THAI NGUYEN UNIVERSITY
UNIVERSITY OF AGRICULTURE AND FORESTRY

PHAM THI HUYEN

ASSESSMENT OF HAZARDOUS MEDICAL SOLID WASTE
MANAGEMENT AT HOSPITALS IN YEN BAI CITY
YEN BAI PROVINCE

BACHELOR THESIS

Study mode

: Full-time

Major

: Environmental Science and Management

Faculty

: Advanced Education Program

Batch

: 2014 – 2018

Thai Nguyen, 2018


Thai Nguyen University of Agriculture and Forestry

Degree Program

Bachelor of Environmental Science and Management

Student name

Pham Thi Huyen

Student ID

DTN1453110069

Thesis Title

Assessment of Hazardous Medical Waste Management at
hospitals in Yen Bai city - Yen Bai province

Supervisor

Dr. Ho Ngoc Son

Abstract:
There has been an increase in public concern about the medical waste management
on a global basis and a significant effort has been directed toward proper and safe
management of hazardous medical wastes in Yen Bai city. The objective of this
study is to analyze the hazardous medical solid waste management of health-care
facilities in Yen Bai city, to access to its current situation, investigate people's
awareness, and then propose solutions. This study was carried out with the 8
member hospitals of Yen Bai's health-care facilities system. Observation and
questionnaire survey method was used to collect real data of the amount of medical

solid waste and the status of medical solid waste management.
Research showed some existing problems in the medical waste management in all
hospitals due to lack of training and resources. Moreover, the amount of medical
solid waste has been increasing over the years, 8 surveyed hospitals discharged 212
tons in 2017 including 55 tons of hazardous medical solid waste. Collection,
separation, and transportation of medical waste have been implemented but there
were still many limitations. Besides, a lack of awareness of the people in Yen Bai
city is an serious problem. While nurse group and waste worker group shows higher
knowledge about medical waste management with over 80%, the figure for doctor
group only 57.1%, moreover, only 26.7% of the patient group were aware of the
waste management regulations of the Ministry of Health and the Ministry of Natural
Resources and Environment. Among the major recommendations is that public
education and awareness of participants should be developed to encourage
sustainably medical solid waste management behavior, increasing construction of
material facilities for the collection, separation, transportation and treatment of

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hazardous medical solid waste; investing in non-burning technology is highly
recommended.
Key Words

Yen Bai city, Health-care Facilities, Hazardous Medical
Solid Waste Management,

Number of Pages

54 pages


Date of Submission

September 25th, 2018

Supervisor’s
signature

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ACKNOWLEDGMENT
To finish this thesis, I received enthusiastic help from many people working in
the Department of Environmental protection of Yen Bai province, friends and family.
First and foremost, I have to thank my research supervisor Dr. Ho Ngoc Son.
Without his assistance and contact motivating supervision in every step throughout the
process, this study would have never been accomplished.
I would also like to show gratitude to staff who are working at the Department
of Environmental protection of Yen Bai province for supporting me during the drafting
process to completing this thesis.
Most importantly, none of this could have happened without my family and my
friends who always beside and support me, moreover, help me a lot during the
investigation and data collection as well as to complete this thesis to the final step.

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TABLE OF CONTENT
ACKNOWLEDGMENT ............................................................................................... iii
TABLE OF CONTENT .................................................................................................iv
LIST OF FIGURE ........................................................................................................ vii

LIST OF TABLE ......................................................................................................... viii
LIST OF ABBREVIATIONS ........................................................................................ix
PART I: INTRODUCTION ............................................................................................1
1.1. Research rationable ..................................................................................................1
1.2. Research’s objective .................................................................................................3
1.3. Research questions ...................................................................................................3
1.4. Limitations ................................................................................................................3
PART II: LITERATURE REVIEW ................................................................................5
2.1. The definitions of medical waste ..............................................................................5
2.2. Generation and components of MSW .............................................................................. 5
2.2.1. Generation of MSW ........................................................................................5
2.2.2. The components and characteristic of MSW ..................................................6
2.3. Classification of medical waste ......................................................................................... 9
2.3.1. Classification rules ..........................................................................................9
2.3.2. Classification of medical waste .....................................................................10
2.4. The impact of hazardous medical solid waste on the environment ..............................10
2.4.1. Impact on soil environment ...........................................................................10
2.4.2. Impact on air environment ............................................................................11
2.4.3. Impact on water environment ........................................................................11

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2.4.4. Impact on human health ................................................................................12
2.5. Situation of medical waste management ........................................................................12
2.5.1. Situation of medical waste management of some countries in the world .....12
2.5.2. Situation of medical waste management in Viet Nam ..................................13
2.5.3. Situation of medical waste management in Yen Bai city .............................15
2.6. Measures for hazardous medical waste treatment .........................................................17
2.6.1. Incinerator technology...................................................................................17

2.6.2. Steam-oven technology .................................................................................17
2.6.3. Sterilize by chemicals....................................................................................18
2.6.4. Microwave technology ..................................................................................18
2.6.5. Biotechnology treatment ...............................................................................19
2.6.6. Radioactive treatment ....................................................................................19
PART III: METHODS ..................................................................................................20
3.1. Material .............................................................................................................................20
3.2. Study design .....................................................................................................................20
3.3. Participants .......................................................................................................................20
3.4. Location and research background .................................................................................21
3.5. Data collection..................................................................................................................21
3.6. Data analysis and processing...........................................................................................22
PART IV: RESULTS AND DISCUSSIONS ................................................................23
4.1. The overview of health facilities in Yen Bai city ..........................................................23
4.2. The situation of management of MSW in Health-care facilities in Yen Bai city ........25
4.2.1. Collection, segregation, and storage .............................................................25

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4.2.2. Transportation, treatment, and equipment ....................................................30
4.3. The awareness of healthcare workers, patients and patient’s family members about
HMSWM .................................................................................................................................35
4.3.1. For medical staff............................................................................................35
4.3.2. For patients and patient's family members ....................................................37
4.4. Solutions to improve hazardous medical waste management in Yen Bai city ............38
4.4.1. Measures on environmental management .....................................................38
4.4.2. Measures to improve the collection, segregation, storage, transportation and
treatment of HMSW ................................................................................................39
4.4.3. Alternative Treatment Technologies .............................................................41

PART V: CONCLUSIONS AND RECOMMENDATIONS .......................................43
5.1. Conclusions ......................................................................................................................43
5.2. Recommendations............................................................................................................45
REFERENCES .............................................................. Error! Bookmark not defined.
APPENDIX 1 ................................................................................................................48
APPENDIX 2 ................................................................................................................53
APPENDIX 3 ................................................................................................................57

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LIST OF FIGURE
Figure 1: Typical waste compositions in health-care facilities .......................................7
Figure 2: The average components of medical waste in Yen Bai province ....................9
Figure 3: General scheme of waste classification in hospitals ......................................28
Figure 4: Perception of color codes for waste containers .............................................36

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LIST OF TABLE
Table 1: Source of medical waste from health sector activities ......................................6
Table 2: Physical and chemical properties of MSW in Yen Bai province ......................8
Table 3: Health-care waste generation according to national income level ..................13
Table 4: Volume of HMW in some localities in Viet Nam in 2014 .............................14
Table 5: Situation of HMSW arising in medical establishments in Yen Bai province .15
Table 6: The overview of hospitals in Yen Bai city ......................................................24
Table 7: The amount of MSW arising in health-care facilities in Yen Bai city in 2017
.......................................................................................................................................26
Table 8: The amount of each type of HMSW in health-care facilities in Yen Bai City

.......................................................................................................................................27
Table 9: Compliance rates for HMSW bags at hospitals ..............................................28
Table 10: Situation of MSW treatment at hospitals in Yen Bai city .............................33
Table 11: The awareness of medical staffs about the medical waste management
regulation .......................................................................................................................35
Table 12: Medical staff knowledge and awareness of hospital waste management .....36
Table 13: The awareness of participant about medical solid waste management .........37

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LIST OF ABBREVIATIONS
HMSW

Hazardous Medical Solid Waste

HMSWM

Hazardous Medical Solid Waste Management

MSW

Medical Solid Waste

MSWM

Medical Solid Waste Management

OMW


Ordinary Medical Waste

WHO

World Health Organization

YHF

Yen Bai’s Health-care Facilities

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PART I: INTRODUCTION
1.1. Research rationable
The environment plays an important role in human life as well as the socioeconomic development of each nation. The environment is degrading and being
pollution, and it becomes a global problem. Thus, all government, department, socioeconomic organizations and each citizens have responsibility for environmental
protection to guard life (Vo Quy, 2011).
Along with the development of socio-economic, the Vietnamese’ life has been
improved coupled with the rised in number of population. Health care needs are
increasingly, for this reason, the system of medical facilities is focused on developing,
expanding and improving the quality of services. On the one hand, it brings a lot of
benefits to humans (Minh Hoang, 2015). On the other hand, it creates a large amount
of medical solid waste, expecially hazardous medical waste.
Hazardous medical solid waste are mainly infectious wastes, inflammables,
explosives, corrosives, toxic wastes such as radioactive substances, cytotoxics and
toxic chemicals arising in the Diagnosis and treatment of diseases, which are the risk
factors for environmental pollution, spreading the disease from the hospital to the
surrounding area. It is therefore necessary to manage the hazardous waste generated
from the health facility safely and appropriately.

Yen Bai city is located in a mountainous province located in the northwest of
Vietnam. There are over 300 medical facilities in the city, including general hospitals
and private clinics. Yen Bai city is the political and economic center of Yen Bai
province with the majority of provincial hospitals serving most of the needs of Yen

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Bai people in general and Yen Bai city's citizens in particular (Do Viet Bach, 2018).
Therefore, the volume of medical waste (including medical waste and medical
wastewater) generated by hospitals in the city accounts for the majority of medical
waste generated in the province. The number of people who need to go to the hospital
is increasing, along with the fact that the amount of waste is increasing rapidly, most
of it are hazardous wastes. At the same time, there are many shortcomings in the
management of hazardous medical waste in these health-care facilities. A number of
public hospitals have been equipped with incinerators or autoclaves to meet
environmental requirements, but there are still many health facilities using manual
incinerators with low environmental safety and many private clinics are under the
control of medical waste. Moreover, the awareness about the danger of HMSW is not
really popular as well as the importance of propaganda in the management of
hazardous waste is undeniable which protects human health and the environment.
Therefore, the management of MSW, especially hazardous waste needs to be improved
to address both health care and environmental protection, also rise people awareness.
Stemming from health-care waste problem in Yen Bai city, in order to find the
management measures to contribute reducing the harm of medical waste, the study:
´´Assessment of hazardous medical waste management in Yen Bai city - Yen Bai
province`` is very important.

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1.2. Research’s objective
The general objective of the study is to assess HMSWM status in Yen Bai city,
moreover, and to raise people awareness about the danger of HMSW and
environmental protection.
In particular, there are some specific objectives:
• To access the current situation of separation, collection, storage, transport
and disposal of HMSW at YHF.
• To investigate the awareness and attitude of medical staff and patients about
the HMSWM.
• To propose measures to manage HMSW to ensure safety and environmental
sanitation in YHF.
• To assess the effectiveness of measures to enhance understanding, awareness
and actions of people about HMSWM.
1.3. Research questions
1. What is the status of HMSW in Yen Bai city annually?
2. How is the HMSW managed in YHF?
3. What are the treatments of HMSW in YHF?
4. What is the level of awareness on HMWSM among respondents?
5. What are solutions to improve the HMWSM?
1.4. Limitations
The study can not survey all accurately HMSW data of all health-care
facilities in the city, include all the status, management issues and treatment of
HMSW. There were some limitations throughout the study.

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• The first limitation is it impossible for the student to collect data in all YHF
and conduct an interview for all waste management staff at each place because there

are many medical facilities in the city.
• The second constrant was the time limitation due to the student had a short
time for this study.

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PART II: LITERATURE REVIEW
2.1. The definitions of medical waste
• Medical wastes are wastes generated during the operation of medical
establishments, including HMSW, ordinary medical wastes and medical wastewater
(Ministry of Health and Ministry of Natural Resources and Environment, 2015)
• Hazardous medical solid wastes (HMSW) are medical wastes containing
infectious agents or other hazardous properties exceeding hazardous waste thresholds,
including contagious wastes and non-contagious hazardous wastes (Ministry of Health
and Ministry of Natural Resources and Environment, 2015)
• Medical waste management is the process of minimizing, classifying,
classifying, collecting, storing, transporting, recycling and disposing of medical waste
and monitoring the implementation process (Ministry of Health and Ministry of
Natural Resources and Environment, 2015).
2.2. Generation and components of MSW
2.2.1. Generation of MSW
MSW in general and hazardous solid medical waste in particular arise mainly
from medical examination and treatment establishments (most of which are hospitals);
Preventive health facilities; Training institutions and research facilities carry out
medical tests. In addition, HMSW can also be found in: home health clinics, traditional
medicine clinics, cardiovascular services place, blood pressure measurement, home
health care. Besides, HMSW can be found in the services for the transportation of
patients in the country and abroad, medicine service establishments, dental services
establishments, clinics and health authorities.


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The source of medical waste from medical activity is shown in the following table:
Table 1: Source of medical waste from health sector activities
Type of waste

Sources
The waste from the kitchen, the administrative area,

Domestic waste
packaging areas, etc.
Waste contains disease

The waste from surgery, internal organs of the body after

germs

dissection, gauze bandages and blood of patients,etc.
The waste discharged after use for patients and waste

Contaminated waste
from the cleaning process.
The types of waste more toxic than the waste above such
as radioactive substances, pharmaceutical chemicals, etc.
Special waste
It is from the department of examination, treatment,
experimental activities, and pharmacy.
(DONRE, 2014)

2.2.2. The components and characteristic of MSW
Most MSW are hazardous bio-waste and have a specific nature compared to
other types of solid waste. If these wastes are not carefully sorted before being
disposed of together with household wastes will cause significant harm (Department of
Natural Resources and Environment of Yen Bai province, 2015).

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Figure 1: Typical waste compositions in health-care facilities

(Chartier et al, 2014)
Figure 1 shows that the main type of MSW is general waste which also knew as nonhazardous health-care waste while the figure for hazardous medical waste was total
15% including infectious and chemical/radioactive waste.
The article 4 of the Joint Circular No. 58/2015 / TTLT-BYT-BTNMT to
delimit the MSW including:
 Infectious waste:
- Sharp waste (type A): Waste that can cause cuts or punctures, which can be
infectious, including needle syringes, sharp ends of the surgical cord, scalpel, surgical
spikes, saws, syringes, fragments of glass and other sharp objects used in medical
activities;
- Infectious non-sharp waste (type B): Waste is infiltrated with blood, the body's
bioavailability and the waste generated by the isolation chamber;
- Highly contagious waste (type C): Waste is generated in laboratories such as
specimens and containers containing specimens; (Minister of Health. 2007) Surgical
waste (type D): Includes tissues, organs, organs of the human body; fetus, fetus and
laboratory animals.
 Noninfectious hazardous waste
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- Disposal chemicals include or contain hazardous ingredients;
- Discharged drugs belong to the cytotoxic group or there is a hazard warning
from the manufacturer;
- Broken, damaged, used medical equipment containing mercury;
- Other hazardous wastes prescribed in the Ministry of Natural Resources and
Environment's Circular No. 36/2015 / TT-BTNMT of June 30, 2015, on the
management of hazardous wastes.
 Ordinary medical waste includes:
- Daily-life solid waste arising in daily-life activities of people and external
wastes in medical establishments;
- OMW arising from Health-care facilities not on the list of those subject to
hazardous medical wastes or on the list but containing hazardous elements below the
hazardous waste threshold.
The composition, ratio, physical and chemical properties of MSW in Yen Bai
province are shown in Tables 2 and Figure 2:
Table 2: Physical and chemical properties of MSW in Yen Bai province
Average emission factor of MSW

1.45kg/day/bed

Ratio of HMW

25%

Specific gravity

130kg/m3

Humidity


40%

The amount of ash content after burning

9.82%

Heat treatment

2.532 Kcal/kg
(DONRE,2010)

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Figure 2: The average components of medical waste in Yen Bai province

(DONRE, 2015)
2.3. Classification of medical waste
The Article 6 of the Joint Circular No. 58/2015 / TTLT-BYT-BTNMT
stipulates principles for classification of medical wastes, including:
2.3.1. Classification rules
• HMW and OMW must be classified directly for management at the places
where they arise and at the time of arising;
• Each kind of medical waste must be classified separately into the packaging,
tools and equipment for storing waste according to Article 5 of Circular No. 58/2015 /
TTLT-BYT-BTNMT. In cases where HMW are incapable of reacting, interacting with
one another and applying the same treatment method, they can be classified in the
same package, tool or storage device;


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• When infection waste is mixed with other wastes or vice versa, the mixture
must be collected, stored and treated as infection waste.
2.3.2. Classification of medical waste
• Sharp infectious waste: Stored in a yellow barrel or carton;
• Non-sharp infectious waste: Store in a bag or lined-bag box and yellowed;
• High-risk infectious waste: Store in a bag or lined-bag box and yellowed;
• Surgical wastes: Stored in 2-layer bag or lined-bag box and yellowed;
• Non-infectious hazardous solid wastes: Stored in a bag or lined-bag box and
in black;
• Non-infectious hazardous liquid wastes: Stored in closed containers;
• OMW does not serve for recycling purposes: Store in a bag or lined-bag box
and in blue;
• OMW serve for recycling purposes: Store in a bag or lined-bag box and in
white.
2.4. The impact of hazardous medical solid waste on the environment
2.4.1. Impact on soil environment
- If MSW are buried incorrectly, pathogenic microorganisms and toxic
chemicals will penetrate the soil causing toxicity of the land, moreover, causing reuse
of burial sites in difficulty.
- MSW have biological agents, microorganisms, bacteria, pathogenic fungus
from patients. The disease is released into the soil and then back to the people:
Salmonella, Vibrio cholera, Amip, eggs, worms, etc.

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- Chemical and physical agents, heavy metal and radioactive substances can be

deposited in the soil, causing pollution and accumulation. People and animals will
have to face with the disease when they eat contaminated vegetables and fruits grown
on that land.
2.4.2. Impact on air environment
From the beginning to the end of the MSW's treatment process has a negative
impact on the air environment (Salman Zafar, 2018):
- When MSW are sorting, collecting, transporting will spread the dust,
microorganisms causing disease, solvent vapors and chemicals into the air.
- At the stage of treatment (from MSW incinerator) generates toxic gases such
as dioxins, furan, etc. In addition, heavy metals such as mercury can also be
discharged by the incinerator exhaust gas.
- From landfill generates toxic gases such as

, etc.

2.4.3. Impact on water environment
The MSW contain pathogenic microorganisms, heavy metals, mainly mercury
from broken thermometers and silver from the X-ray film rinse which polluted the
water environment. In addition, some drugs that are disposed of without treatment may
also contaminate the water supply (Van Huu Tap, 2016).
At the same time, the discharge of wastewater indiscriminate such as
discharging infection wastewater into the conventional wastewater system can
potentially cause the risk of polluting the water source due to the increase of organic
BOD (biochemical oxygen demand).

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2.4.4. Impact on human health
Exposure to hazardous medical waste can cause illness or injury. All

individuals those in the hospital or outside the hospital are at risk of exposure to
hazardous medical waste. Easily exposed people include health care workers such as
doctors, nurses, midwives, technicians; patients, family members and patients visiting
patients. In addition, workers in the waste collection, transportation, laundry; Workers
in waste treatment and disposal facilities such as landfills or incinerators, including
garbage pickers may be exposed to hazardous medical waste (Hysen Mankolli, 2013):
2.5. Situation of medical waste management
2.5.1. Situation of medical waste management of some countries in the world
Research on medical solid waste (MSW) has been conducted in many countries
around the world, especially in developed countries such as the United Kingdom, the
United States, Japan, and Canada, etc. Which, referring to many areas such as MSW
arising situation and classification; Medical solid waste management (measures to
reduce waste, reuse of waste, treatment of waste, assessment of the effectiveness of
waste treatment measures); Harms of health-care solid waste to the environment and
human health (Le Minh Sang. 2016). Moreover, the study proposes measures to reduce
the harmful effects of MSW on public health; the threat of infectious waste to the
community; the impact of medical wastewater on disease transmission; issues of the
public health problem related with MSW (DONRE, 2016). Hospital waste generation
has become a prime concern due to its multidimensional ramifications as a risk factor.
The generation of hospital wastes differs not only from country to country but also
within a country. In middle- and low-income countries, health-care waste generation

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is usually lower than in high-income countries (Miller et al. 2016). Developed
countries face challenges with the sheer volume of waste from the use of disposable
items. On the other hand, developing countries, whose supplies are limited, are dealing
with challenges of sorting and disposing of all types of medical waste in a sanitary
manner (Sushma Rudraswamy, 2013)

Table 3: Health-care waste generation according to national income level
Annual waste generation

National income level
High income counties

(kg/head)

All health-care waste

1.1-12.0

Hazardous health-care waste

0.4-5.5

Middle-income

All health-care waste

0.8-6.0

countries

Hazardous health-care waste

0.3-0.4

All health-care waste


0.5-3.0

Low-income countries

(DONRE, 2017)
2.5.2. Situation of medical waste management in Viet Nam
According to statistics of the Ministry of Health's Health Environment
Management Agency in 2012, there are more than 1,000 hospitals in the country, 350500 tons of medical waste each day, of which about 47 tons of HMSW. However,
many hospitals do not have a dedicated burner system As a result, there are serious
incidents of hospital hazardous waste incineration, which directly affect the patients as
well as the citizens live nearby (Nguyen Hang, 2012). For solid waste generated from
medical activities, along with the increase in hospital beds, the MSW volume tends to
increase. Currently, in the whole country, the average amount of solid waste
discharged daily is 0.86 kg / bed, in which hazardous medical waste is 0.14 kg / bed.
The total amount of solid waste in hospitals across the country is up to 100 tons and 16

13


tons of medical waste need to be treated (Le Thi Tai, 2004). It is estimated that in
2015, the amount of medical discharge was 600 tons/day and in 2020 will be 800
tons/day. However, there is not enough statistics on the number of hospitals where
medical curing facilities are available to meet the required hygiene requirements.
By 2015, the rate of collected medical MSW reached over 75%; The proportion
of hazardous waste collected and treated is about 65%. Most hospitals collect and
classify wastes but the collection vehicles are lacking and incomplete which most of
them are not up to standards and there are no vehicles to ensure the transportation
process is secure. At present, technology for medical treatment of MSW is mainly by
incinerators, however, some technologies for treatment of medical wastes by nonburning methods are encouraged and prioritized for development.
Table 4: Volume of HMW in some localities in Viet Nam in 2014

St.

Name of province

1

Ha Noi

Amount of HMW (ton/year)
1.632

2

Ninh Binh

887

3

Dong Nai

756

4

Nghe An

616

5


Thanh Hoa

283

6

Lang Son

256

7

An Giang

236

8

Nam Dinh

233

9

Dien Bien

173

10


Ninh Thuan

146

11

Ha Tinh

134

12

Kon Tum

64
(DONRE, 2015)

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2.5.3. Situation of medical waste management in Yen Bai city
2.5.3.1. Overview of medical facilities and the amount of HMSW arising in Yen Bai
province
By the end of March 2016, the number of health facilities in Yen Bai province
was 6 hospitals and 07 provincial preventive medicine centers, 09 district health
centers, 19 multi-clinics 180 health clinics in the commune / ward / township, 01
training center, 01 private hospital, 105 general and private clinics and 01 branch
hospital (Hospital of Transportation) located in the area
Table 5: Situation of HMSW arising in medical establishments in Yen Bai province

No.

Type of HMSW

Total avarage amount (kg/day)

1

Infectious waste

309.06

1.1

Group A

100.67

1.2

Group B & C

173.95

1.3

Group D

34.44


2

Chemical waste

18.42

3

Radioactive waste

5.27

4

Pressure tanks

4.76

Total

337.51
(DONRE, 2015)

According to statistics from the Health Department of Yen Bai province and the
Department of Natural Resources and Environment of Yen Bai province (through the
annual report on hazardous waste management), the amount of medical waste arising
from local hospitals the province in general and Yen Bai city in particular increase

15