Waste Management 27 (2007) 912920

www.elsevier.com/locate/wasman

Hospital waste management and toxicity evaluation: A case study

M. Tsakona, E. Anagnostopoulou, E. Gidarakos *

Laboratory of Toxic and Hazardous Waste Management, Department of Environmental Engineers, Technical University of Crete,
GR-73100 Polytechnioupolis, Chania, Crete, Greece

Accepted 26 April 2006

Available online 26 July 2006

Abstract

Hospital waste management is an imperative environmental and public safety issue, due to the wastes infectious and hazardous
character. This paper examines the existing waste strategy of a typical hospital in Greece with a bed capacity of 400600. The seg-
regation, collection, packaging, storage, transportation and disposal of waste were monitored and the observed problematic areas
documented. The concentrations of BOD, COD and heavy metals were measured in the wastewater the hospital generated. The
wastewaters toxicity was also investigated. During the study, omissions and negligence were observed at every stage of the waste
management system, particularly with regard to the treatment of infectious waste. Inappropriate collection and transportation pro-
cedures for infectious waste, which jeopardized the safety of sta and patients, were recorded. However, inappropriate segregation
practices were the dominant problem, which led to increased quantities of generated infectious waste and hence higher costs for their
disposal. Infectious waste production was estimated using two dierent methods: one by weighing the incinerated waste
(880 kg day1) and the other by estimating the number of waste bags produced each day (650 kg day1). Furthermore, measurements
of the EC50 parameter in wastewater samples revealed an increased toxicity in all samples. In addition, hazardous organic compounds
were detected in wastewater samples using a gas chromatograph/mass spectrograph. Proposals recommending the application of a
comprehensive hospital waste management system are presented that will ensure that any potential risks hospital wastes pose to pub-
lic health and to the environment are minimized.
 2006 Elsevier Ltd. All rights reserved.

1. Introduction pital waste management. The recently passed Joint

Hospital waste is a special category of waste, which is
highly hazardous due to its infectious and/or toxic charac-
teristics. Furthermore, in healthcare units the direct expo-
sure of waste management workers and members of the
public to this type of waste increases the hazard that
emerges from their treatment. Despite the fact that current
medical waste management practices dier from hospital to
hospital, the problematic areas are approximately the same
for all healthcare units and at all stages of management,
including segregation, collection, packaging, storage, trans-
port, treatment and disposal.
In Greece, considerable problems exist in this area, as lit-
tle action has been taken to apply a complete system of hos-
*
Corresponding author. Tel.: +30 2821 37789; fax: +30 2821 37850.
E-mail address: gidarako@mred.tuc.gr (E. Gidarakos).
Ministerial Decision 37591/2031/03 regarding the measures
and conditions for the management of healthcare waste can
be considered as the rst important step in this direction.
According to this decision, all healthcare units in Greece
are obliged to design and implement a comprehensive
management strategy so as to safeguard the public and the
environment. In light of such heightened concerns regarding
healthcare waste, the feasibility of managing the wastes pro-
duced in a modern hospital with a 400600 bed capacity in a
developing country such as Greece is examined in this paper.
The quantity and composition of the wastes were mon-
itored, as well as the hazard related to their infectious
character. In addition, all stages of the existing waste
management system were monitored and the problematic
areas of each stage will be presented here.
With a scarcity of data available on toxicity levels in the
wastewater produced at healthcare facilities and other

0956-053X/$ - see front matter  2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.wasman.2006.04.019
 M. Tsakona et al. / Waste Management 27 (2007) 912920
important parameters, samples from the hospitals sewage
were collected and examined. The results are documented,
together with recommendations for the implementation of
an eective waste management system.
2. Healthcare waste generation
2.1. Categories of generated waste
Circumstantial waste characterization is of no great
importance, due to the waste streams heterogeneity. The
focus of concern is on infectious wastes and on their proper
treatment and disposal. Potential infectious wastes, toxic
wastes and potential toxic wastes are classied as wastes
that require special handling.
In an attempt to gain a general appreciation of the type
of wastes generated in a hospital, the waste stream of a typ-
ical hospital was observed and the following categories of
hospital wastes were recorded, in accordance with similar
studies (OTA, 1990; US EPA, 1991; Pruss et al., 1999):
 Municipal wastes (paper, cardboard, food wastes, etc.).
For the purpose of the current study this type of waste
refers to waste with the same characteristics as munici-
pal waste.
 Human blood and blood products (including plasma,
blood cotton batting, etc.).
 Microbiological wastes (laboratory cultures and stocks
suspected to contain pathogens).
 Pathological wastes (human tissues, uids, organs and
body parts).
 Isolated wastes (wastes from patients carrying highly
contagious diseases).
 Contaminated/uncontaminated sharps (needles, hypo-
dermic needles, scalpels, etc.).
 Pharmaceutical wastes (pharmaceutical products that
have expired or are no longer required).
 Chemical wastes (laboratory solvents and pigments,
photographic xing and developing solutions, etc.).
 Genotoxic wastes (wastes of cytotoxic chemicals and
cytostatic drugs).
 Low-level radioactive wastes the hospital selected for
this study was not producing any radioactive waste at
the time its wastes were being analyzed.
 Wastes including high concentrations of heavy metals
(mercury wastes, batteries, etc.).
 Wastewater (from laboratories and units where patients
with contagious diseases are treated).
2.2. Quantities of generated waste
It is important to know the quantity of waste generated
(by type) in order to examine the various treatment
options. However, estimating the quantity of the produced
waste stream often is a dicult task since, in practice, rel-
ative mathematical equations have produced dierent
results for each hospital. Waste production depends on
913
the hospitals capacity, the number of medical sta, and
the applied practices. Therefore, an on-site evaluation of
the hospital waste generated is considered the most appro-
priate technique.
In our study, the quantity of infectious waste produced
was determined by weighing the material before disposal
(see Table 1). The average amount of infectious waste
produced (880 kg day1 or 1.9 kg (day bed)1) seemed
excessive in comparison with similar studies (about
0.5 kg (day bed)1 (Skordilis and Padazopoulos, 1988).
This is due to the inappropriate segregation of the waste
at the source. Previous studies reported that the amount
of hospital waste varies between 1.7 and 4 kg (day bed)1
(Pruss et al., 1999).
Moreover, an attempt was made to estimate the amount
of solid infectious and municipal waste using a dierent
approach. Matrons of each department were asked to
assess the number of red and black bags collected from
their department, which contained infectious and munici-
pal type waste, respectively. This procedure led to the
results presented in Table 2.
The results gave an average of 55 large-sized red bags
(120 L) and 240 large-sized black bags collected daily from
all of the hospitals departments. The calculation of waste
mass was based on a related reference, which identied a
bulk density of 100 kg m3 for infectious waste and
180 kg m3 for municipal waste (Seramidou et al.,
1992). Following the procedure described in the previous
paragraph, the authors took into account the fact that
applied practices of waste collection included the removal
of each bag after being lled up to about three-fourths of
its volume. Taking into consideration the inappropriate
segregation practices used at the hospital, for the purposes
of this study, the bulk density of infectious waste was
increased to 130 kg m3 and the bulk density of municipal
waste decreased to 150 kg m3 for a closer approximation
to actual values.
Finally, it was determined that 650 kg of infectious
waste and 3250 kg of municipal waste were being produced
each day. For an average bed-capacity of 450 beds, the
above quantities corresponded to 1.4 kg of infectious waste
(day bed)1 and 7 kg of municipal waste (day bed)1. The
latter did appear to be considerably high when compared
to a related reference (4.5 kg (day bed)1) (Seramidou
et al., 1992).
Table 1
Daily disposed mass of infectious waste
Days Infectious waste (kg day1)
1st 993
2nd 1014
3rd 978
4th 789
5th 615
Mean average 880
914 M. Tsakona et al. / Waste Management 27 (2007) 912920

Table 2
Daily collection of waste bags per hospital department
Department Number of red bags Number of black bags Number of the
collection frequency
Pathological Unit
A 0 Pathology Department 23 10 23
B 0 Pathology Department 1 20 23
Midwifery Department 12 25 12
Nephrology Department 1 67 23
Pediatrics Department 2 6 23
Pulmonary Department 2 20 23
Cardiology Department 12 67 23
Oncology Department 1 30 34
Hematology Department
Neurology Department
Surgical Unit
A 0 Surgery Department 3 25 3
B 0 Surgery Department 1 1 1
Neurosurgery Department 4 30 1
General Surgery Department 10 10 *
Anaesthesiology Department
Orthopaedics Department 1 10 3
Urology Department 1 25 3
Special Units
Articial Kidney Unit (Not recorded) (Not recorded) 23
Mediterranean Anemia Care Unit 1 4 2
Intensive Care Unit 67 1012 3
Coronary Care Unit 2 4 2
Laboratory Units
X-Ray Department 1/2 (Not recorded) (Not recorded)
Tomography Department 2 5 2
Hematology Department 2 34 2
Microbiology Department
Biochemistry Department 34 34 12
Anatomic Pathology Department 1/2 1/2 1
Cytology Department 1 1 1
Mean average 55 240

3. Segregation at source 4. Collection

At the hospital where the research was conducted, the
following segregation practices were applied:
 Infectious waste was collected in red bags.
 Municipal waste was collected in black bags.
 Sharps were collected in yellow plastic containers.
 Cytotoxic/cytostatic drugs were collected in their
original packaging.
The following practices were identied as problematic:
 Insucient segregation of infectious waste from munici-
pal waste. Several situations were observed during which
municipal waste was placed with infectious waste in the
same red bags. Such a practice increases the amount of
infectious waste and the cost of their disposal.
 The lack of segregation between ammable materials,
toxic substances and other materials that require special
handling.
The collection stage includes the process of packaging
and labeling. At the hospital under observation, the col-
lection of infectious waste (red bags) was limited to the
stas work place and in the rooms of patients with
highly infectious diseases, in order to minimize the num-
ber of persons being exposed to infectious waste. On the
other hand, black bags were placed in patients rooms,
oces, bathrooms and rest areas. Each bag was collected
only after it was lled up to three-fourths of its volume
so as to avoid overloading, which could lead to direct
exposure for the waste handler or to puncture of the col-
lected bag.
The following problematic areas were observed at the
collection stage:
 The use of inappropriate means of collection. Red bags
were characterized by thinness and low resistance to
tears, which enabled the stagnation of liquids on the
oor and the creation of a focus of infection.
 M. Tsakona et al. / Waste Management 27 (2007) 912920
 The absence of appropriate labeling. The name of the
wastes generator was marked on a few red bags only
on rare occasions a fact that hindered the identica-
tion of the generator and the type of waste.
5. Transport
Medical wastes are transported through pre-established
routes, which include specic corridors and elevators on
each oor and are strictly used to transport wastes from
the intermediate storerooms to the nal storerooms in the
basement of the hospital.
The problematic areas at this stage were:
 The transfer of infectious waste with improper means of
transport. The trolleys used for transportation did not
provide protection against leakage. In many cases, med-
ical waste was transported by hand and made contact
with the oor, thereby increasing the danger of the waste
handler being injected or cut by contaminated sharps
(such as needles or glass). Furthermore, on many
occasions municipal waste was transported by the same
vehicle that had been previously used to transport
infectious waste, thereby increasing the possibility of
contaminating the municipal waste with pathogenic
microorganisms.
 Inappropriate cleaning of the trailers, which contributes
to creating a focus of infection.
 Overloading of trailers.
 Unsuitable protective clothing. The wearing of thin
gloves and fabric aprons were the only protective mea-
sures taken during the collection and transportation of
medical waste. Waste handlers were at risk of contract-
ing diseases such as hepatitis B and tetanus by possible
injection from infectious needles.
 Elevators used for waste were often used by the medical
sta, which contributed to the transfer of infectious
agents to dierent hospital departments.
6. Storage
Intermediate storage takes place on every oor in spe-
cially designed storage areas that fulll all of the require-
ments needed to store medical waste for up to 12 h
(ventilation, re protection, cleaning facilities, etc.). Stor-
age before disposal takes place in the basement where
infectious wastes are kept in a refrigerator at a temperature
of 34 C so as to avoid biodegradation, odors and the
attraction of insects and rodents. Municipal wastes are
stored in a dierent room at the same level, which also ful-
lls the conditions of acceptable storage.
Problems were observed in the following areas:
 The inability to ensure that access to the storerooms is
restricted to those people involved in the handling of
medical waste.
915
 Storage of wastes for many hours at times for more
than 24 h.
 Storage of municipal waste in contact with infectious
waste.
 Failure to clean the storerooms after every transporta-
tion cycle. The stagnation of liquids on oors was
observed in some cases it remained for more than 24 h.
 Failure to clean the refrigerator. The stagnation of liq-
uids from infectious waste was observed on the oor
and walls.
7. Recycling reuse
The most common practice to minimize the volume and
mass of wastes is through recycling and reuse. At the hos-
pital evaluated, reusable materials such as medical tools
and equipment made from metallic or plastic components
were being sterilized at the hospitals Sterilization Depart-
ment. At the X-Ray Department the generated residue is
collected and recycled by a public company. Paper is also
recycled in cooperation with the local authorities.
8. Treatment disposal
8.1. Infectious waste
The main purpose of treating infectious waste is to
destroy any infectious agent so that it does not pose a haz-
ard for anyone exposed to it. The technique used to treat
infectious waste at the hospital is through pyrolitic com-
bustion. The healthcare facility operates a two-chamber
pyrolitic combustor, with a capacity of 180 kg h1, during
18 h per day (6 h combustion and 12 h cooling). The rst
chamber is operated at between 650 and 900 C and the
second at 850 C. Proper operation of the combustion
ensures 90% (v/v) and 70% (w/w) reduction of the com-
busted waste.
The main problems arising from the process were:
 The composition of the combusted waste did not fulll
the requirements. A large amount of municipal waste
and liquids (chemical, cytostatic/cytotoxic drugs) were
combusted along with infectious waste a practice that
limited the eciency of the combustion process (Lee and
Human, 1996). The problem mainly derives from the
inappropriate segregation of the waste at the source.
 The combustor operates at low temperatures, at which
pollutants produced from materials such as plastics
and cytotoxic/cytostatic drugs are dicult to destroy.
According to the Greek Joint Ministerial Decision
37591/2031/03, materials that consist of more than 1%
of halogen organic compounds (expressed in terms of
the concentration of chlorine) become inactivated at
temperatures above 1100 C. In addition, most cyto-
toxic/cytostatic drugs require temperatures above
1000 C, with some requiring more than 1200 C (Pruss
et al., 1999).
916 M. Tsakona et al. / Waste Management 27 (2007) 912920

 Emissions from the incinerator did not undergo any fur- rium phosphoreum microorganisms. The bacteria were
ther treatment before being released into the exposed to the solutions for 5 and 15 min. The extent of
atmosphere. absorption of the incident ray was measured by the Micro-
 The resulting ash was not adequately treated. After tox equipment. EC50, which refers to the eective concen-
cooling down the combustor, the ash was collected in tration of a substance (wastewater) that produces a toxic
bags or cardboard boxes, and disposed in landlls. Tak- eect (death) in 50% of the test organisms in a given pop-
ing into account the composition of the combusted ulation under a dened set of conditions, is determined by
waste, heavy metals are likely to exist in signicant con- using mathematical equations that relate absorption to tox-
centrations in the resulting ash, which requires special icity (Gidarakos, 2003). Lower and upper bounds for EC50
handling a fact conrmed by earlier studies (US were calculated at the 95% level of signicance and the
EPA, 1991). results are presented in Table 3.
 The operator of the combustion unit did not have even a The toxicity of the wastewater produced at the laborato-
basic knowledge of the process of pyrolitic combustion ries was high at the exit of the chemical neutralization unit,
or of the hazard to which he was exposed. Therefore, which presumably was due to the fact that only the pH was
the protective measures being taken were unsatisfactory being controlled. However, at the entrance of the municipal
(thin disposable gloves, disposable apron and face mask sewerage system, toxicity was found lower than in samples
no leg protectors or protective shoes). taken from the exit of the chemical neutralization unit.
This suggests that the toxicity of the hospitals sewage
8.2. Municipal waste derives mainly from laboratories. In addition, it is interest-
ing to note that the toxicity of the wastewater owing into
Local authorities are responsible for the treatment of the the municipal wastewater treatment plant is approximately
municipal waste. The hospitals administration is responsi- the same as that of samples taken at the exit of the hospi-
ble only for the proper transfer of the waste from the store- tals sewerage system.
rooms to a specially designed area outside the hospitals
yard. The waste is nally transported to a local sanitary 10. BOD/COD
landll for disposal.
The wastewaters biological oxygen demand (BOD) and
8.3. Wastewater from laboratories chemical oxygen demand (COD) were determined at spe-
cic locations of the hospitals sewerage system to ascertain
Many hospitals in Greece do not have a separate sewer- their organic load and biodegradation ability.
age system. However, at the hospital where the study was The results, presented in Table 4, show that the COD
conducted, wastewater from laboratories is drained away exceeds the permitted limits for sewage to be safely
in a separate sewerage system where it undergoes chemical discharged into the municipal sewerage system. The same
neutralization. A solution of H2SO4 at 98% concentration conclusions were drawn for the BOD of some samples,
and another solution of NaOH at 98.4% concentration
are used to neutralize the alkalinity and the acidity,
respectively.
Table 3
Common problems are: Hospitals wastewater toxicity (EC50) and pH from dierent sampling
points
 Only the pH is controlled. Parameters such as toxicity
Sampling point Samples EC50 EC50 pH
are not evaluated. Measurements carried out at the (5 min)a (%) (15 min)b (%)
authors laboratory showed that treated laboratory
Chemical 1 1.406 2.036 6.57
wastewater had an increased toxicity capable of causing neutralization-exit
dysfunction to the municipal wastewater treatment 2 1.303 0.7612 6.57
plant. 3 0.6322 0.3959 6.57
Hospitals 1 15.66 6.777 77.5
9. Measurements sewerage-exit
2 5.083 2.390 77.5
9.1. Toxicity 3 4.996 1.683 77.5
Primary treatment 1 7.634 4.163 7-7.5
One of the purposes of the current study was to evaluate tank Entrancec
a
the toxicity of wastewater produced at a healthcare facility EC50 (5 min): the eective concentration of wastewater which produces
at the exit of the tank where chemical neutralization is a toxic eect (death) in 50% of test organisms in a given population under
5 min of exposure.
applied, and at the exit of the hospitals general sewerage b
EC50 (15 min): the eective concentration of wastewater which pro-
system before the sewage enters the municipal sewerage duces a toxic eect (death) in 50% of test organisms in a given population
system. The toxicity was measured using the 81.9% Basic under 15 min of exposure.
c
test, Microtox equipment and Vibrio scheriPhotobacte- It refers to the local wastewater treatment plant.
 M. Tsakona et al. / Waste Management 27 (2007) 912920 917

although most of them were within permissible limits (see Table 6

Table 4). Organic compounds detected in the hospitals wastewater
Organic compounds Characteristics
10.1. Heavy metals 5-uorouracil Antineoplasmatic
Benzalkonium Antiseptic
The concentrations of specic heavy metals (Hg, Zn, chloride
Aspirin Analgesic
and Pt) in the hospitals wastewater were measured and Thiopental Anesthetic drug
the results were compared with the permissible limits set Limonene Possible drug by product
by local authorities for heavy metal concentrations in with closed none polycyclic
wastewater owing through the municipal sewerage aromatic rings
system. No sample exceeded the permissible limits (see 1,6-Octadien-3-ol, Drugs components
3,7-dimethyl
Table 5). 1-Decanol Drugs components
1-Tridecanol Drugs components
10.2. Organic compounds 2-Propanamine,2-methyl Drugs components
Undecanoic acid Drugs components
During the study, three samples were collected from the 1- Tridecanol (ISO) Drugs components
Ethylene glycol Drugs components
exit of the hospitals sewerage to determine if any organic monadodecylether
compounds might be present in the hospital wastewater. Tetradecanoic acid Drugs components
A gas chromatograph/mass spectrograph was used for 1,2-Benzenedicarboxylicacid, Chemical component of
these measurements. The compounds detected are pre- bis[2methylpropylester] plastic products (cancerigenic)
sented in Table 6. Diethyl phlalate Chemical component of plastic
products (cancerigenic)
Among the organic compounds detected, 5-uorouracil, Oleic acid Oil
aspirin, thiopental, limonene, benzyl benzonate, 1, 2-Ben- Linoleic acid Acid oil
zenedicarboxylicacid and bis[2methylpropylester] are Acetic acid Biodegradable by-product
characterized as dicult to biodegrade and could possibly Benzyl benzonate Benzoic ring
cause operational problems to the citys wastewater
biological treatment plant. Furthermore, Benzalkonium
chloride belonged to the category of the Absorbed Organic
Halogens, which increase the sewages toxicity. The 11. Proposals
remaining organic compounds detected were not consid-
ered to be hazardous. The waste management strategy applied at the hospital
was observed and problematic areas were determined. All
stages of waste management presented problems, which
Table 4
Hospitals wastewater BOD and COD from dierent sampling points
mainly were due to human neglect. To overcome these
obstacles the following actions were proposed for each
Sampling point BODa (mg L1) COD (mg L1)
stage of waste management.
Chemical 410530 830880
neutralization-exit
Hospitals 340550 770880
 Segregation
sewerage-exit Proper training should be provided to everyone
Municipal 100300 500600 involved in the waste management process regarding
sewagea appropriate segregation practices and the potential
Permitted limits in 500 1000 hazards associated with improper segregation.
municipal sewerage Regimentation and ning are considered necessary to
(Markadonatos, 1990) implement proper procedures.
a
At the entrance of the local wastewater treatment plant.
 Collection
Purchase of good quality storage units (bags (see
Table 5 Table 7), containers) that can provide impermeability
Hg, Zn and Pt concentrations in the hospitals wastewater
and resistance to perforation, and also be easy to
Sampling point Samples Hg Zn Pt handle and clean (California Department of Health
(mg L1) (mg L1) (mg L1)
Services, 1999).
Chemical 1 <0.0002 0.17 <0.1 All bags should be labeled with the name of the
neutralization-exit
department where they are produced, as well as the
Hospitals 1 0.0018 0.084 <0.1 collection date. The biological hazard symbol must
sewerage-exit 2 0.0033 0.18 <0.1
be printed on bags used to collect infectious or other
Permitted limits in 0.005 5 hazardous wastes (Daschner, 2000; California
municipal sewerage Department of Health Services, 1999).
918 M. Tsakona et al. / Waste Management 27 (2007) 912920

Table 7  Transport
Proposed characteristics for storage bags Purchase of good quality carts that would provide
Height length Thickness Material impermeability, be resistant to perforation, and also
(cm cm) (mm) be easy to handle and clean. The carts must be
Black bags labeled with the name of the department in which
Large size 110 80 0.05 Polyethylene (virgin) they are used.
Medium size 80 60 0.05 Polyethylene (virgin)
Small size 60 55 0.03 Polyethylene (virgin)
 Storage
Red bags
Strict entrance prohibition into waste storerooms.
Large size 110 80 0.1 Polyethylene (virgin)
Medium size 80 60 0.1 Polyethylene (virgin) Only waste handlers should be allowed to enter these
areas.
Green bags
Adjusting the frequency of waste collection according
Large size 110 80 0.05 Polyethylene (virgin)
Medium size 80 60 0.05 Polyethylene (virgin) to the facilitys waste production. Wastes should not
remain in any storeroom for more than 24 h, with the
exception of infectious waste that can remain in store-
Apart from the black and red bags used for the collec- rooms at a temperature below 34 C for up to 5 days
tion of municipal and infectious waste, respectively, (US EPA, 1991).
the purchase of green bags is necessary. Materials that
consist of more than 1% of halogen organic com-  Recycling
pounds (expressed in terms of chlorine concentration) Applying a complete recycling and reuse program.
must be collected in dierent color bags (green) and Plastic, glass, metals, batteries and plaster can be
combusted at temperatures above 1100 C (Joint recycled. However, a cost analysis would be required
Ministerial Decision 37591/2031, 2003). before further action could be taken.

Fig. 1. Schematic representation of the waste categories and the proposed treatment and disposal methods at the hospital where research was conducted
(Tsakona et al., 2005).
 M. Tsakona et al. / Waste Management 27 (2007) 912920
 Final disposal
Increase in the temperature of the second combustor
chamber to 1200 C with a residence time of 2 s or to
1000 C with a residence time of 5 s, so as to eliminate
the presence of pollutants such as dioxins in air emis-
sions (Pruss et al., 1999).
Recording the mass of the waste combusted each day
for statistical purposes.
Measure of air pollutants such as: HCl, SO2, NOx,
CO, Hg, Cd, dioxins, etc.
Avoid loading of the incinerator with large amounts
of uids and large bulky moist objects that burn
slowly and produce relatively low temperatures (Cole
et al., 1993).
Avoid loading of the incinerator with materials that
could cause operational problems to the combustion
unit (e.g., ammable materials) or produce toxic pol-
lutants (e.g., batteries).
Purchase and installation of air pollution control
systems.
Treatment of residual ash properly before disposal so
as to stabilize the presence of heavy metals. Disposal
in landlls designed to accept hazardous waste would
be an acceptable solution.
Further treatment of the laboratories wastewater is
required. A bioreactor or ozone system could be
applied (Xia et al., 2001).
 Other recommendations
Substitution of hazardous solutions and materials
with non-hazardous solutions and materials if possi-
ble, e.g., purchase medical tools that contain no
PVCs (polyvinylchlorides).
Ensure stas health and safety through proper pro-
tective clothing (thick gloves, face mask, protective
shoes, disposable clothing, etc.), safety guidelines
(equipment safety procedures, prevention of infection
during waste handling, re safety, etc.) and regular
medical examinations. A comprehensive record of
accidents connected with waste management should
be made.
Fig. 1 presents the generated waste categories, together
with the proposed treatment and disposal methods for each
waste category (Tsakona et al., 2005).
12. Conclusions
Despite the fact that medical wastes are considered as
hazardous, due to their infectious and/or toxic characteris-
tics, little attention is given to their proper management
and disposal. The study conducted at a typical hospital
with a 400600 bed capacity revealed that the waste man-
agement system needs improvement at every stage of waste
handling. Problems were mainly observed because of the
lack of adequate sta training on healthcare waste manage-
ment issues and on the hazards that might emerge from
919
their inappropriate handling. Toxicity was detected in all
of the hospitals wastewater samples, and particularly those
from laboratories, after chemical neutralization. In addi-
tion, combustion was found to be insucient due to the
inappropriate composition and the sheer volume of the
combusted waste (880 kg day1), mainly derived from the
poor segregation of waste. Insucient measures were
applied for waste handlers safety and health. In view of
the problems detected, the guidelines and recommenda-
tions expounded in this paper should be introduced so that
the hospitals administration can ensure a proper waste
management and treatment system.
Overall, the experience gained from the study presented
in the current paper addresses the main problems that med-
ical waste management in developing countries may poten-
tially face and presents the proper procedures to overcome
the problem areas. However, this study indicates the
importance of the examination and monitoring of hospital
wastewater. The properties of hospitals solid wastes have
been examined in various ways but little attention has been
paid to the characteristics of medical sewage. Hospital sew-
age toxicity owing into the municipal sewerage system is
an issue of critical signicance that requires further exam-
ination and research from experts.
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