Point of view

To the Editors:
Management of health care waste in Sri Lanka

In many countries improper management of waste relevant.

generated in health care facilities causes direct health Hazardous waste
harm to the community, to people working in health The WHO classifies hazardous waste into the fol
care fa cilities, and to the environment. In addition, lowing categories [1].
pollution from inadequate treatment of waste can cause
indirect health harm to the community. The disposal of 1. Infectious waste, suspected to contain pathogens
certain types of devices should follow specific safety (bacteria, viruses, parasites, or fungi) in sufficient
rules. For example, a syringe is a common item that concentration or quantity to cause disease in sus
requires safe disposal. It is a usual sight in the vicinity ceptible hosts.
of practically every hospi tal to find unsterile needles, 2. Pathological waste, consisting of tissues, organs,
syringes and containers for sample collection for sale body parts, human foetuses and animal carcasses,
by unscrupulous vendors. The health authorities are blood, and body fluids.
aware of this perilous situation, but are unable to act in 3. Sharps, items that could cause cuts or puncture
a meaningful manner due to the ab sence of a clinical wounds, including needles, hypodermic needles,
waste management infrastructure. Sri Lanka urgently scalpel and other blades, knives, infusion sets,
needs a proper clinical waste manage ment system. saws, broken glass, and nails. Whether or not they
are in fected, such items are usually considered as
Waste management options need to be efficient,
hazard ous health care waste.
safe and environment friendly to protect people from
4. Pharmaceutical waste, includes expired, unused,
volun tary and accidental exposure to waste when
spilt, and contaminated pharmaceutical products,
collecting, handling, storing, transporting, treating or
drugs, vaccines, and sera that are no longer
disposing of waste. Furthermore, in the Sri Lankan
required and need to be disposed off appropriately.
context such op tions need to be cost effective, taking
It also includes discarded items used in the
into account the local logistical needs. Though clinical
handling of pharmaceu ticals, such as bottles or
waste management should be an integral part of the
boxes with residues, gloves, masks, connecting
health care delivery sys tem the principal reason for
tubing, and drug vials.
absence of such infrastruc ture is economic. Health
5. Genotoxic waste, includes certain cytotoxic drugs,
personnel are still to distinguish health care waste from
vomit, urine, or faeces from patients treated with
ordinary garbage.
cytotoxic drugs, chemicals, and radioactive mate
In a discussion of health care waste management it rial. Cytotoxic or antineoplastic drugs are the prin
is important to have clear definitions of various catego cipal substance in this category. These drugs are
ries of health care waste. For the purpose of this article used in highly specialized units.
I have chosen the WHO classification of health care 6. Chemical waste, consists of discarded solid, liquid,
waste. and gaseous chemicals, used for diagnostic and ex
perimental work and for cleaning, housekeeping,
Health care waste and disinfecting procedures. These are considered
haz ardous if at least one of following properties is
This includes all the waste generated by health present; toxic, corrosive (pH<2 or pH>12), flam
care establishments, research facilities and laboratories. mable, reactive (explosive, water-reactive, shock
In addition, it includes the waste originating from sensitive) or genotoxic.
“minor” or “scattered” sources such as that produced in 7. Waste with high content of heavy metals. 8.
the course of health care undertaken in the home Pressurized containers. Many types of gases used in
(dialysis, insulin injections, etc.) [1]. Between 75% and health care are often stored in pressurized cylinders,
90% of the waste produced by health care providers is cartridges, and aerosol cans. Many of these, once
non-risk or “gen eral” health care waste, comparable to empty or of no further use (although they may still
domestic waste. It comes mostly from the contain residues), must be disposed off.
administrative and housekeeping functions of health 9. Radioactive waste.
care establishments. The remaining 10% to 25% of
health care waste is regarded as hazard ous and may
create a variety of health risks [1]. Background data
General health care wastes should be dealt with by Although Sri Lanka has impressive health
the municipal waste disposal mechanisms [1]. This ar indicators, the health system has certain shortcomings.
ticle is confined to the analysis of the current and future They include poor macro- and micro-health planning,
aspects of “hazardous” health care waste management, unequal distri bution of resources, lack of funds and no
principally by government health institutions in Sri long term po litical and bureaucratic commitment
Lanka, with comments on the private sector where towards health issues.
 Vol. 49, No. 3, September 2004 93
Point of view Estimated total health care waste produced by listed
gov ernment hospitals is between 76 623 and 170 789
kg daily (Table 3). It should be noted that no private
A major drawback in planning has been the non-inclu
sector hospital health care waste generation has been
sion of a clinical waste management system, which is
included. Thus it can be assumed that by using high
an integral part of any national health system.
income coun try data we are compensating for the loss
Tables 1 and 2 show generation of health care of waste gen eration from the private sector hospitals to
waste from international sources. This data can be used some degree. Using WHO estimates [1] the daily
as a comparative scale for Sri Lanka. Using data from hazardous waste pro duction in the listed government
Table 2, I have calculated the estimated daily waste hospitals in Sri Lanka between 7 662 and 42 697 kg
generation in a few categories of hospitals in Sri Lanka daily (Table 4).
(Table 3).
Table 4. Estimated hazardous waste generation in
Table 1. Total health care waste generation by region [2] government hospitals in Sri Lanka for year 2000

Region Daily waste generation (kg/bed) Total heath care Hazardous waste
waste (kg/day) (kg/day)
North America 7–10
Western Europe 3–6 At 10% At 25%
Latin America 3 of total of total
Eastern Asia health health
• High income countries 2.5–4 care care
• Middle income countries 1.8–2.2 Eastern waste waste
Europe 1.4–2 Eastern Mediterranean 1.3–3 Lower estimate 76 623 7 662 19 155 Upper estimate 170
789 17 078 42 697
Table 2. Health care waste generation according to type of
hospital [3]
Table 5 gives a breakdown of the type of material
Source Daily waste generation (kg/bed) University hospital generated as waste in Indian hospitals. As India and Sri
4.1–8.7 General hospital 2.1–4.2 District hospital 0.5–1.8 Lanka share many similarities in health issues, manage
Primary health care centre 0.05–0.2 rially and socio-culturally, we can gain some idea as to
the waste composition in Sri Lankan hospitals. The in
Data from high income countries.
fectious waste component in this Indian series was 15%
of the total hospital waste [1]. Further studies are
Table 3. Estimated daily health care waste generation in needed to have a more accurate description of the Sri
selected hospitals in Sri Lanka. (Calculated using bed
Lankan hospital waste composition.
capacities for year 2000)

Hospital Number of Total Estimated daily waste category Table 5. Average composition of hospital waste in India [1]
hospitals number production (kg)
Material Percentage (wet-weight basis) Paper 15
[4] of beds [4] Lower Upper
Plastics 10 Rags 15
estimate estimate
Metals (sharps, etc) 01
1. University 15 14 659 60 102 127 533 and teaching Infectious waste 15
hospitals Glass 40 General waste (food waste,
2. General and sweepings from hospital premises) 53.5
provincial Source: National Environmental Research Institute, 1997.
hospital 6 4 966 10 429 20 857 3. Base hospitals 36 9 The data are average values obtained from 10 large hospitals
865 4 932 17 757 4. Primary health 481 23 212 1 160 4 in Mumbai, Calcutta, Delhi and Nagpur during period 1993 to
642 care centres (156+93+ (13 584+ 1996.
(DH, PU, 167+65) 4 382+660)
RH, MH
Current status
and CD)
The state hospital health care waste produced at
Total 538 52 702 76 623 170 789 present in Sri Lanka is disposed off by the following
DH–District Hospital, PU–Peripheral Unit, RH–Rural methods:
Hospital, MH and CD–Maternity Home and Central 1. Collection by local municipal authority and subse
Dispensary. N.B. Mental, Chest, Leprosy, Police, Prison, quent dumping.
Fever, Dental and Rehabilitation hospitals not included. 2. Burning in the heath care facility premises.

94 Ceylon Medical Journal

3. Burying in the health care facility premises. 4. Dumping at a designated site within hospital premises
or at a designated dumping site of the local authority. to allocate space for the autoclave to be installed. I be
Sri Lanka at present is disposing general health care lieve that if funding is forthcoming the country should
waste according to WHO recommendations [1]. The go for the gold standard in clinical waste management,
point at which Sri Lanka departs from these recommen which is incineration. The possibility of having it
dations is that we dispose hazardous waste along with installed at a central location for the use by both
the general waste into a common disposal system. government and private sector should be explored.
Hazardous waste is not treated before releasing into the
general waste disposal system to render it non Conclusion
hazardous. Some major hospitals in the island are col
lecting waste using the internationally accepted colour Sri Lanka’s population is projected to reach 23.35
coded collection system. However, as there is no sepa million in 2040 [5]. With increase in the number of
rate system for final collection, storage, transport and health care facilities and the use of sophisticated
equipment, the generation of hazardous waste is sure to
disposal of general and hazardous waste there is re
rise. The increase in the domiciliary treatment of
mixing of the two categories. Consequently the initial
certain diseases (insulin injection, home dialysis) will
effort and cost of segregation is lost.
also add to this. As clinical waste management is a
Sri Lanka is beginning to see the effects of unac relatively new concept for Sri Lanka, which needs to be
ceptable hazardous waste disposal, particularly in the integrated into the existing health care system, all
form of contaminated needles and syringes re-entering levels of health professionals should be made aware of
the formal health system. Further studies need to be the usefulness and need for it. I hope that this article
done to document this phenomenon. Improper and will provoke thinking on health care waste
unsafe re cycling of needles and syringes is a major management in Sri Lanka.
concern in Sri Lanka because it jeopardizes our highly
successful childhood immunisation programme. If
vaccination is perceived as unsafe by the public due to References
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lead to an ero sion of public confidence in the able
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consequences. wastemanagement/en/02 to 19.
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Proceedings in Environment ’97 Conference, 16–18
ration did a review of the clinical waste disposal Feb ruary 1997, Cairo. Dokki-Gizza, Egyptian
systems in Sri Lanka. The team recommended the Environmen tal Affairs Agency.
installation of an autoclave to decontaminate clinical
3. Enconomopoulos AP. Assessment of source of air, water
waste generated in the government sector before and land pollution. A guide to rapid source inventory
release into the general waste disposal system[Personal techniques and their use in formulating environmental
communication, Dr. R Fernando]. control strategies. Part 1: Rapid inventory techniques in
This was thought to be more cost effective than environmental pollution. Geneva, World Health Organi
the gold standard of clinical waste disposal, which is zation, 1993.
incin eration. The government is unable to find a 4. Annual Health Bulletin, Department of Health, Sri Lanka.
suitable lo cation for the autoclave for which funding is 2000, 75.
available. The reason for this is that no government 5. Abeykoon ATPL. Demographic trends among major eth
hospital agrees nic groups in Sri Lanka. Sri Lanka Journal of
Point of view Population 2001; 4: 21–39.

Ruvaiz Haniffa, Medical Officer, Sri Jayawardenepura Teaching Hospital, Nugegoda. Sri Lanka. Tel: +94 1 2565696,
e-mail: <ruvaiz@isplanka.lk> (Competing interests: none declared). Received 2 February 2004 and revised version
accepted 22 May 2004.

Vol. 49, No. 3, September 2004 95