Chapter 3 THEORETICAL BACKGROUND

Review of Related Literature From the days of primitive society, humans have made use of the earths resources to sustain life and to dispose of wastes. In those times, waste disposal did not pose significant problems because human populace was considerably smaller and more land was available for the assimilation of wastes. The problems associated with the disposal of wastes started with the growth of population and influx of human settlements and industries. The accumulation of wastes became an inadvertent consequence of life, making waste management form a rapidly growing area of interest. One type of waste is the less known and less generated but more closely regulated waste called health care waste. These wastes are those that are generated by health care providers which include those of the subject of this particular study, the funeral establishments. These wastes are different from those commonly produced by households and other establishments in that they pose potential environmental and health hazards if not properly treated, stored, disposed of or otherwise managed appropriately. This chapter presents the literature and related studies, both local and foreign, which have direct bearing on the study of the health care waste management of funeral establishments in Cebu City. This review includes the definition and classification of both funeral establishments and health care wastes. It also includes the laws and regulations governing funeral establishments and their waste management, especially that of health care wastes, their recommended waste management process and the risks associated with these health care wastes.

As it is quite evident today, waste management has indeed become one of the most discussed topics, other than that of climate change and poverty. Yet as it began to encompass a broader array of topics, the very definition itself of waste management has become quite ambiguous. But even if waste management is a relatively new phenomenon, it has caught the attention of governments all over the globe and today the term waste management covers collecting, sorting, processing, recycling and reusing materials that would otherwise be considered useless (Arshad et al, 2011). Medical or health care wastes are in the form of solid and liquid wastes generated in the diagnosis, treatment or immunization of human beings or animals; in medical research; or in production of vaccines or other substances produced from living organisms and are commonly generated by hospitals, medical or research laboratories, clinics, veterinarians, long term-care facilities and funeral homes (Soncuya et al, 1997). However, there is no single definition of medical waste, and thus, the terms medical waste, hospital waste, and infectious waste have often been used interchangeably (Akbolat et al, 2011). That is why, throughout this study, the terms medical waste, health care waste, clinical waste and hospital waste are presumed to represent one and the same. The World Health Organization reports that from the total of wastes generated by health care activities, almost 80% are general waste, which are comparable to domestic waste while the remaining 20% are considered hazardous materials, the infectious and anatomic wastes together represent the majority or 15 % of the hazardous waste, chemicals and pharmaceuticals amount to about 3% and sharps represent about 1% of the total waste from health care activities (www.who.int). Lack of awareness about the health hazards related to health care waste, inadequate training in proper waste

management, absence of waste management and disposal systems, insufficient financial and human resources and the low priority given to the topic are the most common problems connected with health care waste and also, many countries either do not have appropriate regulations, or do not enforce them which makes the clear attribution of responsibility for the handling and disposal of waste an essential issue (www.who.int). In the Philippines, the potential hazards that health care wastes may bring about is not quite recognized by the general public. There is still somewhat a need for them to be more aware of the proper management of these types of wastes and also the laws and regulations that govern their appropriate handling. There is also a need for intervention strategies relating to the health effects of medical waste which should include continual education and training in proper medical waste management especially to persons that are frequently in contact with medical waste (Turnberg, 1996). As these wastes pose significant risks, those who are involved in any process of waste management should have appropriate knowledge and sufficient training which management should ensure and monitor regularly. A study by Patwary and Sarker (2012) concluded that detailed analysis of the makeup and sources of waste from mortuaries have shown that a major proportion is initially hazardous, and total waste becomes hazardous due to mixing with this hazardous waste thus making all of the waste produced by the mortuaries considered hazardous. Improper management or mishandling of these health care wastes may also lead to adverse environmental concerns. There was even a case wherein a local mortuary inadvertently dumped hazardous waste in barangay Maghaway, Talisay City including waste such as life jackets, used surgical gloves, masks and cadaver bags used in wrapping the bodies of

cadavers from the sunken M/V Princess of the Stars evoking the awareness that although the stench is not as dangerous as it is thought to be, the fluids from the material might reach sources of drinking water or the waste could be dragged by stray dogs to populated areas which may cause great harm (Melecio, 2008). As the proper management of the potentially hazardous waste was not adhered to, the incident became a serious concern especially to the residents of the area who are the most affected by any adverse consequences. This solidifies the concept why health care waste generators, including funeral establishments, should ensure proper waste management continually. Funeral establishments include funeral parlors, funeral chapels, and any similar place used in the preparation, storage and care of the body of a deceased person for burial or cremation whose services include embalming and viewing/wake services, cremation, casket-making, casket-selling and the provision of a chapel for the funeral (www.doh.gov.ph). Other establishments that may fall in the group are mortuaries, autopsy centers, crematories and morgues. Section 93 of P. D. No. 856 classifies these establishments as follows: Category I- establishments with chapels, and embalming facilities and offering funeral services. Category II- establishments with chapels and offering funeral services but without embalming facilities; and Category III- establishments offering only funeral services from the house of the deceased to the burial ground. Funeral establishments are required to comply with pertinent laws and regulations on waste management. One of these laws is the Code on Sanitation of the Philippines of

1975 or P.D. No. 856 which regulates the establishment of all trades and occupations, institutions, commercial undertaking, refuse disposal system, sewage collection and disposal system, etc. including funeral establishments, in accordance with prescribed guidelines and standards promoting environmental sanitation hygiene (www.doh.gov.ph). Though this law may apply to virtually all industries, funeral establishments are of particular concern since they deal with wastes that give rise to morbid attention from the public like those of blood, body fluids, organs and cadavers. Specifically, Chapter XXIDisposal of Dead Persons of P.D. No. 856, applies to all crematories, funeral and embalming establishments, medical and research institutions, undertakers, embalmers, public and private burial grounds and other similar institutions. It also provides some rules and regulations on these establishments like the fact that no funeral parlors, embalming establishments and morgues shall be operated without a sanitary permit (www.doh.gov.ph). However, it is important to note that this permit shall be issued only upon compliance with the sanitary rules and regulations. This sanitary permit is particularly important as mortuary and autopsy centers, funeral establishments are health care providers and as such, one of the sources of medical or health care waste other than health care facilities, institutions, business establishments and other similar health care services (pcij.org). This permit not only serves as verification that the establishment has complied with the code, it also serves as an assurance to the public, especially its customers, that they observe cleanliness and promote health and wellness. Another pertinent law is the Philippine Environmental Code of 1977 or P.D. No. 1152 which is a comprehensive program of environmental protection and management that serves as a basis for an integrated waste management regulation starting from waste

source to the different methods of disposal. P.D. No. 1152 has further mandated specific guidelines to manage municipal wastes, sanitary landfill and incineration, and disposal sites in the Philippines (www.doe.gov.ph). The Ecological Solid Waste Management Act of 2000 or R.A. No. 9003 also ensures the proper segregation, collection, transport, storage, treatment and disposal of solid waste through the formulation and adoption of the best environmental practices and pushes for reforms in the management of health care waste (emb.gov.ph). As humanity became more attuned to environmental concerns, many local and national laws have been enacted to deal with the resulting issues, including that of waste management. These laws were made not only to ensure that proper waste management is being adhered to but also the fact that they should make use of ecological programs and practices that appropriately address environmental concerns. The Toxic and Hazardous and Nuclear Wastes Control Act of 1990 or R.A. No. 6969 also plays a role in the waste management of funeral establishments. This law covers the importation, manufacture, processing, handling, storage, transportation, sale, distribution, use and disposal of all toxic substances and hazardous and nuclear wastes in the Philippines. Under this law, pathogenic and infectious wastes are considered hazardous and therefore covered by this law (emb.gov.ph). The usual connotation of the terms toxic and hazardous are often those that are chemical and industrial in nature, but R.A. No. 6969 elucidates the fact that even pathogenic and infectious wastes, the wastes that are most commonly generated by health care providers such as funeral establishments , are also considered hazardous and as such, should be properly dealt with. The World Health Organization classifies medical or healthcare waste into communal waste or general waste, which is comparable to domestic waste and comes

mostly from the administrative and housekeeping functions of health care establishments including the waste generated during maintenance of health care premises, and hazardous health care waste or special waste (whqlibdoc.who.int). Infectious and other special wastes are collected in accordance with the relevant neutralization methods, while general wastes are by the municipal waste disposal system (Zimmermann et al, 2011). Though in the conduct of the study, the researchers may come across general waste generated by the establishments, more emphasis is geared towards the proper management of special waste. This classification of wastes was also adopted by the Department of Health and promulgated as guidelines for health care facilities, including funeral establishments (pcij.org). Since the researchers are more concerned with local and national regulations rather than that of international standards, greater attention is accorded to the directives promulgated by the Department of Health. Special waste consists of several different categories: Infectious wastes are those suspected to contain pathogens (bacteria, viruses, parasites, or fungi) in sufficient concentration or quantity to cause disease in susceptible hosts. This category includes cultures and stock of infectious agents from laboratory work, waste from surgery and autopsies on patients with infectious diseases, waste from infected patients in isolation wards and any other instruments or materials that have been in contact with infected persons or animals. Pathological wastes consist of tissues, organs, body parts, human fetuses and animal carcasses, blood and body fluids. Within this category, recognizable human or animal body parts are also called anatomical waste. This category should be considered as a subcategory of infectious waste, even though it may also include healthy body parts.

 Sharps are items that could cause cuts or puncture wounds, including needles, hypodermic needles, scalpel and other blades, knives, infusion sets, saws, broken glass, and nails. Whether or not they are infected, such items are usually considered as highly hazardous health-care waste. Pharmaceutical waste includes expired, unused, spilt, and contaminated pharmaceutical products, drugs, vaccines, and sera that are no longer required and need to be disposed of appropriately. The category also includes discarded items used in the handling of pharmaceuticals, such as bottles or boxes with residue, gloves, masks, connecting tubes and drug vials. Genotoxic waste may include cytostatic drugs, vomit, urine, or feces from patients treated with cytostatic drugs, chemicals, and radioactive materials. This type of waste is highly hazardous and may have mutagenic, teratogenic, or carcinogenic properties. Chemical waste consists of discarded solid, liquid, and gaseous chemicals, for example from diagnostic and experimental work and from cleaning, housekeeping, and disinfecting procedures. Chemical waste from health care may be hazardous or nonhazardous. They are considered hazardous if they are toxic, corrosive, flammable or reactive. Nonhazardous chemical waste consists of chemicals with none of those

properties, such as sugars, amino acids, and certain organic and inorganic salts. Wastes with high content of heavy metalsrepresent a subcategory of hazardous chemical waste and are usually highly toxic. This includes mercury waste typically generated by spillage from broken clinical equipment and cadmium from discarded batteries. Pressurized containers consist of full or empty containers with pressurized liquids, gas

or powdered materials, including pressurized cylinders, cartridges, and aerosol cans. Radioactive wastes are wastes containing radioactive substances. These include solid, liquid, and gaseous waste contaminated with radionuclides generated from vitro analysis of body tissues and fluids, in vivo body organ imaging, tumor localization, and therapeutic procedures. The Department of Health presented guidelines on how health care waste should be treated in its Health Care Waste Management Manual (pcij.org). The manual serves as a guideline for hospitals, health care centers and even to other health-related establishments, including funeral establishments. It provides practical information regarding safe, efficient and environmental-friendly waste management options and contains in detail, safety procedures on the collection, handling, storage, transport, treatment and disposal of health care wastes. However, waste management procedures practiced by funeral establishments may vary from one another since the government does not provide a specific standard but rather, encourages the use of the manual. Even from the start of the waste management process, which is waste handling, appropriate measures must be complied with. Segregation, as defined by the manual, is the process of separating different types of waste at the point of generation, keeping them isolated from each other and taking place as close as possible to where the waste is generated and should be maintained in storage areas and during transport (pcij.org). Segregation at source is a key to efficient health care waste management since with better planning and supervision, not only the waste generation is reduced, but overall expenditure on waste management can be controlled (NIIR Board of Consultants & Engineers, 2005). The Department of Health has suggested that color-coding scheme be

abided by in segregating the various wastes that health care providers generate. As a result, wastes of the same category are placed in the same container which would facilitate the transport of these wastes to their subsequent destination. Health care wastes are to be segregated into color-coded containers as follows: Black Green Yellow Yellow with black band Orange Red Non-infectious dry waste Non-infectious wet waste (kitchen, dietary etc.) Infectious and Pathological waste Chemical waste including those w/ heavy metals Radioactive waste Sharps and pressurized containers

After the wastes have been segregated correspondingly, these must be collected and stored in a waste storage area that is marked with warning sign: "CAUTION: BIOHAZARDOUS WASTE STORAGE AREA - UNAUTHORIZED PERSONS KEEP OUT" until transported to a designated off-site treatment facility. This storage area for health care wastes should be located within the establishment or research facility but away from public access areas and in cases where the health care facility lacks the space, daily collection and disposal should be enforced (pcij.org). As it has been mentioned previously, health care waste is different from the waste generated by households and other establishments by the fact that health care wastes are potentially hazardous. This is why it is often emphasized that these wastes should only be handled by trained personnel and should not be easily accessed by the general public. Proper collection and transport is a significant component in health care waste management, which is why the collection must be designed to attain efficient transfer of

waste while minimizing the risks to personnel handling them. Waste should not be allowed to accumulate at the point of production and a program for their collection and transportation should be established as part of the health care waste management plan and also, staff should ensure that waste bags are tightly closed or sealed to prevent spilling during handling and transportation (pcij.org). In the collection of health care wastes, important aspects include the frequency and volume to be collected. The health care waste generator should make certain that collection is not too infrequent that the wastes eventually accumulate beyond their capacity and cause problems nor too frequent that it becomes inefficient and costly. It is also imperative to note that the waste containers should be properly sealed and are easy to load and unload during transport. The health care waste generator is responsible for the safe packaging and adequate labeling of waste to be transported for treatment and final disposal and these should comply with the national regulation governing the transport of hazardous wastes or Republic Act No. 6969 and maintain that it presents no danger to the public during transport and also, it is imperative to be aware that they are ultimately responsible for ensuring that their wastes are properly treated and disposed of in an approved disposal facility and that all health care waste to be transported shall be transported only by a DENR-accredited transporter or carrier (pcij.org). The study is limited only to the waste management programs that the funeral establishments are implementing, and so, the handling by the subsequent collecting system would be beyond the scope of the research. However, it is to be emphasized that it is the health care generator, the funeral establishment, that has the responsibility of ensuring that the transporters or carriers they employ are duly accredited by the proper authorities.

The purpose of treating health care waste is to change the biological and chemical character of the waste to minimize its potential to cause harm and incineration used to be the method of choice in treating health care waste, however, with the implementation of the Clean Air Act of 1999, this method is no longer (pcij.org). Today, autoclaves or steam sterilizers are the most common treatment method as they have the lowest capital costs among alternative technologies (Emmanuel, 2007). For a long time, the preferred treatment used to be incineration and even up to now, most of the public still assume that health care waste are still subject to this treatment . However, with its banning by the Clean Air Act of 1999 as a response to environmental concerns, it is now the alternative processes that are more ecological that are advocated and being utilized. The Manual on Health Care Waste Management provides three suggested waste disposal systems which include the sanitary landfill, which is an engineered method designed to keep the waste isolated from the environment, the safe burial on establishment premises and lastly, the septic or concrete vault, which is especially suitable for the disposal of used sharps and syringes (pcij.org). The proper health care waste disposal is a paramount concern not only for the health sector or the environmentalists but also for society, which is affected invariably as well. The health care waste generator, the funeral establishments, have the fundamental responsibility of ensuring that the wastes to be treated and disposed of are processed in government approved treatment and disposal facilities. Health care wastes represent only a very small percentage of the entire waste generated by humans. However, even if they constitute only an infinitesimal fraction, they should be dealt with strictly and accordingly as they provide greater risks than those

of other types of wastes. Improper handling and disposal of potentially hazardous wastes, including health care wastes, may become a considerable sociological problem today as it may affect human health, the environment and the economy. They pose risks to human health due to their potential to spread diseases and may even cause illness or death from exposure to toxins and chemicals. An incident in Russia illustrates the danger: children playing with waste bins near a health center were infected with live strains of smallpox from exposure to discarded ampoules of the vaccine (Bryant, 2000). Also, the emergence of an army of human scavengers in recent times who make their living from refuse dumps have added another dimension to the general concern on medical waste disposal (Oruonye, 2012). In developing countries, scavenger families who make a living of recycling materials from open dumpsites are at great risk especially from sharps waste (Emmanuel, 2007). Improper disposal can also inflict problems to the environment and the economy. Cleaning up of improperly disposed wastes and contaminated sites can be damaging to the natural environment and be costly and time consuming, particularly in poor communities. Several studies have been done to assess the management of hazardous wastes abroad, especially in developing countries. A study conducted by Sarkar et al (2006) in Bangladesh observed that wastes of most hospitals are normally collected from small bowls or plastic bins provided for each bed and stored either in large plastic bags or buckets which are then put in a pushcart and carried to the nearest municipal bins outside for dumping without any segregation or treatment. These open dumps are of ready access to scavengers who collect used blood bags and syringes and to domestic animals and pests that could potentially spread diseases. In Lagos, Nigeria, a study was also

conducted and results showed that even though medical waste attracted a high level of segregation in most hospitals, it is generally co-disposed with the municipal solid waste stream by waste handlers (Longe, 2006). Also, non treatment of infectious waste before final disposal was observed along with open dumping either within the hospital premises or at government recognized dumpsites. Another study, that of Kumar et al (2010), also found that collection, storage, handling by the staff, transportation for disposal and final disposal of health care wastes in Pakistan were not up to the national and World Health Organization guidelines. A study by Blenkharn (2007) concluded that the standards of performance in clinical waste management of hospitals in the United Kingdom remain poor, with evidence of neglect of basic hygiene, housekeeping and safety standards. Also, despite the implementation of the Hazardous Waste Regulations 2006 that provides further control on all wastes management issues, the reality of clinical waste management in some National Health Service (NHS) hospitals continues to be largely inadequate. A comprehensive study by Ananth et al (2009) was also conducted to assess the health care waste management of 12 countries which comprise of Cambodia, China, Indonesia, Japan, Laos, Malaysia, Mongolia, Myanmar, Vietnam, Thailand, Singapore and the Philippines in relation to the World Health Organization (WHO) requirements. It was revealed that the economically developed countries, Japan and Singapore, have established compliance with the WHO requirements for quite obvious reasons financial and policy support, regulatory push and willingness of healthcare service providers while the other countries are at different stages of establishing systems and processes to ensure appropriate handling and management of healthcare waste. The study then concluded that

health care waste management is a subject of concern among all selected developing countries of the study since though some countries are ambitious about taking health care waste management progressively, they either lack knowledge, strategies, legislations, budgets or a mix of all. In the Philippines, quite a few studies have also been conducted to evaluate the management of health care wastes. A study on hospital waste management in Metro Manila showed that hazardous medical wastes were not properly handled (Soncuya et al, 2007). Majority of the hospitals do not adhere to the color-coding system as recommended and have no treatment procedures prior to the disposal of their infectious waste while some even continue to dispose their infectious wastes in municipal landfills together with general wastes. Another study on waste management practices of hospitals in Metro Manila conducted by Molina for the Department of Health revealed that although most of the hospitals perform waste segregation, less than 50% of the 144 hospitals studied did not have the proper mechanisms for proper waste handling and segregation (Alfaro, 2009). The study also revealed that some hospitals make use of incineration for final disposal of wastes. In Zamboanga City, a study by Morones (2009) showed that waste segregation among hospitals is being practiced through color-coding scheme and separation of infectious waste from non- infectious waste. However, though wastes were properly sorted in the hospital, the local government garbage truck collects the waste and disposes it in the city dump site - a practice that defeats the purpose of waste segregation in hospitals. A similar study on clinical laboratories in the same locale conducted by Alfaro (2009) revealed that waste segregation is done by majority (89%) of the laboratories, however, the methods are not completely implemented in terms of color

segregation schemes, containers, and waste categories. Unlike other countries, the Philippines has no definitive law or standard that governs the management of health care wastes. Instead, only the laws that govern common or general wastes are readily available. Data found from the Department of Health only include licensing requirements, qualifications, and the Health Care Waste Management Manual (Alfaro, 2009). And so, the regulations that deal with the management of health care wastes are mostly just the guidelines presented in the Health Care Waste Management Manual promulgated by the Department of Health. From the review, it has been presented that there are very few studies and journals in the Philippines that tackle the subject of health care wastes and their management. Most, if not all of them, only study only the health care wastes generated by hospitals and clinics and not of other institutions like funeral establishments. Presently, there are very few studies found describing waste management practices of funeral establishments from local libraries and other sources such as online search engines and websites for journals. However, those that were found focused more on the handling and disposal of cadavers, which is outside the scope of this study. Considering the health hazards related to health care waste, this research is essential in providing information of waste management of funeral establishments in Cebu City and to promote proper health care waste management practices.