Biosafety - Public Health and Veterinary Waste Management: A Case Study in Veterinary Clinics in Kermanshah. Iran

Document Type: Infectious agents- Diseases- Surgery

Authors

1 Assistant Professor of Immunology, Department of Basic sciences and Pathobiology , microbiology section, Faculty of Veterinary Medicine, Razi University , Iran

2 Undergraduate Veterinary student Laboratory Sciences, Faculty of Veterinary Medicine, Razi University, Iran

Abstract

BACKGROUND: The harmful, dangerous essence of the veterinary waste of hospitals, clinics and labora- tories and the consequences of their inconsistent management, such as problems caused by lack of planning in separating, storing, collecting, transporting and disposing of them, causes many environmental and health problems. On the other hand, according to clause 11 and 2 of the Special Waste Management Law of the Environment Protection Organization (E.P.O) and the Ministry of Health of Iran, the waste of veterinary clinics isalso hazardous waste due to the presence of a variety of microorganisms harmful to humans and animals (such as anthrax & brucellosis, etc.).
OBJECTIVES: The guidelines and checklist of the Environment & World Health Organization (WHO) were used in order to increase awareness of the management of the waste from veterinary centers.
METHODS: The answers to the questions were completed by the direct referral of the researcher to 6 pub- lic and private veterinary centers. Statistical evaluation was analyzed using SPSS Version 22.
RESUTLS: The results showed that although veterinary waste management in clinics and government laboratories is relatively more favorable than private veterinary clinics, it is far from world health standards.
CONCLUSIONS: Application of rules and guidelines, increasing the level of knowledge and staff training at all levels, and continuous monitoring of the collection, transportation and disposal of veterinary waste are necessary.

Keywords


Article Title [Persian]

ایمنی زیستی - بهداشت عمومی و مدیریت زباله های دامپزشکی : یک مطالعه موردی از کلینیک های دامپزشکی در کرمانشاه، ایران

Authors [Persian]

  • مهرداد پویانمهر 1
  • محمدرضا برزنونی 2
1 گروه علوم پایه و پاتوبیولوژی- بخش میکروبیولوژی- دانشکده دامپزشکی- دانشگاه رازی- کرمانشاه ایران
2 دانش آموخته علوم آزمایشگاهی دامپزشکی، دانشکده دامپزشکی،دانشگاه رازی، کرمانشاه، ایران
Abstract [Persian]

زمینة  مطالعه:  ماهیت خطرناک پسماندهای دامپزشکی (بیمارستان ها، کلینیک ها و آزمایشگاه ها) و عواقب ناشی از مدیریت ناهماهنگ آنها مانند مشکلات ناشی از عدم برنامه ریزی در مدیریت تفکیک ، جداسازی ، ذخیره ، جمع آوری، حمل ونقل و دفع آنها سبب بروز مشکلات زیست محیطی و بهداشتی فراوانی خواهد شد. ازطرفی به استناد ماده ی 11 و 2  قانون مدیریت پسماندهای ویژه مربوط به سازمان محیط زیست و وزارت بهداشت ایران ، پسماندهای کلینیک های دامپزشکی نیز به دلیل برخورداری از انواع میکروارگانیسم های بیماری زای خطرناک برای انسان و دام (مانند آنتراکس ، بروسلوز و....) جزء پسماند های ویژه است.
هدف: برای آگاهی از ﻧﺤﻮه ﻣﺪﯾﺮﯾﺖ ﭘﺴﻤﺎﻧﺪﻫﺎی مراکز  دامپزشکی ، از دستورالعمل و ﭼﮏ ﻟﯿﺴﺖ اﺳﺘﺎﻧﺪارد ﺳﺎزﻣﺎن ﻣﺤﯿﻂ زﯾﺴﺖ و بهداشت جهانی استفاده شد.
روش کار: پاسخ به ﺳﺆاﻻت ﻣﻮرد ﻧﻈﺮ ﺑﺎ ﻣﺮاﺟﻌﻪ مستقیم  پژوهشگر ﺑﻪ 6 مرکز دامپزشکی دولتی و خصوصی تکمیل ﺷﺪ. ارزیابی آماری با استفاده از SPSS   نسخه 22 بررسی و ﺗﺠﺰﯾﻪ وﺗﺤﻠﯿﻞ شد.
نتایج:  نتایج نشان داد اگرجه مدیریت پسماند در کلینیک ها و آزمایشگاه های دولتی نسبت به مراکز خصوصی دامپزشکی مطلوبیت  نسبی بیشتری  دارد اما با استاندارد های بهداشت جهانی فاصله دارد.
 نتیجهگیری نهایی:  اعمال ﻗﻮاﻧﯿﻦ و دﺳﺘﻮراﻟﻌﻤﻞﻫﺎ ، اﻓﺰاﯾﺶ ﺳﻄﺢ آﮔﺎﻫﯽ و آﻣﻮزش ﮐﺎرﮐﻨﺎن در تمامی ﺳﻄﻮح ، ﻧﻈﺎرت، ﮐﻨﺘﺮل ﻣﺴﺘﻤﺮ ﺑﺮ ﻧﺤﻮه ﺟﻤﻊ آوری، ﺣﻤﻞ و  دﻓﻊ بهداشتی ﭘﺴﻤﺎﻧﺪﻫﺎی دامپزشکی ﺿﺮوری است.
 

Keywords [Persian]

  • ایمنی زیستی
  • بهداشت عمومی
  • مدیریت زباله
  • کلینیک های دامپزشکی

Introduction

Medical and veterinary waste manage- ment is one of the many complex and de- manding challenges facing humanity as the global population swells and the demand for medical services increase. Medical waste is classified by the World Health Organization (WHO) as: “waste that is generated in the di- agnosis, treatment or immunization of human beings or animals.” Medical waste that is not properly handled and disposed of represents a high risk of infection or injury to healthcare personnel, as well as a lesser risk to the gen- eral public through the spread of micro-or- ganisms from healthcare facilities into the environment.As a result, the environmental pollution problems caused by waste produc- tion have attracted the attention of research- ers (Oweis, Al-Widyan, & Al-Limoon, 2005; Sharma & Gupta, 2017; Windfeld & Brooks, 2015). To ensure the health of humans and animals, in addition to environmental protec- tion, proper management  of waste  disposal is very important. Hospital and infectious wastes are one of the most dangerous envi- ronmental pollutants. According to the re- port of World Health Organization (WHO), hospital waste is produced during diagnos- tic, therapeutic, medical, veterinary and bio- logical activities (Moreira & Günther, 2013; Oweis et al., 2005). Particularly, part of the waste produced in the process of providing health services to hospitals, clinics, medical and veterinary laboratories hazardous wastes is infectious (Komilis, Makroleivaditis, & Nikolakopoulou, 2017). Veterinary waste is an important part of the infectious waste con- taining dangerous and pathogenic agents. On the other hand, the issue of the management of veterinary and medical wastes is a chal- lenge with lack of awareness, general  educa-


 

 

tion and absence of adequate funding for the proper implementation. The collection and disposal of these types of waste are import- ant because it directly contributes to creating a variety of risks for public and environmen- tal health (Abdulla, Qdais, & Rabi, 2008). Therefore, as in the case of hazardous medi- cal waste, it is also necessary to decide on the nature and methods of disposal of veterinary waste as a serious threat to human health and the environment(Chen, Liu, Feng, & Chen, 2012; Uysal & Tinmaz, 2004, Coad, 1992; Lee, Ellenbecker, & Moure-Eraso, 2004). This study was conducted  for the first  time to survey the current status of the hazardous and infectious waste management of veter- inary service centers (public and private) in Kermanshah, Western Iran.

Material & Methods

Medical & veterinary waste control reg- ulation of Iran

According to the guidelines, the   National

Environmental Law and the Iranian Ministry of Health have special provisions to control the management of the medical and veteri- nary infectious waste. On that basis, the col- lection, temporary storage,  transportation  and disposal of the waste produced in health centers are divided into six main groups (IN- REH, CWMIM&V, 2005). According to the regulations, solid waste should  be  collect- ed in black plastic bags and recyclable ma- terials in blue bags.  In addition,  according  to clause 11 and 2 of the Hazardous Waste Management legislation of the High Coun- cil of the Environment and the Ministry of Health (Iran’s Medical Waste Control Regu- lation, IMWCR 2008, Iran’s Ministry of En- vironment  and Health,  2008),  sharp objects

 

 

 

should be put in yellow plastic  containers and infectious waste, hazardous chemicals and pharmaceutical waste in red bags with a minimum capacity of 10 kilograms.

Study tool

In this descriptive-analytical project based on the guidelines of the Environmental Pro- tection Agency, Iran's Ministry of Health and the World Health Organization, a question- naire including seven questions about how to manage the waste of veterinary centers was designed (guideline* and questionnaires**). Then  with  direct  referral  and  responding  to the researcher's questions by experts in each department in three public veterinary centers(I) and three private clinics(II) (Clin- ics and laboratories), the questionnaire was completed. In order for more accurate eval- uation, qualitative data (yes or no answers in the items) was turned into quantitative val- ues. Based on this subject, the state of 1. Sep- aration 2. Collection  3. Primary autoclave and non-bacterial culture medium 4. Keeping Temporarily  5. Evanescence at the site  (fur-

 

                       

    

 

Figure 1. The general state of waste management in stud- ied centers

*SC: Standard Center, Public sector (A), (B), (C), Private sector (D), (E), (F)

** S: Separation, CO: Collecting, P: Primary autoclave and non-bacterial culture medium, K: Keeping temporary, SH: Shipment, ES: evanescence at the site (furnace or lime-well), EO: Evacuated outside the place with a special device hazardous waste

 

nace or lime well (6. Transportation 7. Evac- uated outside the place with a special hazard- ous waste device and disposal of hazardous and infectious wastes, the coefficient 14.285 was considered (in total 100%). General state of waste management for type of study cen- ters was arranged. Favorable (score 1), Av- erage (0.75), Unfavorable (0.5) and   Critical

(0.25). Finally, 14.285 coefficient was used for calculating the above scores. The total score for each question was calculated. The final score of the waste management was re- corded. Data analysis, comparison and rank of public and private centers were performed using SPSS version 22 software with a sig- nificance level (P ≤ 0.05).

  1. Three public veterinary centers of Ker- manshah, including veterinary centers of the city NO:1 (A), provincial NO:2 (B) and aca- demic NO:3 (C).
  2. Three private veterinary centers of Ker- manshah, including NO:1(D), NO:2(E) and NO:3(F).

 

 

                       

    

 

Figure 2. The percentage of separation in waste manage- ment in studied centers.

*SC: Standard Condition, Public sector (A), (B), (C), Pri- vate sector (D), (E), (F)

 

 

                               

 

Figure 3. The percentage of collecting in waste manage- ment in studied centers

*SC: Standard Condition, Public sector (A), (B), (C), Pri- vate sector (D), (E), (F)

 

 

 


Figure 4. The percentage of primary autoclave and non-bacterial culture medium

in waste management in studied centers

*SC: Standard Condition, Public sector (A), (B), (C), Pri- vate sector (D), (E), (F)

 

 

 

Table 1:General state of waste management for type of study centers

Veterinary Centers Invested: Standard Condition. (SC). Public sector (A), (B), (C), Private sector (D), (E), (F) Condition: Favorable (1). Average (0.75). Unfavorable (0.5). Critical (0.25) Standard Condition. (SC)

Coefficient Ultimate =14.285

 

 

Results

The waste management status of the veter- inary centers was completed on the basis of the checklist. The results showed that the state veterinary sectors (provincial, city adminis- tration and veterinary medical-educational center) with 67.852%, 60.708%, 60.708%, re- spectively, compared with private veterinary clinics (NO:1 clinic, NO:2 clinic and NO:3 clinic) had a better status of 50.394%  (Table 1). The situation of waste separation and col- lection in all public and private centers was medium and average (10.713%). The primary


safe disposal of infectious waste of the mi- crobiological laboratory was carried  out only in public centers with an average condition (14.285%). This process was not carried out  at any of the private centers (0%). The evacu- ation proceeding hazardous infectious wastes in and outside place and shipment of this  waste with special disposal devices in public and private centers with 3.571% & 7.142% respectively, were critical. Also, the unfavor- able grade of all centers was 21.426%. (Table 2). The status of waste management of public and private veterinary centers is shown sepa- rately (Fig.  1 - 8).

 

 

 

 

 

           

Figure 5. The percentage of keeping temporary in waste management in studied centers.

 

*SC: Standard Condition, Public sector (A), (B), (C), Pri- vate sector (D), (E), (F)

 

 

 

 

 

Figure 6. The percentage of shipment in waste manage- ment in studied centers.

*SC: Standard Condition, Public sector (A), (B), (C), Pri- vate sector (D), (E), (F)

 

 

 

Figure 7. The percentage of evanescence at the site (fur- nace or lime well)

in waste management in studied centers.

*SC: Standard Condition, Public sector (A), (B), (C), Pri- vate sector (D), (E), (F)

 

 

 

 


Figure 8. The percentage of evacuated outside the place with a special device

hazardous waste in waste management in studied centers.

*SC: Standard Condition, Public sector (A), (B), (C), Pri- vate sector (D), (E), (F)

 

 

           

Table 2:General status of the waste management according to the type of medical institution stud- ied Based on the degree of quality (P ≤ 0.05). *Numbers are expressed in percentage terms.

 

Veterinary Centers Invested: Standard Condition. (SC). Public sector (A),(B), (C), Private sector (D), (E), (F) Condition: Favorable (1). Average (0.75). Unfavorable (0.5). Critical (0.25) Standard Condition. (SC)

Coefficient Ultimate =14.285

 

 

 

Discussion

Focusing on human, animal and environ- mental health with proper waste manage- ment is very important. Infectious waste destroys the environment by contaminating soil and water (directly) and air (indirect- ly).The dangerous nature of the veterinary waste ignorance and the consequences of improper management of this type of waste (such as problems caused by lack of man- agement of chemical uses, pharmaceutical, separation, primary processing, collection, storage, transportation and disposal) cause widespread environmental and health-re- lated problems (Mahasa & Ruhiiga, 2014; Omar, Nazli, Subramaniam, & Karuppan- nan, 2012). Despite special management requirements for medical and hospital infec- tious waste, according to clause 2 of Note 1 of the Iranian Environmental Organization's Waste Management Code, the waste from veterinary clinics is given less attention de- spite the presence of a variety of pathogenic microorganisms dangerous to humans, live- stock and the environment. The increase in the percentage of hazardous waste may be due to the type of hospital waste manage- ment, in particular the separation of hazard- ous waste from usual waste. On the other hand, the lack of training and disregard for the separation and collection of non-infec- tious waste in bags specialized for infectious waste can also be another reason for the in- creased percentage of infectious  waste  that is now more in number than the total waste produced (Bazrafshan & Kord Mostafapoor, 2011). According to the WHO report, about 85% of hospital wastes are safe, 10% in- fectious and about 5% are  non-infectious  but dangerous. However, in some cases, the amount of the latter type of waste has risen as a result of inappropriate management  and


the comixture of general wastes with infec- tious waste (Birchard, 2002; Chartier, 2014; Lee et al., 2004; Mohee, 2005). According  on the results of the present study the low- est produced waste was the chemical waste. In the examined centers, due to not using radio-medication and related compounds in veterinary services, no radioactive waste was observed. It was also found, in some cases, that separation of the waste from the source was not performed correctly, it was possible that some types of waste (drugs, blades, win- ners, etc.) could be replaced in infected bags. In the centers studied, complete separation was not thought to have been fully per- formed between the veterinary waste and the sub-homemade waste (safe). In all centers, the bags were shipped to the temporary stor- age location, without the specified label ex- plaining the contents of the bags. There was no burial place and no carcass burning oven in any of the centers and therefore the critical conditions for the elimination of veterinary waste were 100% neglected. Also, the waste of the studied centers was not kept away from the effects of climate factors. In all cen- ters of temporary storage tanks,  they  were not sterilized and penetrated for moisture. Accession to veterinary waste from the place of production to the temporary storage facil- ity was easy. Only at state veterinary centers were the microbiological laboratory wastes after the sterilization initially safe, then it  was shipped with other waste produced by ordinary contractors of urban waste. There was not statistically significant difference between public and private centers in the waste separation and collection. Based on researcher's assessment in this case, all cen- ters had average conditions for garbage col- lection. In all public and private centers, tem- porary storage of waste was unfavorable.   In

 

 

 

this case only the veterinary  administration of the province was in a desirable situation. Also, in all centers, waste produced by ordi- nary trucks without the hazardous waste sign was shipped in an unfavorable situation. The results of this research showed that general management of waste in public veterinary centers is more favorable than private ones (Fig. 1 - 8). Considering the great variety and volume of veterinary centers waste, espe- cially the infectious waste, hazardous waste, the high cost of management of infectious waste, careful and continuous monitoring of the management of this type of waste to pro- vide, maintain and increase the level of staff, other people in the community and the envi- ronment health will be essential. Therefore, the type of veterinary waste management, especially the way of separating hazardous waste from public waste is very important. On the other hand, there is a lack of training of personel, especially service staff, lack of proper supervision over their activities, lack of motivation and some neglect of medical staff in non-infectious waste commixture in waste bags specialized for infectious  waste or vice versa. The reasons are the increase in the percentage of infectious waste compared with the total waste. The type of transport and disposal of veterinary waste is done ordinari- ly and by the contractors of city hall. How- ever, state veterinary centers are required to provide better and higher quality services because of their profitmaking, lack of need for more income and more attention to legal materials. According to factors such as, 1-the use of different colored waste bags for the separation of infectious and non-infectious waste 2- suitable waste storage tanks 3- dai- ly washing and disinfection of tanks 4- the creation of a suitable distance between the temporary storage site and the closest part of


the center 5- more alternation in the collec- tion and transport of waste from the parts to the place of temporary storage until reach- ing the final disposal site 6- more attention   to health issues, have a better relative posi- tion. On the other hand, the flexibility and freedom of managers  of  veterinary  centers in the private sector are likely to attract less attention to waste management and reduce the cost of this important issue. Part of the evaluated cases in this study is consistent with some of the studies in the final  phase  of disposal management for private medical clinics in relation to the release of this waste and the increase of environmental risk and human health (Gulyurt, 2012). The status of waste management in the studied veterinary centers had more unfavorable condition than the status of waste management of the human hospitals reported in Iran, Tabriz University Hospitals, Tehran University of Medical Sci- ences, Shahid Beheshti and North Khorasan, (Dehghani, Azam, Changani, & Dehghani Fard, 2008; Jaafari, Dehghani, Hoseini, & Safari, 2015;  Majlesi,  Alizadeh,  Forutani,  & Gachkar, 2007; Naimi et al., 2015;  Ta- heri, Hamidiyan, & Khazaei, 2013).  Based on the findings of the present study, the type and amount of waste produced by veterinary service centers are not only different in the studied centers, but also somewhat different from those of other countries.  The  reason for this difference is mainly due to various factors such as waste management, type of services provided by the centers, number of active sectors, cultural, economic status  of the community, and so on (Le et al., 2018; Oweis et al., 2005; Tsakona, Anagnostopou- lou, & Gidarakos, 2007).  Failure  to proper- ly implement the rules for the management  of infectious wastes is a major problem for veterinary wastes .As a result, the   challenge

 

 

 

of quantity and quality of waste management and its harmful environmental effects in the country will be  minimized.Therefore,  due  to the health importance of various types of waste, especially veterinary wastes, special attention is paid to these types of waste.

Conclusion and Recommendations

One of the most important measures nec- essary to reduce the environmental  and health problems and management costs of veterinary infectious waste is the proper im- plementation of the approved guidelines and regulations (waste separation program and monitoring of their proper disposal and san- itation).The environmental laws in Iran are mainly focused on the management of med- ical waste, especially hospital waste. The re- sults of this study were impressive.According to available data, although there is no direct relationship between the quantities produced by hazardous and non-hazardous waste by different veterinary institutes, management  of veterinary waste has important deficien- cies and is a serious threat to the environ- ment. The management of veterinary centers should be committed to the proper manage- ment of hazardous waste. Therefore, despite the sufficient standards and regulations, the lack of attention of the managers of the cen- ters leads to a poor conclusion about waste management. Also, to improve the status of waste management in veterinary treatment centers, to train staff and increase their level of knowledge at all levels, to apply rules and guidelines, to fully comply  with  standards, to design and implement a program for the proper management of infectious waste, to continuously monitor collection, transporta- tion and disposal of this type of waste is es- sential. In this case, in order to overcome the problems of this type of waste, the expansion

 

of inter-departmental cooperation is of great importance in the Ministry of Health, Med- ical Education, Veterinary, Environmental Protection, Veterinary Schools and city hall. Also, to reduce the potential risk of this type of waste, equipping clinics and veterinary health centers with modern sterilization sys- tems of hospital waste is  necessary.

Acknowledgment

This study was related to the research proj- ect as a part of the activities required to ob- tain a bachelor's degree in Veterinary Labo- ratory Sciences at the Faculty of Veterinary Medicine, Razi University of Kermanshah (Iran), Number :497 Date: 6.1.2018. The au- thors are very grateful to all experts in the veterinary clinics who cooperated and hon- estly responded to the questionnaire.

Conflicts of Interest

The author declared no conflict of interest.

Abdulla, F., Qdais, H. A., & Rabi, A. (2008). Site investigation on medical waste management practices in northern Jordan. Waste Manag, 28(2), 450-458. https://doi.org/10.1016/j. wasman.2007.02.035

Bazrafshan, E., & Kord Mostafapoor, F. (2011). Survey of  medical  waste  characterization  and management in Iran: a case study  of  Sistan and Baluchestan Province.  Waste Manag Res, 29(4), 442-450. https://doi. org/10.1177/0734242X10374901

Birchard,K.(2002).Outofsight,outofmind…themed- ical waste problem. Lancet, 359(9300), 56. https:// doi.org/10.1016/S0140-6736(02)07256-2

Chartier, Y. (2014). Safe management of wastes from health-care activities: World Health Organ.

Chen, Y., Liu, L., Feng, Q., & Chen, G. (2012). Key issues study on the operation management of medical waste incineration disposal facilities.

 

 

 

Procedia Environ Sci, 16, 208-213. https://doi. org/10.1016/j.proenv.2012.10.029

Coad, A. (1992). Managing medical waste in developing countries. World Health Organ, Ginebra.http://www.who.int/iris/han- dle/10665/63022

Dehghani, M., Azam, K., Changani, F., & Deh- ghani Fard, E. (2008). Assessment of medical waste management in  educational  hospitals  of  Tehran  university  medical  sciences.  Iran.

J. Environ. Health Sci Eng, 2008, Vol. 5, No. 2, pp. 131-136. https://www.researchgate. net/.../272498209

Gulyurt, M. (2012). Biomedical Instrument Ap- plication: Medical Waste Treatment Technolo- gies A Roadmap of Biomedical Engineers and Milestones: InTech. June 5th 2012. https://doi. org/10.5772/39276

Jaafari, J., Dehghani, M. H., Hoseini, M., & Sa- fari, G. H. (2015). Investigation of hospital solid waste management in Iran. World Re- view of Science, Technology and Sustainable Development, 12(2), 111-125. https://doi. org/10.1504/WRSTSD.2015.073820

Komilis, D., Makroleivaditis, N., & Nikolakopou- lou, E. (2017). Generation and composition of medical wastes from private medical microbi- ology laboratories. Waste Manag, 61, 539-546. PMID:28162901. https://doi.org/10.1016/j. wasman.2017.01.033

Le,  A.  B.,  Hoboy,  S.,  Germain,  A.,  Miller, H.,

Thompson, R., Herstein, J. J., . Lowe, J. J.(2017). A pilot survey of the US medical waste industry to determine training needs for safely handling highly infectious waste. Am J Infect Control, 46(2), 133-138. https://doi.org/10.1016/j. ajic.2017.08.017  PMID:28958444.

Lee, B.-K., Ellenbecker, M. J.,  &  Moure-Ersa- so, R. (2004). Alternatives for treatment and disposal cost reduction of regulated medical wastes. Waste Manag, 24(2), 143-151. https:// doi.org/10.1016/j.wasman.2003.10.008 PMID:  14761753

Mahasa, P. S., & Ruhiiga, T. M. (2014). Medical waste management practices in north eastern Free State, South Africa. J Hum Ecol,     48(3),


Majlesi, M., Alizadeh, S., Forutani, F., & Gachkar,

L. (2007). Evaluating the solid waste manage- ment of hospitals affiliated with shaheed be- heshti medical university. Pajoohandeh Jour- nal, 12(4), 299-311. URL: http://pajoohande. sbmu.ac.ir/article-1-591-en.html

Mohee, R. (2005). Medical wastes character- isation in healthcare institutions in  Mauri-  tius.  Waste   Manag,  25(6),  575-581.   PMID:

15993341 https://doi.org/10.1016/j.was-r man.2004.10.003

Moreira, A., & Günther, W.  (2013). Assessment of medical waste management at a primary health-care center in São Paulo, Brazil. Waste management, 33(1), 162-167. https://doi. org/10.1016/j.wasman.2012.09.018 PMID: 23122204.

Naimi, N., Tavakoli Ghochani, H., Nekohi, N., Ghorbanpour, R., Karimkoshte, S., Amiri,   H.,

. . Dolati, M. (2015). Assessment of medical waste management in hospitals of North Kho- rasan university of medical sciences. Journal of North Khorasan University of Medical Scienc- es, 6(4), 935-945. doi:10.29252/jnkums.6.4.935

Omar, D., Nazli, S. N., Subramaniam, A., & Karuppannan, L. (2012). Clinical waste man- agement in district hospitals of Tumpat, Batu Pahat and Taiping. Procedia Soc Behav  Sci, 68, 134-145. https://doi.org/10.1016/j.sb- spro.2012.12.213

Oweis, R., Al-Widyan, M., & Al-Limoon, O. (2005). Medical waste management in Jor- dan: A study at the King Hussein Medical Center. Waste  Manag, 25(6), 622-625.  PMID:

15946839 https://doi.org/10.1016/j.was-r man.2005.03.011

Sharma, S. K., & Gupta, S. (2017). Healthcare waste management scenario: A case of Himach- al Pradesh (India). Clin Epidemiol Glob Health, 5(4), 169-172. https://doi.org/10.1016/j. cegh.2017.07.002

 

 

Taheri, M., Hamidiyan, A. H., & Khazaei, M. (2013). A study on waste management in hos- pitals affiliated to Tabriz University of Medical Sciences during 2010-2011. Journal of Mazan- daran University of Medical Sciences, 23(105), 111-115. URL: http://jmums.mazums.ac.ir/ article-1-2766-en.html

Tsakona, M., Anagnostopoulou, E., &  Gidarakos,

E. (2007). Hospital waste management and tox- icity evaluation: a case study. Waste Manag, 27(7), 912-920. PMID: 16872822 https://doi. org/10.1016/j.wasman.2006.04.019

Uysal, F., & Tinmaz, E. (2004). Medical waste management  in  Trachea  region  of   Tur-   key: suggested remedial  action.  Waste  Manag Res, 22(5), 403-407. https://doi. org/10.1177/0734242X04045690 PMID: 15560445.

Windfeld, E. S., & Brooks, M. S.-L. (2015). Med- ical waste management–A review. J Environ Manag, 163, 98-108. PMID:   26301686