Assessment of medical waste management at a primary health-care ...

Waste Management 33 (2013) 162–167

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Assessment of medical waste management at a primary health-care center in São Paulo, Brazil A.M.M. Moreira ⇑, W.M.R. Günther Department of Environmental Health, School of Public Health, University of São Paulo, Avenida Doutor Arnaldo 715, São Paulo 01246-904, Brazil

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Article history: Received 28 June 2012 Accepted 29 September 2012 Available online 31 October 2012 Keywords: Waste management Medical waste management Primary health-care center Infectious waste Waste generation Recyclable materials

a b s t r a c t According to the Brazilian law, implementation of a Medical Waste Management Plan (MWMP) in healthcare units is mandatory, but as far as we know evaluation of such implementation has not taken place yet. The purpose of the present study is to evaluate the improvements deriving from the implementation of a MWMP in a Primary Health-care Center (PHC) located in the city of São Paulo, Brazil. The method proposed for evaluation compares the first situation prevailing at this PHC with the situation 1 year after implementation of the MWMP, thus allowing verification of the evolution of the PHC performance. For prior and post-diagnosis, the method was based on: (1) application of a tool (check list) which considered all legal requirements in force; (2) quantification of solid waste subdivided into three categories: infectious waste and sharp devices, recyclable materials and non-recyclable waste; and (3) identification of non-conformity practices. Lack of knowledge on the pertinent legislation by health workers has contributed to non-conformity instances. The legal requirements in force in Brazil today gave origin to a tool (check list) which was utilized in the management of medical waste at the health-care unit studied. This tool resulted into an adequate and simple instrument, required a low investment, allowed collecting data to feed indicators and also conquered the participation of the unit whole staff. Several non-conformities identified in the first diagnosis could be corrected by the instrument utilized. Total waste generation increased 9.8%, but it was possible to reduce the volume of non-recyclable materials (11%) and increase the volume of recyclable materials (4%). It was also possible to segregate organic waste (7%), which was forwarded for production of compost. The rate of infectious waste generation in critical areas decreased from 0.021 to 0.018 kg/procedure. Many improvements have been observed, and now the PHC complies with most of legal requirements, offers periodic training and better biosafety conditions to workers, has reduced the volume of waste sent to sanitary landfills, and has introduced indicators for monitoring its own performance. This evaluation method might subsidize the creation and evaluation of medical waste management plans in similar heath institutions. Ó 2012 Elsevier Ltd. All rights reserved.

1. Introduction In Brazil, two federal resolutions (ANVISA, 2004; CONAMA, 2005) have placed upon the shoulders of all health-care waste generators the responsibility for their internal and external waste management. This requires the development, implementation and control of a Medical Waste Management Plan (MWMP). The national solid waste policy (BRAZIL, 2010) does not deal specifically with medical waste. However, it binds the regulation of this sort of waste to environmental and health surveillance systems, and determines that every hazardous waste generator must develop a specific waste management plan based on its own inherent risk. A MWMP is defined as a document reporting every internal and external step taken towards waste management, considering the characteristics and risks of each type of waste generated in or⇑ Corresponding author. Address: Rua Gabriel dos Santos 67, 125, São Paulo 01231-011, Brazil. Tel.: +55 11 99390 8118; fax: +55 11 3031 5464. E-mail address: [email protected] (A.M.M. Moreira). 0956-053X/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.wasman.2012.09.018

der to prevent occupational accidents, avoid any environmental impact and protect public health (ANVISA, 2004). According to both federal resolutions mentioned above, medical waste is currently classified into five groups. Some components of each of these groups produced by the PHC are shown in Table 1. Considering that generated waste is mostly comprised of nonhazardous material, similar to household waste, management of medical waste also includes waste minimization, which means avoiding wastefulness, reasonable use of disposable medical appliances and selective segregation of recyclable materials, in order to reduce the quantity of waste sent to landfills (CONAMA, 2005) and to reduce environmental impact. Despite the all-encompassing nature of legal regulations, including both major1 and minor generators,2 the situation in Brazil 1 Major generator: health-care facility producing more than 20 kg of infectious waste per day. 2 Minor generator: health-care facility producing less than 20 kg of infectious waste per day (São Paulo, 2002).

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Table 1 Classification of Brazilian medical waste. Source: ANVISA (2004) and CONAMA (2005). Groups

Description/examples

A

Waste representing risk to public health and the environment due to presence of biological agents such as: blood, bodily fluids, drainage fluids or excreta. Ex. surgical gloves, gauze, cotton, bandages; laboratory plates and blades; microorganism cultures; vaccines discarded and devices used for transference, inoculation or stir cultures Substances representing risk to public health and the environment, depending on their characteristics of inflammability, corrosiveness, reactivity and toxicity. Ex. some chemical products and pharmacological substances Radioactive waste General waste represented by recyclable materials (ex. paper, cardboard, plastic, metals, and glass) and non-recyclable (ex. organic substances, food leftover, and toilet paper) Sharp devices. Ex. needles, syringes, lancets and similar tools

B C D E

has not improved as expected. In fact, so far only a few health-care establishments, mostly private hospitals, are duly complying with those regulations. External medical waste management is also a reason for concern in Brazil. According to a review on solid waste conducted in 2011, only 76% of Brazilian cities provide either partial or full services related to medical waste management. Current devices for treating waste are: incinerator (39.8%), autoclave (14.5%) and microwave (4%). The remaining quantities of waste are disposed on the soil, that is, they are delivered in sanitary landfills (18%), skeptical ditches (11.2%) or open-air dumps (12.5%) (ABRELPE, 2011). Assessment studies on medical waste management in other developing countries (Askarian et al., 2004; Phengxay et al., 2005; Marinkovic et al., 2008) have detected several problems and defaults: segregation, handling and storage are not appropriately conducted. Practices for waste minimization are poor; hazardous and common waste are commingled and disposed in open dumps or landfills; waste incinerators are not equipped with an emission control apparatus; chemical waste is disposed through the public sewerage system and there are no staff training programs. So far only a small number of studies and interventions have shown some improvement in hospitals (Almuneef and Memish, 2003; Alagöz and Kocasoy, 2008; Askarian et al., 2010). A Primary Health-care Center (PHC) is a relatively small medical facility that delivers care to outpatients, participates in immunization programs and consequently produces limited quantities of waste (WHO, 2005). There are currently in Brazil 31,418 PHCs (Ministry of Health, 2012) providing basic public health assistance to outpatients which includes clinical practice, gynecology, obstetrics, pediatrics, geriatrics, dental offices, mental health, physiotherapy, occupational therapy, nutritional assistance, pharmacology, and nursing care such as immunization, wound dressing and medication. PHCs, which in Brazil are considered minor generators, produce notably lower quantities of medical waste (MW) than hospitals, which are considered major generators. However, some factors should also be taken into consideration, such as the large number of units spread throughout the country, inherent characteristics of the waste produced, and lack of concern by the professionals involved about matters related to occupational health and environmental impact. Da Silva et al. (2005) analyzed 91 Brazilian health-care facilities located on the south of the country, including 21 hospitals, 48 Primary Health-care Centers (PHCs) and 22 clinical laboratories. With regard to PHCs, these authors showed that only 4.2% have implemented a MWMP; 10.4% have developed training programs, but none has formed a medical waste committee. According to the authors, the situation is far from ideal, but anyway it is still better than in other Brazilian regions. The purpose of the present study was to evaluate the management of medical waste in a public Brazilian PHC located in the city of São Paulo, Brazil. After 1 year working on the development and implementation of a MWMP, the effort was transformed into a case study. For such, a diagnosis of the former situation was performed,

and a MWMP was developed based on specific data collected. The plan was then implemented and monitored for a period of 1 year.

2. Materials and methods This study was conducted in São Paulo municipality, a Brazilian metropolis with more than 11 million inhabitants (IBGE, 2010) – approximately 5.7% of total Brazilian population – and considered a national reference in terms of medical services. According to data collected by the Ministry of Health (2012), the total number of private and public health-care facilities currently operating in São Paulo comprises 225 hospitals, 2227 medical clinics, 10,143 doctor’s offices, 36 emergency services, and 564 public and primary health-care centers. The primary health-care center surveyed is located in a central area of São Paulo municipality adjacent to the School of Public Health. It is a teaching unit which has been routinely utilized for training nursing, nutritional, and medical skills; and has been used as a research field for graduating and post-graduate students. This PHC employs 104 people and provides public preventive and primary assistance; it also develops other related activities and provides assistance to the nearby population. Sectors identified as critical areas for generating infectious and sharp waste include two laboratories (clinical and dermatological analyses); some consulting rooms (woman’s health, dental assistance, dermatology and acupuncture) and sectors for nurse assistance, such as immunization, medication and wound dressing. The methodology for this study involved the following steps (Fig. 1).

2.1. Step 1: diagnosis of first situation at the PHC studied 1. Field observation and data collection using a form-based check list supported by current Brazilian legislation and technical standards (ABNT, 1993) was performed in order to identify: Required documents (licenses, contracts, certificates and the like). Characteristics of the facility and available equipment. Workers’ routine in critical areas by the time measurements were taken, pondering the generation of hazardous waste. Internal operational practices – segregation, collection, transport and storage – registered by photographic records. 2. Characterization of waste according to groups: A (infectious), D (recyclable and non-recyclable) and E (sharp devices). This study has not considered group B (hazardous chemicals), since generation of this kind of waste is scarce and unsystematic. Group C (radioactive) waste is not generated in this sort of unit. 3. Measurement of daily waste generation: total and per group (kg of waste/day) – every bag of solid waste, previously identified, was weighed over a period of five consecutive days.

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Average of total daily waste generation, except for chemical waste (kg/day). Average of total daily generation of recyclable and nonrecyclable waste (kg/day). Average of daily infectious waste (including sharp devices) generated in critical areas (kg/day). Waste distribution per category: Groups A + E; Group D recyclable and Group D non-recyclable (%). Generation rate of infectious waste (including sharp devices), balancing quantities generated in critical areas with the number of invasive procedures performed in the same areas (kg/procedure in critical areas). 3. Results and discussion

Fig. 1. Methods of study.

2.2. Step 2: development of the MWMP After analyzing the previous diagnosis, a proposal for a medical waste management plan was developed, approved by unit administrators and subsequently implemented at the PHC. 2.3. Step 3: intervention upon implementation of the MWMP The MWMP did not require any complex strategy, just the following ordinary changes: Presentation and compliance with required documents. Acquisition and allocation of equipment according to current regulations. Distribution of informational cards, warnings and identification symbols. Adjustment of operating practices so as to provide greater safety to workers and users. Improvement of segregation, collection and storage of recyclable materials. Preparation of three sequential lectures providing collective training to doctors, nurses, administrative employees and cleaning staff. Support and continuous training to cleaning staff concerning adequate operating practices. A monitoring process was subsequently rolled out. The unit was inspected at least once a month and supervising visits took place as needed. Strategies concerning employee’s mobilization and sensibilization were also adopted. 2.4. Step 4: second diagnosis One year later, the same steps taken by the time of the first diagnosis were reproduced: the form-based check list was reapplied, new pictures were taken, and waste generation was once again quantified for a period of five consecutive days. 2.5. Step 5: evaluation of the MWMP Qualitative results were analyzed by comparing the difference between the first and the second diagnosis. Improvement was supported by photographic records of practices and equipment in service. Quantitative results were represented by the following indicators:

Health-care waste studies have already been conducted in developing countries (Alagöz and Kocasoy, 2008; Askarian et al., 2004; Dehghani et al., 2008; Tsakona et al., 2007), but there are scarce indications that, in practice, waste management is improving to satisfactory levels. The World Health Organization published guidelines to assist large (Prüss et al., 1999) and small health-care institutions (WHO, 2005) to draw up their own management plans. However, research conducted in South America (Da Silva et al., 2005), as well as in some African (Abor and Bouwer, 2008) and Asian countries (Mohamed et al., 2009; Phengxay et al., 2005; Shinee et al., 2008), shows that only few hospitals or small health-care centers (PHC, medical clinics, dental, veterinary, and medical offices) have shown qualitative and quantitative improvements as it would be expected. As it can be seen in some of these researches, there is a lack of regulatory legal framework or specific public policies involving the subject (Askarian et al., 2004; Dehghani et al., 2008). Nevertheless, this is not a problem in Brazil. Since 1993, federal resolutions dealing with management of medical waste have been issued and progressively updated. Current regulations (ANVISA, 2004; CONAMA, 2005) are complementary and cover every step of internal and external management. In spite of this, small health-care establishments continue to disregard those determinations. The problem in Brazil is that no assessment of health institutions after implementation of their respective MWMPs has been performed. The present study, conducted at a PHC located in São Paulo during the period ranging from 2008 to 2009, found that most of the legal requirements were still unknown to managers and to health workers. Many noncompliance episodes detected by this PHC first diagnosis were similar to those reported by Da Silva et al. (2005), 3 years before our study, at primary health-care establishments located in another Brazilian state. Likewise, in China, Gai et al. (2010) recognized that primary health-care centers showed a number of waste management inadequacies larger than that of secondary or tertiary establishments, and listed as examples: poor waste segregation, lack of equipment, inadequate locations for storage, poor sanitary protective measures, and unsafe on-site disposal. Similar noncompliance instances had been reported in PHC assessments conducted in several developing countries such as Laos (Phengxay et al., 2005), Turkey (Alagöz and Kocasoy, 2008), Mongolia (Shinee et al., 2008), and others. Another finding was the lack of procedures regarding waste segregation, such as for example developing selective collection programs for recyclable materials, which is the case in many hospitals and in the majority of minor generators. The worse scenario was found in minor generators, where waste generation is not systematically quantified (Abor and Bouwer, 2008; Haylamicheal et al., 2010; Marinkovic et al., 2008). According to Tsakona et al. (2007), it is important to know the quantity of waste generated, and such waste should be classified by type, in order to allow consideration of the various treatment options. Several authors have

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A.M.M. Moreira, W.M.R. Günther / Waste Management 33 (2013) 162–167 Table 2 Non-Conformities and Respective Adjustments. Situation before MWMP

Adjustments

Absence of waste management policies, plans or protocols Lack of documents and certificates required by law Absence of a technical person responsible for issues related to waste Practices for waste minimization were restricted to separation of cardboard for recycling Inadequate segregation of waste owing to absence of different collection bins

A MWMP was developed and implemented These documents and certificates have been gradually provided A professional responsible for the MWMP was assigned Other materials such as paper, plastic, glass, aluminum cabs and some organic materials have been included Color-coded and identified bins for each waste category were distributed: nonrecyclable, recyclable and infectious White bins with cover, pedal and the international bio-hazardous symbol for infectious waste were provided in critical areas White high density polyethylene bags labeled with the bio-hazardous symbol were provided for storing infectious materials; black bags for non-recyclable materials, and translucent bags for recyclable material were also provided Cardboard puncture-proof boxes for storing sharp devices were fixed on the walls

Use of inadequate bins for infectious waste: colored, without cover, pedal, or identification Usage of non-standardized plastic bags (thin and fragile): they should be black for general waste, and white or gray for infectious waste Cardboard puncture-proof boxes lying over sinks or on the floor, bringing risks of contamination and spoiling Absence of an exclusive white wheeled bin for carrying and temporarily storing infectious waste, resulting in white plastic bags containing infectious waste lying on the floor External shelter for storing infectious waste, in disagreement with Brazilian technical standards Absence of an autoclave for treating infectious materials from laboratories; only a chemical process was used for decontamination Doubts on where to discard expired drugs, choosing inaccurately common, infectious or receptacles of sharp devices Lack of knowledge about hazardous waste, posing occupational risk for the unit staff

employed indicators such as daily waste generation (kg/day) and distribution by category (%), in order to analyze and compare the results obtained from several health-care establishments. Other researchers (Alagöz and Kocasoy, 2008; Da Silva et al., 2005; Gai et al., 2010) have chosen to utilize a rate which correlates the quantity of medical waste generated to the total number of beds existing in the institution (kg/bed day). In practice, however, studies about medical waste generation in health-care establishments have produced a large spectrum of results, probably for not taking into account some important differences with respect to the characteristics of the establishment studied, such as: complexity level (primary, secondary or tertiary), location (urban or rural), socioeconomic status of patients and visitors, actual days of service operation and type of procedure provided (invasive or noninvasive). All these aspects directly interfere with the generation of solid waste, and should be considered and clearly explained in related studies. The parameters adopted should be as close as possible to the reality of the service. Askarian et al. (2010) applied a more specific indicator (kg/occupied bed day), while Alam et al. (2008) and Shinee et al. (2008) adopted kg/patient day. Phengxay et al. (2005), Dehghani et al. (2008) and Mohamed et al. (2009) chose to use separate medical waste generation rates according to the nature of the medical care: kg/inpatients day or kg/outpatients day. A more specific indicator was proposed and employed in the present study (kg/procedures in critical areas), which correlates the amount of infectious waste generated (including sharp devices) with the number of procedures implemented in critical areas. Such indicator reflects the way segregation of infectious waste was performed, and contributes with a more significant criterion in terms of preventing environmental and occupational risks. In addition, such indicator would not be subject to the interference of the volume of waste generated by the assistance provided in non-critical areas, which exclusively generates common waste. The use of a more specific indicator for hazardous waste reflects more closely the reality of minor generators, and helps monitoring segregation of hazardous waste. Qualitative and quantitative improvements obtained by the present study are listed below.

White wheeled bins to transport and internally store infectious waste were provided A white container for storing plastic bags was acquired; a net to prevent flies from entering the bin was installed, and the international biohazardous symbol was fixed on the dump An autoclave for treating laboratory contaminated materials was acquired Information leaflets and warning cards were displayed Continuous monitoring and periodic training of health professionals and cleaning staff have been developed and conducted

3.1. Qualitative improvements Gaps detected in the first diagnosis have been gradually filled. It is important to point out that the investment made in order to achieve a satisfactory status was quite low. Table 2 shows some non-conformities detected in the first diagnosis, and due improvements and adjustments have been made in order to comply with regulations.

3.2. Quantitative improvements Implementation of the MWMP resulted also in quantifiable improvement (Table 3). There was a reduction of 11% in the generation of common waste, which declined from 14.6 kg/day (2008) to 13.3 kg/day (2009), even with the increment of 2.3 kg/day in total generation of solid waste. This increase could be justified by the addition in the number of outpatients assisted – from 689 to 819 – in the period (Table 4). Consequently, reduction of common waste can be explained by better segregation of waste at the source, implementation of a selective collection program for recyclable materials and reuse of organic waste. After implementation of the plan, the quantity of recyclable materials collected increased 1.2 kg/day (4%), owing to diversification of recyclable materials. While previously only cardboard was collected for recycling, other materials such as paper, plastic, metal and glass have been incorporated to the recycling process. In addi-

Table 3 Total daily waste generation by groups, in 2008 and 2009. Waste groups

Waste generation 2008

General waste (D) Recyclable material (D) Organic waste (D) Infectious (A) + Sharp devices (E) Total solid waste

2009

kg/day

%

kg/day

%

14.6 3.1 0 5.8 23.5

62 13 0 25 100

13.3 4.3 1.8 6.4 25.8

51 17 7 25 100

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Table 4 Performance Indicators in 2008 and 2009. Indicators

2008

2009

Average of daily total waste (kg/day) Daily number of outpatients assisted (number/day) Rate of total waste generation (kg/outpatients assistance) Average of daily infectious waste (kg/day) Daily number of procedures in critical areas (number/day) Rate of infectious waste generation (kg/procedure in critical areas)

23.5 689 0.034 5.8 274 0.021

25.8 819 0.031 6.4 344 0.018

tion, in March 2009 a household composter was developed at the site, starting the reuse of fruit and vegetable leftovers, coffee dregs, leaves and garden pruning, which contributed to a reduction of 7% (1.5 kg/day) of common waste sent to landfills. Another effect refers to the increment of 0.6 kg/day in the quantity of infectious waste and sharp devices in the period. However, it was found that in the second quantification (2009) the number of medical procedures generating infectious waste in critical areas had also increased from 274 to 344 (Table 4). Therefore, in reality, there was a relative reduction of 0.003 kg of infectious waste per procedure, which can be attributed to greater awareness of segregation at the source. 4. Conclusion The MWM plan for the PHC studied was developed according to data collected based on a tool (check list) that considered all legal requirements in force. This instrument supported the first and second diagnoses of waste management at the PHC and proved to be a simple and appropriate tool for promoting improvements on waste management, occupational health conditions and also implementation of sustainable actions. Based on the reality existing at the PHC studied, a MWMP was developed, implemented and monitored throughout a whole year, allowing participation of the large majority of the staff, required a low investment and achieved most of the objectives proposed. Moreover, data on qualitative and quantitative evaluations of medical waste management performance concerning minor generators were produced. Although the PHC researched is linked to a university and located in the city of São Paulo, several legal non-conformities were detected in the first diagnosis, thus corroborating other studies involving small health-care facilities in developing countries, and indicating that close attention should be given to waste management. Unawareness of legislation by health-care workers also contributes to non-conformities, and this tool would also provide appropriate information on this issue. Considering that PHCs rely on limited human and financial resources for promoting research, plans and programs, and that a waste management plan must comply with the legislation in force, this tool could be used for supporting the development of MWMP for similar health-care establishments and, consequently, contribute to improve their performance. The main challenges were to change people’s behavior by teaching them the right way of segregating waste and by maintaining engaged the large diversity of professionals who works at the health-care unit. In this case, the workers were attracted by the program; they embraced it and stayed onboard throughout the study, which has contributed to give continuity and sustainability to the plan. Although total generation of waste has increased, its percentage distribution in categories changed into a more favorable composition under environmental and sanitary viewpoint. A reduction in non-recyclable waste and an increment in segregation of recycla-

ble material could be observed, as well reutilization of organic waste for composting. A reduction in the rate of infectious waste generation in critical areas could also be observed. Thus, greater attention to minimize the generation of waste and to valorize waste leads to a situation that contemplates sustainability aspects and reduction of health risks. The use of a more specific indicator – infectious waste generation rate (kg/procedure in critical areas) – proved to be more adequate to the reality of minor generators, where there are no patients hospitalized. It will allow long-term tracking of the unit’s performance in terms of waste segregation, as well as correlating results among similar establishments. Some actions are recommended in order to obtain better results: include hazardous chemical substances and special materials (fluorescent lamps, batteries, electric–electronic equipment, etc.) in the waste management plan; run a continuous quality and quantity monitoring process; support an effective employee training program; attain commitment of subsequent administrators and new staff members; promote educational campaigns in order to obtain the engagement of patients and visitors. Acknowledgement The authors would like to thank the entire staff body of the Health-Care Center for the warm reception and valuable contribution given during the development of the present study. This study was not funded. References ABNT, 1993. Brazilian Technical Standards Association. NBR 12809. (Handling of wastes from health services: procedures). Abor, P.A., Bouwer, A., 2008. Medical waste management practices in a Southern African hospital. International Journal of Health Care Quality Assurance 21 (4), 356–364. ABRELPE, 2011. Brazilian Public Cleaners Companies and Special Waste Association. (Overview of solid waste in Brazil: Edition 2011). (accessed June 2012). Alagöz, A.Z., Kocasoy, G., 2008. Determination of the best appropriate management methods for the health-care wastes in Istanbul. Waste Management 28 (7), 1227–1235. Alam, M.M., Sujauddin, M., Iqbal, G.M., Huda, S.M., 2008. Report: healthcare waste characterization in Chittagong Medical College Hospital, Bangladesh. Waste Management & Research 26 (3), 291–296. Almuneef, M., Memish, Z.A., 2003. Effective medical waste management: it can be done. American Journal of Infection Control 31 (3), 188–192. ANVISA, 2004. National Health Surveillance Agency. Resolution No. 306, December 2004. (Adopts provisions concerning technical regulation for managing healthcare waste). (accessed June 2012). Askarian, M., Vakili, M., Kabir, G., 2004. Results of a hospital waste survey in private hospitals in Fars province, Iran. Waste Management 24 (4), 347–352. Askarian, M., Heidarpoor, P., Assadian, O., 2010. A total quality management approach to healthcare waste management in Namazi Hospital, Iran. Waste Management 30 (11), 2321–2326. BRAZIL, 2010. Federal Law No. 12305, August 2010. (Establishes National Policy of Solid Waste). (accessed June 2012). CONAMA, 2005. National Environmental Council. Resolution No. 358, April 2005. (Adopts provisions concerning treatment and disposal of waste of healthcare services). (accessed June 2012). Da Silva, C.E., Hoppe, A.E., Ravanello, M.M., Mello, N., 2005. Medical waste management in the south of Brazil. Waste Management 25, 600–605. Dehghani, M.H., Azam, K., Changani, F., Fard, E.D., 2008. Assessment of medical waste management in educational hospitals of Tehran university medical sciences. Iranian Journal of Environmental Health Science & Engineering 5 (2), 131–136. Gai, R.Y., Xu, L.Z., Li, H.J., Zhou, C.C., He, J.J., Yoshihisa, S., et al., 2010. Investigation of health care waste management in Binzhou District, China. Waste Management 30 (2), 246–250. Haylamicheal, I.D., Dalvie, M.A., Yirsaw, B.D., Zegeye, H.A., 2010. Assessing the management of healthcare waste in Hawassa city, Ethiopia. Waste Management & Research, 1–10. IBGE, 2010. (Brazilian Institute of Geography and Statistics). (accessed June 2012).

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