Structure of solid waste management in hospitals of

Bandar Abbas city

Naser Rahmanian

, Abbas Ghavam

* and Abbas Yazdanpanah

Department of Healthcare Management, Marvdasht Branch, Islamic Azad University, Marvdasht Iran

Assistant Professor, Department of Environmental Science, Institute of Sciences and High Technology and

Environmental Sciences, Graduate University of Advanced Technology, Kerman, Iran

Assistant professor, Department of Healthcare Management, Marvdasht Branch, Islamic Azad University,

Marvdasht, Iran

ABSTRACT

One of the major sources of waste in each city is the hospital centers, which produce a wide range of waste. These

wastes should not be mixed with municipal wastes, because the spread of chemical and biological materials con-

taining the dangerous pathogens causes the speci c environmental and health hazards. Lack of control and lack of

attention to proper management of hospital wastes on how to collect, store, transport and dispose of such waste,

will lead to the prevalence of regional and urban epidemics and diseases and waste of money that this is a serious

threat to the public health and environment. The aim of this study is to evaluate trends in waste management in

hospitals of Bandar Abbas and adapt this process with the national standards. This is an applied study conducted

in a descriptive-analytic method. In this study, one sample t method was used. The sample consisted of 107 waste

production sites in 8 hospitals in Bandar Abbas that the census method was used. To evaluate the variables, it was

used the Health Ministry’s standard checklist for hospital waste review. The data was analyzed by SPSS software

and using the descriptive and inferential statistics. There is no signi cant difference between the average total per

capita solid waste per bed in hospitals in Bandar Abbas and the average total per capita solid waste per bed set by

the Ministry of Health (t = 1.922). It means the average per capita waste generation in hospitals in Bandar Abbas is

consistent with the regulations of the Ministry of Health. There is a match between the average per capita ordinary

solid waste generation with the average ordinary solid waste generation set by the Ministry of Health (t = 1.631). It

means the average ordinary waste in hospitals of Bandar Abbas is consistent with the regulations of the Ministry

of Health. The average duration of waste storage in hospitals of Bandar Abbas is consistent with the average waste

storage in accordance with regulations of the Ministry of Health related to similar areas (hot and humid conditions

(t = 22.12). This means that the average duration of waste storage in hospitals of Bandar Abbas corresponds to the

164

ARTICLE INFORMATION:

*Corresponding Author: ghavam39@gmail.com

Received 30

Dec, 2016

Accepted after revision 12

March, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF : 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

Biosci. Biotech. Res. Comm. Special Issue No 1:164-171 (2017)

Rahmanian, Ghavam and Yazdanpanah

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS STRUCTURE OF SOLID WASTE MANAGEMENT IN HOSPITALS OF BANDAR ABBAS CITY 165

time determined by the Ministry of Health for the hot and humid weather conditions. Using the above results, it can

be concluded that the establishment of environmental health experts at hospitals, daily tracking and proper training

for personnel involved in the production, and collection and disposal of hospital wastes could play an effective role

in preventing the risks of hospital wastes.

Correct management training and disposal of hospital wastes should be one of the operational objectives of hos-

pital managers and this important issue should be included in planning courses for staff of all hospitals.

KEY WORDS: SOLID WASTE – MANAGEMENT – HOSPITAL –BANDAR ABBAS

INTRODUCTION

Today, increasing waste and environmental pollution

and health hazards resulting from it has been raised as

one of the most important problems in human societies

today, (Chartier, 2014). The whole extent of this waste

is so high in which we can  nd the ordinary household

waste to the dangerous chemical and biological contam-

inants. One of the major sources of waste generation in

each city is the hospitals which produce a wide range of

waste (Zarei, Taghdisi, Keshavarz Mohamadi, & Tehrani,

2013).

The great thing about the medical wastes is that these

wastes should not be mixed with municipal wastes,

because the spread of chemical and biological materials

containing the dangerous pathogens causes the speci c

environmental and health hazards. Classi cation and

composition of medical waste with particular attention

to the collection and disposal of it include a wide range

of different materials, such as ordinary or household-

like, infectious, chemical, and pharmaceutical wastes

(Chartier, 2014), (Zarei et al., 2013). The household-like

wastes includes materials such as paper, cardboard, car-

ton, plastic materials, remnants of food and fruit that if

not mixed with the hazardous and infectious materials

are safe and they can be collected and disposed of as

the household waste (Kumar, Samrongthong, & Shaikh,

2013). The potentially infectious wastes exist in various

forms as the contaminated disposable supplies and sharp

instruments products containing blood, and laboratory

culture media, (Nie, Qiao, & Wu, 2014 and Ndejjo et al.,

2015).

Based on WHO, the infectious wastes include the

wastes that contain the pathogens to the extent that

can cause the disease in the susceptible hosts, (WHO,

2004). There are different opinions in the classi cation

and de nition of infectious wastes. The sharp wastes

include the needles, syringes, broken glasses and scal-

pels. Since these components can create the injury and

lead the pathogens such as hepatitis and AIDS to enter

the human body, therefore it is necessary to separate

them from other infectious wastes (Rastegar & Gholami,

2014). The chemical and pharmaceutical wastes includes

the drugs, pharmaceutical products and various chemi-

cals that are produced by the speci c health activities

in these centers. The drugs and chemicals returned or

discarded and expired are also part of this category.

Therefore, the particular attention to the separate col-

lection and disposal of them is very important. This is

while sometimes seen in Bandar Abbas that for reasons of

high cost of solid waste disposal, the illegal and hygienic

ways are used to dispose of the wastes. Since the lack

of control and lack of attention to proper management

of hospital wastes on how to collect, preserve, transport

and dispose of such waste will lead to the prevalence of

regional and urban epidemics and diseases and waste of

money, this is considered as a serious threat to the public

health and environment.

This study aimed to assess the waste management

process in hospitals of Bandar Abbas and adapt this pro-

cess with the national standards. So, at  rst, the aim of

this study is to evaluate the waste management process

in hospitals of Bandar Abbas and adapt this process with

the national standards and secondly, to  nd the stand-

ard deviation and provide the administrative approaches

to standardize the structure.

MATERIAL AND METHODS

In this descriptive-analytic study, the research environ-

ment was the hospitals of Bandar Abbas, including the

university hospitals (Shahid Mohammadi- chilrens’),

private hospitals (Om-e-Leila and Imam Reza), hospitals

af liated with the police and armed forces (Saheb-al-

Zaman, Seyed-al-Shohada and Khatam-ol-anbia) and

Persian Gulf hospital af liated to social security. The

study population consisted of 107 waste production sites

in the 8 hospitals of Bandar Abbas. (N=107)

The standard waste management checklist of Ministry

of Health related to the collection of waste management

data in country’s hospitals was used by the researcher

to collect the data. The standard checklist Ministry of

Health has been 105 years that after soliciting the opin-

ion of experts of environmental health department of

the Health Center in Hormozgan province and profes-

sors of environmental health department at the School

of Health in Bandar Abbas, it was summarized to the 42

Rahmanian, Ghavam and Yazdanpanah

166 STRUCTURE OF SOLID WASTE MANAGEMENT IN HOSPITALS OF BANDAR ABBAS CITY BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

questions to collect better data. So, the checklist used

to collect the research data had 42 questions that was

applied for the different stages of hospital waste man-

agement, including how to produce waste, status of col-

lection, transportation, weighing, disinfecting and  nal

disposal of hospitals’ solid wastes in Bandar Abbas.

The checklist includes six scales that are the per cap-

ita waste, disinfecting procedures, management com-

ponents in waste disposal, waste separation, storage,

transportation and methods of  nal disposal of waste.

Questions of subscales are as follows: Per capita waste,

questions 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16; that how

to measure on these questions is as kg per day. Disin-

fecting methods, questions 17, 18, 19 and 20; which the

method of measurement is based on standard or non-

standard methods.

Management components in waste disposal, ques-

tions 21, 22, 23, 24 and 25; that the method of measur-

ing them is as yes / no, complete / incomplete. Waste

separation, questions 25, 26, 27 and 28, that the method

of measuring them is as yes / no, complete / incomplete.

Storage and transportation, questions 29, 30, 31, 32, 33,

34, 35, 36, 37, 38, 39, 40, 41, 42, 43 and 44, that the

measurement method is as yes / no, complete / incom-

plete. Methods for  nal disposal of wastes, questions 45,

46, 47 and 48, that the measurement method is as yes /

no, complete / incomplete. In this questionnaire, obtain-

ing less points means more consistent with the standards

of the Ministry of Health.

In this review, after completing the paperwork and

obtaining the necessary permits, in collaboration with

the Deputy Treatment and Deputy Health of medical

university and hospital managers in Bandar Abbas, the

research data in hospitals of Bandar Abbas was collected

in 4 steps as follows.

FIRST STAGE

The research environments were visited in a  eld method

(waste production sites, including wards, outpatient

departments, clinics, diagnostic departments, operating

rooms, drug stores, administration and support depart-

ments, kitchens and cafeterias) and the solid waste col-

lection sites, people involved in the production process,

collection, transportation, storage and  nal disposal of

wastes were identi ed.

SECOND STAGE

At this stage, it was justi ed the people involved in the

production process to the  nal disposal of wastes in hos-

pitals on the goal of the study, for this purpose, in coor-

dination with the hospital manager and health experts

based in hospitals, the people gathered in the audito-

rium of the hospital and the functional objectives and

implementation phases of the study were described for

them. As the number of people involved in the Shahid

Mohammadi hospital was great, 3 brie ngs were held in

this hospital and 2 brie ngs were held in the children’s’

hospital and Persian Gulf hospital. In other hospitals, a

meeting was held to justify the people involved.

THIRD STAGE

At this stage, the designated sites were daily visited

and then the process of collecting, transporting, stor-

ing, weighing and disposing of the wastes generated

was observed and recorded for each site and  nally, the

completed information related to the various stages of

producing solid waste in each hospital was recorded in

the standard checklist of Ministry of Health (checklist

of visiting the management of the collection, storage,

transportation and disposal of wastes in the country’s

hospitals). It should be noted that the standard check-

list Ministry of Health related to the different stages

of solid waste disposal in country hospitals has been

105 years that after soliciting the opinion of experts of

environmental health department of the Health Center

in Hormozgan province and professors of environmen-

tal health department at the School of Health in Bandar

Abbas, it was summarized to the 42 questions by the

researcher to collect better data.

FOURTH STAGE

At this stage, after collecting the data required in all

hospitals, the data collected was entered into SPSS 16

software and then using the descriptive and analytic

statistics and statistical tests, the per capita produc-

tion, duration of waste storage and waste management

method in the hospitals of Bandar Abbas were compared

with the regulations of the Ministry of Health.

In this study, the SPSS 16 software and descriptive

statistics including frequency, mean and standard devi-

ation; and inferential statistics including one sample

t-test (at the signi cance level 0.05) were used to ana-

lyze the data.

RESULTS

According to the results of this study, the amount and

percentage of the waste generated is shown in Table 1.

Accordingly, the amount of waste produced daily in hos-

pitals was 1987.45 kg that the waste generation in the

university hospitals was 921.45 kg, in the private hospi-

tals 383 kg, in the military and police hospitals 296 kg,

and in the social security hospital 387 kg per day.

As seen in Table 1, the highest average total pro-

duction of waste is in Social Security hospitals in the

Rahmanian, Ghavam and Yazdanpanah

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS STRUCTURE OF SOLID WASTE MANAGEMENT IN HOSPITALS OF BANDAR ABBAS CITY 167

Table 1. The quantitative components of the waste by the type of surveyed hospitals

Parameter Production

(Kg / d)

Average

(Kg / d)

Standard

deviation

(Kg / d)

Minimum

(Kg / d)

Maximum

(Kg / d)

% of ordinary

waste production

to the total

ordinary waste

produced

% Of total

Production

The total amount of waste

produced in university

hospitals

921.45 26.32 30.17 5 160 3.387 4.366

The total amount of

waste produced in private

hospitals

383 14.18 11.23 3 45 2.933 1.279

The total amount of waste

produced in military and

police hospitals

296 8.96 10.87 4 30 1.199 1.894

The total amount of waste

produced at the Social

Security Hospital

387 32.25 24.51 7 140 19.5 1.479

Table 2. Per capita waste generation in different hospitals studied

Hospitals Number of active beds Ordinary waste per capita

per active bed(Kg/d)

total waste per capita

per bed(Kg/d)

University hospitals 325 1.34 2.83

Private hospitals 169 1.6 2.26

Military and police hospitals 163 1.33 1.81

Social Security hospital 107 1.85 3.61

All hospitals 758 1.52 2.62

amount of 32.25 kg per waste production site and then

in the university hospitals with an average 26.33 kg of

waste per site. The lowest total waste production is in

the military and police hospitals with an average 8.96

kg per waste generation site. It is observed 37.38% of

ordinary wastes are created in the university hospitals

that this seems natural considering that most active beds

are related to the university hospitals and on the other

hand, these hospitals are teaching and more staff and

university students are working in them. The lowest per-

centage of ordinary waste production (Alam, Sujauddin,

Iqbal, & Huda, 2008) is also related to the military and

police hospitals in Bandar Abbas.

According to the study results, the number of active

beds and per capita total waste generation in the univer-

sity hospitals with 325 beds is 2.83 Kg / d, in the private

hospitals with 169 active beds is 2.26 Kg / d, in the

military and police hospitals with 163 beds is 1.81 Kg /

d and in the social security hospital with 107 active beds

is 3.61 Kg / d per active bed.

Another important indicator of waste management is

the waste storage time in the temporary storage site of

waste. The information in this section is presented in

Figure 1.

According to the  gure, in 62.6% of the hospitals sur-

veyed, the waste storage time in temporary sites was

24 hours and in 25 percent of hospitals, the time was

between 24 to 48 hours and in 12.5% , the time was

between 48 and 72 hours.

According to the results of this study, most waste stor-

age time in temporary sites is respectively in the police

and military hospitals with an average of 56 hours, in

Social Security hospitals with an average of 28 hours, in

private hospitals with an average of 23 hours and less

time keeping waste is in the university hospitals with an

average of 21 hours.

1. Lack of disinfection of waste containers

2. Disinfection of waste containers

3. Non-coding and labeling waste separated

4. Coding and labeling the waste

5. The absence of valid contracts with authorized

centers for transport and disposal of chemical and

pharmaceutical waste

6. Valid contracts with authorized centers for transport

and disposal of chemical and pharmaceutical waste

As seen in Figure 2, disinfection and labeling of waste

are done in 100 percent of hospitals, but only in 50 per-

Rahmanian, Ghavam and Yazdanpanah

168 STRUCTURE OF SOLID WASTE MANAGEMENT IN HOSPITALS OF BANDAR ABBAS CITY BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

cent of hospitals, it has been signed with authorized

centers to transport and dispose of chemical and phar-

maceutical waste.

1. The absence of Safety Box to collect the sharp

waste

2. The existence of Safety Box to collect the sharp

waste

3. The lack of organs and limbs cut and dead fetus

4. Failure to collect the organs and limbs cut and

dead fetuses in accordance with regulations

5. Collecting the organs and limbs cut and dead fe-

tuses in accordance with the regulations

6. Collection along with other wastes

7. Separately storage method of chemical and phar-

maceutical wastes

As seen in Figure 3, the chemical, pharmaceutical and

biological wastes are separately kept in 75% of hospitals

studied. Also, in all the hospitals that have the patho-

logical wastes (organs and limbs cut and dead fetus, etc),

these wastes are collected according to regulations of

the Ministry of Health. This graph also shows that in the

majority of hospitals studied (87.5%), there is the safety

box for collecting the sharp wastes.

FIGURE 1. The waste storage time in temporary storage site of waste

Table 3. The average duration of waste storage by the

type of surveyed hospitals

Row Hospitals by the

type of ownership

The average

duration of waste

storage per hour

1 University Hospitals 21

2 Private Hospitals 23

3 Police Military Hospitals 56

4 Social Security Hospital 28

Total average 32

FIGURE 2. Maintenance management structureand transportation of waste containers

Rahmanian, Ghavam and Yazdanpanah

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS STRUCTURE OF SOLID WASTE MANAGEMENT IN HOSPITALS OF BANDAR ABBAS CITY 169

The above table shows that there is no signi cant dif-

ference between the average total per capita solid waste

per bed in hospitals in Bandar Abbas and the average

total per capita solid waste per bed set by the Ministry

of Health (p=<0.01 , t=1.922). The average total per cap-

ita solid waste generation in hospitals in Bandar Abbas

corresponds to the average total per capita solid waste

determined by the Ministry of Health.

DISCUSSION

Per capita waste production in hospitals studied in

Bandar Abbas was obtained 2.62 kg/b.d. In this study,

except ordinary wastes (1.5 per active bed per day, i.e.

57.25% of the total waste production), other wastes was

considered infectious that the amount of these wastes

is 1.12 kg/b.d, i.e. 42.74% of total wastes generated. In

a same study, entitled the hospital waste management

in hospitals in West Azerbaijan in 2007, the amount of

waste generated per bed per day had been equivalent

to 0.95 kg/b.d that the amount increased to 3 kg/b.d in

2012 that is consistent with the amount of waste gener-

ated in this study (2.62 kg/b.d) (2).

In the study of Dehghani et al that was done in hos-

pitals of Arak University of Medical Sciences, entitled

the review of medical waste management status, the

results showed that the rate of waste production is 4.42

kg/b.d, which is consistent with this study(Dehghani,

Azam, Changani, & Dehghani Fard, 2008). The results

also show that per capita waste generation was higher in

our study compared to the study of Al-Khatib et al with

0.59 to 0.93 kg/b.d medical waste production(Al-Khatib,

Al-Qaroot, & Ali-Shtayeh, 2009), study of A.B.Wahab

et al with 0.37 to 1.25 kg/b.d infectious waste in public

hospitals and 0.12 and 0.28 kg/b.d in private hospitals

(Wahab & Adesanya, 2011) and the study of Cheng.Y.W

et al with 0.19 to 0.88 kg/b/d infectious waste produc-

tion.

On the other hand, according to the results obtained

in this study, 57.25% of the ordinary wastes and 42.47%

of infectious wastes constitute the total wastes gener-

ated in the hospitals. The infectious waste generated in

this study compared to the Taghipoor’s study in Tabriz

were higher (29.4 percent)(Taghipour & Mosaferi, 2009).

The study of Farzad Kia et al in which the infectious

waste was 10 to 15 percent in Tehran educational hos-

pitals (Farzadkia, Moradi, Mohammadi, & Jor , 2009)

FIGURE 3. Separately storage management of Chemical, pharmaceutical and biological waste

Table 4. Comparing the total production of solid waste (infectious and non-infectious)

in the hospitals of Bandar Abbas with the regulations approved by the Ministry of

Health and Medical Education

Variables

Statistical indicators

Average t Signi cance *

Average per capita production of solid waste per active

bed in hospitals in Bandar Abbas

2.62

1.922 0.09

Average per capita production of solid waste per active

bed set by the Ministry of Health

2.7

Rahmanian, Ghavam and Yazdanpanah

170 STRUCTURE OF SOLID WASTE MANAGEMENT IN HOSPITALS OF BANDAR ABBAS CITY BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

is not consistent with this study. In a study of Davoodi

conducted in the hospitals of Mashhad, it was 34.90%

(Davoodi et al., 2014) and in the study of Alam MM et al,

it has been reported that the infectious waste (at a rate of

37%) is more than the present study (Alam et al., 2008).

Furthermore, in the study of Nemathaga F conducted

in South Africa and in Limpopo Province, the average

percentage of the components of medical wastes was

60.47% ordinary wastes and 30.32 % infectious wastes

that these results are almost consistent with the results

of this study(Nemathaga, Maringa, & Chimuka, 2008).

According to this study (Table 2), per capita waste pro-

duction in university hospitals is 2.38 kg/d, in private

hospitals is 2.26 kg/d, in police and military hospitals is

1.81 kg /d and in social security hospitals is 3.61 kg/d/b.

It seems that high per capita waste generation can be

due to the hospital inappropriate management struc-

ture, early replacement of hospital administrators and

inexperience of environmental health expert based in

the hospital.

According to the results of Figure 1, most waste stor-

age time in temporary sites is respectively in the police

and military hospitals with an average of 56 hours, in

Social Security hospitals with an average of 28 hours, in

private hospitals with an average of 23 hours and less

waste storage time is in the university hospitals with an

average of 21 hours. It seems that one of the reasons for

long-term accumulation of waste in public hospitals is

associated with the traf c problem of vehicles to col-

lect and transport waste in military areas as well as the

lower volume of daily waste than the volume of trucks

carrying the waste.According to Figure 4, in 62.5% of

hospitals, the pharmaceutical and chemical waste  nal

disposal method is the sanitary land ll. In 25 percent of

these hospitals, the methods of container making and

piling up are used for  nal disposal of the wastes and

in 12.5 percent of the hospitals studied, it is used other

methods. The sanitary land ll and incineration methods

are not used in any of the hospitals.

CONCLUSION

Lack of control and lack of attention to proper manage-

ment of hospital wastes on how to collect, store, trans-

port and dispose of such waste will lead to the preva-

lence of regional and urban epidemics and diseases and

waste of money that this is considered a serious threat to

the public health and environment. On the other hand,

due to urban sprawl and population growth, the pace

of creation of institutions and medical centers such as

the hospitals and paying attention to the management

of hospital wastes are necessary. Therefore, the present

study was conducted in this regard that the results of

this study showed total per capita waste generation in

hospitals of Bandar Abbas is 2.62 kg/b.d that 1.5 kg is

related to the household-like wastes (ordinary) and 1.12

kg belong to the infectious wastes including the sharp

waste, pharmaceutical waste, chemical and hazardous

wastes, pathological wastes and genotoxic waste.

According to the World Health Organization (2014),

which is approved by the Ministry of Health, 85% of

waste generated in hospitals are without risk or ordi-

nary and only 15 to 25% of them constitute the hazard-

ous waste. While in the hospitals studied, 42.74 percent

of hospital wastes are infectious and hazardous that

is more than the amount recommended by the World

Health Organization and the Ministry of Health. It seems

that this is often due to neglect and lack of awareness of

the environmental hazards and pollution and economic

losses caused by mixing the ordinary and infectious

wastes in all stages of production, transportation and

storage of waste in hospitals.

Based on the results of this study, we can conclude

that the per capita production of solid waste per bed

as well as the average duration of waste storage in the

temporary site of waste at hospitals of Bandar Abbas

is almost accordance with the standards recommended

by the World Health Organization and the Ministry of

Health. But there is no consistency in the waste compo-

sition, the infectious waste ratio to the total waste gen-

erated and the proportion of infectious and hazardous

waste in hospitals of Bandar Abbas is about 2 times the

amount recommended by the World Health Organization

and the Ministry of Health that it should be prevented

the mixing of infectious and ordinary waste, especially

in production by implementing more effective training

programs and making a commitment and responsibility

in all employees involved in the infectious waste pro-

duction and performing ongoing monitoring by manag-

ers and health experts in hospitals as well as the univer-

sity students in different  elds in hospitals. Moreover,

it is necessary to force the hospital of cials and admin-

istrators in implementing the waste management rules.

OFFERS

With respect to the implementation of effective train-

ing programs for managers and personnel involved in

the production, transportation and disposal of hospital

waste, it is recommended at  rst the training needs of

different groups involved in the production of hospital

wastes are determined based on scienti c principles and

then the required training programs are developed and

implemented based on these results.

In the educational needs of different groups based on

scienti c principles involved in the production of hospi-

tal wastes were determined and then based on the results

required training programs developed and implemented.

Rahmanian, Ghavam and Yazdanpanah

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS STRUCTURE OF SOLID WASTE MANAGEMENT IN HOSPITALS OF BANDAR ABBAS CITY 171

ACKNOWLEDGMENT

The authors thank and appreciate the sincere cooperation

of all managers, head nurses and health experts working

in hospitals of Bandar Abbas and also the health experts in

health center of Bandar Abbas and Hormozgan province.

REFERENCES

Al-Khatib, I. A., Al-Qaroot, Y. S., & Ali-Shtayeh, M. S. (2009).

Management of healthcare waste in circumstances of limited

resources: a case study in the hospitals of Nablus city, Pales-

tine. Waste Management & Research, 27(4), 305-312.

Alam, M. M., Sujauddin, M., Iqbal, G. M. A., & Huda, S. M.

S. (2008). Report: Healthcare waste characterization in Chit-

tagong Medical College Hospital, Bangladesh. Waste Manage-

ment & Research, 26(3), 291-296.

Chartier, Y. (2014). Safe management of wastes from health-

care activities: World Health Organization.

Davoodi, R., Eslami Hasan Abadi, S., Sabouri, G., Salehi, M.,

Ghooshkhanei, H., Rahmani, S.Gharaeian Morshed, M. (2014).

Medical Waste Management in the second largest City of Iran

(Mashhad) with Three-Million Inhabitants. Journal of Patient

Safety & Quality Improvement, 2(4), 160-164.

Dehghani, M., Azam, K., Changani, F., & Dehghani Fard, E.

(2008). Assessment of medical waste management in educa-

tional hospitals of Tehran university medical sciences.

Farzadkia, M., Moradi, A., Mohammadi, M. S., & Jor , S.

(2009). Hospital waste management status in Iran: a case study

in the teaching hospitals of Iran University of Medical Sci-

ences. Waste Management & Research, 27(4), 384-389.

Kumar, R., Samrongthong, R., & Shaikh, B. T. (2013). Knowl-

edge, attitude and practices of health staff regarding infectious

waste handling of tertiary care health facilities at metropolitan

city of Pakistan. Journal of Ayub Medical College Abbottabad,

25(1-2), 109-112.

Ndejjo, R., Musinguzi, G., Yu, X., Buregyeya, E., Musoke, D.,

Wang, J.-S Williams, P. (2015). Occupational health hazards

among healthcare workers in Kampala, Uganda. Journal of

environmental and public health, 2015.

Nemathaga, F., Maringa, S., & Chimuka, L. (2008). Hospital

solid waste management practices in Limpopo Province, South

Africa: A case study of two hospitals. Waste Management,

28(7), 1236-1245.

Nie, L., Qiao, Z., & Wu, H. (2014). Medical Waste Management

in China: A Case Study of Xinxiang. Journal of Environmental

Protection, 2014.

Rastegar, A., & Gholami, H. (2014). Survey of Solid Waste

Management in Small and Large selected Hospitals of Tehran.

www. sjimu. medilam. ac. ir, 22(2), 149-157.

Taghipour, H., & Mosaferi, M. (2009). Characterization of med-

ical waste from hospitals in Tabriz, Iran. Science of the total

environment, 407(5), 1527-1535.

Wahab, A., & Adesanya, D. (2011). Medical waste generation in

hospitals and associated factors in Ibadan Metropolis, Nigeria.

Res J Appl Sci Eng Technol, 3, 746-751.

WHO (2004). National Health-Care Waste Management Plan

2004 (pp. 7-23).

Zarei, F., Taghdisi, M. H., Keshavarz Mohamadi, N., & Tehrani,

H. (2013). Health Promoting Hospital: A pilot study in Bo-Ali

hospital, Qazvin, Iran. Journal of Fasa University of Medical

Sciences, 3(3), 215-223.