Waste Management 29 (2009) 1376–1382

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Waste Management
journal homepage: www.elsevier.com/locate/wasman

Medical waste management in China: A case study of Nanjing

Zhang Yong a,*, Xiao Gang b,1, Wang Guanxing a,2, Zhou Tao a,2, Jiang Dawei a,2
a
Transportation School, Southeast University, Si Pai Lou 2, Nanjing, Jiangsu 210096, China
b
School of Energy and Environment, Southeast University, Si Pai Lou 2, Nanjing, Jiangsu 210096, China

a r t i c l e i n f o a b s t r a c t

Article history: Medical waste management is of great importance due to its infectious and hazardous nature that can
Accepted 21 October 2008 cause undesirable effects on humans and the environment. The objective of this study was to analyze
Available online 20 January 2009 and evaluate the present status of medical waste management in the light of medical waste control reg-
ulations in Nanjing. A comprehensive inspection survey was conducted for 15 hospitals, 3 disposal com-
panies and 200 patients. Field visits and a questionnaire survey method were implemented to collect
information regarding different medical waste management aspects, including medical waste generation,
segregation and collection, storage, training and education, transportation, disposal, and public aware-
ness.
The results indicated that the medical waste generation rate ranges from 0.5 to 0.8 kg/bed day with a
weighted average of 0.68 kg/bed day. The segregated collection of various types of medical waste has
been conducted in 73% of the hospitals, but 20% of the hospitals still use unqualified staff for medical
waste collection, and 93.3% of the hospitals have temporary storage areas. Additionally, 93.3% of the hos-
pitals have provided training for staff; however, only 20% of the hospitals have ongoing training and edu-
cation. It was found that the centralized disposal system has been constructed based on incineration
technology, and the disposal cost of medical waste is about 580 US$/ton. The results also suggested that
there is not sufficient public understanding of medical waste management, and 77% of respondents think
medical waste management is an important factor in selecting hospital services.
The problematic areas of medical waste management in Nanjing are addressed by proposing some rec-
ommendations that will ensure that potential health and environmental risks of medical waste are
minimized.
Ó 2008 Elsevier Ltd. All rights reserved.

1. Introduction
During the past few years, there has been an increase in public
concern about the management of healthcare waste on a global ba-
sis (Shinee et al., 2008). Medical waste is a special category of
waste because it poses potential health and environment risks,
typically including sharps, human tissues or body parts and other
infectious materials (Baveja et al., 2000). Approximately 15–25%
(by weight) of medical waste is considered infectious (Shinee
et al., 2008). Despite the fact that current medical waste manage-
ment practices vary from hospital to hospital, the problematic
areas are similar for all healthcare units and at all stages of man-
agement, including segregation, collection, packaging, storage,
transport, treatment and disposal (Tsakona et al., 2007). Improper
waste management can cause environmental pollution, unpleasant
* Corresponding author. Tel./fax: +86 025 83795384.
E-mail addresses: zhang7678@126.com (Z. Yong), xiaogangtianmen@seu.edu.cn
(X. Gang), shiny_ever@163.com (W. Guanxing), ViolaZitta@yeah.net (Z. Tao),
jdw87@163.com (J. Dawei).
1
Tel.: +86 025 83794744; fax: +86 025 83795508.
2
Tel./fax: +86 025 83793685.
odors, and growth of insects, rodents and worms; it may lead to
transmission of diseases like typhoid, cholera, and hepatitis
through injuries from sharps contaminated with human blood
(Abdulla et al., 2008). It is of great importance to manage medical
waste in a proper manner to avoid health risks and damage to flora,
fauna, and the environment.
2. Medical waste management in China
Many studies have focused on medical waste in countries such
as Jordan (Abdulla et al., 2008), Iran (Askarian et al., 2004), Egypt
(Soliman and Ahmed, 2007), Mauritius (Mohee, 2005), Korea (Jang
et al., 2006), Turkey (Birpinar et al., 2008), Brazil (Da Silva et al.,
2005), Mongolia (Shinee et al., 2008), Greece (Tsakona et al.,
2007), the USA (Lee et al., 2004), the UK (Tudor et al., 2005), and
India (Patil and Shekdar, 2001). In many developed countries, spe-
cific rules and regulations have been implemented for hospital
waste management systems and, thus, these systems are more
effective than those in many developing countries. The manage-
ment of medical waste in many less-developed countries is often
poor and fraught with difficulty (Prüess et al., 1999). In many
developing countries such as Iran and India, there is lack of suitable

0956-053X/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.wasman.2008.10.023
 Z. Yong et al. / Waste Management 29 (2009) 1376–1382
waste treatment facilities, protective measures, and efficient train-
ing (Patil and Shekdar, 2001; Askarian et al., 2004).
China has historically paid little attention to the proper man-
agement of medical waste, as is the case for many other developing
countries. By the end of 2003, the Ministry of Health had issued the
first official act addressing the control of medical waste under the
waste management act and infectious ill control act, named Med-
ical Waste Control Act 380 (China Department of State, 2003). The
first act attributes specific responsibilities to the various sectors in-
volved: generators, sanitation and environment. Act 380 states that
generators are mandated to properly manage medical waste and
that centralized disposal of medical waste is required in China.
The act also specified definitions, principles and the procedures
for collection, transportation, temporary storage and disposal of
medical waste. According to Act 380, medical waste is defined as
any solid waste that is generated by medical treatment facilities
and laboratory facilities operating in hospital settings that is con-
sidered to be potentially hazardous to human health. In the same
year that Act 380 was passed, the Ministry of Health and State
Environmental Protection Administration issued Regulation 287
related to the medical waste category (China Ministry of Health,
2003). According to Regulation 287, waste generated from health-
care facilities is classified into five main groups, listed in Table 1.
In 2004, the Ministry of Health and State Environmental Protec-
tion Administration issued the Administrative Penalty Regulation
21 concerning the behaviors and the generators of improper med-
ical waste management (China Ministry of Health, 2004). Further-
more, Standard HJ 421-2008 (‘‘Standard of packaging Bags,
Containers And Warning Symbols Specific to Medical Waste”)
was implemented in 2008 (China Ministry of Health, 2008).
Although there have been efforts to construct a regulation
framework related to medical waste management in China, many
investigations and studies have suggested that many proper waste
management procedures are still not being well implemented (Liu
et al., 2003; Shen et al., 2003; Liang and Pang, 2005; Hua, 2005;
Feng et al., 2007; Wang et al., 2008). Outside of Nanjing, many
studies have focused on the management of medical waste in cities
of China such as Foushai (Liang and Pang, 2005), Jiaozuo (Geng
et al., 2006), and Nanchang (Wang et al., 2008).
Recently, Nanjing, like other cities in China, has witnessed a ra-
pid development in both public and private medical care establish-
ments. In 1997 there were 17,599 beds in public and private
healthcare facilities, which increased to about 20,100 by 2006.
Likewise, the number of healthcare facilities in the year 1997
Table 1
Classification of medical waste (China Ministry of Health, 2003).
Waste category Components
Tissues Human or animal pathological wastes, including
tissues, organs, blood, pus, and body parts and
fluids
Infectious waste Blood, blood products and objects that are
contaminated with them; microbiological
laboratory wastes; quarantine wastes; dialysis
wastes; used surgical operating clothes; infectious
organ pieces, blood and anything contaminated
with these materials
Sharp objects Needles, syringes, broken glass, blades, and other
items that could cause a cut or puncture
Chemical waste Hazardous chemicals, heavy metal containing
wastes, pharmaceutical wastes, amalgam wastes,
gynotoxic wastes, gentoxic wastes
Medicine waste Common medicines that are expired or are no
longer required or are discarded; other medicines
discarded that could cause cancers or genetic
diseases; the discarded vaccine products
1377
was 1301, which increased to about 2085 by 2006. Currently, there
are 159 hospitals in Nanjing. There has been a corresponding in-
crease in the number of patients being treated, adding to the al-
ready large quantity of medical waste that institutions must
dispose of properly.
In Nanjing, medical waste management falls under the respon-
sibility of the environment protection agencies. According to Med-
ical Waste Control Act 380 and regulations, a centralized disposal
system of medical waste has been constructed in the last few years.
In 2002, 97 healthcare facilities participated in the centralized dis-
posal system, which increased to about 409 by 2006. In 2002, the
quantity of disposed medical waste was 298 tons, which increased
to about 2006 tons by 2006. It has been suggested that there has
been much progress in the centralized disposal and management
of medical waste in Nanjing (Hua, 2005); however, there are still
some problems in the field of medical waste management accord-
ing to the related Chinese regulations.
In order to improve medical waste management and develop a
management strategy for Nanjing, it is important to understand
and evaluate current practices in medical waste management.
Information regarding medical waste management in Nanjing is
currently insufficient.
The main objective of this study is to assess the current man-
agement practices of medical waste in Nanjing. Medical waste
management was surveyed by gathering information regarding
medical waste generation, collection, segregating, storage, trans-
portation, disposal, training, and public awareness to find potential
problems. Additionally, some measures are suggested to improve
the present conditions and solve the identified problems.
3. Materials and methods
Data collection was carried out during site visits and by ques-
tionnaires from July to August 2007. The survey was conducted
in accordance with the recommendations of the World Health
Organization for evaluation of medical waste management in
developing countries (Prüess et al., 1999) and the information col-
lected related to the amount of medical waste, the process of seg-
regation and handling, storage, transportation, disposal, training,
and public awareness.
Personnel from the Environment Protection Agency in charge of
medical waste management were interviewed. They relayed advice
about how to carry out the survey and provided their perspectives
of the medical waste management in Nanjing. According to their
recommendations, 15 hospitals were selected for sampling. These
hospitals can be divided into three categories according to the type
or services provided: 53.3% (8) are general care, 33.3% (5) are spe-
cialized, and the additional two are Chinese medicine hospitals. In
this study, ‘‘general hospitals” refers to hospitals that provide med-
ical services and are typically the first patient contact; ‘‘specialized
hospitals” refers to hospitals that provide medical services for a
particular group of patients; and ‘‘Chinese medical hospitals” refers
to hospitals that provide Chinese medical services for general pa-
tients. After interviewing the hospital director at each hospital,
the hospitals were contacted by a survey team. The team met with
hospital personnel involved in the management of the medical
waste observing the process of waste collection and disposal.
Waste was weighed every day for one week. According to a
walk-through survey of all medical departments and facilities in
those hospitals, the team completed the survey of each hospital.
Moreover, in order to assess public awareness of medical waste
management, we interviewed 200 hospital patients, selected ran-
domly from within the 15 hospitals, using a questionnaire. The
questionnaire was reviewed and edited by experts from Southeast
University and the Environment Protection Agency in Nanjing. The
1378 Z. Yong et al. / Waste Management 29 (2009) 1376–1382
survey questions involved seven aspects of waste management:
medical waste classification; potential risks of the medical waste;
disposal methods; breakdown of disposal costs; sources of medical
waste disposal costs; degree of satisfaction of the current medical
waste management; selection of hospitals based on their medical
waste management practices. At the end of this survey, 164 ques-
tionnaires were valid (the response rate was 80.2%).
Furthermore, three medical waste disposal companies, Jiangbei,
Huifeng and Jingzhijie, were investigated by site visits. Much infor-
mation regarding medical waste disposal was concerned with dis-
posal technology, disposal expenditures, operational
arrangements, facility conditions, storage facilities, and monitoring
procedures.
The data forms and questionnaires were completed and stored
for further analysis. Data were coded and analyzed using SPSS 13
software.
4. Results and discussion
4.1. Medical waste generation
In order to develop proper waste management strategies, it is
important to have accurate information on the medical waste gen-
eration rate. The generation rate of medical waste depends upon
several factors such as the size of the healthcare facility, occupancy
rate of hospital beds, medical waste segregation program, location
of the facility, type of healthcare facility, and type of services
provided.
Results from the survey suggested that 33% of the hospitals sur-
veyed generated less than 100 kg each day, 47% of the hospitals
generated between 100 and 200 kg per day, and 20% of the hospi-
tals generated more than 200 kg per day. According to this survey,
the average generation rate of medical waste produced at the 15
hospitals is between 0.5 and 0.8 kg/bed day with a weighted aver-
age of 0.68 kg/bed day. These results were compared with the gen-
eration rates determined in other studies from different cities in
China, as well as from different countries. In the study performed
in the Jilin province in China, the average generation rate of med-
ical waste was about 0.5 kg/bed day (Shen et al., 2003). A study
conducted by Abdulla et al. (2008) indicated that the weighted
average generation rate was 0.83 kg/bed day in northern Jordan.
Birpinar et al., 2008 investigated 192 hospitals in Turkey and re-
ported an average generation rate of 0.63 kg/bed day. Mato and
Kassenga (1997) reported an average generation rate of 1.5–
3.9 kg/bed day. Finally, Tsakona et al. (2007) reported an average
generation in Greece of about 1.9 kg/bed day. According to a sum-
mary by Diaz et al. (2008), the total amount of healthcare waste
generated in selected hospitals in developing countries varied from
0.016 to 3.23 kg/bed day, and the percentage of infectious waste in
the total healthcare waste stream in developing countries was
about 63% (from 0.01 to 0.65 kg/bed day).
By the end of 2006 in Nanjing, the number of hospital beds was
20,100 and the average bed-occupancy was 75.59%. Thus, the total
quantity of the medical waste in Nanjing was estimated at about
3771 tons in 2006, given that the average generation rate was
0.68 kg/bed day for 365 workdays. Comparing this estimate with
the tons of medical waste recorded by centralized disposal in
2006, it is suggested that a great deal of medical waste was re-
moved by other unmanaged channels. According to this survey,
there are two main problems with medical waste generation
management:
 Although the amount of medical waste generated for every hos-
pital is monitored by the Environment Protection Agency, based
on Medical Waste Control Act 380, the medical waste weight is
only calculated by departments with the hospital. Thus, it is easy
for the hospitals to ignore other statistics of medical waste gen-
eration such as the source, type, and time.
 In accordance with this survey, some hospitals surveyed have
not constructed an effective management framework for collect-
ing data on medical waste generation. There is a lack trained
personnel responsible for collecting statistics of medical waste.
4.2. Segregation and collection
In light of Act 380, medical waste has been divided into five cat-
egories: sharp waste, infectious waste, tissues waste, chemical
waste and medicine waste. The medical waste should be segre-
gated for collection by using colored bags and containers (plastic,
metal or paper) as stated in the current legislation. This survey
showed that 73% of the hospitals use segregated collection for all
medical waste, while 27% of the hospitals have not yet imple-
mented segregated collection for all medical waste. The segrega-
tion practices have been applied as follows: infectious waste was
collected in yellow bags; municipal waste was collected in black
bags; sharps were collected in plastic containers; and cytotoxic/
cytostatic drugs were collected in their original packaging. The seg-
regation practices of the selected hospitals in Nanjing were similar
to the medical waste management practices reported in the litera-
ture (Tsakona et al., 2007). In 80% of the hospitals, trained person-
nel took charge of the collection activity, while in 20% of the
hospitals they did not. From these observations, some problematic
practices were identified:
 In some hospitals, the workers handled medical waste without
any protective equipment. In Istanbul, approximately 77% of
the hospitals use appropriate equipment for their collection per-
sonnel (Birpinar et al., 2008). As Medical Waste Control Act 380
outlined, workers are required to wear appropriate uniforms
and protective equipment when collecting medical waste.
 Although a system of color coding or labeling of waste contain-
ers/bags has been adopted in these 15 hospitals, all hospitals did
not strictly follow the color coding system issued by national
standard HJ 421-2008. Because of the absence of appropriate
labeling, it is difficult for the public and workers to identify
the source and the type of medical waste.
 In some cases, infectious waste was mixed with municipal waste
because of lack of sufficient segregation, while in other cases,
the municipal waste was collected as medical waste. These prac-
tices may increase the cost of disposing medical waste and the
risks posed to public health and the environment.
 There is a lack of waste minimization and effective recycling
practices.
4.3. Storage
After the medical wastes are segregated and collected, the staff
should move them from the location of generation to temporary
storage in Nanjing, based on the current regulations. The tempo-
rary storage location, storage containers and storage management
have a direct impact on the resulting environmental and health
risks at the hospital, which must be well sanitized and secured
for access only to authorized personnel (Prüess et al., 1999).
According to the results from the survey, 93.3% of the hospitals
had a temporary storage location. This situation is better than in
some other cities. Da Silva et al. (2005) reported that in southern
Brazil about 85% of hospitals have external storage areas for med-
ical waste management. Birpinar et al. (2008) reported that in
Istanbul 63% of the hospitals have a temporary storage depot and
 Z. Yong et al. / Waste Management 29 (2009) 1376–1382
94% of these depots satisfy the MWCR requirements. Askarian et al.
(2004) reported that in Iran 80% of hospitals have a temporary
storage area.
Of the hospitals in this study, 75% had well sanitized temporary
storage areas, compared to 26.7% of the hospitals in investigated in
Iran (Askarian et al., 2004). In this study, only 53.3% of hospitals
used standardized packaging containers, and only 33% of the hos-
pitals had some special logo in the storage location.
Form on-site observations, some problematic aspects in the
storage practices are identified as follows:
 In some cases, locations of the temporary storage are not satis-
factory and are close to the municipal waste storage. In one case,
the medical waste was stored together with the municipal
waste.
 Inappropriate storage practices were observed in some hospi-
tals. Although these hospitals have used containers such as blue
plastic barrels, in many cases the yellow bags filled with medical
waste were put directly on the floor of the storage location. This
practice leads to environmental and personnel risks.
 In some cases, there are no personnel responsible for the storage
locations, such that anyone could take medical waste from these
hospitals.
 Workers typically do not wear sufficient protective gear, which
increases the potential health risks.
 In some hospitals, storage areas were not sufficiently cleaned
after the medical wastes are transported to disposal facilities.
4.4. Training and education
Proper training must be carried out with hospital employees to
develop awareness of health, safety and environmental issues (Mo-
hee, 2005). If the understanding of medical waste disposal meth-
ods is increased, medical waste management will be greatly
enhanced. Each hospital in this study assigned a person to take
responsibility for waste management while in Iran only 46.7% of
hospitals assigned a person to be responsible for medical waste
management (Askarian et al., 2004).
Of the hospitals surveyed, 93.3% provided training for staff at
some point, while only 20% of the hospitals had ongoing training
and education. The survey indicated that training programs regard-
ing medical waste management for doctors, nurses and technicians
were limited in Nanjing. Birpinar et al. (2008) reported that, in
Istanbul, 98% of hospitals organize courses for their collection per-
sonnel, and healthcare services organize training programs regard-
ing medical waste management for doctors, nurses, and
technicians; almost 63% of healthcare services organize courses
at least once a month, while 31% organize courses at least twice
a year. Askarian et al. (2004) reported that 60% of hospitals in Iran
provided some training for cleansing staff; however, newly hired
waste management personnel were not trained properly. Abdulla
et al. (2008) reported that 29% of the hospitals in northern Jordan
had not provided training to doctors and other personnel regarding
medical waste management and the related hazards; 57% of
hospitals provided limited training for support staff (maintenance
engineers, cleaning workers). In developed countries, such as the
USA, there are effective training programs and educational plans
related to medical waste management for all staff (Askarian
et al., 2004).
According to the survey, some problematic areas were found in
the field of training and education:
 There is a lack of sufficient training and education programs for
all hospital staff. In some hospitals, the training and education
programs were only focused on the doctors and nurses, while
1379
the cleaning workers and technicians did not receive any train-
ing regarding how to deal with medical waste to avoid related
risks.
 The training and education mechanism in some hospitals have
not been developed. In these hospitals, there is a lack of effective
organization controlling and evaluating the performance of the
training and education programs for medical waste manage-
ment. In fact, some hospital staff lack proper understanding of
medical waste management despite being trained and educated
several times a year.
4.5. Transportation
According to Act 380, Nanjing has constructed a central disposal
system for medical waste. The hospitals have the responsibility for
providing on-site transport of medical waste, while off-site trans-
port to the final disposal site is handled by disposal companies.
These companies are also in charge of the final disposal of medical
waste in Nanjing. Medical waste is transported through pre-estab-
lished routes, which include specific corridors and elevators on
each floor, and are strictly used to transport waste from the inter-
mediate storerooms to the final storerooms in the basement of the
hospital (Askarian et al., 2004). The disposal companies arrange for
special trucks to collect medical waste from various hospitals once
every 1–2 days. Commonly, the off-transport times are determined
by the transport distances and the quantity of medical waste.
According to scientific standards, infectious waste in tropical areas
can be kept in a temporary storage area for 24 h during the hot sea-
son and up to 48 h in cooler seasons (Prüess et al., 1999). The sche-
dule for collection of medical waste by the disposal company was
often uncertain, which creates a more complex problem for these
hospitals.
The off-site transport activities are organized by the disposal
companies. The off-site transport costs are included in the total
disposal costs paid by the hospitals. Some problems were observed
at the off-site transport stage for medical waste:
 The truck routes are still not monitored by the Environment Pro-
tection Agency. In some cases, the medical wastes were lost in
the process of off-site transport activity. In contrast to this situ-
ation, in 2002, an on-line manifest system was established to
monitor the medical waste transportation in Korea (Jang et al.,
2006).
 The drivers and the trucks do not always strictly follow Act 380.
According to the requirements of Act 380, licenses are required
for the drivers of the trucks that transport medical waste.
 In many cases, the medical waste was transported by improper
methods. For example, the drivers or workers handle the medi-
cal waste bags manually with no protective measures.
 The logistics containers are not fully used in the procedure of
transport, which often increased the risks to people and the
environment. Additionally, the plastic and paper bags were
often punctured by some sharp medical waste items.
 Medical waste was often transported together with industrial
wastes.
4.6. Disposal of medical waste
Centralized disposal of medical waste has been implemented in
Nanjing since 1997. According to Act 380, hospitals are not permit-
ted to dispose of their own medical waste. Three private disposal
companies, Jiangbei, Huifeng and Jingzhijie, are responsible for
medical waste disposal generated from the hospitals in Nanjing.
The Environmental Protection Agency is responsible for monitor-
1380 Z. Yong et al. / Waste Management 29 (2009) 1376–1382

Table 2  The disposal companies sometimes disposed medical waste

Responses by patients to questionnaire on medical waste management in Nanjing. together with municipal waste by means of incineration.
Question Response
1. Do you know about the medical Very clear (1%); clear (20%); medium
waste and its categories? (33%); not clear (46%) 4.7. Public awareness of medical waste management
2. What are the potential risks of Great risks (49%); medium risks (46%);
medical wastes? a few risks (1%); no risks (0%); not clear Seven questions in the questionnaire were related to public
(4%)
3. What type of facility will be Special disposal facility (72%); solid
awareness of medical waste management. The questions and re-
responsible for final disposal of waste incinerator (12%); solid waste sponses are given in Table 2. It is important for medical waste
medical waste in Nanjing? collecting station (5%); other places managers to take public awareness into account in developing an
(11%) effective strategic program in Nanjing.
4. What is the breakdown of the Dedicated containers investments
From the questionnaire survey, some valuable conclusions are
medical waste management costs? (18%); monitoring facilities (31%);
transportation costs (31%); disposal identified:
costs (40%)
5. Are you satisfied with the medical Very satisfied (1%); satisfied (9%);  Public understanding of medical waste procedures is lacking.
waste management in Nanjing? medium (53%); unsatisfied (27%); very Moreover, the survey showed that people under age 40 had
unsatisfied (10%)
more awareness of medical waste, likely due to a generally
6. Who do you think should pay for Patients (24%); local government
medical waste management costs? (39%); disposal companies (17%); higher level of education.
hospitals (20%)  The majority of respondents were confused about the differ-
7. Are the medical waste management Very important (2%); important (35%); ences between medical waste, recyclable waste and ordinary
practices an important factor for you medium (40%); unimportant (22%);
garbage, and how they should be handled and disposed.
in selecting hospital services? very unimportant (1%)
 The respondents thought that medical waste management costs
are ranked as follows: disposal costs, monitoring facilities con-
ing the disposal of all medical waste. From this survey, the medical struction costs, dedicated container investments and transporta-
waste generated from all selected hospitals was transported to the tion costs.
centralized disposal facilities. The disposal costs of medical waste  In constructing a creative operational mechanism for improving
is about 580 US$/ton, while in northern Jordan the monthly cost waste management, it is interesting to note that 24% of respon-
of disposal is between 70 and 1330 US$/month (Abdulla et al., dents stated they were willing to pay the related medical waste
2008). management costs.
There are several medical waste disposal methods, such as  The majority of the respondents are considerably dissatisfied
incineration, steam sterilization (or sanitation), microwave sanita- with the medical waste management in Nanjing.
tion, chemical disinfection, dry heat disinfection, and disinfection  Only 23% of the respondents considered medical waste manage-
with superheated steam (Jang et al., 2006). Only incineration tech- ment as unimportant or very unimportant when selecting hospi-
nologies have been implemented by the three disposal companies tal services. These results suggest that if the hospitals improve
in Nanjing. Currently, the major fraction of healthcare waste col- their medical waste management, their market credibility will
lected in developing countries is incinerated (Diaz et al., 2005). be enhanced.
With the strict environmental protection regulations and laws,
the incineration technology has received some criticism from the
public and researchers in recent years. The disadvantages have 5. Conclusions
been discussed in many studies (Jang et al., 2006; Lee et al.,
2004; Diaz et al., 2005). Medical waste incinerators can emit vari- The number of private and government hospitals in Nanjing is
ous toxic pollutants such as carbon monoxide, particulate matter, constantly increasing. This leads to an increase in the total quantity
and hydrogen chloride; have high operation and maintenance of medical waste generated from various hospitals. Although the
costs; and require ash disposal. Ministry of Healthcare together with State Environmental Protec-
Some problematic areas were identified in the stage of medical tion Administration has developed regulations aimed to ensure
waste disposal: appropriate handling and processing of medical waste, there is still
need to put these regulations into practice based on integrated
 Medical waste disposal options are limited, and small-scale medical waste management options. To achieve this, current med-
incinerators have been used as a last solution. Incinerators emit ical waste management practices in Nanjing should be evaluated
a variety of harmful pollutants, including particulate matter, from the viewpoint of integrated management. In conclusion, the
mercury, dioxins and furans. main findings of this study are identified below:
 Each company incinerates about 2 tons of medical waste every
day. Because the quantity is low, there are no economies of scale  The medical waste generation rate ranged from 0.5 to 0.8 kg/bed
and the disposal cost is high. day with a weighted average of 0.68 kg/bed day.
 The emissions of medical waste incinerators and the ash dis-  The segregated collection of various types of medical waste has
posal were not strictly monitored in this survey. been conducted properly in 73% of hospitals, but 20% of the hos-
 Each company is responsible for disposal in some region in Nan- pitals still use inappropriate personnel for medical waste collec-
jing. Thus, the collection of medical waste from various hospitals tion. Protective measures, the color coding system
is often not in accordance with Act 380. implementation, waste minimization management, and effec-
 Medical waste storage practices need improvement, and second- tive recycling practices were not sufficient in some cases.
ary pollution can occur in the disposal facilities.  93.3% of the hospitals had temporary storage areas. Some stor-
 In some cases, workers responsible for the medical waste incin- age practices were not strictly conducted in accordance with
erators lacked necessary training and knowledge. the requirements of the regulations.
 A disposal cost mechanism has not been developed based on the  93.3% of the hospitals surveyed have provided training for staff,
market economics. Higher disposal costs often encourage some while only 20% of the hospitals had ongoing training and educa-
hospitals to dispose of medical waste themselves. tion. This suggests that there is a lack of sufficient training and
 Z. Yong et al. / Waste Management 29 (2009) 1376–1382
education programs for all hospital staff and that the training
and education mechanism in some hospitals is still not
developed.
 Centralized disposal of medical waste has been implemented in
Nanjing based on incineration technology. The disposal cost of
medical waste is about 580 US$/ton; the quantity of medical
waste is low and does not allow for economies of scale. Storage
management, worker training, disposal transaction mechanisms
and emissions monitoring are still insufficient.
 Survey respondents showed various levels of understanding
of medical waste categories, risks, costs and disposal meth-
ods. There was insufficient and improper understanding of
medical waste risks and management by many respondents,
and 77% of respondents thought that the medical waste man-
agement was an important factor when selecting hospital
services.
6. Recommendations
The current practices of medical waste management in Nanjing
were observed and some problematic areas were identified. Based
on these findings, it can be noted that there is potential to improve
the medical waste management in the local context. To overcome
these obstacles, some recommendations are presented for different
aspects of medical waste management.
 Generation
– A medical waste minimization management framework
should be implemented in order to reduce the amount of
medical waste generated by hospitals (Mohee, 2005).
– Apart from the weight, the types, sources, and the character-
istics of medical waste generated should be monitored based
on the information system.
– There is a need to manage the life-cycle of every type of med-
icine in hospitals, which consists of purchasing, using, collec-
tion, segregation, transportation and final disposal.
 Segregation and collection
– Proper training should be provided to everyone involved in
the waste management process regarding appropriate segre-
gation practices and the potential hazards associated with
improper procedures such as handling without protective
measures (Tsakona et al., 2007).
– A system of color coding or labeling of waste containers/bags
according to the requirements of the national standard HJ
421-2008 should be used consistently.
 Storage
– Strict control of temporary storage areas should be imple-
mented. Only medical waste handlers should be allowed to
enter these areas.
– Proper locations of temporary storage areas should be
enforced, i.e., away from other functional areas, such as
municipal waste storage areas.
– There is a need to keep the storage areas clean.
– Good quality logistics containers should be purchased.
 Information system application
– The information system of the hospitals needs to be
improved.
– There is a need to improve the RFID technology implemented
in the hospitals.
 Training and education
– Training and education programs for all personnel should be
conducted; training of new staff and cleaning workers should
be emphasized.
– The effectiveness of training and education programs should
be periodically evaluated.
1381
 Transportation
– A manifest on-line system should be implemented to moni-
tor transportation routing of medical waste.
– Fixed schedules for transportation should be defined, thus
reducing the complexity of medical waste management.
– Good quality transportation containers/packaging for medi-
cal waste should be used.
 Disposal
– In order to create environmental benefits, it is necessary for
Nanjing to renew disposal facilities and the technology of
medical waste disposal. New alternative disposal technolo-
gies that are more environmentally friendly should be imple-
mented (Diaz et al., 2005).
– The market mechanism must be introduced to balance the
interest conflicts between hospitals, government, disposal
companies and the patients, because the disposal costs are
directly determined by the Environmental Protection Agency.
– Professional training of workers should be strengthened,
especially regarding how to deal with ash.
– Some advanced operators for medical waste disposal should
be introduced from other cities or abroad to create market
competition of Nanjing.
– Ash and air pollutants generated from medical waste inciner-
ation, such as HCI, CO, Hg, Cd, and SO2 should be measured.
– Workers’ health and safety in disposal facilities should be
protected by the use of proper protective clothing and by fol-
lowing safety guidelines.
– The monitoring system should be improved by installing air
pollution control systems.
 Public awareness
– The participation and enthusiasm of the general public and
their knowledge of medical waste should be enhanced by
using various techniques, such as propaganda boards, the
internet and the public welfare advertisements.
– A medical waste strategy in Nanjing should be evaluated by
analyzing the public’s awareness of medical waste
management.
Acknowledgements
This study was funded by National Natural Science Foundation
of China (No. 50806013). The authors would also like to gratefully
acknowledge the assistance of professors from the US. We are
grateful for valuable comments and suggestions for improvements
from these anonymous reviewers.
References
Abdulla, Fayez, Qdais, Hani Abu, Rabi, Atallah, 2008. Site investigation on medical
waste management practices in northern Jordan. Waste management 28, 450–
458.
Askarian, Mehrdad, Vakili, Mahmood, Kabir, Gholamhosein, 2004. Results of a
medical waste survey in private hospitals in Fars province, Iran. Waste
Management 24, 347–352.
Baveja, G., Muralidhar, S., Aggarwal, P., 2000. Medical waste management – an
overview. Hospital Today 5 (9), 485–486.
Birpinar Mehmet Emin, Mehmet Sinan Bilgili, et al. 2009. Medical waste
management in Turkey: A case study of Istanbul. Waste Management 29,
445–448.
China Department of State, 2003. China medical waste control act. China
Department of State office No. 380. Beijing, China (in Chinese).
China Ministry of Health, State Environmental Protection Administration, 2003.
China medical waste category regulation. China Ministry of Health office No.
287. Beijing, China (in Chinese).
China Ministry of Health, State Environmental Protection Administration, 2004.
Administrative penalty regulation for medical waste management. State
Environmental Protection Administration office No. 21. Beijing, China (in
Chinese).
1382 Z. Yong et al. / Waste Management 29 (2009) 1376–1382
China Ministry of Health, State Environmental Protection Administration, 2008.
Standard of packaging bags, containers and warning symbols specific to medical
waste. China Environmental Science Press, Beijing, China (in Chinese).
Da Silva, C.E., Hoppe, A.E., Ravanello, M.M., Mello, N., 2005. Medical wastes
management in the south of Brazil. Waste Management 25, 600–605.
Diaz, L.F., Savage, G.M., Eggerth, L.L., 2005. Alternatives for the treatment and
disposal of healthcare wastes in developing countries. Waste Management 25,
626–637.
Diaz, L.F., Eggerth, L.L., Enkhtsetseg, Sh., Savage, G.M., 2008. Characteristics of
healthcare wastes. Waste Management 28, 1219–1226.
Feng, Ke-ming, Wu, Huai-li, Pai, Guo-jing, 2007. Study on the problems of medical
waste management and some measures. Modern Preventative Medicine 134
(35), 2914–2915 (in Chinese).
Geng, Rui, et al., 2006. Study on current situation and the strategies of medical
waste disposal in Jiaozuo city. China Environmental Management special issue
2, 57–58 (in Chinese).
Hua, Jie, 2005. Study of administration of medical junk. ACT Universitatis
Medicinalis Nan Jing (Social Science) 1, 45–48 (in Chinese).
Jang, Yong-Chul, Lee, Cargro, Yoon, Oh-Sub, Kim, Hwidong, 2006. Medical waste
management in Korea. Journal of Environmental Management 80, 107–115.
Lee, Byeong-Kyu, Ellenbecker, Michael J., Moure-Ersaso, Rafael, 2004. Alternatives
for treatment and disposal cost reduction of regulated medical wastes. Waste
Management 24, 143–151.
Liang, Ming-shen, Pang, Shai-jiang, 2005. Medical waste disposal practice and some
recommendations for Foushai city. Environmental Science Trends 1, 36–38 (in
China).
Liu, Chi-bing et al., 2003. Current situation of disposing medical waste and
developing method in China. China Environmental Management 22 (6), 37–38
(in Chinese).
Mato, R.R., Kassenga, G.R., 1997. A study problems of management of medical solid
wastes in Dar Es Salaam and their remedial measures. Resources, Conservation
and Recycling 21, 1–16.
Mohee, R., 2005. Medical wastes characterization in healthcare institutions in
Mauritius. Waste Management 25, 575–581.
Patil, A.D., Shekdar, A.V., 2001. Health-care waste management in India. Journal of
Environmental Management 63, 211–220.
Prüess, A., Giroult, E., Rushbrook, P., 1999. Safer Management of Wastes from
Healthcare Activities. World Health Organization, Geneva.
Shen, Bao-hong, Wang, Xiu-chuan, Li, Jing-shun, Zhang, Yu-hua, 2003. Current
situation and disposing countermeasure of medical waste in Jilin province.
China Environmental Management 22 (4), 35–36. 38. (in Chinese).
Shinee, Enkhtsetseg, Gombojav, Enkhjargal, Nishimura, Akio, Hamajima, Nobuyuki,
Ito, Katsuki, 2008. Healthcare waste management in the capital city of
Mongolia. Waste management 28, 435–444.
Soliman, SaharMohamed, Ahmed, Amel Ibrahim, 2007. Overview of biomedical
waste management in selected Governorates in Egypt: a pilot study. Waste
Management 27 (12), 1920–1923.
Tsakona, M., Anagnostopoulou, E., Gidarakos, E., 2007. Medical waste management
and toxicity evaluation: a case study. Waste management 27, 912–920.
Tudor, T.L., Noonan, C.L., Jenkin, L.E.T., 2005. Healthcare waste management: a case
study from the National Health Service in Cornwall, United Kingdom. Waste
Management 25 (6), 606–615.
Wang, Yue-hua et al., 2008. Study on the potential hazard and control measures of
medical waste in Nanchang. Modern Preventative Medicine 135 (12), 2216–
2218 (in Chinese).