| Abstract|| |
Aim: This study is proposed to assess the knowledge and practices among dental practitioners in the implementation of biomedical waste (BMW) management rules (2016) in Kumbakonam, Tamil Nadu; to assess the effective usage of the four colour-coded bins, those are used to handle the BMW; and to assess the service of the BMW collecting and disposing agents. Methodology: A questionnaire comprising of 12 closed-ended and 1 open-ended question regarding the dental practitioner's management of BMW in their daily clinical practice was developed. After validation, the questionnaire was sent as Google forms to 54 dental practitioners who are practicing at Kumbakonam, and responses were received from all. The collected data was entered in an Excel sheet, and then percentages were obtained for each response from the participants. Result: The most common challenges were, space-occupying BMW disposal bins as well as the lack of regular collection of BMW, this may be because the disposal agent's services cover a larger geographical area with lesser wastage collecting manpower. Though most of the study participants were well aware and practiced the management, still a small percentage of practitioners were lacking in this. The responses on storage and handling the BMW management reflect the knowledge gap in more than half of them. Conclusion: These challenges indicate the need for a well-established network of BMW collecting agencies and cost-effective, tailor-made colour-coded bins for suitable and continuous usage in dentistry.
Keywords: Biobin, biomedical waste management, challenges, cross-sectional study, dental practitioners, dentists, Kumbakonam, waste disposal
|How to cite this article:|
Sarvathikari R, Pavithran VK, Ravichandiran R. Challenges in implementation of biomedical waste management among the dental practitioners in a tier 2 town in India – A cross-sectional study. Indian J Dent Res 2021;32:443-7
|How to cite this URL:|
Sarvathikari R, Pavithran VK, Ravichandiran R. Challenges in implementation of biomedical waste management among the dental practitioners in a tier 2 town in India – A cross-sectional study. Indian J Dent Res [serial online] 2021 [cited 2022 Dec 3];32:443-7. Available from: https://www.ijdr.in/text.asp?2021/32/4/443/345432
| Introduction|| |
Biomedical waste (BMW), also known as infectious waste or medical waste, is defined as waste generated during the diagnosis, testing, treatment, research or production of biological products for humans or animals. BMW is an important source of spreading infection. The scientific disposal of BMW through segregation, collection and treatment is called as BMW management. BMW includes syringes, live vaccines, laboratory samples, body parts, bodily fluids and waste, sharp needles, cultures and lancets. Dental practices also produce a few other types of waste, such as mercury, silver amalgam and various chemical solvents.
It has been estimated that up to 85% to 90% of the waste generated in hospitals is non-infectious (without any body fluids, which is like domestic waste). It is the remaining 10–20% of waste that is of concern because it is hazardous and infectious. According to the World Health Organization (WHO), the 11 South-East Asian countries together produce approximately 350,000 tonnes of healthcare waste per year which is both hazardous and non-hazardous. Hence, proper collection and segregation of BMW are important. Hospital waste is not only infectious but also hazardous, which has a significant contribution to the environmental pollution.
The Ministry of Environment and Forest has notified, “Biomedical Waste (Management and Handling) Rules 1998/ 2000 under the Environment (Protection) Act, 1986 that compel all hospitals, clinics, nursing homes, slaughterhouses and laboratories to ensure safe and environmentally sound management of waste produced by them. 'Biomedical waste' means any waste which is generated during the diagnosis, treatment or immunisation of human beings or animals or in research activities pertaining thereto or in the production or testing of biologicals. These rules apply to all persons who generate, collect, receive, store, transport, treat, dispose or handle bio-medical waste in any form. 'Authorised person' means an occupier or operator authorised by the prescribed authority to generate, collect, receive, store, transport, treat, dispose and/or handle bio-medical waste in accordance with these rules and any guidelines issued by the Central Government. BMW management is currently a burning issue more so with the increasing healthcare facilities and increasing waste generation.
Improper management of waste generated in healthcare facilities causes a direct health impact on the community, the healthcare workers and the environment. In our nation, widespread awarness is required because the studies suggest gaps in knowledge and lacunae in attitudes and practices among the various categories of healthcare worker, about biomedical waste management. Dental setup is a multidisciplinary system that consumes a lot of items for the delivery of dental care. This study is proposed to assess the knowledge and practices of the dental practitioners towards the new BMW management rules (2016) in its early implementation period, in a town like Kumbakonam, a taluk headquarters, in Tamil Nadu; to assess the effective usage of the four colour-coded bins, those are used to handle the BMW; and to assess the service of the BMW collecting and disposing agents.
| Materials and Methods|| |
A descriptive, cross-sectional study was carried out among private dental practitioners throughout Kumbakonam. The total duration of the study was 2 months, August and September of 2019. The study was carried out after obtaining ethical clearance from Rajah Muthiah Institute of Health Sciences, Annamalai University, Chidambaram (IHEC/583/2019).
A panel of five faculty members was formed to check the clarity and unambiguity of the 13-point questionnaire. This questionnaire comprised of 12-trichotomous close-ended and 1 open-ended question to assess the knowledge, the effective usage of the colour-coded four bins and the service of the BMW collecting and disposing agents, thereby the common difficulties the dental practitioners face in implementing the new BMW management rules (2016) in their daily clinical practice. A pilot study was conducted among 30 dental practitioners (not part of the main study) to assess the validity of the questionnaire and the feasibility of the study. The face validity, content validity using Aiken's V index (for each item ranged between 0.75 and 0.95) and the internal consistency using Cronbach's alpha (0.76 - acceptable) of the questionnaire were assessed. The questionnaire comprised of the following questions:
- Is the existing BMW management essential?
- According to BMW management rules 2016, is the system easily applicable in your dental clinic?
- As a dental practitioner are you comfortable with four colour-coded bins system?
- Do all the four bins fill up daily in your clinic?
- According to the BMW management rules 2016, waste should not be stored beyond_________ number of hours?
- Do you dispose of the contents of all the bins daily?
- Do you think it is economical to dispose of medical waste daily, considering the investment required to put on the colour-coded plastic bags within the bins?
- Do you have a tie-up contract with any municipal corporation/medical waste disposal agent?
- If yes, is the agency easily accessible?
- Are such agencies responding to the effort of the dental practitioners in supporting and practicing correct waste disposal methods?
- Does the municipal corporation/medical waste management collect the BMW from your dental clinic daily?
- Do the municipal corporation/medical disposal agent follow the BMW management protocol 2016?
- Do you have any other challenges in managing BMW, if so please mention
A convenience sampling method was employed to include all the private dental practitioners in and around Kumbakonam as study participants. The questionnaire was sent as Google forms through social media (WhatsApp). The participant's consent was obtained through the initial section of the questionnaire before the start of the survey. Totally, 54 (n) dental practitioners participated in the study and responded. One participant refused to participate and did not mention any reason for the refusal.
The collected data was entered into the Microsoft Excel sheet. Percentages were obtained for each of the closed-ended question's responses. For the final open-ended question, themes were categorised and codes were assigned to each of the themes and then its frequency and proportion were estimated.
| Results|| |
Among the 54 dental practitioners, 1 was unwilling to participate. The total response rate was 98.14% [Table 1]. Around 90.56% of the participants responded yes to the essentiality of BMW management in India, this reflects their awareness about the possible harm produced by the BMW, 3.77% of participants responded no and 5.67% of the participants had no idea about the same [Table 2].
The BMW management rules 2016 were easy to practice or follow for 49.05% of dentists who participated in the study. Whereas 32.07% opted no and 18.88% of the participants did not have any idea about the BMW management rule 2016 [Table 2].
The implementation of four colour-coded bin systems was comfortable for 69.82% of practitioners, but the usage of all four bins did not receive a favourable answer. 84.90% of practitioners responded that not all four bins were getting filled up daily [Table 2]. Regarding the knowledge about BMW storage, 24.53% answered rightly as 48 h, 58.49% answered as 24 h, reflecting the knowledge gap about BMW [Table 3].
|Table 3: Knowledge of dental practitioners regarding the duration of storage of waste according to BMW management rules 2016 (%)|
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There were 43.40% of dental practitioners who were disposing of the contents of all bins daily and 56.60% were not disposing of daily. On the contrary, only 15.09% of practitioners responded yes to the question, it is economical to dispose of waste daily and the remaining 75.47% responded no and 9.44% had no idea [Table 4].
A total of 69.81% of dental practitioners at Kumbakonam had contracts with municipal corporation or BMW management agents. 24.52% of them did not have any such contracts and 5.67% of them had no idea of the same [Table 4].
On the contrary, only 41.50% of dentists responded yes for easy accessibility of municipal corporation or medical waste disposal agency in their area and 45.28% responded that the agencies are supporting their efforts of practicing correct disposal methods. 32.07% of the dental practitioners responded no for easy accessibility and 26.41% of dentists responded no to the support of agencies. 26.43% had no idea about the accessibility of the agencies in their area and 28.31% of dentists had no idea about their support [Table 4].
The daily collection of BMW by the agencies scored only 69.81%, showing a lag in the collection network. The question about the 2016 BMW management application by the municipal corporation or medical waste management agencies was also included in the study, for which only 26.41% of dentists answered yes, 13.20% answered no and 60.39% had no idea about the same [Table 4].
The open-ended question revealed that around 24.52% (n = 13) dental practitioners faced challenges and difficulties in the management of BMW. The most common concerns were that the BMW disposal bins are space-occupying, disposal agent is not from their particular town, these agencies come once in 2/3 days to collect waste, increased monthly expenses that directly affect patients and the number of waste disposal agents is not sufficient to meet the burden of hospital's BMW disposal needs.
| Discussion|| |
Among the total participants, around 90.56% of the participants responded yes to the essentiality of BMW management in India which is similar to the study of Jamkhande et al., and Khatri et al. stated 94.6% and 98.67% of the dentists have awareness of the BMW legislation. Our study showed better results compared to the study by Lakshmikantha et al. and Sood et al. that 88.4% and 75% of the practitioners were aware of BMW generation whereas 6.8% were not aware of it. Response to this question is favourable to the fact that most of the dentists practicing in Kumbakonam want proper biomedical management for dentists in India.
The BMW management rules 2016 were easy to practice or follow for 49.05% of dentists who participated in the study. Therefore, this shows only around 50% of the dentist in Kumbakonam are comfortable with the application of BMW rule 2016, while the remaining participants found it difficult to apply.
The implementation of four colour-coded bin systems is comfortable for 69.82% of practitioners, whereas better results are shown in the study by Jamkhande et al. that 79.5% of the participants segregated the BMW and colour-coded the waste before disposal, and a study by Pawar et al. shows 93.8% of the dentists segregate BMW in their clinic. Our study shows 58.7% of the participants disposed the biomedical waste following the BMW regulations, which is higher than the study conducted by Kulkarni et al., but still 41.3% of participants disposed them incorrectly. whereas 41.3% of residents still disposed of them incorrectly. Similar results are seen in the study by Abhishek et al. that 68% of the practitioners have the habit of segregating waste based on colour-coding whereas 29.5% disposed of the waste without segregation. Better results were shown in the study by Potlia et al. in which 98.3% of the dentists were aware of the colour-coding segregation of BMW.
Regarding the knowledge about BMW storage, 24.53% answered rightly as 48 h, 58.49% answered as 24 h, reflecting the knowledge gap about BMW. The variations in the results between the studies can be attributed to the variation in the duration of practicing BMW management, in the place of the current study, that was the beginning of the implementation of BMW management.
There were 43.40% of dental practitioners who were disposing of the contents of all bins daily, whereas better results are shown in the study by Khandelwal et al. that 75% of the practitioners disposed of waste every day, 18% of them disposed of it once in 2 days and remaining disposed of the waste after 2 days.
Registration with BMW collecting agency is mandatory, however, only around 69.81% of dental practitioners at Kumbakonam had contracts with municipal corporation or BMW management agents. This shows still one-third of practitioners are yet to implement proper disposal. A study by Jamkhande et al. and Pawar et al. shows that 81% and 87.5% were registered with the BMW disposal service provider which is better than our study. A study by Abhishek et al., Sood et al. and Khatri et al. shows that 68%, 68% and 74.6% of the practitioners have registered with a certified waste carrier service to recycle or dispose of the BMW in their clinic which is similar to our study.,,
Our study result shows that 26.43% had no idea about the accessibility of the agencies in their area and 28.31% of dentists had no idea about their support. Similar results are seen in the study by Abhishek et al. that 26.5% of the dentist have a lack of information and non-availability of agency service are the most common problems in BMW management.
The daily collection of BMW by the agencies scored only 69.81%, showing a lag in the collection network, whereas better results are seen in the study by Navya et al. in which 90% of the dentists say that dental waste has been taken away by the waste management authority people every alternate day. Our study showed a better result than the study by Khatri et al., where 32.5% of the practitioners do follow the daily disposal of the waste. This variation may be because Khatri et al. study was conducted in 2011, a beginning period of BMW management awareness.
The question about the 2016 BMW management application by the municipal corporation or medical waste management agencies shows only 26.41% of dentists answered yes; this indicates the lack of transparency in the operation system of agency, which is much needed to promote the practitioners to continue BMW management more effectively. Limitations of the study include restriction of the study to one town, which may lead to an undesirable sampling error.
- Emphasis on correct practices of BMW management and disposal (2016) among dental practitioners.
- Tamil Nadu State Dental Council conducting continuing dental education (CDE) programmes for the same.
- Longitudinal studies after continuous implementation and monitoring of BMW management practices.
- Innovation of newer methods or equipments for easy and convenient management and disposal of BMW.
- A well-established network of the BMW management agency.
- A cost-effective and tailor-made colour-coded bin for usage in the health sector will make BMW management effective and sustainable.
| Conclusion|| |
The study suggests that dental practitioners are aware and admit BMW management is essential, but a knowledge gap is evident. They abide by the rules of BMW management, but they also have challenges in the application of the new 2016 rules, its cost factor, effective usage of colour-coded bins, regular collection by BMW agency and accessibility to the municipal corporation and the medical waste management agencies. Overcoming these challenges through a well-established network of BMW management agencies and a cost-effective and tailor-made colour-coded bin for usage in the health sector will make BMW management effective and sustainable.
Declaration of participants
The questioner was sent to the participants, the first question in the questioner was about their willingness to participate in the study. After obtaining their willingness as consent, the participants answered the other questions in the questioner and participated in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Reethu Ravichandiran
Department of Oral Medicine and Radiology, Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]