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. 2021 Jan 6;16(1):e0243817. doi: 10.1371/journal.pone.0243817

Awareness and practice of medical waste management among healthcare providers in National Referral Hospital

Zimba Letho 1,*, Tshering Yangdon 2, Chhimi Lhamo 3, Chandra Bdr Limbu 3, Sonam Yoezer 3, Thinley Jamtsho 3, Puja Chhetri 3, Dawa Tshering 3
Editor: Itamar Ashkenazi4
PMCID: PMC7787467  PMID: 33406119

Abstract

Introduction

The management and treatment of Medical Waste (MW) are of great concern owing to its potential hazard to human health and the environment, particularly in developing countries. In Bhutan, although guidelines exist on the prevention and management of wastes, the implementation is still hampered by technological, economic, social difficulties and inadequate training of staff responsible for handling these waste. The study aimed at assessing the awareness and practice of medical waste management among health care providers and support staff at the National Referral Hospital and its compliance with the existing National guidelines and policies.

Materials and methods

An observational cross-sectional study was conducted from March to April 2019. Three research instruments were developed and used; (i) Demographic questionnaire, (ii) Awareness questions, and (iii) the Observational checklist. The data was coded and double entered into Epi data version 3.1 and SPSS version 18 was used for analysis. Descriptive statistics were used to present the findings of the study.

Results

The majority of the respondents were female (54.1%) with a mean age of 32.2 (±7.67) years, most of whom have not received any waste management related training/education (56.8%). About 74.4% are aware of medical waste management and 98.2% are aware on the importance of using proper personal protective equipment. Only 37.6% knew about the maximum time limit for medical waste to be kept in hospital premises is 48 hours. About 61.3% of the observed units/wards/departments correctly segregated the waste in accordance to the national guidelines. However, half of the Hospital wastes are not being correctly transported based on correct segregation process with 58% of waste not segregated into infectious and general wastes.

Conclusion

The awareness and practice of medical waste management among healthcare workers is often limited with inadequate sensitization and lack of proper implementation of the existing National guidelines at the study site. Therefore, timely and effective monitoring is required with regular training for healthcare workers and support staff. Furthermore, strengthening the waste management system at National Referral Hospital would provide beneficial impact in enhancing safety measures of patients.

Introduction

A health care facility inevitably produces medical wastes (MW) that may be hazardous to health [1–3]. MW refers to all categories of waste generated from health facilities, clinics, animal husbandries, veterinary hospitals and other clinical laboratories, and home-based treatment of patients [3]. Although the MW is classified broadly, in general, it is categorized as Sharps, Infectious, Pathological, Pharmaceutical, cytotoxic, pressurized containers, chemical, radioactive and non-hazardous or general waste [1–4]. Hazardous MW is referred to any wastes which have the potential to cause harmful effects to human or environment if poorly managed [3]. Fig 1 provides the types of hazardous wastes, waste bin, and color code and biohazard symbols [5].

Fig 1. Details of hazardous waste, PPE, color code and symbols of wastes.

Fig 1

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Although MW management practices differ from hospital to hospital, the implementation of MW management still poses a challenge. For the MW management, WHO has prepared various biomedical waste management guidelines to ensure the safe management of the wastes from healthcare facilities.

In Bhutan, the Government with various initiatives developed guidelines on proper management of healthcare waste including developing environmental code of practice for hazardous waste management 2002, waste prevention and management act of Bhutan 2009, Guideline for Infection Control and healthcare waste management in health facilities 2006 and National Infection Control and Medical Waste Management guidelines 2018 [3, 5, 6] however, implementation is still hampered by technological, economic, social difficulties and inadequate training of staff responsible for the handling of these waste [3, 7].

Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), the apex Hospital of the capital city Thimphu, Bhutan caters to the healthcare services delivery for the population residing in Thimphu as well as to the patients referred from district hospitals. Being the only tertiary care hospital, large number of patients and referral samples are received at JDWNRH leading to increase medical waste generations. For the management of the waste generated, JDWNRH consist of infection control focal team headed by deputy nursing superintendent who supervises the overall monitoring of the infection control and waste management by conducting annual monitoring system in all the departments (Annual report 2018).

This study was conducted at JDWNRH which is also the teaching hospital affiliated to Khesar Gyelpo Medical University of Bhutan (KGUMSB). JDWNRH is 350 bedded hospital situated in Thimphu consisting of 1300 staff with an annual turnout of 5, 26,491 patients in OPD and 17,468 patients in IPD (Annual Report, 2017). This study targeted the staff and supporting staff working at National referral hospital on their awareness and practice on MW management practice.

The appropriate MW management process includes vital steps: Collection, segregation, storage, transportation, treatment, and disposal [2]. Table 1 show the procedure for collection, transportation, treatment of MW according to the National guideline [5].

Table 1. Collection, transportation, treatment and disposal of medical waste.

Hazardous waste Collection Transportation Treatment Method Disposal
Solid infectious waste When bin is 3/4th full Only on specified waste trolley or cart 1. Autoclaving Municipal bin
2. Chemical disinfection Deep burial pit
3. Incineration
Pathological waste When bin is 3/4th full Dispose of in deep burial pit Deep burial pit
Liquid infectious waste Procedure specific collecting container Decontaminate with 0.5% bleaching solution in equal proportions (1:1) for 10 minutes Sewage system with plenty of water
*Sharps When the box is 3/4th full 1. Autoclaving & shredding or incineration Deep burial pit or recycle
Chemical & Pharmaceutical waste Collected and sent to pharmacy for final disposal Encapsulation Landfill
Cytotoxic waste Collect in leak-proof container and store in designated area 1. Encapsulation 2. Incineration 3. Chemical disinfection Landfill and deep burial pit
Radioactive waste Collect in lead container Decay by storage
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Segregation is based on color-coding of the non-infectious and infectious wastes [4]. The segregated waste are stored in designated storage area within the units/wards/departments and storage duration is 24–48 hours (summer time) and 24–72 hours (winter time). The waste is collected every morning from the all the wards/unit/department and transported to the waste treatment unit. The infectious waste is treated by autoclaving and disposed off along with the general waste. The waste like cardboard box, pet bottles are sold to the vendor to reduce the waste going to the land fill and the food waste are used to prepare organic compost for fertilizer.

In an audit report by Royal Audit Authority (RAA) on Medical Waste Management conducted in 2008, it was found that the support staff handling MW of JDWNRH lacked awareness and knowledge on proper handling and management. Also, the waste handlers were seen handling the MW without protective gear such as utility gloves, apron, gumboots and mask [8]. Therefore, this study aimed at assessing the awareness and practice of health care providers on the management of medical wastes and implementation of the existing national guidelines.

Materials and methods

An observational cross-sectional study was conducted to describe the awareness and current practice of medical waste management at JDWNRH. All Bhutanese citizenship health workers registered with Bhutan Medical and Health Council BMHC) and working permanently fulltime in JDWNRH were interviewed including the supporting staff who handles the MW.

Sampling

The convenience sampling method was used to collect data from all 18 departments of JDWNRH. The 18 departments were Clinical Departments (n = 15), Community Health Department (n = 1) and Diagnostic Departments (n = 2).

Sample size

The sample size in this study was calculated using Krejcie and Morgan 1970 [9] formula to determine the sample size for finite population as follows:

S=X2NP(1−P)d2(N−1)+X2P(1−P)

Where:

S = required sample size

X = Z value (e.g. 1.96 for 95% confidence level)

N = population size

P = population proportion [expressed as decimal, assumed to be .5 (50%)]

d = degree of accuracy (5%), expressed as a proportion (.05); it is a marginal of error

In this study, 350 participants were recruited to target maximum number of participants from healthcare workers and supporting staff.

Research instrument

Three research instruments were used in this study according to WHO standards (1) viz. i) Demographic questionnaire, (ii) Awareness questions, and (iii) the Observational checklist. All the research instruments were pilot tested and validated by the researchers prior to using on the participants.

PART I: The demographic questionnaire

This part of the questionnaire was developed by the researcher which include all demographic variables (as given in the questionnaire) (S1 File).

PART 2: Awareness questionnaire

This tool consists of 15 questions to test the awareness of medical waste management. Face to face interview was carried out to collect the data. The correct response was coded as 1 and incorrect as 0 respectively (S2 File).

PART 3: Observational checklist

This checklist consist of assessing the process and practice on handling the MW by the healthcare workers and supporting staff by visual observation at the work station on the disposal method. The observation was coded as; 1 for Yes, 0 for No and 9 for Not applicable (S3 File).

Data collection and analysis

Data were collected from March to April 2019. Head of Departments were explained on the objective of the study and the written informed consent were obtained from all the volunteer participants. Ethical clearance was sought from Research Ethic Board (REBH), Ministry of Health (Ref. No. REBH/PO/2019/012). Ethical waive was granted since there was no clinical intervention and the protocol fulfilled the criteria for ethical exemption from REBH.

The data was coded and double entered into Epi data version 3.1 and SPSS version 18 was used for analysis. Descriptive statistics were used to present the findings of the study. The current practice and awareness of medical waste management among health care providers in JDWNRH was described in terms of frequency, percentage, mean (M), and standard deviation (SD).

Results

Part 1: Demographic characteristics of participants

Table 2 shows the demographic characteristics of health care providers. A majority of the respondents were female (54.1%) as compared to males. The mean age of the health care providers was 32.2 years (SD = 7.35) with a minimum and maximum age of 20 and 55 years respectively. The age range of most health care providers was between 26 and 30 years (33.8%). Most of them (32.9%) had a Diploma followed by a Certificate degree (30.9%) and a bachelor's degree (18.8%). The average years of experience of the health care providers were 8.48 years (SD = 7.67) and 37.6% had an experience of fewer than 4 years. It also revealed that the highest respondents were nurses (44.1%) followed by technicians (23.5%) and least were health assistants (3.2%). Most of them had not received any waste management related training/education (56.8%). It is worth to note that 82.9% of health care providers have been vaccinated against Hepatitis B virus which is provided as mandatory vaccination for all healthcare providers and support staff.

Table 2. Frequency and percentage of demographic characteristics (N = 340).

Demographic characteristics n %
Gender
    Male 156 45.9
    Female 184 54.1
Age in Years (m = 32.2; SD = 7.35; Min = 20; Max = 59)
    20–25 years 57 16.8
    26–30 years 115 33.8
    31–35 years 78 22.9
    >35 years 90 26.5
Level of Education
    Certificate 105 30.9
    Diploma 112 32.9
    Bachelor’s Degree 64 18.8
    Higher than Bachelor’s Degree 19 5.6
    Others* (support staff minimum of 8th standard) 40 11.8
Years of Experience (m = 8.48; SD = 7.67; Min = 1; Max = 35)
    0–4 years 128 37.6
    5–8 years 89 26.2
    9–12 years 45 13.2
    >12 years 78 22.9
Place of Work
    Medical and Surgical (Oncology & Dialysis) 84 24.7
    Emergency Department 24 7.1
    Critical Care Units 12 3.5
    Pediatrics 09 2.6
    Community Health Department 17 5.0
    Physiotherapy Department 20 5.9
    Obstetrics/Gynecology 20 5.9
    Laboratory Department 25 7.4
    Pharmacy Department 19 5.6
    Others (Orthopedic, Eye & ENT, Dental Department, OPDs) 110 32.4
Profession
    Doctors 25 7.4
    Nurses 150 44.1
    Health Assistants 11 3.2
    Technicians 80 23.5
    Technologist 26 7.6
    Others (Support staff) 48 14.1
Training Attended on Waste Management
    Yes 147 43.2
    No 193 56.8
Vaccination against Hepatitis B
    Yes 282 82.9
    No 58 17.1
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Part 2: Awareness questionnaire

Table 3 describes awareness about biomedical waste management among health care providers in JDWNRH. Almost all (98.5%) heard about medical waste and 69.7% are aware of regulation on medical waste management. About 74.4% of health care providers are aware of the biohazard symbol and only 45.3% knew about eight categories of medical waste.

Table 3. Awareness about medical waste management among health care providers (N = 340).

Items Aware Not Aware
n % n %
1. Have you ever heard about medical waste? 335 98.5 5 1.5
2. Are you aware of regulation on medical waste management? 237 69.7 103 30.3
3. Do you know about the biohazard symbol? 253 74.4 87 25.6
4. Can you name eight categories of medical waste? 154 45.3 186 54.7
5. Can you list down the guidelines provided for color coding in workplace? 267 78.5 73 21.5
6. What is puncture proof container for sharps? 265 77.9 75 22.1
7. What is the correct bag for disposal of cytotoxic drugs? 73 21.5 267 78.5
8. What is the correct bag for intravenous sets, catheters and tubes? 263 77.4 77 22.6
9. HIV AIDS can be transmitted through medical waste. 284 83.5 56 16.5
10. Hepatitis B and C can be transmitted through medical waste. 300 88.2 40 11.8
11. Personal protective measures are necessary while handling medical waste. 334 98.2 6 1.8
12. When do you discard medical waste from the bin? 196 57.6 144 42.4
13. Do you know about the methods for medical waste treatment? 152 44.7 188 55.3
14. Disinfection of medical waste is necessary. 306 90.0 34 10.0
15. Bleaching solution of 0.5% is used for the disinfection of infectious medical waste. 248 72.9 92 27.1
16. The maximum time for medical waste to be kept in the hospital premises is 48 hours. 128 37.6 212 62.4
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It's encouraging to note that 83.5% and 88.2% of the respondents are aware that HIV/AIDS and Hepatitis B & C can be transmitted through medical waste respectively. Also, the majority (98.2%) are aware that personal protective measures are necessary while handling medical waste. 90.0% believe that the disinfection of medical waste is necessary and 72.9% are aware that a bleaching solution of 0.5% is used for the disinfection of infectious medical waste. However, only 37.6% are aware that the maximum time for medical waste to be kept in hospital premises is 48 hours.

Part 3: Observational checklist

Table 4 describes the observation of the current practice on medical waste management for four categories; a) condition of waste receptacles, b). Segregation of waste, c) Transportation of medical waste, d) Appropriate use of PPE. The observation was carried out by visiting the department/unit/wards and visually observing whether the waste disposal process was followed in accordance to National guidelines on infection control (3).

Table 4. Observation of current practice of medical waste management.

Parameters Yes No NA
(%) (%) (%)
A. Condition of waste receptacles
    1. Is green colored waste bin available in ward 29 (93.5%) 1 (3.2%) 1 (3.2%)
    2. Is yellow colored waste bin available in ward 28 (90.3%) 3 (9.7%) 0
    3. Is red colored waste bin available in ward 30 (96.8%) 0 1 (3.2%)
    4. Is blue colored waste bin available in ward 14 (45.2%) 12 (38.7%) 5 (16.1%)
    5. Has green bag been placed lining the inner side of green bin 23 (74.2%) 6 (19.4%) 2 (6.5%)
    6. Has red bag been placed lining the inner side of red bin 29 (93.5%) 1 (3.2%) 1 (3.2%)
    7. Has blue bag been placed lining the inner side of blue bin 1 (3.2%) 20 (64.5%) 10 (32.3%)
    8. Is green bag securely fitted with the bin 23 (74.2%) 6 (19.4%) 2 (6.5%)
    9. Is red bag securely fitted with the bin 27 (87.1%) 3 (9.7%) 1 (3.2%)
    10. Is blue bag securely fitted with the bin 7 (22.6%) 15 (48.4%) 9 (29.0%)
    11. Are waste bins covered 18 (58.1%) 12 (38.7%) 1 (3.2%)
    12. If covered, is cover foot-operated 23 (74.2%) 6 (19.4%) 2 (6.5%)
    13. Is the biohazard symbol imprinted over waste bags 28 (90.3%) 3 (9.7%) 0
    14. Are posters to guide users displayed near waste bins 21 (67.7%) 10 (32.3%) 0
B. Segregation of waste
    15. Does green bag contain only general waste 25 (80.6%) 3 (9.7%) 3 (9.7%)
    16. Does yellow bag contain only sharp waste 27 (87.1%) 1 (3.2%) 3 (9.7%)
    17. Does red bag contain only soiled infected waste 21 (67.7%) 8 (25.8%) 2 (6.5%)
    18. Does blue bag contain only food waste 3 (9.7%) 12 (38.7%) 16 (19.4%)
C. Transportation of medical waste
    19. Appropriate on-site transport of medical waste used 18 (58.1%) 4 (12.9%) 9 (29.0%)
    20. Is transportation of medical waste done during non-busy hours 15 (48.4%) 16 (51.6%) 0
    21. Are infectious and general waste transported separately 13 (41.9%) 18 (58.1%) 0
D. Appropriate use of PPE 11 (35.4%) 10 (32.3%) 10 (32.3%)
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On an average, 93.5% of the waste bins were appropriately available in the required color-coded bins (83.85%), however, the availability of blue-colored waste bin was minimum (45.2%). Only 58.1% of the waste bins were covered with 74.2% being foot-operated. The biohazard symbol was imprinted in the majority of the waste bin (90.3%) with 67.7% user posters displayed in waste bins.

About 61.3% of the observed units/wards/departments have correctly segregated the waste accordingly. Only 48% of the waste generated is transported in accordance with the transportation guideline with 58% of the waste not segregated into infectious and general wastes. Only 35.4% was found to be using appropriate PPE with 32.3% not complying and 32.3% not applicable.

Discussion

The majority of the respondent were nurses which are concurrent with the highest number of health workers at JDWNRH being nurses followed by paramedical staff. Of these, the respondents were mostly in the age group of 26–30 years old and having a diploma course certificate. Less than half of the health care workers (43.2%) attended training on medical waste management which was a similar finding from the study conducted in 2015 [10]. However, it is noteworthy that the majority of the health care workers were vaccinated against Hepatitis B virus which is mandatory for all healthcare providers and support staff. Although most of them were aware of the regulations on medical waste management, the failure to adhere to these guidelines may be due to a lack of inspection from the authorities and the absence of strict rules and regulations. Therefore framing rules and regulations followed by proper and timely reminders of the importance of adhering to the rules and regulations are important by hospital infection control team.

There was satisfactory knowledge of color coding of wastes which is an essential factor for proper segregation of waste (80%) which was similar to the study conducted in Nigeria with 81.9% [11]. Our study revealed that the majority of the waste bins were color-coded (83.85%) which indicates the understanding of the respondents on the management of medical waste into infectious and non-infectious waste.

The waste generated is required to be transported by following the national guideline [3, 5]. Such wastes are collected and transported using a trolley, wheeled barrow, trucks, etc. Data from this study revealed that the waste is transported in trolleys and supporting staff loads it into the trucks by hand which could be dangerous. Although WHO stipulates that different trolleys should be used in transporting the different categories of wastes, this requirement does not adhere to 58% of wastes not segregated at source. Indeed, all the wastes generated are carried with the same trolley and this could also lead to cross-contamination [12].

As important as protective equipment is to anybody who handles medical wastes, only 35.4% complied with the use of appropriate PPE which is not consistent with the recommended standard of WHO which requires the use of heavy-duty gloves, boots, and apron [11]. There is a need to properly equipped and educate those in charge of on-site transportation of wastes, given the great danger associated with this task.

Conclusion

Although national regulations exist on medical waste management, adherence to the practice is often limited due to inadequate sensitization amongst the health care workers and support staff. Most notably, the use of appropriate PPE while handling waste is often neglected causing potential risk. Therefore, timely and effective monitoring from the authorities should be implemented and regular training sessions to be provided for the healthcare workers and support staff.

Our findings suggest that although many of the respondents are aware of the National guideline on infection control and waste management, the practice is limited due to lack of proper training and sensitization on medical waste management process. Even though the hospital infection control team performs the assessment on waste management bi-annually, the findings and corrective action implementation needs to be strengthened by regular follow-up on action plan and providing incentives for the best medical management practice in the units/wards/departments.

Supporting information

S1 File. Demographic questionnaire.

(DOCX)

Click here for additional data file. (36.1KB, docx)
S2 File. Awareness questions.

(DOCX)

Click here for additional data file. (13.6KB, docx)
S3 File. Observational checklist.

(DOCX)

Click here for additional data file. (14.7KB, docx)

Acknowledgments

Authors would like to thank the Department of Nursing and JDWNRH administration and all the health care provides who were involved in the study and provided their immense support.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The Jigme Dorji Wangchuck National Referral Hospital provided material support for this study but had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Awareness and Practice of Biomedical Waste Management among Healthcare Providers In

National Referral Hospital

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Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Review and Recommendations PONE-D-20-06712: Awareness and Practice of Biomedical Waste Management among Healthcare Providers in National Referral Hospital

Research Summary:

The authors conducted an observational cross-sectional study to evaluate healthcare provider awareness, knowledge, and practice concerning medical waste handling at a national referral hospital. The study sought to assess the familiarity with- and practices used by a variety of healthcare workers in their current work at a large medical facility as it pertains to their daily work assignments involving the handling of medical waste generated during patient care. While study participants were aware of potential risks associated with handling and disposing of medical waste, only a small proportion of the them followed best waste management practices. National and international guidelines exist regarding the proper handling of medical waste and the identification of potential health risks to healthcare providers improper handling presents. Deficiencies contributing to challenges encountered in the proper handling and full implementation of a compliant medical waste handling program are identified.

The identification of specifics regarding deficiencies and discussion of their potential impact is limited. The manuscript would be enhanced by providing additional descriptive information about training programs, facility enforcement measures, the range of available personal protective equipment and its use by the healthcare providers as well as what program resources are dedicated to medical waste program activities. Background information introduced in different sections of the manuscript could be pulled together more completely earlier in the document. Additional description in the methods of the rationale for approaches used in this study would enhance understanding of how the authors selected the evaluation tools used. This would add additional insight into any challenges investigators encountered. Including the strengths and limitations of the study and the methods used will provide other investigators with additional considerations for further research efforts involving medical waste handling programs in healthcare settings. Inclusion of some overall findings from this study to support the authors’ conclusion and recommendations would provide readers seeking considerations for improving medical waste handling in healthcare settings and the protection of healthcare workers from potential hazards associated with medical waste is suggested.

General Reviewer comments:

From my review of the manuscript it appears that the investigators’ presentation of their findings would benefit from some additional revision. The current organization of the manuscript along with identified information gaps suggest additional work is needed to refine this work prior to publication and reflect more fully the extensive work that was done. More in-depth examination of the data collected along with additional background and more extensive discussion of their findings would help develop their findings and the potential value of this work for other researchers and readers interested in this topic. While all of the data (responses) from the study participants that is presented in the manuscript appears to be found in the tables, I think the results and their presentation as well as the discussion and conclusions would be more informative if additional findings extracted from the collected data across respondents would have been included. Greater characterization within the subgroups of their attributes and then comparison with the other groups within the larger category could provide additional insights strengthening your findings. More specific comments and questions are provided throughout this review. The authors may want to consider whether incorporating some graphical presentation of their results would help with conveying the results rather than leaving it only to some large tables backing up the written results presentation. Were any photos obtained as part of the observational checklist process? That could add to the presentation of the findings. The manuscript organization along with the varying use of subheadings became increasingly confusing from lines 102 – 199. Please spell out acronyms the first time they are used.

The complete review document is found in the attached Word document. Total character count exceeded 22,000 character limit.

Reviewer #2: The manuscript titled “Awareness and Practice of Biomedical Waste Management among Healthcare Providers In National Referral Hospital” presents the results of the questionnaire study conducted among health care providers related to the medical waste management in the National Referral Hospital in Bhutan. The subject of the study is consistent with the thematic scope of the journal, but although is very important for national public health in Bhutan, it does not contain elements of novelty on a global scale. The study was well planed and correctly conducted but the description of the Methods and materials section is too general, the lack of some essential information. Results are presented by absolute values and percentages without analyses of selected correlations e.g. between awareness and job seniority, position or education level and statistical significance indicators. Additionally the presented data should be grouping in thematic issues instead of the showing the raw questions from the questionnaires (tables 2 and 3). Discussion section is too general and includes repetitions of details from Methods and Results sections. However, it is worth noting that the language of the manuscript is generally written in standard English and conclusions are supported by the presented data.

Minor comments:

- the key words could be extended to improve the visibility of the article;

- lines 27-28: not clear sentence

- lines 29-30: not clear sentence

- Methods and materials sections: Lack of very important details about the process of obtaining consent from responders to participate in the study (e.g. how they were asked, in writing or orally; with the information about the study of the hospital management or supervisor or without such consent; whether the respondents were informed about the agreement between the authors and the superiors).

- There is not clear who filled in the Observational Checklists and how numerous was the group of responders.

- line 129: “15 questionnaires”?

- lines 160-162: not clear sentence

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachment

Submitted filename: PONE-D-20-06712_manuscript_review.docx

Click here for additional data file. (28KB, docx)
PLoS One. 2021 Jan 6;16(1):e0243817. doi: 10.1371/journal.pone.0243817.r002

Author response to Decision Letter 0

3 Aug 2020

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found

We have edited and followed the guidelines of style/ template in according to PLOS ONE

2. Thank you for including your ethics statement:

"Ethical clearance was sought from Research Ethics Board of Bhutan [REBH], Ministry of Health and JDWNRH management. Anonymity of the participants was ensured by not entering their names or any other identifiable information and a code was assigned to each case. The data collected was kept confidential and accessible only to the researcher. The findings was reported as a group and not as individual".

Please amend your current ethics statement to confirm that your named institutional review board or ethics committee specifically approved this study.

Once you have amended this statement in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research."

We have attached the ethical waive from the REBH in supporting document.

3. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (a) whether consent was informed and (b) what type you obtained (for instance, written or verbal). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.”

We have attached the consent form for reference

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (31.9KB, docx)

Decision Letter 1

Itamar Ashkenazi

24 Sep 2020

PONE-D-20-06712R1

Awareness and Practice of Medical Waste Management among Healthcare Providers in National Referral Hospital

PLOS ONE

Dear Dr. yangden,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Being the academic editor reponsible for this submission, I decided to let the readers decide on the strengths and weaknesses of this manuscript. However, some concerns still need to be addressed:

1) As noted by Reviewer #1,  some clarifications, which were included in your Response to Reviewer, have not been reported in the revised  main text (for example, the sampling method choice has been justified in the Response to reviewers, but not in the main text; please address this concern in the manuscript text)

2) Please edit the manuscript carefully. At present, we note that the numbering of the Tables is incorrect (for example, two different tables are labelled "Table 1"); and that some of the references are incorrectly displayed , as highlighted by Reviewer #1. 

Please submit your revised manuscript by Nov 07 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Carmen Melatti

Associate Editor

PLOS ONE

on behalf of 

Itamar Ashkenazi

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Review PONE-D-20-06712R1: Awareness and Practice of Biomedical Waste Management among Healthcare Providers in National Referral Hospital

Research Summary:

The authors conducted an observational cross-sectional study to evaluate healthcare provider awareness, knowledge, and practice concerning medical waste handling at a national referral hospital. The study sought to assess the familiarity with- and practices used by- a variety of healthcare workers in their current work at a large medical facility as it pertains to their daily work assignments involving the handling of medical waste generated during patient care. While study participants were aware of potential risks associated with handling and disposing of medical waste, only a small proportion of the them followed best waste management practices. National and international guidelines exist regarding the proper handling of medical waste and the identification of potential health risks to healthcare providers improper handling presents. Deficiencies contributing to challenges encountered in the proper handling and full implementation of a compliant medical waste handling program are identified.

The identification and development of specifics regarding findings from the study among the participants involving medical waste and discussion of their potential impact remains limited. Some text changes are noted in the revised manuscript in response to review comments but actual clarification addressing the original comments and questions was difficult to find. Added clarifying and supporting information in response to reviewer comments has primarily been included through the addition of two new tables and revision of headings and subheadings for sections within the manuscript to improve readability. Some minor changes in the text are also noted. Overall manuscript changes and clarification or the provision of rationale as to why addressing reviewer comments is not needed because of information already presented in the manuscript by the authors appears minimal.

General Reviewer comments:

From my review of the initial manuscript it appeared that the investigators’ presentation of their findings would benefit from additional revision more fully responding to the original review comments. Changes identified in the revised manuscript along with responses to review comments are limited for a major revision. Additional problems appear in the revised document – some immediate ones are identified in the following section. Overall, I think the revisions made and responses to reviewer comments appear to be very limited or unresponsive.

Specific Comments:

Review comment responses of “Changes made and rectified” are nonspecific as to what revisions the authors made.

Requested clarifications and information to strengthen the original manuscript reporting the study, its conduct, results, and their significance is limited in this revision.

The track-changes manuscript copy including the deletions and revisions made by the authors in response to review comments apparently was unavailable

The presence and discussion of two Table 1’s and two Table 2’s in the revised manuscript indicates an immediate problem concerning the revision process.

Additional information suggested for inclusion such as identifying 18 departments included in the study were listed in the author response to reviewer comments. Within the revised manuscript (lines 120-121) presentation of this information is minimal.

Deletions in the revision required a line-by-line comparison of the original manuscript with the revised version along with in-hand reference to the original review comments and the authors’ responses to identify actual changes. It appears from this process that not all comments were addressed.

Some reference changes and deletions were noted along with missing references for works cited in the manuscript (line 86 - Annual Report 2017; line 123 - Krejcie and Morgan 1970). Other examples of reference problems include: reference 11 line 243 now identifying a descriptive study in Mosul Nurs J 2013 which, while the text is unchanged from the original manuscript, originally cited the National Integrated Solid Waste Management Strategy, Thimphu, Butan 2014; and reference 10 line 247 originally cited a 1999 WHO document but now cites a 2015 article from the Journal of Environmental Management. In this second example the manuscript text also remains unchanged.

The revision of the manuscript and response of the authors to reviewer comments is incomplete.

Reviewer #2: Text is well prepared and fulfills all requirements for scientific work. Manuscript can be accepted to publication in scientific journal.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2021 Jan 6;16(1):e0243817. doi: 10.1371/journal.pone.0243817.r004

Author response to Decision Letter 1

23 Nov 2020

1. Changes made in the main text under subheading 'sampling'

2. Changes made and table labelled accordingly

Response to Reviewer #1:

The tables mentioned is as per the content of the manuscript. For instance the tables used in the introduction part is mentioned as Table 1 and 2 respectively. Similarly, in the results part, different tables used for depicting the results are labeled as Table 1, 2 and 3 respectively. So there's appearance of two Table 1's and two table 2's based on its purpose on different headings.

18 departments are segregated based on its purpose namely Clinicals, community health and diagnostic and not elaborated in order to reduce the use of space in the text. However, those 18 departments if need to be specified are as follows:

1. Department of Anesthesiology and Critical Care

2. Department of Community Health

3. Department of Dentistry

4. Department of Dermatology

5. Department of Emergency Medicine

6. Department of Forensic Medicine

7. Department of Medicine

8. Department of Obstetrics and Gynecology

9. Department of Ophthalmology

10. Department of ENT

11. Department of Orthopedics

12. Department of Pediatrics

13. Department of Pathology and laboratory Medicine

14. Department of Physiotherapy

15. Department of Pharmacy

16. Department of psychiatry

17. Department of Radio Diagnosis and Imaging

18. Department of Surgery

Reagarding ethical consideration, the Research Ethics Board of Health (REBH) under Ministry of Health is the ethical board responsible for the ethical considerations. link : http://www.moh.gov.bt/about/program-profiles/357-2/. Thus, the ethical clearance was sought from REBH prior to the start of the study and approved. The ethical statement has been presented only on the materials and method section of the manuscript.

Attachment

Submitted filename: Response to reviewer.docx

Click here for additional data file. (34.3KB, docx)

Decision Letter 2

Itamar Ashkenazi

27 Nov 2020

Awareness and Practice of Medical Waste Management among Healthcare Providers in National Referral Hospital

PONE-D-20-06712R2

Dear Dr. yangden,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Itamar Ashkenazi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Itamar Ashkenazi

11 Dec 2020

PONE-D-20-06712R2

Awareness and Practice of Medical Waste Management among Healthcare Providers in National Referral Hospital

Dear Dr. Yangdon:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Itamar Ashkenazi

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 File. Demographic questionnaire.

    (DOCX)

    Click here for additional data file. (36.1KB, docx)
    S2 File. Awareness questions.

    (DOCX)

    Click here for additional data file. (13.6KB, docx)
    S3 File. Observational checklist.

    (DOCX)

    Click here for additional data file. (14.7KB, docx)
    Attachment

    Submitted filename: PONE-D-20-06712_manuscript_review.docx

    Click here for additional data file. (28KB, docx)
    Attachment

    Submitted filename: Response to reviewers.docx

    Click here for additional data file. (31.9KB, docx)
    Attachment

    Submitted filename: Response to reviewer.docx

    Click here for additional data file. (34.3KB, docx)

    Data Availability Statement

    All relevant data are within the manuscript and its Supporting Information files.

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