Citation: Al-Dahiri M., Maraqa M.A. and Kanbour F., Medical waste management in the UAE, Kuwait Waste Management Conference, April 7-9, 2008, Kuwait.

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1 MEDICAL WASTE MANAGEMENT IN THE UAE Maryam A. Al-Dahiri 1, Munjed A. Maraqa 2, and Fouad Kanbour 3 1 Support Services, Tawam Hospital, Al Ain, UAE, mdhaheri@tawam-hosp.gov.ae. 2 Dept. Civil and Environmental Engineering, UAE University, Al Ain, UAE, m.maraqa@uaeu.ac.ae. 3 Middle East Environment Advisory Co., 6608 Fifth Avenue, Pittsburgh, PA, USA. fkanbour@yahoo.com ABSTRACT Medical waste management at major hospitals in the UAE was assessed following the WHO guidelines. A questionnaire that accounts for all steps of waste management was distributed among 14 hospitals in the country and direct onsite visits were performed for selected hospitals. Results revealed that the rate of medical waste generated averages 1.95 kg/bed/d, but varies from 0.2 to 4.5 kg/bed/d among the surveyed hospitals. Waste segregation is applied for pathological, sharps, and infectious waste. But, not all surveyed hospitals practice segregation of other types of medical waste. A separate on-site storage room for medical waste exists at many hospitals. Collection of medical waste is conducted using color-coded bags. However, not all surveyed hospitals practice marking on the disposed containers neither are they employ a waste tracking system. Many hospitals do not have pretreatment capabilities for medical waste possibly due to budget constraints or wide use of disposable items. Some hospitals, however, apply pretreatment for pathological and infectious waste using autoclave or chemical disinfection. Incineration is widely used for treatment of medical waste. But, some incinerators are old and poorly maintained. All radionuclides used at the UAE hospitals have relatively short half-lives. Meanwhile, hospitals using radionuclides have special storage facilities for radioactive waste with a decay storage period that varies from 2 to 3 weeks, but could reach 6 months depending on the isotope present in the waste. Guidelines for medical waste management, excluding radioactive waste, have been developed in some emirates, but those for management of radioactive medical waste are greatly lacking. Better management of medical waste can be achieved if a hospital coordinates activities among its different departments. Also, hospitals should train their staff to become aware of the hazards associated with infectious or toxic waste. It is also recommended that hospitals immunize workers at risk and document all cases of infection or poisoning result from exposure to or handling of medical waste. Overall, the system of medical waste management in the UAE is developing. Citation: Al-Dahiri M., Maraqa M.A. and Kanbour F., Medical waste management in the UAE, Kuwait Waste Management Conference, April 7-9, 2008, Kuwait. 1. INTRODUCTION Medical waste is a growing problem with the expectation that it will become more complex in the future. The importance of properly managing medical waste has lead the World Health Organization (WHO) to launch an informative site 1

2 Abu Dhabi Dubai Sharja Ajman Um- Elqewain Ras Al Khaima Al-Fujaira Number of beds. Abu Dhabi Dubai Sharja Ajman Um- Elqewain Ras Al Khaima Al-Fujaira Number of hospitals Kuwait Waste Management Conference, April 7-9, 2008, Kuwait ( that aims to provide practical information on health-care waste management options. With more stringent environmental regulations, the expense of proper disposal of medical waste will probably be escalated in a manner that would increase the cost of health provision. These costs will possibly be passed onto the patient. A management plan for medical waste should incorporate a cradle-to-grave approach (Meany and Pual, 1989). This includes adoption of standard operating procedure to address issues such as waste generation, waste segregation, handling, storage, transportation, treatment and disposal. All these issues should be regulated to assure no occupational or environmental health impact. Furthermore, medical waste management framework may include components such as offerings of training programs to individuals dealing with the waste in all stages from generation until disposal. In the UAE, tremendous progress and development in the health sector have been achieved in the last decade. In the early seventies, there were 7 hospitals, with a total of 70 beds, and 12 health centers. In 2004, there were 40 public hospitals, over 108 pediatric health centers, 29 private hospitals, and 7955 beds in all hospitals (UAE MoH, 2004). The distribution of the hospitals among the emirates as of 2004 along with the corresponding number of beds is presented in Fig. 1. It should be noted that some government hospitals are under the UAE Ministry of Health (UAE MoH) while other government hospitals are not under the MoH Government (MoH) Government (not MoH) Private Goverment (MoH) Government (not MoH) Private 0 Fig. 1: Distribution of hospitals in the UAE (extracted from UAE MoH (2004)). 2

3 2. METHOD OF ASSESSMENT Medical waste management in UAE was assessed through a survey and on-site visits to major hospitals in the country. The survey and the visits were conducted in Results of the survey were further updated to reflect the current situation. The main purpose of the survey was to evaluate procedures for medical waste management, and to identify opportunities for improving waste collection, handling and disposal. Fourteen hospitals were selected in the survey (Table 1). These hospitals were distributed among the 7 emirates. Five of the hospitals are located in Abu Dhabi Emirate, 4 in Dubai, and one hospital is located in each of the remaining emirates. Two of the selected hospitals in the Emirate of Abu Dhabi (i.e., Al-Mafraq and Al Jazeira) are located in Abu Dhabi city while the other three are located in Al-Ain. Hospital selection was based on the number of beds available. The total number of beds in the selected hospitals is 4032, representing about 50% of the total number of beds in all the hospitals in the country. Among the 14 selected hospitals, 12 are funded by the government while the other two (i.e. the American and Oasis) are private owned. A questionnaire was distributed among the selected hospitals. The questionnaire was based on the format prepared by WHO (WHO, 1997) for assessing hospital waste management. The questionnaire was expanded to include information pertaining to medical waste treatment and disposal methods. The questionnaire consisted of eleven major questions, covering different aspects of waste management including legislation, waste handling, storage, pretreatment, treatment, and disposal. The questionnaire also addressed issues such as incinerator availability within the facility and the presence of pollution control equipment. Furthermore, the questionnaire tackled issues such as staff responsibilities, training and awareness. In addition to the questionnaire, on-site visits were made to all selected hospitals where direct communication with personals in-charge was performed. The purpose of these visits was to observe the actual management practices in relation to procedures suggested by the UAE MoH. 3. RESULTS AND DISCUSSION Data presented here include (1) quantity and rate of medical waste produced, (2) waste handling including segregation, use of color-coded bags, and labeling waste bags, (3) presence of on-site waste storage facility and methods of waste transportation, (4) techniques used for treatment of waste, (5) existence of internal and government guidelines at the hospital, (6) presence of training programs for staff involved in waste handling, and (7) use of radioisotopes and methods of handling/disposal of generated radioactive waste. 3.1 Rate of Medical Waste Generated Table 1 shows the annual amount of medical waste produced at each hospital and the number of beds occupied. From this information, the rate of medical waste generated was 3

4 calculated (Table 1). The rate of medical waste produced ranges between 0.2 to 4.5 kg/bed/d. High rate of medical waste generated at some hospitals could be due to having expanded specialization, which allows them to receive patients from other hospitals for further treatment and to diversify their services. Another reason could be due to variation in the allocated hospital budget. These factors could, to some extent, explain the large variations in the generation of medical waste between the major hospitals. Such variations were reported in other countries (Liberti et al., 1996). Table 1: Rate of medical waste generated at the surveyed hospitals. Hospital Emirate Beds Occupancy (%) Daily amount generated 4 Rate (kg/bed/d) (kg) Al-Mafraq Abu Dhabi Al-Jazeira Abu Dhabi Tawam Abu Dhabi Al-Ain Abu Dhabi Oasis Abu Dhabi Rashid Dubai Dubai Dubai Al-Baraha a Dubai American Dubai Al-Qasimi Sharja Shiekh Khalifa Ajman Al-Fujerah Al-Fujerah Saqr Ras Al Khaimah Um-Alqewain Um-Alqewain a Previously Al-Kuwait The average rate of medical waste generated was calculated by dividing the quantity of medical waste generated each day at all the surveyed hospitals by the total number of beds occupied: Total quantity 6060kg/day Average rate 1.95 kg/bed/d occupied beds 3109 bed This value is higher than 1.41 kg/bed/d reported by Al-Shuwaiter (1994). This discrepancy is possibly due to the method used to determine the rate value. In this study, the actual number of occupied beds was utilized in the determination of the rate value, whereas in Al-Shuwaiter s case the total number of beds in the hospital was used instead. The total quantity of medical waste produced by the selected hospitals is about 2200 ton per year. Given that the selected hospitals contain 50% of the total number of hospital beds in the country, it is estimated that the amount of medical waste generated by the UAE hospitals in 2001 is about 5600 ton. The total amount would be higher since contribution from other medical care supporting facilities is not included in the analysis. The rate of medical waste produced in the UAE is typically lower than values reported for Europe and the United States (Table 2). This could be due to (1) the limited types of

5 operations conducted at the UAE hospitals and (2) the presence of public healthcare centers, through which some medical waste generated at these centers would have been counted on the hospitals had these facilities did not exist. Table 2: Rate of medical waste generated in different countries. Country Rate of generation Year of study Reference (kg/bed/d) Bahrain UNEP/WHO, 1997a France Liberti et al., 1996 Iran UNEP/WHO, 1997b Jordan Abdulla et al., 2008 Morocco UNEP/WHO, 1997c Netherlands Coad, 1994 Norway WHO, 1985 Peru Coad, 1994 Spain WHO, 1985 UK WHO, 1985 USA Coad, 1994 Venezuela Coad, 1994 India Patil and Shekdar, 2001 Italy Liberti et al., Waste Handling Results obtained from the surveyed hospitals concerning segregation practices, the use of color-coded bags, marking on bags and containers, and estimation of the amounts of each type of medical waste are presented below. Segregation Medical waste is usually segregated into risk and non-risk categories by sorting it into color-coded bags. Segregation of different types of medical waste at the surveyed hospitals is summarized in Fig. 2. All the hospitals surveyed indicated that they apply segregation procedures for pathological, sharps, and infectious waste. However, not all hospital practice segregation of other types of medical waste including chemical, pharmaceutical, and pressurized containers. Three public hospitals (i.e. Tawam, Al- Baraha and Saqr) practice segregation of all types of medical waste. The two private hospitals that were included in this study are also performing segregation of all types. Both chemical waste and pressurized containers receive the least segregation practice among the hospitals. Color-coded bags Many of the UAE hospitals use two-color coded bags: black and yellow. Black bags are used for hospital waste that is not classified as medical waste while yellow bags are used for medical waste. In the Emirate of Abu Dhabi, however, red bags are used for medical waste and yellow ones are used for waste generated from chemotherapy. In the Emirate of Dubai, yellow bags are used for medical waste and purple ones for toxic waste. All the 5

6 Pathological Infectious Sharps Chemical Pharmaceutical Pressurized containers Number of hospitals. Pathological Infectious Sharps Chemical Pharmaceutical Pressurized containers Number of hospitals. Kuwait Waste Management Conference, April 7-9, 2008, Kuwait surveyed hospitals responded positively on the questions pertinent to the use of colorcoded bags as shown in Fig. 3. The figure depicts that all the hospitals use color-coded bags or containers for disposal of pathological and infectious waste as well as sharps. Less than half of the surveyed hospitals indicated the use of color-coded bags for chemical and pharmaceutical waste. Other hospitals either do not generate this type of waste or do not use color-coded bags for disposal Yes No Not available Not applicable Fig. 2: Segregation of medical waste by type at the surveyed hospitals Yes No Not available Not applicable Fig. 3: Use of color-coded bags for medical waste at the surveyed hospitals. Labeling of bags/containers The proper procedure for handling medical waste is to label each container and specify the originating department or source of such waste. All medical waste generated leaving the storage areas are sealed and labeled, so that the source and quantity of the waste containers can be identified. This helps the housekeeping department to monitor and take proper action in case any problem occurs. The practice of marking on bags and 6

7 Pathological Infectious Sharps Chemical Pharmaceutical Pressurized containers Number of hospitals. Kuwait Waste Management Conference, April 7-9, 2008, Kuwait containers at the UAE hospitals varies widely. Tawam, Rashid, Oasis, American, and Dubai, are practicing marking for all types of medical waste, while other hospitals, like Al-Baraha, Saqr, and Al-Qasimi, do not practice marking for any type. Figure 4 summarizes the response of the surveyed hospitals on the question of labeling waste bags and containers Yes No Not available Not applicable Fig. 4: Marking on bags and containers at the surveyed hospitals. Medical waste distribution by type Most hospitals in the UAE do not estimate the quantity of each type of medical waste produced with the exception of Al-Mafraq, Oasis, and Shiekh Khalifa hospitals. Based on the information provided by Al-Mafraq Hospital, the distribution of each type of medical is: Pathological 11.1%, infectious 83.8%, sharps 3.8%, pharmaceutical 1.0% and radioactive 0.3%. The high percentage of infectious waste generated indicates that laboratory waste associated with test procedures (i.e. cultures, stocks of infectious agents, and associated biological) is the predominate type of medical waste produced. 3.3 Waste Storage and Transportation Proper handling, segregation and storage of hospital waste require placement of instructions at each waste collection point in order to remind staff of the correct procedure. Containers are to be removed to a central storage point for subsequent treatment and disposal. WHO suggests that waste in the storage room is not to exceed the limit of three quarters full neither should be left for more than one day. Separate central storage locations are to be designated inside the hospital. The storage location is to be a separate, locked room or building with access restricted to authorized individuals. Results of this study revealed that about 70% of the hospitals included in the survey have a separate on-site storage area for medical waste, with 64% have the storage facility disinfected periodically. Also, about 70% have dedicated carts/vehicles for transporting medical waste within the health care establishment. Most of the hospitals have posted procedures explaining the proper ways for transporting medical waste and their disposal. These posts also describe procedures for collecting bags containing 7

8 medical waste and storing them either in a cold storage room or special temporary holding in a storage room for a certain period of time that ranges from hours to one day before the waste is transported by a special vehicle to the disposal area. On-site visitation showed that most storage areas are open and without locks. In some cases, some of the waste bags were left in the open until being collected at the end of the day for treatment. It was further noticed that on-site incinerators at some hospitals are located quite a large distant from the source. In the absence of special vehicles or trolleys, workers placed medical waste bags inside a black bag to be dumped in dumpsters that are available in a close by vicinity. Boatright and Edwards (1995) reported that many healthcare facilities in the State of Oklahoma were disguising their red bags into domestic waste dumpsters so that the local collection and disposal process would not be interrupted or expensive alternative to local disposal required. The absence of strong enforcement and control on handling and disposal of medical waste will encourage practice similar to the ones mentioned above. Other practices may as well be encouraged such as the illegal dumping at sites that are not authorized. For example, the Irish Environmental Protection Agency discovered at least 487 sites (out of possible 2000 illegal dump sites) where hazardous materials including medical waste and toxic substances are thought to be buried (Birchard, 2002). 3.4 Pretreatment and Treatment of Medical Waste Waste pretreatment The purpose of medical waste pretreatment is to reduce the pathogen content in the medical waste. This process commonly requires high temperature to be maintained for periods of up to an hour. There are several types of pretreatment methods that can be applied including microwave, autoclave, gas/vapor, and irradiation or chemical disinfection for liquid. Most of the hospitals in the UAE do not have pretreatment capabilities, possibly due to budget constraints or due to the wide use of disposable items. Microwave, gas/vapor, and irradiation are not used in any of the surveyed hospitals. However, autoclave is being used at Al-Baraha Hospital for pretreatment of infectious and pathological wastes and at the American Hospital for pathological waste. Chemical disinfection is used in a few hospitals including Al-Ain and Al-Fujerah for pretreatment of pathological and infectious wastes. Waste treatment Currently, most hospitals located in the UAE use incineration for medical waste combustion and destruction of pathogens. However, medical waste in the Emirate of Abu Dhabi is collected from all hospitals and transferred to Al-Mosafah area via contactors where it is shredded, chemically disinfected and then placed in designated landfill. This excludes expired medicine which is either incinerated at Tawam Hospital or returned to the original source. In Dubai, expired medicine is sent to a landfill. It should be noted that medical waste in Al-Ain area will soon be treated in a newly-built centralized incinerator. 8

9 Some of the medical waste incinerators in the UAE are old. A common practice is to add water to the content during incineration so as to cover up the black smoke with white steam. Some of the incinerators are equipped with filters, but the filters are not operational. Thus, gaseous emissions from these incinerators are of a concern. 3.5 Guidelines As demonstrated in Table 3, there are two types of guidelines that exist at the UAE hospitals to manage medical waste: government and internal guidelines. A technical committee from the UAE MoH established the government guidelines (UAE MoH, 1999). Government guidelines were made available to all hospitals in the country through the MoH, albeit some hospitals do not have these guidelines. The objectives of the government guidelines were to define various categories of medical waste and provide means for proper segregation, and safe collection, storage, transportation and disposal of medical waste carried out by well trained personnel, under the supervision of suitably qualified staff. Government guidelines classified medical waste into six categories on the basis of its risk potential and prescribed methods for its proper segregation, containment, safe collection, storage, transportation, and disposal. These guidelines also set specifications of bags and containers used for medical waste collection. Medical waste bags are classified into four different colors and vary in other characteristics including thickness and tear resistance. A few emirates provide their hospitals with internal guidelines. For example, the Health Authority of Abu Dhabi (HAAD) established a policy for management of waste generated by health care facilities (HCFs) in the Emirate (HAAD, 2007). The policy requires all HCFs to abide by the Federal Law 21 of 2005 for waste management in the Emirate of Abu Dhabi and Schedule 3, Amendment 31 of 2001 for the Federal Law 24 of 1999 for the protection and development of the environment. Table 3: Existence of guidelines for managing medical waste at UAE hospitals. Hospital Government guidelines Internal guidelines Al-Mafraq Yes No Al-Jazeira Yes Yes Tawam Yes No Al-Ain No No Oasis Yes Yes Rashid Yes Yes Dubai Yes Yes Al-Baraha Yes Yes American Yes Yes Al-Qasimi No Yes Shiekh Khalifa Yes No Al-Fujerah Yes No Saqr Yes Yes Um-Alqewain Yes Yes 9

10 The HAAD policy requires that waste management becomes the responsibility of the HCF. As such each HCF should provide the required resources and designated staff for proper waste management at its premises. This includes training of staff members especially those involved in the house keeping and cleaners whether directly employed by the HCF or out sourced by the HCF. Furthermore, all HCFs staff, including waste handlers, should be immunized for Hepatitis B. The policy also requires that HCFs maintain a log book for the purpose of tracking and maintaining a record of all disposed medical waste. The policy further outlines requirements for waste storage, use of color coded bags and marking on packaged medical waste bags and containers. In Dubai, the Central Committee for Control of Hospital Infections (1998) published internal guidelines entitled Infection control policy and guidelines. The manual addresses the health and safety aspects including health hazards risk to personnel and external health hazards. The manual further explores means of waste handling, storage, transportation, treatment, and disposal. The manual is based on well-documented and widely accepted recommendations according to standards established in various UK hospitals and the Center for Disease Control and Prevention in the USA. In general, it was found that about two-thirds of the surveyed hospitals indicated the existence of internal guidelines, and almost all hospitals, with the exceptions of Al-Ain and Al-Qasimi, have government guidelines (Table 3). It should be noted that at certain visited hospitals, only some specialized departments have internal guidelines and are limited to methods of treatment of generated waste. A distinction, however, should be made between the presence of guidelines within the healthcare institution and the implementation of these guidelines. 3.6 Staff Training Some professions are inherently at risk from exposure to medical waste. The most obvious are healthcare workers who come in contact with patients carrying infectious disease. Others are people who are in waste-handling occupations (Burke, 1994). The highest probability of exposure for both groups is needelstick injuries. As reported by Lichtveld et al. (1992), sharps cause about one-third of the work related injuries in hospitals. Thus, it is the responsibility of the administration of a healthcare institution to monitor regularly the health and safety of their staff, patients and visitors. This means that proper handling, storage, treatment and disposal of waste should be implemented. Lack of good training of workers on handling medical waste may result in a more expensive waste disposal. Boatright and Edwards (1995) discovered that many healthcare facilities were paying for the disposal of a large volume of biomedical waste that was not covered under the existing state regulations for biomedical waste management. As the author indicated, this was due to confusion among many of the surveyed institutions as to what exactly constituted biomedical waste. Tudor et al. (2005) suggested that staff training and awareness could potentially reduce disposed medical waste quantities by as much as 20 30% (wt.) and costs by around 25 35%. 10

11 Results of the survey conducted herein showed that 64% of the hospitals have specific unit that deals with medical waste management in the hospital. These units employ various numbers of staff that are responsible for transfer of waste from the patient room or various units to the storage area. At the end of the day, the waste is transferred using specialized vehicles to a designated incinerator or landfill. All hospitals have reported the presence of training and awareness raising programs for the staff engaged in medical waste management. On-site visits revealed that hospitals are dealing with their waste through private housekeeping contractors. These contractors are generally recruiting poor, non-educated personals that are difficult to communicate with. Those workers lack knowledge of the risk associated with handling of medical waste. It was further understood that not all the staff are included in the offered training program, but it is limited to those who work in high-risk areas. The UN Development Program (1998) also noticed that there are no experienced workers for hospital cleaning within the institution or any other cleaning company. The UN report further highlighted the lack of special supervisors or departments who monitor the handling of medical waste. 3.7 Radioactive Medical Waste Results of the conducted survey showed that the use of radionuclides for diagnostic purposes is limited to few hospitals in the country (Table 4). Furthermore, only three isotopes are used including Tc-99m, I-131, and I-125, with the former isotope is being the only one used at the majority of the hospitals. Also, all the isotopes used at the UAE hospitals have a relatively short half-life. Table 4: Radionuclides used at UAE hospitals. Hospital Isotope Half-life Energy per disintegration (MeV) 11 Emission Average use (mci/month) Al-Mafraq Tc-99m 6 hr Al-Jazeira Tc-99m 6 hr Tawam Tc-99m 6 hr I d , 400 I d < , 300 Al-Ain Tc-99m 6 hr Dubai Tc-99m 6 hr Al-Fujerah Tc-99m 6 hr Saqr Tc-99m 6 hr Most of the hospitals perform segregation of generated radioactive waste, use colorcoded bags, and label these bags. However, only few hospitals conduct estimates of the amount of radioactive waste generated. In most of the cases, the deactivated waste is incinerated. This is, however, is not the current practice in the Emirate of Abu Dhabi where the deactivated waste is treated as a regular medical waste, except at Tawam Hospital where it is incinerated. On-site visits revealed that hospitals have special storage

12 facilities for radioactive waste. The decay storage period varies from 2-3 weeks. This period is more than 10 times the half-life of the commonly used Tc-99m. At Tawam Hospital, I-131 is used at the Radiotherapy Department and I-125 at the Nuclear Medicine Department. Radioactive medical waste produced at the hospital undergoes storage periods that range from one month to less than six months. Few hospitals still use long half-life radioactive Cs-137 which has a half-life of about 30 years. These hospitals usually have a special room for a long period of storage. The wall of these rooms presumably is lined with lead bricks to prevent radiation. In some hospitals, these materials have been in the storage rooms since the hospital was opened. Some hospitals (like Tawam and Dubai) mentioned that long half-life radioactive materials are usually returned to vendors. Tawam started to substitute long half-life material with short half-life for ease of disposal. In the UAE there is no law or legislation regarding management of radioactive waste. The report on safe handling and disposal of medical waste (UAE MoH, 1999) set guidelines for management of medical waste with the exception of radioactive waste. A law in Abu-Dhabi Emirate, however, states that medical radioactive waste should be incinerated or buried after decay storage (Abu Dhabi Law, 1998). 4. CONCLUSION 1. The average rate of medical waste generated at the UAE hospitals is 1.95 kg/bed/d, with high variations (i.e. 0.2 to 4.5 kg/bed/d) among the surveyed hospitals. While the total quantity of medical waste generated at the UAE hospitals is known, most of the hospitals do not estimate the quantity of each type of medical waste generated. 2. All surveyed hospitals apply segregation procedures for pathological, sharps, and infectious waste, but not all hospitals practice segregation of chemical, pharmaceutical and pressurized containers. 3. Hospitals in the Emirate of Abu Dhabi use red bags for disposal of medical waste, while hsopitals in the other emirates use yellow bags. However, not all hospitals are practicing marking on the disposed bags and containers. 4. There is a separate on-site storage room for medical waste at most hospitals in the UAE. On-site transportation of medical waste for incineration is conducted using special vehicles or trolleys. Off-site transportation for treatment or disposal is conducted using special vehicles. Nevertheless, not all hospitals employ a waste tracking system. 5. Incineration is used by most hospitals in the UAE for treatment of medical waste. But, some of the incinerators are old, poorly maintained with no proper equipment to control air pollution. 6. Surveyed hospitals are using contractors for handling generated waste. All hospitals have reported the presence of training programs for staff recruited by the contractors. 7. Federal guidelines for management of medical waste exist but are not strictly implemented by the hospitals. However, guidelines set by Dubai are strictly applied by the hospitals in the Emirate. 12

13 ACKNOWLEDGEMENT The authors are grateful to the staff members at the surveyed hospitals for their cooperation and assistance. REFERENCES Abdulla F., Abu Qdais H. and Rabi A. (2008). Site investigation on medical waste management practices in northern Jordan, Waste Management, 28: Al-Numairy, S. (1994). Short summary on medical waste management in the UAE, WHO/UNEP Workshop on MWM in West Asia and Eastern Mediterranean, March, Sharjah, UAE. Al-Shuwaiter, H. (1995). Management of hospital wastes in the United Arab Emirates, M.Sc. Thesis, UAE University, Al Ain, UAE. Birchard, K. (2002). Out of sight, out of mind the medical waste problem, Lancet, 359 (9300): 56. Boatright, D. and Edwards, A. (1995). A comprehensive biomedical waste survey, J. Environmental Health, 57 (8): Central Committee for Control of Hospital Infections (1998). Infection Control Policy and Guidelines, Department of Health and Medical Services, Health Authority, Government of Dubai. Coad, A. (1994). Managing medical wastes in developing countries. Report of a consultation on medical wastes management in developing countries, WHO, Geneva. HAAD (2007). Medical waste management in health care facilities, Health Authority- Abu Dhabi, Reference number: PPR/HCP/P0002/07. Liberti, L., Tursi, A., Constantino, N., Ferrara, L. and Nuzzo, G. (1996). Optimization of infectious hospital waste management in Italy: Part II. Waste characterization by origin, Waste Management and Research, 14: Lichtveld, M., Rodenbeck, S. and Lybarger, J. (1992). The findings of the Agency for toxic substances and disease registry: Medical Waste Tracking Act Report, Environmental Health Perspectives, 98(11): Meany, J. and Pual, N. (1989). Medical wastes strategy, Pollution Engineering, 21(11): Patil, A. and Shekdar A. (2001). Health-care waste management in India, J. Environmental Management, 63(2): Tudor T. L., Noonan C. L. and Jenkin L. E. T. (2005). Healthcare waste management: a case study from the National Health Service in Cornwall, United Kingdom, Waste Management, 25: UAE MoH (1999). Safe handling and disposal of medical waste (excluding radioactive waste), A report of the Technical Committee, Abu Dhabi, UAE. UAE MoH (2004). Annual Statistics Report, Ministry of Health, United Arab Emirates. UN Development Program (1998). Development of systems for environmental management in Abu-Dhabi Municipality, Project number UAE/95/004, Abu Dhabi, UAE. WHO (1985). Management of waste from hospitals, WHO Regional Office for Europe (EURO Reports and Studies, No. 97), Copenhagen, Denmark. 13

14 WHO (1997). Action plan for the development of national programme for sound management of hospital wastes. An outcome of the Regional Consultation on Sound Management of Hospital Waste, Chiang Mai, Thailand, November New Delhi, World Health Organization Regional Office for South-East Asia. WHO/UNEP (1997a), Regional expert meeting on medical waste management in West Asia, 30 November-3 December, Bahrain. Bahrain Country Report. WHO/UNEP (1997b), Expert meeting on medical waste management in West Asia, 30 November-3 December, Bahrain, Iran Country Report. WHO/UNEP (1997c), Expert meeting on medical waste management in West Asia, 30 November-3 December, Bahrain, Morocco Country Report. 14