Medical waste: Masaka’s neglected health hazard

Dangerous. A Masaka hospital cleaner drops waste at the dumping site on February 2. photo By Moses Muwulya

What you need to know:

  • Concern. Many hospitals in the country burn infectious waste in open pits, which exposes human life to toxic emissions that cause respiratory complications.

Masaka.

As she gets out of her house, 30-year-old Annet Nabbada finds her child holding a piece of stained cotton wool.
“Dirty, dirty! Put it down, these dogs have again carried hospital waste from the dumping site to our compound,” she exclaims as she runs towards the child.
Nabbada curses Masaka Regional Referral Hospital administration for reckless dumping of its medical waste near residences and taking long to incinerate it, resulting in choking stench.
Her neighbour Shamira Nakagwa says they have to keep a keen eye on their children who often loiter around the dumping site, picking infectious waste such as syringes, which expose them to injury.
Before the two mothers conclude their narrative, an old man comes dragging a big waste bin, walks through burnt waste mostly syringes.
Standing in the middle of the pit, bare-handed, he starts emptying the bin of soiled cotton wools and other forms of infectious waste. He picks a can of fuel and burns the waste.
However, the residents say the burning worsens the situation as the resultant toxic emissions hang in the air and cause respiratory complications.
“We do not know what happened because they used to use an incinerator. They now dump and burn waste in an open shallow pit,” a female resident who preferred anonymity lamented.
The duo stays in the backyard about 30 metres away from where the hospital dumps and burns its medical waste.
A similar ordeal is echoed by residents near Lyantonde General Hospital in Lyantonde District.
“The stench from the site where the hospital drops its waste before it is taken is unbearable. It covers the entire place and at worst scenarios, the flies from it get into contact with our household utensils,” says Mr John Kaweesi, a resident of Lyantonde Town.
He says their efforts to seek help from the municipal authorities have been fruitless.
The Ministry of Health classifies this waste as: Highly infectious waste such as amputated limbs, placenta, extracted teeth, used test tubes and test kits, used blood bags, and food items from highly infectious patients.
Infectious waste: It includes used gauze, used cotton, pads and clothes, and contaminated bottles for infusion fluids.
Sharps: These are used syringes, needles cut off infusion sets, used scalpels, broken glass, ampoules, and cannulas.
Pharmaceutical waste: These include expired and damaged drugs, lab reagents, empty vials and heavy metals.
Non-infectious waste: These contain food items, empty bottles for drinks, paper, and packaging material.
In Uganda, infectious and non-infectious waste generated in hospitals averages 92kg and 42kg at Health Centre IVs level daily. Health Centre IIs and IIIs generate about 20kg to 25kg of waste.
According to WHO, 15 per cent of medical waste is harmful material and infectious. Such waste requires safe disposal to prevent health care workers, waste handlers, patients and communities in the vicinity of the respective health facilities from risks of nosocomial infections and other hazards.
Nosocomial infections are health care related and acquired from health facilities due to breaches of infection control practices for proper waste disposal.
In Uganda, many hospitals burn infectious waste in shallow open pits, which generates toxic emissions that affect people’s health. This is contrary to the recommended use of incinerators, an ideal method for disposal of such waste.
An incinerator is an apparatus used for burning waste material, especially industrial waste, at high temperatures until it is reduced to ash.
Mr Peter Waiswa, an associate professor at Makerere School of Public Health, explained that incineration renders infectious medical waste harmless and reduces the waste mass and volume by more than 90 per cent.
However, many public and private hospitals in Uganda lack incinerators, but even in a few health facilities where government has installed them, many of them are defective and cannot do the job.
At Masaka Regional Referral Hospital, a modern incinerator that was installed in 2013 to end many years of poor waste disposal, is dysfunctional. It has turned into a shed for goats and other domestic animals.
The hospital infectious waste is burnt in an open pit.
Mr Edward Kabuye, the hospital principal administrator, said they shunned the incinerator because it is defective.
“We resorted to open burning of infectious waste using diesel because the incinerator could not burn waste to the required temperatures,” Mr Kabuye noted.
However, he said the challenge of waste disposal will soon be settled when the hospital secures an investment partner.
“Rakai Health Science programme is going to build for us a good incinerator. They have already built one for Kalisizo Hospital in Kyotera District and it is doing well,” said Mr Kabuye.
During a visit to Nakaseke Hospital recently in Nakaseke, the parliamentary committee on Health was shocked to learn that the hospital has had no incinerator for 30 years.
Mr David Ssemakula, the hospital administrator, told the MPs that government supplied an incinerator but it had never worked.
We have since been using a private company to dispose of medical waste, but the contract expired recently and we resorted to open burning,” he told the legislators.
Similarly, Lyantonde General Hospital, in Lyantonde District, had a modern incinerator but it was abandoned for similar reasons.

Contracting services
The hospital medical waste officer, Ms Hope Kayesu, said they rely on Green Label Services, a private company contracted by Aids Free Uganda, to dispose of the infectious waste to reduce risk of HIV infection.
“They normally collect it once in a week and take it for safe disposal,” Ms Kayesu told Daily Monitor in an interview recently.
However, the heap of ash and half burnt items at the spot where the waste is briefly kept before collection, suggests the waste is at times burnt there and not taken away for safe disposal as claimed.
The residents in the neighbourhood are crying of a choking stench exuded by the waste, but Ms Kayesu blamed the contractor.
“He brings new employees without briefing them on what to do. These end up ignorantly burning the waste from the collection point,” Ms Kayesu said. In Sembabule District, Sembabule Health Centre IV acquired an incinerator but the facility is not using it claiming it has no funds to buy petrol to be used in the incinerator as Mr Ken Ojuma, the Mawogola Health Sub District Health Inspector noted.
“We get little Primary Health Care funds—between Shs7m and Shs8m quarterly, which is spent on electricity, immunisation and paying supporting staff,” Mr Ojuma said, adding that there is nothing allocated for waste management.
In Masaka District, Dr Godfrey Ziwa, the officer-in-charge of Kiyumba Health Centre IV, insisted they use the incinerator to burn waste. However, this is contrary to Daily Monitor’s observations.
The incinerator appears not to be in use presently. There is no waste around and there is a pit behind the maternity ward, suggesting it is where the waste is burnt.
While Dr Ziwa insisted they burn only general waste in the pit, the presence of unburnt syringes and half burnt soiled cotton in the pit confirms that infectious waste is also burnt at the same place.
Some mothers, who were in the maternity ward, which is near the pit, said their babies where getting choked whenever wind blew the stench or smoke towards the ward.

The case with private hospitals
Although many private facilities in Masaka claimed they dispose of their waste at Masaka government hospital, Mr Kabuye denied any arrangement with them.
“We are already overwhelmed with our own waste, and can’t add on an extra burden. They must be doing it illegally since our dumping site is not fenced,” Mr Kabuye reasoned.
Other private health facilities simply dump waste on the roadside or in ordinary municipal waste bins in town, which poses dangers to the garbage collectors.
Masaka Municipal Council workers have often times complained of medical waste being dumped in the general garbage bins on the streets.
“Many of our friends have been pricked with needles and matters get worse because we do not have gloves,” a municipal support worker who declined to be named, said.

Dangers surrounding open air burning
The WHO says open burning of medical waste can produce toxic emissions, furans, and particulate matter which are dangerous to human beings.
Mr Waiswa warns that such emission goes in the atmosphere and it is the air that people breathe thus breathing contaminated air.
He warns that drugs are naturally toxic and when exposed to harsh conditions they change into substances that are toxic to human beings. They can affect lungs, skin and even cause cancers.
“This is a pertinent issue, which deserves serious attention,” Mr Waiswa warned.
He said pharmacies and clinics should be monitored on how and where they dispose of their expired drugs and waste.

Environmental Impact
According to National Environment Management Authority (NEMA), improper healthcare waste disposal affects natural resources such as air, soil and water.
Treatment and disposal of healthcare waste may pose health risks indirectly through the release of pathogens and toxic pollutants into the environment.
Further, the disposal of untreated healthcare waste in landfills can lead to contamination of drinking, surface and ground water if those landfills are not properly constructed.
Dr Diana Atwine, the permanent secretary for Ministry of Health, said government is equally concerned about medical waste disposal.
“It is going to be in our next budget cycle,” Dr Atwine said but declined to say how the ministry intends to resolve the problem.
She also did not comment on the dysfunctional idle incinerators, which hospitals abandoned because they are defective or substandard.

Loopholes
In the 2009/10-2011/12 National Health Care Waste Management Plan, the Healthcare Waste Management Technical Working Group noted that there are huge gaps in the law for monitoring the HCWM system.
“There are no healthcare waste management regulations and the National Environment Act does not make specific and detailed provisions for HCW management,” the Plan reads in part.
The document lists inadequate legislative and enforcement tools, poor financial base of most health facilities, inadequate human resource base especially in key technical areas, poor maintenance and giving little priority medical waste disposal.
A study conducted in 2016 by Makerere University School of Public Health on Health Care Waste Segregation Behaviour among health workers in Uganda, established that health workers’ segregation behaviour is poor.
Segregation is a pre-disposal practice where waste is separated as it is generated. Here different colour codes for different types of waste are used.
The colour codes as specified in the Infection Control Policies and Procedures by Ministry of Health are: Red for infectious waste, Yellow for sharps and Blue for non-infectious waste.
At Lyantonde General Hospital, Ms Kayesu explained that waste is not segregated due to lack of suitable bins.
“We have small bins, which are meant for Health Centre IIs and these get filled easily. We are forced to put all kinds of waste in one bin which is not ideal as this exposes huge risks to waste handlers,” Ms Kayesu told Daily Monitor the interview.
Besides waste disposal, the health facilities that we visited lack infection control committees, which are responsible for HCWM.
The organisational structure for healthcare system provides for an infection control committee responsible for waste management and must be headed by the person in charge of the health facility.
In Sembabule District, Mr Ojuma admitted they lack infection control committees in the health centres.