 40 tones before the epidemic occurred, according to Chinas Ministry of Ecology and Environments emergency office. To fight this enormous number of medical wastages, the central government deployed 46 mobile medical waste treatments facilitates to the city of Wuhan and built a new plant with a capacity of 30 tonnes within 15 days in March. Biomedical wastes are hazardous because they host potential virus particles that can be hidden beneath human tissues, items contaminated with blood bags, needles, syringes or any other sharp object, body fluids-remaining like dressings, plaster casts, cotton swabs, beddings contaminated with blood or body fluid etc. Experts say medical wastages are not like other wastes such as the household or industrial wastages. It can infect one directly through the skin or by ingestion and inhalation with objects like inhalers or ventilating pipes. Many contagious viruses including HIV and Hepatitis (B and C) can easily be generated from such wastes and can harm the ones who do not have the diseases. Germs and viruses, which are antibiotic-resistant (such as the COVID-19 at this point) can easily spread from medical waste. Biomedical wastes are

hazardous because they host potential virus particles that can be hidden beneath human tissues, items contaminated with blood bags, needles, syringes or any other sharp object, body fluids-remaining like dressings, plaster casts, and cotton swabs, beddings contaminated with blood or body fluid etc.1. The safe management of household waste is also likely to be critical during the COVID-19 emergency. Medical waste such as contaminated masks, gloves, used or expired medicines, and other items can easily become mixed with domestic garbage, but should be treated as hazardous waste and disposed of separately. These should be separately stored from other household waste streams and collected by specialist municipality or waste management operators2.

To analyze the impact of coronavirus on the production of bio medical waste Maintaining the Integrity of the Specifications

To decide to use proper technique for the bio medical waste management.

LITERATURE REVIEW

Healthcare waste comprises the waste generated by healthcare facilities, medical laboratories and biomedical research facilities. Improper treatment of this waste poses serious risks of disease transmission to waste pickers, waste workers, health workers, patients, and the community in general through exposure to infectious agents. Poor management of the waste emits harmful and deleterious contaminants into society. However, contamnation of highly contagious agents such as the COVID-19 virus has created enormous instability in healthcare waste handling and subsequent recycling because of the volume of the waste generated and its contagious nature. Several countries have adopted safety measures to combat this contamination and manage healthcare waste; however, these measures are insufficient and vary depending on the context of the country. In addition, the WHO has set out guidelines for management of healthcare waste. These guidelines are helping to manage the highly contagious healthcare waste resulting from the current pandemic. Proper healthcare waste management may add value by reducing the spread of the COVID-19 virus and increasing the recyclability of materials instead of sending them to landfill. Disinfecting and sorting out healthcare waste facilitates sustainable management and allows their utilization for valuable purposes. This review discusses the different healthcare solid waste management strategies practiced in different countries, the challenges faced during this management, and the possible solutions for overcoming these challenges. It also provides useful insights into healthcare solid waste management scenarios during the COVID-19 pandemic and a possible way forward.

Biomedical waste poses various health and environmental hazards. Hence, it should be handled with the utmost care and disposed off safely. Several lacunas exist in the management of biomedical waste in India, and the pandemic posed by the coronavirus has made it even more challenging. The sudden outbreak of the virus led to an exponential rise in the quantity of biomedical waste. Furthermore, the poor infrastructure and lack of human resources have aggravated this situation. To combat this serious problem in a timely manner, the government has formulated various standard operating procedures and has amended the existing rules and guidelines.

Biomedical waste (BMW) is generated in hospitals, research institutions, health care teaching institutes, clinics, laboratories, blood banks, animal houses and veterinary institutes. Hospital waste management has been brought into focus in India recently, particularly with the notification of the BMW (Management and Handling) Rules, 1998. This study was conducted in Sharda hospital, Greater Noida with the aim to find out bacteriological profile of BMW with study of practices being followed in management and disposal of this waste with standard procedure. Total 500 cases of biomedical waste samples were taken in the study for bacterial culture, 136 samples of biomedical waste showed growth of bacteria. Pseudomonas species was the predominant bacteria isolated from these cultures. This study also suggests about the optimum practice which is to be followed in management of biomedical waste.

Medical waste management problems are rising due to the crisis brought upon by the coronavirus disease 2019 (COVID-19) as a worldwide pandemic. The security management of medical care worldwide increases their attention due to the high risk of COVID-19 medical waste. This paper gives a review of medical waste management during the COVID-19 pandemic around the world. Furthermore, an effort has been made to prepare a review of the characteristics, generation, collection, transportation, disposal, and treatment technologies of solid waste management worldwide. Detailed data on medical waste management practices, including collection, recovery, and disposal, have been presented. The poor medical waste management in Iraq before and during COVID-19 causes a huge environmental risk and can be a possible reappearing infection source. Hence, the study also points out some recommendations for handling COVID-19 pandemic medical waste properly to reduce possible secondary effects on health and the environment and manage any possible pandemics in the future.

Considering the widespread transmission of Coronavirus disease (COVID-19) globally, India is also facing the same crisis. As India already has inadequate waste treatment facilities, and the sudden outbreak of the COVID-19 virus has led to significant growth of Bio-medical waste (BMW), consequently safe disposal of a large quantity of waste has become a more serious concern.

This study provides a comprehensive assessment of BMW of India before and during the COVID-19 pandemic. Additionally, this article highlights the gaps in the implementation of BMW rules in India. This study uses various government and non-government organizations, reports and data specifically from the Central Pollution Control Board (CPCB). The finding of the study demonstrated that most of the States/Union Territories (UTs) of India are lacking in terms of COVID-19 waste management. India has generated over 32,996mt of COVID-

19 waste between June and December 2020. During this period, Maharashtra (789.99mt/month) is highest average generator of COVID-19 waste, followed by Kerala (459.86mt/month), Gujarat (434.87mt/month), Tamil Nadu (427.23mt/month), Uttar Pradesh (371.39mt/month), Delhi (358.83mt/month) and West Bengal (303.15mt/month), and others respectively. We draw attention to the fact that many gaps were identified with compliance of BMW management rules. For example, out of all 35 States/UTs, health care facilitates (HCFs), only eight states received authorization as per BMW management rules. Moreover, the government strictly restricted the practice of deep burials; however, 23 States/UTs are still using the deep burial methods for BMW disposal. The present research suggests that those States/UTs generated on an average of 100mt/month COVID-19 waste in the last 7months (JuneDecember 2020) should be considered as a high priority state. These states need special attention to implement BMW rules and should upgrade their BMW treatment capacity

Objectives: Proper handling, treatment and disposal of biomedical wastes are important elements in any health care setting. Not much attention has been paid to the management of Biomedical Waste (BMW) in recent years, in dental colleges and hospitals in India. The present systematic review was conducted to assess knowledge and awareness regarding BMW management among staff and students of dental teaching institutions in India.

Material and Methods: A systematic review of relevant cross- sectional studies was conducted regarding BMW management in India in dental teaching institutions in India. Six studies were finally included in the present review after conducting both electronic and manual search like PubMed, EMBASE etc. and after making necessary exclusions. Potential biases were addressed and relevant data was extracted by the concerned investigators.

Results: Six studies were finally included in the review. Color coding of wastes was not done by 67% of the subjects in one of the studies conducted in Haryana. Almost all the subjects agreed to the fact that exposure to hazardous health care waste can result in disease or infection in another study. According to another study reports, none of the respondents was able to list the legislative act regarding BMW when asked.

Conclusions: The results of the present review showed that knowledge and awareness level of subjects was inadequate and there is considerable variation in practice and management regarding BMW. There is a great need for continuing education and training programmers to be conducted in dental teaching institutions in India.

The aount of biomedical waste generated per day is increasing day by day with increase in the healthcare facilities. This paper presents an analysis study of various techniques used for biomedical waste management along with the knowledge and attitude of people and healthcare workers. Along with this the scenario of biomedical waste management in various hospitals in India is discussed. This waste is sometimes very hazardous and can lead to dreadful effects. So, the waste is needed to be treated using adequate treatment method

Covid-19 Pandemic leads to medical services for the society all over the world. The Covid-19 pandemic influence the waste management and especially medical waste management. In this study, the effect of the Covid-19 outbreak on medical waste was evaluated via assessing the solid waste generation, composition, and management status in five hospitals in Iran. The results indicated that the epidemic Covid-19 leads to increased waste generation on average 102.2 % in both private and public hospitals. In addition, the ratio of infectious waste in the studied hospitals increased by an average of 9 % in medical waste composition and 121 % compared with before COVID-19 pandemic. Changes in plans and management measurement such as increasing the frequency of waste collection per week leads to lower the risk of infection transmission from medical waste in the studied hospitals. The results obtained from the present research clearly show the changes in medical waste generation and waste composition within pandemic Covid-

19. In addition, established new ward, Covid-19 ward with high-infected waste led to new challenges which should be managed properly by change in routine activities.

To discusses the different healthcare solid waste management strategies practiced in different countries, the challenges faced during this management, and the possible solutions for overcoming these challenges.

Several countries have adopted safety measures to combat this contamination and manage healthcare waste; however, these measures are insufficient and vary depending on the

context of the country. In addition, the WHO has set out guidelines for management of healthcare waste. These guidelines are helping to manage the highly contagious healthcare waste resulting from the current pandemic provides useful insights into healthcare solid waste management scenarios during the COVID-19 pandemic and a possible way forward

The most populous cities like Delhi, Mumbai, Bangalore, Chennai, Hyderabad, etc. are the most affected cities by COVID-19. According to data published by NDTV on September 18, 2020, the country is generating a considerable amount (Above 100 tones/day) of COVID-19 related biomedical waste in the country. Maharashtra contributes for approximately 17% of total COVID-19 related BMW. Now the national daily waste generation is reaching around 850 tones/day.10,11 The details on the monthly generation of COVID-19 related BMW across several state of India (From June 2020December 2020) is referenced in Table 1. The country does not have sufficient infrastructure and human resources to handle this huge amount of BMW. The presence of 198 CBMWFs and 225 captive incinerators was insufficient to dispose off 700 tonnes of waste generated in a day. This additional BMW stirred up havoc in the disposal of BMW. The workers involved in BMW management are pitching in extra hours to cater to this need.11 According to the Supreme Court report, there is an increment in the quantity of BMW ranging from 25 to 349tonnes/day during the month of MayJuly and it is expected to have doubled during the months of AugustOctober. Presently, there is a poor practice of segregation at the site of generation due to the exponential rise in the generation, thus elevating the risk to the environment. Additionally, inadequate safety measures for the BMW workers continue to remain another major challenge in the Indian

METHODOLOGY

Generally, the waste generated from healthcare facilities, research centers, and laboratories relating to medical procedures is considered healthcare waste. Approximately 7590% of healthcare solid waste is similar to waste produced in households, and is thus categorized as non- hazardous or general healthcare waste. In reality, this waste is generated from the administrative, kitchen, and housekeeping functions of medical and healthcare facilities. The remaining 1025% of waste is designated hazardous waste, which poses serious environmental and health risks (Yves charter et al., 2014). It has been observed that the composition of healthcare solid waste during the COVID-19 pandemic is more or less similar to that produced in normal circumstances, except for the generation of a huge quantity of plastics/ micro-plastics. However, the pandemic has seen the generation of a vastly increased quantity of waste (Singh et al., 2020a). As observed during normal circumstances, the composition of healthcare solid waste is very important, as this dictates its ability to be recycled and sustainably managed, which is vital during the current pandemic

Hazardous healthcare waste

Chemical waste

Chemicals are omnipresent in healthcare facilities. As major consumers of chemicals, the chemical waste these facilities generate can have deleterious impacts on health and the environment. This type of waste accounts for about 3% of waste originating from healthcare activities (Ilyas et al., 2020). Waste that contains chemical substances, i.e. laboratory reagents, film developing reagents, expired/unused disinfectants, solvents, and waste containing heavy metals (batteries, broken thermometers, blood-pressure gauges, etc.) is considered chemical

healthcare waste (Yves charter et al., 2014). Due to serious health concerns, a growing number of hospitals have substituted some of their most hazardous substances with safer alternatives and adopted careful management strategies.

However, there are plenty of facilities in both

developing and developed countries that still use these toxic chemicals and have poor chemical waste management strategies.

Infectious waste

Waste that contains infective pathogens, resulting in disease incidence and progression, is defined as infectious healthcare waste; it comprises materials contaminated with blood and body fluids, human excreta, laboratory cultures, and microbiological products (Askari net al., 2010; Yves charter et al., 2014). PPE, i.e., boots, long-sleeved gowns, heavy- duty gloves, masks, goggles, and face shields are also considered infectious waste, and waste generated from these materials has increased by a substantial amount during the COVID-19 pandemic

(WHO, 2020b). Therefore, there is a tremendous challenge in managing this type of waste during the pandemic (Rowan and Laffey, 2021).

Pathological waste

Pathological waste is typically a smaller portion, part, or slice of any tissue, organ, or body part, taken from surgical or microbiological specimens from animal or human bodies

(Yves charter et al., 2014). This type of waste originates from tissues or samples of tissues that are

inspected and/or examined in a laboratory to diagnose or study abnormality or diseased tissues. In essence, this type of waste is similar to infectious waste, and careful handling is required to manage it during the current pandemic. It can spread infection in a similar fashion to infectious waste because of the presence of infective viral particles in the tissue samples (WHO, 2020b)

Radioactive waste

Radioactive waste is a by-product of various nuclear technologies used in healthcare facilities, including nuclear medicine, radiotherapy, and reagents for research This waste contains radioactive substances, i.e., unused liquids from radiotherapy or laboratory research. Radioactive contaminated glassware, packages/absorbent paper, urine, and excreta from patients treated or tested with unsealed radionuclides also constitute radioactive waste (Yves Chertier et al., 2014). Exposure to radioactive elements can cause serious health problems and also poses a risk to the environment if not managed properly. The outbreak of the COVID-19 pandemic has compromised the containment of radioactive waste, and special measures need to be put in place to manage this toxic waste so that its exposure to humans and the environment can be minimized.

Sharps waste

Sharps waste is another type of healthcare solid waste; it is composed of used sharps including used or unused hypodermic, intravenous, or other needles, auto-disable syringes, syringes with attached needles, infusion sets, scalpels, pipettes, knives, blades, and broken glasses (Askari an et al., 2010; Halogenide et al., 2018; Mato and Cassena, 1997; Yves Chertier et al., 2014). Generated sharps healthcare waste should be treated with extra care and properly managed during the COVID-19 pandemic (WHO, 2020b), as it has been found that SARS-CoV-2 can survive on different surfaces for a certain period. Waste workers could be easily infected by sharps contaminated with the virus, and this could increase community transmission.

Pharmaceutical waste

Pharmaceutical waste can be generated from many activities and locations in healthcare facilities, i.e., pharmacies, distribution centers, and hospitals. Expired and contaminated pharmaceutical products are considered pharmaceutical waste (Yves Chertier et al., 2014). Used biological products for therapy and transdermal patches, and contaminated pharmaceuticals including vaccines, are also listed as pharmaceutical waste (Mascaro, 2020). The amount of pharmaceutical waste has increased substantially during the COVID-19 pandemic due to the increased number of hospital admissions. Waste workers who collect this type of waste from pharmacies, distribution centers, and hospitals can easily be infected with SARS-CoV-2 if they come into contact with COVID-19 patients and virally contaminated pharmaceutical waste during its collection from designated treatment units.

Non-hazardous healthcare waste

Used plastic water bottles, office paper, magazines, newspapers, food waste, and food packaging are considered

non-hazardous healthcare solid waste (Askari an et al., 2010; Halogenide et al., 2018) if not contained alongside hazardous waste. Non-hazardous waste is comparable to domestic waste and can be recycled for sustainable waste management. It is probable that both asymptomatic and symptomatic COVID- 19 patents generate a huge amount of non-hazardous SARS- CoV-2 contaminated healthcare waste during their daily actions in healthcare facilities, which poses a serious risk of community transmission.

Other waste

The test kits and waste generated from different diagnostic methods for COVID-19 are another additional type of healthcare waste that has been generated in substantial amounts during the COVID-19 outbreak, as global transmission and prevalence have necessitated the detection of infections to aid with appropriate social distancing and quarantine measures. The use of rapid test kits for identifying an infected person produces additional waste in the waste stream, as each kit is used only once. There is always a chance that this waste could be contaminated with SARS- CoV-2 and contribute to further spread if not managed properly

Treatment and disposal techniques for biomedical waste There are several methods that have been successful in the treatment of infectious waste. The following are the methods that will show the treatment that may be available at your facility. The methods are: Autoclaving, Incineration, Thermal inactivation, Gas/Vapor Sterilization, Chemical Disinfection etc.

Autoclaves are closed chambers that apply both heat and pressure, and sometimes steam, over a period of time to sterilize medical equipment. Autoclaves have been used for nearly century to sterilize medical instruments for reuse. Autoclaves are used to destroy microorganisms that may be present in medical waste before disposal in a traditional landfill. Autoclaves can be used to process up to 90% of medical waste, and are easily scaled to meet the needs of any medical organization [15]. Small counter-top autoclaves are often used for sterilizing reusable medical instruments while large autoclaves are used to treat large volumes of medical waste. Steam sterilization is most effective with low-density material such as plastics, metal pans, bottles, and flasks [16]. High-density polyethylene and polypropylene plastic should not be used in this process because they do not facilitate steam penetration to the waste load. Plastic bags should be placed in a rigid container before steam treatment to prevent spillage and drain clogging. Bags should be opened and caps and stoppers should be loosened immediately before they are place in the steam sterilizer. Care should be taken to separate infectious wastes from other hazardous wastes. Infectious waste that contains noninfectious hazards should not be steam-sterilized [17]. Waste that contains anti neoplastic drugs, toxic chemicals, or chemicals that would be volatilized by steam should not be steam-sterilized.

Incineration

Thermal inactivation

Thermal inactivation involves the treatment of waste with high temperatures to eliminate infectious agents. This method is usually used for large volumes [20]. Liquid waste is collected in vessel and heated by heat exchangers or a steam jacket surround the vessel. The types of pathogens in the waste determine the temperature and duration of treatment. After treatment, the contents can be discharged into the sanitary sewer in a manner that complies with State, Federal, and local requirements. This method requires higher temperatures and longer treatment cycles than steam treatment.

Gas/vapor sterilization

Gas/vapor sterilization uses gaseous or vaporized chemicals as the sterilizing agents. Ethylene oxide is the most commonly used agent, but should be used with caution since it is a suspected human carcinogen. Because ethylene oxide may be adsorbed on the surface of treated materials, the potential exists for worker exposure when sterilized materials are handled [20].

Chemical disinfection

Chemical disinfection is the preferred treatment for liquid infectious wastes. Consider the following: Type of microorganism, Degree of contamination, Amount of proteinaceous material present, Type of disinfectant, Contact time, Other relevant factors such as temperature, pH, mixing requirements, and the biology of the microorganism [20]. Ultimate disposal of chemically treated waste should be in accordance with State and local requirements

Disposal of treated waste:

Infectious waste that has been effectively treated is no longer biologically hazardous and may be mixed with the disposed of as ordinary solid waste, provided the waste does not pose other hazards that are subject to federal or state regulations.

EPA recommends:

Contacting state and local governments to identify approved disposal options.

• <>Discharge of treated liquids and pathological wastes (after grinding) to the sanitary sewer system.

Approval of the local sewer authority must be obtained.

Health hazard from biomedical waste

The improper management of bio-medical waste causes serious environmental problems in terms of air, water and land pollution. The nature of pollutants can be classified into

Air Pollution can be caused in both indoors and outdoors. Bio-Medical Waste that generates air pollution is of three types – Biological, Chemical and Radioactive. Indoor air pollutants like pathogens present in the waste can enter and remain in the air in an institution for a long period in the form of spores or as pathogens itself. Chemical Pollutants that cause outdoor air pollution have two major sources- open burning and incinerators [21]. Open burning of biomedical waste is the most harmful practice and should be strictly avoided

Water Pollution is another major threat from Bio-medical waste. If the waste is dumped in low-lying areas, or into lakes and water bodies, can cause severe water pollution. Water pollution can either be caused due to biological, chemicals or radioactive substances [22]. The pathogens present in the waste can leach out and contaminate the ground water or surface water. Harmful chemicals present in bio-medical waste such as heavy metals can also cause water pollution.

Challenges of biomedical waste in India

(Bio-medical Waste (Management and Handling) Rules. Ministry of

Environment and Forests Notification, New Delhi. 1998)

To treat 420561 kg per day of bio medical waste in accordance with Bio-Medical Waste Rules.

Number of Common Bio Medical Wastes Treatment Facility (CBMWTF) to be increased manifold. Presently there are 157 facilities which are not adequate to handle all the bio medical wastes generated

CBMWTF is to be set up under public private partnership mode.

New technologies to be promoted for destruction of toxic bio medical wastes.

Which treatment is preferable?

Incineration is a high-temperature dry oxidation process that reduces organic and combustible waste to inorganic, incombustible matter and results in a very significant reduction of waste volume and weight. This process is usually selected to treat wastes that cannot be recycled, reused, or disposed of in a landfill site. The process flow is illustrated schematically in. The combustion of organic compounds produces mainly gaseous emissions, including steam, carbon dioxide, nitrogen oxides, and certain toxic substances (e.g. metals, halogenic acids), and particulate matter, plus solid residues in the form of ashes. If the conditions of combustion are not properly controlled, toxic carbon monoxide will also be produced. The ash and wastewater produced by the process also contain toxic compounds, which have to be treated to avoid adverse effects on health and the environment. Most large, modern incinerators include energy-recovery facilities. In cold

climates, steam and/or hot water from incinerators can be used to feed urban district-heating systems, and in warmer climates the steam from incinerators is used to generate electricity. The heat recovered from small hospital incinerators is used for preheating of waste to be burnt.

BMW is directly related to waste management which is indeed related environmental engineering as this targets environmental safety.

Objective of environmental engineering is to ensure societal development and use of land, water and air resources are sustainable. These targets are achieved by managing these resources so that environmental pollution and degradation is minimized.

The ongoing COVID-19 pandemic has already turned healthy places around the world into a living hell with massive death tolls because of its fastest-spreading nature, and continuously leading to lockdowns in almost every part of the world. Amid all the problems so far it created, one significant problem that can create major havoc in this already devastating and contagious atmosphere in a densely populated city is, not handling medical waste properly.

If the massive amount of medical wastages cannot be managed through maintaining proper and adequate guidelines, chances of community-based spreading of COVID-19 can exceed the limit and take more lives in the upcoming days In simple term the preferrable technique for the bio medical waste management is incineration. It is Adequate for all infectious waste, most chemical waste, and pharmaceutical waste and also very high disinfection efficiency.

BWM Relevance To Civil Engineering

Bio medical waste in itself is a huge problem. As developing countries are making transition into developed countries, need for healthcare is increasing and due to such economic advancements, BMW waste generation is also increasing at rapid pace.

In India BMW is a huge problem. There is lack of awareness and absence of stringent rules and regulations l, it is sometimes found that hospitals are dumping waste into ground or river which is very dangerous because it contains hazardous and infected substance like blood, skin, imputed organs, syringe, needles, etc.

As an aware citizen and a civil engineer, it is our responsibility to find efficient ways to properly treat BMW. As a civil engineer we need to work towards making structures so that BMW is properly treated so that the damage footprint is least on river or land. Our job is to make product reusable by transforming it into usable product.

Daljit Kapoor , Ashutosh Nirola , Vinod Kapoor , Ramandeep-Singh Gambhir 4 Journal of Environmental Health Science and Engineering (2021) 19:831836 https://doi.org/10.1007/s40201-021-00650-9

Dr Irin Hossain*1, Dr Ashekur Rahman Mullick2, Dr Shazly Bari3,Mohammad Tahsin Islam4 Dr Irin Hossain et al JMSCR Volume 08 Issue 05 May 2020

Kerkar, S. S., and S. S. Salvi. "Application of eco-enzyme for domestic waste water treatment." International Journal for Research in Engineering Application and Management 5.11 (2020): 114-116.

Lee B K, Ellenbecker M J and Moure-Ersaso R 2004 Alternatives for treatment and disposal cost reduction of regulated medical wastes, Waste management 24(2):143-51.

Michael Ugom, 2020 Managing Medical Wastes During the Covid-19 Pandemic in Nigeria,

Prüess A, Giroult E, Rushbrook P 1999 Safer management of wastes from Medical care Activities.World Health Organization, Geneva.

Ritchie H, Ortiz-Ospina E, Beltekian D, Mathieu E, Hasell J, Bobbie Macdonald B,Charliem Giattino C and Roser M 2020 Coronavirus (COVID-19) deaths. https://ourworldindata.org/covid-deaths

Rutala WA, Weber DJ. Disinfection, sterilization and control of hospital waste. In: Mandell, Douglas and Bennett's Principles andpractice of infectious diseases 2005; (6th Ed.). Elsevier Churchill Livingstone Publication. Pg: 3331-47.

Salvi, Sahil & Mantute, Komal & Sabale, Rutuja & Lande, Siddhi & Kadlag, Akash & Professor, Assistant. (2021). A STUDY OF WASTE PLASTIC USED IN PAVING BLOCK. 2320-2882.

Sharma M. Hospital waste management and its monitoring, 2002; (1st Ed.), Jaypee Brothers Medical Publication.

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Knowledge, attitude and practice towards bio-medical waste management among healthcare workers: a northern Saudi study

Ashokkumar thirunavukkarasu.

1 Department of Community and Family Medicine, College of Medicine, Jouf University, Sakaka, Aljouf, Saudi Arabia

Ahmad Homoud Al-Hazmi

Umar farooq dar, ahmed mohammed alruwaili.

2 Medical Student, College of Medicine, Jouf University, Sakaka, Aljouf, Saudi Arabia

Saleh Dhifallah Alsharari

Fahad adel alazmi, saif farhan alruwaili, abdullah mohammed alarjan, associated data.

The following information was supplied regarding data availability:

The raw data is available as a Supplemental File .

Health care workers (HCWs) involved in day-to-day care and other healthcare activities play a significant role in biomedical waste (BMW) management. The World Health Organization stated some of the causes for the failure of BMW management, namely, lack of awareness of the health hazards related to BMW and inadequate trained HCWs in BMW management. The present study assessed knowledge, attitude, and practice (KAP) towards BMW management among the HCWs in northern Saudi Arabia.

Methodology

The present study assessed KAP through a self-administered and validated questionnaire. Using a multistage probability sampling method, 384 HCWs from different healthcare facilities participated in this survey. We performed binomial logistic regression analysis to find association between KAP subscales and sociodemographic characteristics. Spearman’s correlation test was performed to find the strength and direction of correlation ( rho ) between KAP scores.

Of the population studied, high knowledge, attitude, and practice scores were found in 47.1%, 65.1%, and 49.5% of the HCWs, respectively. The present study found that knowledge score was significantly higher among the age group from 30 to 39 years (ref: age less than 30 years: AOR = 2.25, 95% CI [1.05–4.85], p  = 0.04) and non- Saudi nationals (ref: Saudi: AOR = 2.84, 95% CI [1.63–4.94], p  < 0.001) The attitude score towards BMW management was significantly lower among the HCWs working in tertiary care settings (ref: PHC: AOR = 0.38, 95% CI [0.12–0.69], p  = 0.01). Regarding the practice score, the male categories had a significantly higher score (ref: female: AOR = 1.82, 95% CI [1.19 –2.99], p  = 0.02), while pharmacist (ref: physicians: AOR = 0.39, 95% CI [0.18–0.58], p  = 0.02) and lab technicians (ref: physicians: AOR = 0.31, 95% CI [0.11–0.53], p  = 0.02) had a significant lower practice score. The test results revealed a weak positive correlation of knowledge with the attitude scores (rho = 0.249, p  = 0.001), and a moderately strong positive correlation was found between attitude and practice scores (rho = 0.432, p  = 0.001).

This study suggests that a regular training program for the HCWs on BMW management is necessary through symposiums, role play, interactive lectures, and other feasible training methods. Furthermore, a multicentric prospective exploratory study is to be conducted in other regions of the KSA to understand the region-specific training needs of HCWs.

Introduction

Biomedical waste (BMW) is defined as “any type of waste that is generated during diagnosis, treatment, or research in humans and/or animals” ( Singh et al., 2001 ). As per the World Health Organization (WHO), around 85% of the total amount of waste generated during healthcare activities is non-hazardous waste similar to domestic waste, and only 15% is considered hazardous waste that includes various forms of waste such as human anatomical parts, blood and tissues, radiation waste, chemo-toxic drugs, and broken medical equipment ( WHO, 2021 ). BMW is commonly generated in hospitals, primary health care facilities, medical colleges, research centers, and veterinary hospitals ( Pandey et al., 2016 ; Meleko, Tesfaye & Henok, 2018 ).

Advancement in medical care and the introduction of more advanced equipment has dramatically increased the amount of waste generated per patient in healthcare facilities worldwide. Globally, a large amount of health care waste generated everyday ranges from 0.9 kg/bed/day to 3 kg/bed/day. In the Kingdom of Saudi Arabia (KSA), the amount of health care generation is reported as 1.66 kg/bed/day ( Alagha, Alomari & Jarrah, 2018 ). The WHO stated that around 16 billion injections are given every year for treatment or immunization. Unfortunately, not all used needles and syringes are disposed of as per the legislation and safety norms, leading to the risk of needle prick injury and acquiring the related infection. This also provides opportunities for reuse ( WHO Injection Safety Geneva, 2022 ). The COVID-19 pandemic worsens the existing healthcare waste burden as healthcare waste management during the COVID-19 pandemic has faced several challenges due to increased production of infectious waste, interruption of recycling strategy, and inadequate resources to handle increased waste production ( Dehal, Vaidya & Kumar, 2022 ; Kothari et al., 2021 ; Rahman et al., 2020 ; Das et al., 2021 ).

Health care workers (HCWs) involved in day-to-day care to the patients and other health care activities play a significant role in BMW management ( Wafula, Musiime & Oporia, 2019 ; Letho et al., 2021 ). The WHO classifies these health workers into several categories: general and specialist medical practitioners, nurses and midwifery professionals, complementary medicine practitioners, pharmacists, physiotherapists, etc. ( WHO, 2021 ). The WHO stated some of the causes for the failure of BMW management, namely, lack of awareness about the health hazards related to BMW, inadequate trained HCWs in BMW management, lack of legislation and rules regarding waste management systems, inadequate human and monetary resources ( WHO Healthcare Waste Geneva, 2021 ).

Deress et al. (2018) conducted a study in 2018 that assessed the KAP of healthcare professionals of northwest Ethiopia towards BMW management and associated factors for good KAP scores. They found that 56.8%, 66.2%, and 77.4% of the HCWs had good knowledge, attitude, and practice scores, respectively. Regarding the associated factors, those who had higher level qualifications and the availability of color-coded bins were more likely to have favorable KAP scores. Another survey conducted by Jalal et al. (2021) during COVID-19 times that evaluated the KAP toward BMW management among healthcare professionals stated that nearly a quarter of healthcare professionals had poor knowledge regarding BMW management. The mean knowledge scores were significantly higher among nurses and physicians than others.

In the KSA, infection control and BMW management are implemented uniformly in all healthcare facilities according to ministry of health (MOH), KSA and Gulf Cooperation Council Centre for Infection Control policies ( NGHA, 2022 ). The infection prevention and control departments have primary responsibilities to train HCWs. All national HCWs seeking jobs in healthcare facilities must clear the Saudi Commission for Health Specialties test to qualify for health sector jobs. However, there are no specific requirements for separate and compulsory BMW management and infection control training to apply for health sector jobs and contract renewal. Assessment of knowledge, attitude, and practices (KAP) towards BMW among the HCWs are essential in planning the training program for them towards BMW management to the extent they need ( Al Balushi et al., 2018 ; Reddy & Al Shammari, 2017 ; Olaifa, Govender & Ross, 2018 ) so that they will dispose of the BMW according to the regulation implemented in their hospitals; this will eventually decrease the health hazards that will arise from BMW ( Alqahtani et al., 2019 ; Aliyu et al., 2017 ). To the best of the authors’ knowledge, there is limited data available in northern Saudi Arabia on this topic. Therefore, the present study was planned to assess knowledge, attitude, and practice in the management of biomedical waste among the HCWs of public healthcare facilities in Aljouf province, KSA, to determine the influencing factors on knowledge, attitude, and practices among them and to identify the correlation between the scores of knowledge, attitude, and practices.

Participants & Methods

Study design and setting.

The present cross-sectional survey was conducted from December 2021 to February 2022 among the HCWs from different healthcare facilities in Aljouf province, Saudi Arabia. The Aljouf province is located in the northern regions of the KSA. The present study included the HCWs working in the healthcare facilities under the ministry of health (MOH) for a minimum of one year. Currently, in the KSA, healthcare is provided through four levels, namely, primary health centers (PHC), general hospitals, specialty hospitals, and medical cities. There are 62 primary health centers, 13 general hospitals, and two specialty hospitals in the Aljouf province under the MOH, KSA. The HCWs from the infection control department and those not willing to participate were excluded from the study. Also, those on vacation were excluded from the sampling frame when selecting sample participants.

Sample size and sampling method

We calculated the required sample for this study based on Cochran’s sample size estimation equation (n = z2pq/e2). In this formula, n is the number of participants required, z  = 1.96 in 95% confidence interval,  p = expected proportion,  q = 1-p, and e is 5% of margin of error. Since previous studies reported different prevalence on this subject, we have taken 50% as the expected proportion to obtain the maximum sample size. Applying the values mentioned above in Cochran’s equation, the estimated sample size for the present study was 384.

The research team applied the multistage probability proportional sampling (PPS) method to select the required number of HCWs in each category. Firstly, we have included all the 62 PHCs from the Aljouf province. Then a general hospital (from 13 hospitals) and a tertiary care hospital (from two hospitals) in the Aljouf region were selected using the lot method. The required number of participants was selected from each type of healthcare facility based on the total HCWs registered in the facilities. After obtaining approval from selected healthcare facilities, we have arranged the total HCWs according to the assigned numbers in the ascending order for each type of healthcare facility. Finally, we have applied a systematic random sampling method according to the allotted number to select the participants from each healthcare facility.

Data collection methods

The present study data collection began after obtaining the required ethical clearance from the regional ethics committee, Aljouf region (Local research ethics committee, Qurayat Health Affairs, Ministry of Health, KSA: Approval number-116), and concerned healthcare facilities authorities. The research team communicated with the selected participants for their availability to collect data. Data collectors made three attempts to contact the selected participants in one month. A selected participant who could not be reached despite three attempts in a month and who was unwilling to participate was considered nonrespondent. The next HCW of the same category was invited to participate in the survey in case of nonrespondent.

Survey questionnaire

After briefing the study objectives and obtaining written informed consent from the participants of the present study, we conducted the data collection process using a self-administered, standard, validated questionnaire adapted from a previously published study ( Jalal et al., 2021 ). The research team obtained written permission from the corresponding author of the study by Jalal SM et al. to use and adapt/modify for local settings. After receiving the data collection tool (with the necessary permission to adapt and modify) from the reference study author, the present research team modified it to reduce the duration of the survey to improve the validity and reliability as suggested by existing literatures ( Story & Tait, 2019 ; Kost & de Rosa, 2018 ). We have followed the following steps to test the validity and reliability of the adapted questionnaire before proceeding to collect data. Firstly, the adapted tool is reviewed by the community medicine and infection control department experts through a focus group discussion. Secondly, we have conducted a pilot study among thirty different category HCWs in the local settings. All pilot study respondents acknowledged that the data collection form was simple, clear, and easy to understand. Furthermore, there was no missing data in all thirty completed forms. Cronbach’s alpha ( α ) values for the knowledge, attitude, and practice scores were 0.75, 0.83, and 0.86, which exhibited good internal consistency in the current form of the data collection tool. A google form was created and given to the selected participants in the personal digital device of the data collector. However, only the principal investigator had the authorization to access and download the spreadsheet. The data collection form consisted of two sections. The first section inquired about the participants’ background details, including age, gender, education status, marital status, nationality, HCW category, and duration of work experience. In our study, HCWs were grouped into five categories, namely, medical practitioners, nursing and midwifery professionals, laboratory technicians, pharmacists, and others (this includes remaining all categories mentioned in the classification of WHO) ( WHO, 2021 ). We categorized the continuous data (age and duration of work experience) as per the class interval. Since the Ph.D./Fellowship in education status category is less than 30, as a rule of thumb, we combined it with masters and regrouped it into a master’s and above. A similar rule we have applied for the marital status for grouping. The second section consisted of ten questions in knowledge, attitude, and practice categories. In the knowledge section, we inquired about participants’ knowledge regarding different forms and sources of BMW, disposal methods, and hazards due to improper BMW management. Correct answers were given as one mark in the knowledge category, and wrong answers were given zero marks. In both attitude and practice categories, the participants responded on a 5-point Likert scale as “strongly agree,” “agree,” “neutral,” “disagree,” and “strongly disagree,” which were given scores 5, 4, 3, 2, and 1, respectively. Overall knowledge, attitude, and practice scores were interpreted as high (score 80% and above), medium (60 to 79%), and low (less than 60%).

Statistical analysis

The spreadsheet (excel) is exported to the statistical package for social science (SPSS) version 20 and coded as per the predefined coding sheet for further analysis. The present study’s descriptive statistics are presented as frequency (n) and proportion (%). In Saudi Arabia, the HCWs are expected to have excellent/good knowledge (≥ 80%) in infection control and other common public health activities as they are the first in line in managing the BMW. Our categorization is in accordance with the original Bloom’s cut-off point for assessing KAP and is supported by previous studies conducted among healthcare workers in the KSA and other parts of the world ( Mohammed Basheeruddin Asdaq et al., 2021 ; Feleke, Wale & Yirsaw, 2021 ; Abalkhail et al., 2021 ). Additionally, we combined low and medium scores as a single category for further analysis, and previous studies among the HCWs strongly support our categorization ( Abalkhail et al., 2021 ; Thirunavukkarasu et al., 2021 ; Ukwenya et al., 2021 ). The association of the subscales’ categories and sociodemographic characteristics was assessed by Pearson’s chi-square test. Furthermore, we performed binomial logistic regression analysis to find the predictors for the subscales of KAP. In this technique, we adjusted the covariables of the study to get an adjusted odds ratio (AOR) The Kolmogorov–Smirnov normality test (KS) of the knowledge, attitude, and practice data did not meet the normality assumption. Therefore, we have executed Spearman’s correlation test to find the strength and direction of correlation ( rho ) between knowledge, attitude, and practice scores ( de Winter, Gosling & Potter, 2016 ). All statistical tests used in this study were two-tailed and a p -value less than 0.05 was established as a statistically significant value.

Table 1 depicts the sociodemographic characteristics of the respondents. Of the 384 participants, the majority (59.9%) respondents were males, Saudi nationals (71.1%), married (46.1%), highest education qualification as bachelor’s degree (60.4%), and had 5 to 10 years of work experience in the healthcare settings (34.6%). Of the sample studied, 35.9% of the HCWs were nurses and midwiferies, 37.0% were working at general hospitals, and the mean (±SD) of the age of the participants was 34.35 ± 9.5 years.

Figure 1 presents the categorization (low/medium/high) of KAP scores. Of the 384 respondents, high knowledge, attitude, and practice scores were found in 47.1%, 65.1%, and 49.5% of the HCWs, respectively.

The cross-tabulation between knowledge score categories and sociodemographic characteristics found a significant association between age groups ( p  = 0.001), nationality ( p  = 0.001), education status ( p  = 0.018), and work experience duration ( p  = 0.01). Of the studied participants, high knowledge was noticed among the HCWs aged 40 years and above (56.1%), who had higher education qualifications (65.5%), and work experience of more than 10 years (58.1%) ( Table 2 ).

The cross-tabulation between attitude score categories and sociodemographic characteristics is presented in Table 3 . Of the 384 samples analyzed, a significant association was found among health care working settings ( p  = 0.005) and work experience ( p  = 0.001). No other sociodemographic characteristics, including age, gender, nationality, marital status, education and HCWs category had a significant association with the attitude score categories.

Cross-tabulation between practice score categories and sociodemographic characteristics found a significant association between age groups ( p  = 0.001), gender ( p  = 0.008), nationality ( p  = 0.001), marital status ( p  = 0.020), and duration of work experience ( p  = 0.001) ( Table 4 ).

Binomial logistic regression analysis on KAP subscales (low/medium vs high) and its association with participants sociodemographic characteristics are presented in Table 5 . The present study found that knowledge score was significantly higher among the age group from 30 to 39 years (ref: age less than 30 years: AOR = 2.25, 95% CI [1.05–4.85], p  = 0.04), non- Saudi nationals (ref: Saudi: AOR = 2.84, 95% CI [1.63–4.94], p  < 0.001), and those with higher education (ref: diploma holder: AOR for bachelors = 1.98, 95% CI [1.06−3.68], p  = 0.04 and AOR for masters and above = 3.78, 95% CI [1.59−8.97], p  = 0.03). The attitude score towards BMW management was significantly lower among the HCWs working in tertiary care settings (ref: PHC: AOR = 0.38, 95% CI [0.12–0.69], p  = 0.01). Regarding the practice score, the male categories had a significantly higher score (ref: female: AOR = 1.82, 95% CI [1.19–2.99], p  = 0.02), while pharmacist (ref: physicians: AOR = 0.39, 95% CI [0.18–0.58], p  = 0.02) and lab technicians (ref: physicians: AOR = 0.31, 95% CI [0.11–0.53], p  = 0.02) had a significant lower practice score.

The present study data did not meet the normality assumption criteria. Therefore, we have executed Spearman’s correlation test. The test results revealed a weak positive correlation of knowledge with the attitude ( rho = 0.249, p  = 0.001) and practice scores ( rho = 0.104, p  = 0.042). Also, a moderately strong positive correlation was found between attitude and practice scores ( rho = 0.470, p  = 0.001) ( Table 6 ).

Improper handling of medical waste generated at health care facilities may pose a serious threat to the HCWs, common people and the surrounding environment, asserted by the WHO, UN, and CDC ( WHO, 2021 ; CDC, 2021 ). Since the HCWs play an important role in regulated biomedical waste disposal, it is important to have a high level of awareness. This emphasizes the importance of evaluating the knowledge, attitude, and practice of HCWs with respect to BMW management and the factors that influence them.

Knowledge is an essential resource in health science education, and inadequate knowledge may lead to improper application of knowledge that may be detrimental to any healthcare organization ( Karimi, Hosseinian & Ahanchian, 2014 ; Shahmoradi, Safadari & Jimma, 2017 ). The present study results revealed that less than half (47.1%) of the participants had high knowledge of medical waste management generated at their work settings. Similar to our study findings, a recent survey conducted by Jalal SM in the Al-Hasa region of the KSA also found that only 41% of the healthcare professionals had excellent knowledge of biomedical waste disposal ( Jalal et al., 2021 ). Interestingly, surveys conducted in some other countries also reported that a low proportion of the HCWs had favorable knowledge of healthcare handling and disposal ( Deress et al., 2018 ; Olaifa, Govender & Ross, 2018 ; Woromogo et al., 2020 ; Krithiga et al., 2021 ). In contrast to our study, a study conducted by Reddy & Al Shammari (2017) in the Hail region of the KSA and Akkajit, Romin & Assawadithalerd (2020) in Thailand stated that a higher proportion of healthcare professionals had good knowledge. The possible difference between our study and the latter studies could be the inclusion of healthcare facilities. The present study included multiple healthcare facilities (PHCs, general and tertiary hospitals), while later included outpatient clinics and PHCs.

Our study found a significant association between knowledge category and age groups (ref: age less than 30 years: AOR = 2.25, 95% CI [1.05–4.85], p  = 0.04), nationality(ref: Saudi: AOR = 2.84, 95% CI [1.63–4.94], p  < 0.001), and education status (ref: diploma holder: AOR = 3.78, 95% CI [1.59−8.97], p  = 0.03) Other surveys conducted in the KSA, and other countries support the present study results. Jalal et al. (2021) conducted a survey in 2021 which also revealed a statistically significant association between the excellent knowledge category and the level of education qualification, genders, and work experience. However, the present study did not find a significant association between gender and knowledge category. Educational qualification is one of the important factors that influence the ability to have high knowledge. The results of the current study revealed that HCWs who had a higher level of education had a significantly higher level of knowledge than diploma holders (ref: diploma holder: AOR = 3.78, 95% CI [1.59−8.97], p  = 0.03). Similar to the current study findings, other surveys conducted by Deress et al. (2018) , Reddy & Al Shammari (2017) and Dixit et al. (2021) also revealed a positive association among highly qualified healthcare professionals. It is worth mentioning again that all national HCWs working in healthcare facilities had to clear the Saudi Commission for Health Specialties test to get eligible for health sector jobs. However, there are no specific requirements for separate and compulsory BMW management and infection control training to apply for health sector job and contract renewal. A study done by Al-Ahmari, Alkhaldi & Al-Asmari (2021) reported that the majority of the primary care professionals did not receive sufficient infection control training programs, which affects their knowledge significantly. The Saudi government initiated Saudization for health sector jobs and young Saudi graduates are entering the job market. This could be the possible reason for the significant association between knowledge scores with the nationality and age group ( Elsheikh et al., 2018 ; Al-Hanawi, Khan & Al-Borie, 2019 ).

A positive attitude will guide the HCWs to follow the standards, protocols, and evidence-based practices established by the healthcare organization ( Mariano et al., 2018 ; Sayankar, 2015 ). This study found that nearly two-thirds of the participants had a high attitude towards biomedical waste disposal (65.1%). Using binomial logistic regression analysis, a significant association with attitude was found among different work settings (ref: PHC: AOR = 0.38, 95% CI [0.12–0.69], p  = 0.01), and no other sociodemographic variables were significantly associated with attitude. Identical to our study findings, a study by ( Dalui, Banerjee & Roy, 2021 ) also found that a high proportion of healthcare providers had an excellent attitude towards BMW management. Another study conducted in Cairo, Egypt, reported that the duration of work experience was not significantly associated with attitude ( Hakim, Mohsen & I, 2014 ). Interestingly, some studies found that doctors had a higher positive attitude towards healthcare waste disposal than nurses and other HCWs ( Reddy & Al Shammari, 2017 ; Hakim, Mohsen & I, 2014 ; Basavaraj, Shashibhushan & Sreedevi, 2021 ). These huge variations in the results among different studies could be due to the variations in data collection tools, survey settings, and cultural variations.

The present study results revealed that only half of the participants had high scores in practice. Our study found a positive association with practice scores were found among male gender (ref: female: AOR = 1.82, 95% CI [1.19–2.99], p  = 0.02), and HCW category (ref: physicians: AOR = 0.39, 95% CI [0.18–0.58], p  = 0.02). Similar to our study, Reddy & Al Shammari (2017) also reported that only 50% of the HCWs had excellent practice scores. In contrast to the present study results, a survey conducted in Ethiopia reported that a higher proportion of HCWs had a satisfactory practice score ( Deress et al., 2018 ). In contrast to the current study findings, some other surveys found a positive association of duration of work experience and older age with the practice scores ( Reddy & Al Shammari, 2017 ; Akkajit, Romin & Assawadithalerd, 2020 ; Hakim, Mohsen & I, 2014 ). Similar to this study results, some studies found a positive association with the type of HCW ( Dalui, Banerjee & Roy, 2021 ; Rao et al., 2018 ). The present study’s results revealed that BMW management practices were not significantly associated with the marital status of the participants. Similarly, a study conducted by Desta et al. (2018) did not find an association between marital status and good practice. Interestingly, a survey conducted in the KSA in 2021 on assessing KAP among the HCWs on the COVID-19 prevention found a significant association between marital status and appropriate practices ( p  = 0.024) ( Almohammed et al., 2021 ).

The Spearman’s rank correlation test results revealed a weak positive correlation of knowledge with the attitude scores ( rho = 0.249, p  = 0.001), and a moderately strong positive correlation was found between attitude and practice scores (rho = 0.432, p  = 0.001). These findings reassert the importance of association between KAP for the proper BMW management. Furthermore, our results conclude that the HCW’s favorable knowledge led to positive attitude and proper practice. Our study results are supported by several studies that assessed KAP towards healthcare waste management in different countries ( Reddy & Al Shammari, 2017 ; Woromogo et al., 2020 ; Akkajit, Romin & Assawadithalerd, 2020 ).

Even though the present study was conducted with the proper methodology and adequate sample size among different HCWs working in multiple healthcare facilities, certain limitations are to be noted on reading the results of this survey. Firstly, we assessed only the association through this cross-sectional survey, not the causation and direction. Secondly, the possible bias associated with the self-reported data could influence the results of this survey. Finally, this survey was conducted in the northern region of the KSA, and therefore, the findings cannot be generalized to the other areas of the KSA and other countries in the Middle East.

Conclusions

The present study assessed KAP towards BMW among healthcare providers working in different healthcare facilities using a standard and validated tool. Our study revealed that less than half of the participants had insufficient knowledge and practice scores, while one-third had low and medium attitude scores. Furthermore, our results conclude that the HCW’s good knowledge may lead to a positive attitude and proper practice. The findings of this study suggest that a regular training program for the HCWs on BMW management is necessary through symposiums, role-play, interactive lectures, and other feasible training methods. These training programs can be focused and targeted oriented to the HCWs category with low and medium scores in KAP. Finally, a multicentric prospective exploratory study is to be conducted in other regions of the KSA to understand the region-specific training needs of the HCWs.

Supplemental Information

Supplemental information 1, acknowledgments.

The research team wish to thank all healthcare workers for their participation in this study. We also extend our thanks to the healthcare facilities for facilitating data collection in their healthcare settings. Finally, we wish to thank Dr. Bashayer Farhan ALruwailli, Assistant Professor of Family Medicine, Jouf University for her input for the article during revision time.

Funding Statement

This work was funded by the Deanship of Scientific Research at Jouf University under grant number (DSR-2021-01-03144). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Additional Information and Declarations

The authors declare there are no competing interests.

Ashokkumar Thirunavukkarasu conceived and designed the experiments, performed the experiments, analyzed the data, prepared figures and/or tables, authored or reviewed drafts of the article, and approved the final draft.

Ahmad Homoud Al-Hazmi conceived and designed the experiments, performed the experiments, prepared figures and/or tables, authored or reviewed drafts of the article, and approved the final draft.

Umar Farooq Dar conceived and designed the experiments, performed the experiments, prepared figures and/or tables, authored or reviewed drafts of the article, and approved the final draft.

Ahmed Mohammed Alruwaili analyzed the data, authored or reviewed drafts of the article, and approved the final draft.

Saleh Dhifallah Alsharari performed the experiments, analyzed the data, authored or reviewed drafts of the article, and approved the final draft.

Fahad Adel Alazmi conceived and designed the experiments, performed the experiments, analyzed the data, authored or reviewed drafts of the article, and approved the final draft.

Saif Farhan Alruwaili analyzed the data, authored or reviewed drafts of the article, and approved the final draft.

Abdullah Mohammed Alarjan conceived and designed the experiments, performed the experiments, analyzed the data, authored or reviewed drafts of the article, and approved the final draft.

The following information was supplied relating to ethical approvals (i.e., approving body and any reference numbers):

The Research Ethics Committee Qurayyat Health Affairs approved this study (Approval number-116).