Health-care waste management is of great importance due to its infectious and hazardous nature that can cause undesirable effects on humans and the environment. The health care sector constitutes a broad spectrum of health care facilities which have a size diversity from large general and specialist hospitals to small municipal dispensaries. All these facilities are an essential part of our society with an aim to reduce health problems and to eliminate imminent threat to people’s health.1 In India, the health-care sector is growing at a tremendous rate due to its strengthened coverage services and increasing expenditure by public as well as private players. Rapid increase of Health Care Units (HCU) such as hospitals and dispensaries in India has generated massive health-care wastes creating an alarming situation for local governments. However it is ironic that the health-care settings, which restore and maintain community health is also threatening their well-being. Poor waste management practices pose a huge risk to the health of the public, patients, professionals and contribute to environment degradation.2 In India, there are about 17,86,108 hospital beds, over 16,9913 health-care facilities with thousands of registered nursing homes, countless unregistered nursing homes and dispensaries, and above all a very large number of quacks practicing at every nook and corner of urban and semi-urban locality. There are innumerable pathology laboratories, the data of which is hardly available. With average per bed per day medical waste generation of the country – 0.277 kg/day.3 Management of biomedical waste has to be viewed from a holistic approach, wherein concepts, training, action plans and standard operative procedures have to be ingrained into the system percolating to each and every health-care facility. The plans and programs should be people oriented as the waste management is to be achieved through them. It should also stress the importance of community awareness and should aim at facilitating their participation though IEC activites.4 Health-care waste-generation data are best obtained from quantitative waste assessments. An assessment entails defining goals, planning, enlisting the cooperation of staff, procurement of equipment (e.g. weighing scales, personal protective equipment), data collection, analysis and recommendations. The process of waste assessment provides an opportunity to improve current practices, sensitize health workers about waste, and determine the potential for waste minimization. Health-care waste management is still in its infancy all over the world. There was a lot of confusion regarding the problem among generators, operators, decision makers and the general community about the safe management of bio-medical waste, the reason may be a lack of awareness. Hence resource material relating to the environment for the use of hospital administrators, doctors, nurses, paramedical staff and waste retrievers is the need of the hour.5 With an exponential growth of health-care sector in Karimnagar city is now heading towards providing a medical hub for the region of North Telangana. Hence, the present study aimed to study the present state of health-care waste management in Karimnagar and elucidating the knowledge, attitude and practices of the health-care workers regarding health-care waste management. This is in turn can help to develop suitable strategies specific for health-care workers or twist the existing rules and guidelines which should be amended from time to time in order to improve compliance and strengthen the implementation of environmentally sound management of bio-medical waste in India.

This was a cross-sectional study that has been conducted among the Health care establishments in Karimnagar city, the headquarters of Karimnagar district of Telangana state for a period of 1year from June 2017 – August 2018. A total list of Health care establishments in Karimnagar city of about 234 was prepared. By using the stratified sampling method among 234 health centres, about 25% (i.e., 58 centers) those HCE who were willing to provide us information was selected for this study. Total list of health care centers present in Karimnagar city are shown below. 1. Government hospitals (District hospital and Maternal and child health) - 8 2. Private teaching hospital -2 3. Private hospitals (specialty & super specialty hospitals, Nursing homes, Clinics) - 183 4. Diagnostic centers -15 5. Support services (Blood bank, Pharmacy, Mortuary and Veterinary hospitals) - 25 The questionnaire mainly addressed the issues of: a) Mode of management of the categories of HCW. b) Final disposal methods of HCW. c) Existing waste management practices. d) Knowledge, attitude and practices regarding Health care waste management practices among health care staff. Informed verbal consent was obtained from the subjects after explaining the purpose of the study. In collecting the data, questionnaire surveys and in depth interviews were arranged to get a greater understanding of the existing management practice of medical wastes. A number of specific questions were asked to health administrator, doctors, nurses and sweepers for eliciting their understanding. The respondents were asked to indicate their views on waste management policy, practices and their attitude related to the issue. During the entire process, adequate privacy and comfort was ensured. Ethical clearance was obtained before conducting the study from the Ethical Committee of Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar. The collected data was entered by using Microsoft excel 2010 and analysis was performed mainly with descriptive statistics, while qualitative mode of analysis was mainly narrative. The obtained data was tabulated and results were interpreted by using chi square test of significance with the help of SPSS 24 to determine the present state of health care waste management in Karimnagar city. Inclusion Criteria 1). All the participants who consented to be a part of the study 2).Those were on duty were included in the study. Exclusion Criteria 1). Temporary staff, trainees, and contract workers were not included in the study. 2).Those was not given consent.

Table 1: Staff pattern in various groups of health care centres Groups of health care centres No. of Doctors No. of Nursing staff No. of Lab technicians No. of Auxiliary staff Total Group-1 (n=2) 66 84 12 64 226 Group-2 (n=1) 68 250 40 116 474 Group-3 (n=45) 105 95 42 85 327 Group-4 (n=4) 6 0 17 8 31 Group-5 (n=6) 5 1 7 7 20 Total (n=58) 250 (23.3%) 430 ( 39.9) 118 (10.9%) 280 (25.9%) 1078 It was observed from the above table-1 that the study comprised of a total sample size of 1078 staff members working in 58 different health care centers. Among 1078 staff members, 250 (23.3%) were doctors, 430 (39.9%) were nursing staff, 118 (10.9%) were laboratory technicians and 280 (25.9%) was auxiliary staff. Table 2: Demographic characteristics of various levels of staff members in health care centres Variables Doctors Nurses Technicians Auxiliary staff Total 1078 (%) No % No % No % No % Age <25 15 6 220 51.2 22 18.6 53 18.9 310 (28.8%) 25 - 34 70 28 148 34.4 68 57.6 76 27.1 362 (33.6%) 35 - 44 97 38.8 41 9.5 25 21.2 96 34.3 259 (24%) >44 68 27.2 21 4.9 3 2.5 55 19.6 147 (13.6%) Gender Male 129 51.6 45 10.5 107 90.7 134 47.9 415 (38.5%) Female 121 48.4 385 89.5 11 9.3 146 52.1 663 (61.5%) Qualification PG 182 72.8 0 0 0 0 0 0 182 (16.9%) UG 68 27.2 318 74 86 72.9 0 0 472 (43.8%) Inter 0 0 112 26 32 27.1 35 12.5 179 (16.6%) Secondary 0 0 0 0 0 0 152 54.3 152 (14.1%) Primary 0 0 0 0 0 0 30 10.7 30 (2.8%) Illiterate 0 0 0 0 0 0 63 22.5 63(5.8%) Out of 1078 various levels of staff members working in health care centers, all members were interviewed. The overall response rate was 80%. There were 415 males and 663 females regarding KAP assessment, score level 50% has been taken as cut of criterion. Table 3: KAP of staff members of different groups regarding health care waste management Variables Doctors (n= 66) Nurses (n= 84) Technicians (n= 12) Auxiliary staff (n= 64) Chi-square value Group 1 (n= 226) Knowledge Score≥50% 53(80.3) 59(70.2) 6(50.0) 23(35.9) 34.02 (0.001) Score<50% 13(19.7) 25(29.8) 6(50.0) 41(64.1) Attitude Score≥50% 47(71.2) 67(79.8) 8(66.7) 41(64.1) 4.7 (0.19) Score<50% 19(28.8) 17(20.2) 4(33.3) 23(35.9) Practices Score≥50% 41(62.1) 55(65.5) 6(50.0) 33(51.6) 3.55 (0.31) Score<50% 25(37.9) 29(34.5) 6(50.0) 31(48.4) Variables Doctors (n=68) Nurses (n= 250) Technicians (n=40) Auxiliary staff (n= 116) Chi -square value Group 2 (n= 474) Knowledge Score≥50% 53(77.9) 172(68.8) 23(57.5) 50(43.1) 30.29 (0.001) Score<50% 15(22.1) 78(31.2) 17(42.5) 66(56.9) Attitude Score≥50% 50(73.5) 194(77.6) 26(65.0) 66(56.9) 17.36 (0.000) Score<50% 18(26.5) 56(22.4) 14(35.0) 50(43.1) Practices Score≥50% 39(57.4) 147(58.8) 20(50.0) 53(45.7) 6.04 (0.10) Score<50% 29(42.6) 103(41.2) 20(50.0) 63(54.3) Variables Doctors Nurses Technicians Auxiliary staff Chi -square value (n= 105) (n=95) (n= 42) (n= 85) Group 3 (n= 327) Knowledge Score≥50% 83(79.0) 49(51.6) 25(59.5) 35(41.2) 30.70 (0.001) Score<50% 22(21.0) 46(48.4) 17(40.5) 50(58.8) Attitude Score≥50% 69(65.7) 70(73.7) 20(47.6) 43(50.6) 14.46 0.002 Score<50% 36(34.3) 25(26.3) 22(52.4) 42(49.4) Practices Score≥50% 46(44.0) 83(87.4) 28(66.7) 28(32.9) 62.14 0.001 Score<50% 56(53.3) 12(12.6) 14(33.3) 57(67.1) Variables Doctors Nurses Technicians Auxiliary staff Chi -square value (n= 6 ) (n=0) (n=17) (n=8 ) Group 4 (n= 31) Knowledge Score≥50% 5(83.3) 0 9(52.9) 3(37.5) 2.96 (0.22) Score<50% 1(16.7) 0 8(47.1) 5(62.5) Attitude Score≥50% 4(66.7) 0 9(52.9) 4(50.0) 0.43 (0.80) Score<50% 2(33.3) 0 8(47.1) 4(50.0) Practices Score≥50% 3(50.0) 0 7(41.2) 3(37.5) 0.22 (0.89) Score<50% 3(50.0) 0 10(58.8) 5(62.5) Variables Doctors Nurses Technicians Auxiliary staff Chi -square value (n= 5) (n= 1 ) (n= 7) (n=7 ) Group 5 (n= 20) Knowledge Score≥50% 3(60%) 1(100%) 3(42.9%) 2(28.6%) 1.91 (0.383) Score<50% 2(40%) 0 4(57.1%) 5(71.4%) Attitude Score≥50% 4(80.0%) 1(100.0%) 2(28.6%) 3(42.9%) 4.09 (0.19) Score<50% 1(20.0%) 0(0.0%) 5(71.4%) 4(57.1%) Practices Score≥50% 5(100.0%) 1(100.0%) 6(85.7%) 6(85.7%) 0.21 (0.63) Score<50% 0(0.0%) 0(0.0%) 1(14.3%) 1(14.3%) The above table 3 shows the correct knowledge about health care waste management among the doctors, nursing staff, lab technicians, and auxiliary staff were 53(80.3%), 59(70.2%), 6(50.0%) and 23(35.9%) respectively. The difference in knowledge levels of staff members among group 1 regarding health care waste management were statistically highly significant. With regard to attitude the correct responses among the doctors, nursing staff lab technicians and auxiliary staff were 47(71.2%), 67(79.8%), 8(66.7%) and 41(64.1%) respectively. Attitude of various levels of staff members among group 1 regarding health care waste management was statistically not significant. Regarding HCW practices, the correct responses among the doctors, nursing staff, lab technicians and auxiliary staff were 41(62.1%), 55(65.5%), 6(50.0%) and 33(51.6%) respectively. The difference in practices levels of staff members among group 1 regarding health care waste management was statistically not significant. In Group 2, 53(77.9%) doctors, 172(68.8%) nursing staff, 23(57.5%) lab technicians and 50(43.1%) auxiliary staff had correct knowledge about HCWM. In group 2, Doctors had a statistically significant better knowledge than other staff members. It was found that 50(73.5%) doctors, 194(77.6%) nursing staff, 26(65.0%) lab technicians and 66(56.9%) auxiliary staff had a positive attitude. The difference in attitude of various levels of staff members among group 2 regarding health care waste management was highly statistically significant. Regarding BMW practices, it was found that nurses practiced health care waste management better than other staff members, but it is statistically not significant. In group 2, it was found that 39(57.4%) doctors, 147(58.8%) of the nurses, 20(50%) lab technicians and 53(45.7%) auxiliary staff practiced health care waste management. The above table shows the correct knowledge about health care waste management among the doctors, nursing staff, lab technicians and auxiliary staff as 83(79%),49(51.6%), 25(59.5%) and 35 (41.2%) respectively. In group 3 doctors had a statistically significant better knowledge than auxiliary staff members. With regard to attitude, the correct responses among the doctors, nursing staff, lab technicians and auxiliary staff were 69(65.7%), 70(73.7%), 20(47.6%) and 43(50.6%) respectively. The difference in attitude of various levels of staff members in group 3 regarding health care waste management was statistically significant. With regard to the practices, the correct responses among the doctors, nursing staff, lab technicians and auxiliary staff were 46(44%), 83(87.4%), 28(66.7%) and 28(32.9%) respectively. The difference in practice of various levels of staff members in group 3 regarding health care waste management was highly statistically significant. From the above table it is observed that, the correct knowledge about health care waste management in group 4 among the doctors, lab technicians and auxiliary staff were 5(83.3%), 9(52.9%) and 3(37.5%) respectively. However the difference in knowledge of various levels of staff members among group 4 regarding health care waste management were statistically not significant. With regard to attitude, the correct responses among the doctors, lab technicians and auxiliary staff were 4(66.7%), 9(52.9%) and 4(50.0%) respectively. However the difference in attitude of various levels of staff members in group 4 regarding health care waste management was statistically not significant. With regard to the practices, the correct responses among the doctors, lab technicians and auxiliary staff were 3(50.0%), 7(41.2%) and 3(37.5%) respectively. The difference in practice of various levels of staff members in group 4 regarding health care waste management was statistically not significant. It is observed from the above table that, the correct knowledge about health care waste management among the doctors, Nursing staff, Lab Technicians and auxiliary staff were 3(60%), 1(100%), 3(42.9%) and 2(28.6%) respectively. In group 5 doctors and nursing staff had a better knowledge than other staff members, but it was not statistically significant. With regard to attitude the correct responses among the doctors, nursing staff, lab Technicians and auxiliary staff members were 4(80.0%), 1(100.0%), 2(28%) and 3(42.9%) respectively. The difference in attitude of various levels of staff members in group 5 regarding health care waste management was statistically not significant. With regard to the practices the correct responses among the doctors, Nursing staff, Lab Technicians and auxiliary staff members were 5(100%), 1(100.0%), 6(85.7%) and 6(85.7%)respectively. The difference in practice of various levels of staff members in group 5 regarding health care waste management was statistically not significant. Table 4: Personal protective measures used by various health care centres Group of health care centres Personal protective measures Apron Masks Gloves Boots Soap & water Group-1 (n=2) 1 1 1 0 1 Group-2 (n=1) 1 1 1 0 1 Group-3 (n=45) 13 5 26 0 44 Group-4 (n=4) 0 2 4 0 3 Group-5 (n=6) 1 2 5 0 3 Total (n=58) 16(28%) 11(19%) 37(63%) 0 52(90%) It was evident from the above table-4 that among a total of 58 health care centers, 16 (28%) health care centers i.e., group1, group 2 , 13 health care centers in group3 and 1 health care center in group 5 were provided with apron as personal protective measure when handling hospital waste. Around 11(19%) health care centers that is group1, group 2, 5 in group 3, 2 in group 4 and 2 in group 5 were provided with mask in their health center. Regarding usage of gloves, about 37(63%) health care centers i.e., group, group 2, 26 health care centers in group 3, group 4 and 5 health care centers in group 5 were using them. Majority of health care centers 52(90%) emphasized the importance of hand washing thereby provided with soap and water in their health care center. None of the respondent in any of the health care centers had used boots in the study. Table 5: Provision of immunization by HCE to their staff Group of health care centres Tetanus and Hepatitis B Group-1 (n=2) 2 Group-2 (n=1) 1 Group-3 (n=45) 38 Group-4 (n=4) 4 Group-5 (n=6) 3 Table 5 reflects distribution of health-care center groups with regard to immunization. Regarding immunization against Tetanus and Hepatitis, around 48(82%) health care centers provided immunization against these specified diseases in the study.

Knowledge, attitude and practice act as three pillars, which make up the dynamic system of life itself. Knowledge is some information that is acquired or gained. It results in congeniality and advertence about an eclectic thing or a situation. Knowledge, being the basic criterion that allows one to earmark between the right and the wrong, is a mixture of comprehension, experience, discernment and skill. Attitude accredits to thinking towards a proper situation. Practice means contemplation of rules and knowledge that lead to action. Thus, a right knowledge, a positive attitude and a good practice are imperative to guide and serve the patients.6 The present study was carried out among 1078 health care personnel involved in the various health care centers to assess the status of health care waste management in Karimnagar city. Health-care workers who handle waste are at high risk of getting fatal diseases like hepatitis B and C and HIV by contaminated needles and other waste sharps.7 Hence, knowledge regarding the transmission of all these infections and immunization against hepatitis B is necessary among health care workers. The present study showed immunization against TT and Hepatitis B provided by HCE was observed in 48 (82%) health care centers. Our study findings were in consistent to the findings of study conducted by Ananthachari KR et al., found that 70.7% were fully immunized against hepatitis B of which 22.1% (125) nursing staff, 9.5% (54) laboratory technicians, 19.4% (110) interns and 19.7% (112) doctors52. Whereas in another study done by Kumar M et al., on health care workers in a tertiary care hospital Haldwani, Nainital reports 31.0% of the health care workers were unvaccinated against hepatitis B93. In a study conducted by Meenu Kalia et al.,8 found that the immunization status for tetanus and hepatitis B was found to be very low among sweepers (12% and 7%) though it was good among nurses and laboratory technicians. It was due to the institute’s policy of immunizing the staff at the time of joining. This is in corroboration with the findings of De Silva and Hoppe.9 It was observed that the most 32 (55.2%) of health-care centers provided training to various groups of staff members regarding Bio-medical waste management compared to 40% reported in the study conducted in Iran. 10 In study of Abdulla et al., 200840, in Jordan about 29% of the hospitals had not provided training to doctors and other personnel about medical waste management and their potential hazards. Some hospitals (57%) provided limited training for support staff (maintenance engineers/ technicians, cleaning workers). For instance, 14% of respondents at Al Shifa (Governmental hospital) received their training about medical waste at Ministry of health, while no one of Al Awdah (Private hospital) received training course at MOH, but around 17 % of them received their training inside Al Awdah hospital. Training in HCW reduces the negative impact that can be caused by poor HCW management. Lack of training of personnel in health-care waste poses a serious risk to patients, the public and the environment.11 Health Care Workers handling BMW were not equipped with adequate protective devices. Regarding personal protective measures used by the various groups of health-care centers, the study revealed that about 16 (28%) health-care centers used aprons as personal protective measures, masks were used by 11 (19%) health-care centers, and gloves were used by 37(63 %) health-care centers. The soap and water were provided by 52 (90%) health-care centers. None of the respondent in any of the health care centers had used boots in the present study. Whereas in a study conducted by Meenu Kalia et al., showed that gloves and aprons were the only protective devices used. Sweepers were not using any of the protective devices except gloves.8 Many of the studies reported that healthcare personnel have knowledge regarding BMW management but it has not being practiced. Government of India has made it a legal responsibility of health-care facilities and set up guidelines for proper health-care waste management. However, health-care personnel’s knowledge and perceived importance are crucial for its apt implementation.13 A total of 1347 respondents working in 58 different health-care centers, 1078 members were recruited for the study of which 250 (23.3%) were doctors, 430 (39.9%) were nursing staff, 118 (10.9%) were technicians and 280 (25.9%) were attenders. The overall response rate was 80%. Amongst the respondents who participated in the study across all the sampled healthcare facilities, 663 (61.6%) were female while the other 415 (38.4%) were male. The mean age of the respondents was 38.67 ± 8.57 years and most of the, 362(33.6%) of the respondents were between the age group of 25-34years followed by >25 years 310(28.8%). Majority of nurses and lab technicians were graduated whereas most 152 (14.1%) of the auxiliary workers had secondary education. A study conducted by Amal Sarsour et al., showed that the study involved different categories of health workers at hospitals who supposed to deal with medical waste directly, as 25 % of respondents were doctors, 34% nurses, 22 % cleaners, while the other 19% of respondents were distributed among laboratory technician, X-Ray technician, pharmacist, cleaner, in addition to quality management personnel who are responsible about quality assurance at health-care center. 14 Another study conducted by Meenu Kalia et al., showed that majority of the nurses and laboratory technicians were graduates, whereas most of the sweepers (79%) had studied up to primary level only. Of the respondents, 68% were men. Here, 41% of nurses and 43% of laboratory technicians were in the age group of 25–34 years whereas 71% of sweepers were in the age group of 25 years.12 In the present study the level of awareness was different among the different groups of health-care staff. Correct knowledge about health-care waste management among the doctors, were 80.3%, 70.2%, 50.0% and 35.9% respectively in group1. In group-2 Correct knowledge about health-care waste management among the doctors, nursing staff, lab technician and auxiliary staff were 77.9%, 68.8%, 57.5% and 43.1% respectively. Whereas in group- 3 correct knowledge about health-care waste management among the doctors, nursing staff, lab technician and auxiliary staff were 79%, 51.6%,59.5% and 41.2% respectively and in group-4 the correct knowledge about health-care waste management among the doctors, lab technician and auxiliary staff were 83.3%, 52.9% and 37.5% respectively. Finally in the group-5 the correct knowledge about health-care waste management among the doctors, nursing staff, lab technician and auxiliary staff were 60%,100%, 42.9% and 28.6% respectively. The overall Knowledge assessment regarding health-care waste management among the various groups of health care centers reveal that doctors had a statically significant better knowledge than the nursing staff, lab technicians and auxiliary staff. Our study findings were contrary to a study conducted by Ananthachari KR et al., showed that Knowledge regarding the collection, segregation, rules, and disposal of bio-medical waste management is more among nursing staff compared to other health-care workers.15 Whereas in a study by Mathur V et al., on knowledge, attitude and practices about bio-medical waste management among health-care personnel opined overall colour coding and waste segregation at source was found to be better among nurses as compared to doctors.16 Regarding health-care waste management among the various groups of health-care centers did not reveal any statistically significant difference in attitude and practice between the various levels of staff members. Saini et al., reported positive attitudes and fair knowledge of nurses in a tertiary care set up in New Delhi.17 In another study on healthcare waste segregation by Deo et al., nurses and lab technicians had better knowledge (90%) than medical staff like doctors (80.6%).18 As much as 59% of the nurses gave positive response for healthcare waste management in a study by Waseem et al.,.19 In the present study, a good number of staff nurses, auxiliary staff, doctors and lab technicians were conscious about the knowledge regarding the segregation of wastes as well as the method of disposing sharp wastes. However, the knowledge regarding the storage time of wastes and the familiarity of the staff with the bio-hazard symbol was much less. There was higher level of awareness about State Pollution Control Board/Pollution Control Committee which is the prescribed authority for the implementation of the Rules in the States/Union Territories regarding bio-medical waste management. Regarding the attitude of health-care staff, the findings of the study conducted by Radha R (2012), showed that the attitude of healthcare personnel was a matter of concern. They felt that the safe management was an extra burden and was the responsibility of the institution and not the individuals.20 It was also observed by Singh and Srivastava (2013) that in a study at a trauma center of C.S.M. Medical University, Lucknow that the attitude of healthcare personnel was unsatisfactory.21 Conversely in a teaching hospital of Ludhiana carried out by Mathew (2011) found that the doctors’ attitude towards bio-medical waste was casual but the paramedical staff and nurses were more particular and careful. 22 Similar was the case in a tertiary care hospital of Kolkata where the attitudes of the nurses was best amongst all the categories of staff followed by the GDAs and sweepers, though their awareness level was quite poor but the attitude of doctors and medical technologists was unsatisfactory. 23 Another study done by Bala and Narwal et al., observed that nursing staff of Dental College and Hospital of Haryana had more positive attitude. At the same time paramedical staff was found to have a comparatively negative attitude.24 A study reported that the teaching staff of the hospital gave more correct responses (97.4%) to questions on BMW management than non-teaching staff (80.6%).25 In another study, nurses had a statistically significant better knowledge than the technical and house-keeping staff. It was also found that nurses had significantly positive attitude when compared to the technicians and housekeeping staff. Regarding BMW practices, it was found that nurses practiced BMW management better than the technical and house-keeping staff and a significant difference was found. 26 A study conducted in Gujrat, had found that doctors were aware of risk of health hazards, whereas auxiliary staff (ward boys, ayabens and sweepers) had very poor knowledge about health-care waste management.27 Health-care workers who handle waste are at high risk of getting fatal diseases like hepatitis B and C and HIV by contaminated needles and other waste sharps.7 Hence, knowledge regarding the transmission of all these infections and immunization against hepatitis B is necessary among health care workers. The present study showed immunization against TT and Hepatitis B provided by HCE was observed in 48 (82%) health care centers. Our study findings were in consistent to the findings of study conducted by Ananthachari KR et al., found that 70.7% were fully immunized against hepatitis B of which 22.1% (125) nursing staff, 9.5% (54) laboratory technicians, 19.4% (110) interns and 19.7% (112) doctors.15 Whereas in another study done by Kumar M et al., on health care workers in a tertiary care hospital Haldwani, Nainital reports 31.0% of the health care workers were unvaccinated against hepatitis B.28 In a study conducted by Meenu Kalia et al.,12 found that the immunization status for tetanus and hepatitis B was found to be very low among sweepers (12% and 7%) though it was good among nurses and laboratory technicians. It was due to the institute’s policy of immunizing the staff at the time of joining. This is in corroboration with the findings of De Silva and Hoppe.9 It was observed that the most 32 (55.2%) of health-care centers provided training to various groups of staff members regarding Bio-medical waste management compared to 40% reported in the study conducted in Iran.10 In study of Abdulla et al., 200840, in Jordan about 29% of the hospitals had not provided training to doctors and other personnel about medical waste management and their potential hazards. Some hospitals (57%) provided limited training for support staff (maintenance engineers/ technicians, cleaning workers). For instance, 14% of respondents at Al Shifa (Governmental hospital) received their training about medical waste at Ministry of health, while no one of Al Awdah (Private hospital) received training course at MOH, but around 17 % of them received their training inside Al Awdah hospital. Training in HCW reduces the negative impact that can be caused by poor HCW management. Lack of training of personnel in health-care waste poses a serious risk to patients, the public and the environment.11

Until recently, the management of medical wastes has received little attention despite their potential environmental hazards and public health risks. The findings of this study revealed important information on the current status of health care waste management and knowledge, attitudes and practice of various levels of health care workers working in the health care centers of Karimnagar city, Telangana. In majority of the health care centers staff members did not received training regarding health care waste management. One of the promising findings of the study is, KAP regarding health care waste management among the various groups of health care centers reveal that doctors had a statically significant better knowledge than the nursing staff, lab technicians and auxiliary staff. Regarding health care waste management among the various groups of health care centers did not reveal any statistically significant difference in attitude and practice between the various levels of staff members. The health care waste management practices of Karimnagar city are improper and inadequate. Lack of awareness, appropriate policy and laws, and apathy are responsible for improper management of medical waste in Karimnagar city. Hence the persons handling the waste should be equipped with protective materials like apron, thick rubber gloves, long boot and face mask. They should be immunized against communicable diseases. The workers should be checked for respiratory disorders at least once in six months. Wearing of personal protective materials should be encouraged in awareness programe. A mandatory inducting training programe should be organized for all new staff in hospital to familiarize them with the operating procedures practiced in the hospital. Bio-Medical Waste Management programe cannot successfully be implemented without the desire, devotion, self-motivation, collaboration and participation of all divisions of employees of any health-care establishment. If we want to protect our environment and health of community we must sensitize ourselves to this important issue not only in the interest of health managers but also in the interest of community.

1. Sanjeev R, Suneesh Kuruvilla, Knowledge, attitude, and practices about biomedical waste management among dental healthcare personnel in dental colleges in Kothamangalam: a cross-sectional study, Health Sciences 2014; 1(3):JS001I 2. Acharya D.B, Singh Meeta. The Book of Hospital Waste Management, 1st Ed. New Delhi. Minerra Press, 2000. 3. Central Pollution Control Board (Hazardous Waste Management Division) DELHI – 110 032 4. Patil, V. Gayatri and K. Pokhrel, Bio-medical solid waste management in an Indian hospital: a case study. Waste Management, 2005, 25: 592–599. 5. Almuneef M, Memish Z, Effective medical waste management: it can be done. American Journal of Infection Control, 2003, 31, 188–192. 6. Sanjeev R, Suneesh K, Subramaniam R. Knowledge, attitude and practices towards droplet and airborne isolation precautions among dental health care personnel in a dental college in Kothamangalam: A cross sectional study. J Odontol Res 2013; 1: 30-6. 7. Suryakantha AH, Management of hospital waste. In: Suryakantha AH, Editor. Community medicine with recent advances.4th ed. Jaypee brothers medical publishers Ltd. New Delhi. 2017:93 8. Kalia M, Virk A, Gupta BP, Singh J. Biomedical waste management practices in a tertiary-care hospital in Punjab. Int J Med Sci Public Health 2015; 4:179-183. 9. De Silva CE, Hoppe AE. Hospital waste management in the South of Brazil. Waste Manag 2005; 25:600–5. 10. Askarian M, Vakili M, Kabir G. Hospital waste management status university hospital of the Fars province, Iran. Int J Environ Health Res. 2004a; 10(4): 295-305 11. Miyazaki M, Une H. Infectious waste management in Japan: A revised regulation and a management process in medical institutions. Waste manage 2005; 25: 616-621. 12. Kalia M, Virk A, Gupta BP, Singh J. Biomedical waste management practices in a tertiary-care hospital in Punjab. Int J Med Sci Public Health 2015; 4:179-183. 13. Rekha Sachan, Patel ML, Anuradha Nischal. Assessment of the knowledge, attitude and Practices regarding Biomedical Waste Management amongst the Medical and Paramedical Staff in Tertiary Health Care Centre. International Journal of Scientific and Research Publications.2012; 2(7). 14. Amal Sarsour, Aaeid Ayoub, Ihab Lubbad, Abdelnaser Omran, Isam Shahrours. Assessment of Medical Waste Management within Selected Hospitals in Gaza Strip Palestine: A Pilot Study. International Journal of Scientific Research in Environmental Sciences, 2014, 2 (5), pp. 164-173. 15. Ananthachari KR, Divya CV; A study on assessment of knowledge on bio-medical waste management among health-care workers of tertiary care hospital. Int J Community Med Public Health, 2016,3: 2409-13 16. Mathur V, Dwivedi S, Hassan MA, Misra RP.; Knowledge, attitude and practices about Bio-medical waste management among health care personnel: A cross-sectional study. Indian J Comm Med. 2011, 36:143–5. 17. Saini S, Nagarajan SS, Sharma RK.; Knowledge, attitude and practices of bio-medical waste management amongst staff of a tertiary level hospital in India. J Academy Hospital Administration. 2005, 17(2):1-12. 18. Deo D, Tak SB, Munde SS. 2006; A study of knowledge regarding bio-medical waste management among employees of a teaching hospital in rural area. J Indian Soc Hospital Waste Management. 5(1):12-6. 19. Q. Waseem, G. M. Khan, G. Hassan et al., “Awareness of biomedical waste management amongst staff of the government S M H S hospital, Srinagar, a tertiary level hospital in Kashmir Valley,” JK Practitioner, 2007, vol. 14, no. 1, pp. 60–61. 20. Radha R. Assessment of existing knowledge, attitude, and practices regarding biomedical waste management among the health care workers in a tertiary care rural hospital. Int J Health Sci Res. 2012; 2(7):14-19. 21. Singh, A. and Srivastava, R. N., ‘Knowledge, Attitude and Practice of Bio-medical Waste Management amongst Staff of Institutional Trauma Center level II’, International Journal of Research in Health Sciences, 2013, ISSN: 2321 – 7251, Vol. 1(2), pp. 62-68. 22. Savan Sara Mathew, A. I. Benjamin, Paramita Sengupta. Assessment of biomedical waste management practices in a tertiary care teaching hospital in Ludhiana. Healthline 2011;2(2):28-30 23. Ray(Ghosh), et al., ‘A Study of Knowledge Attitude and Practices of Bio-medical Waste Management at a Tertiary Care Hospital, Kolkata’, Journal of Medical Science And Clinical Research, 2014, ISSN (e)-2347-176x, Vol. 2(8), pp. 1930-1940. 24. Bala, S. and Narwal, A., ‘Awareness of Bio-Medical Waste Management among Dental College and Hospital Employees – A Panoramic View’, Journal of Oral Health and Community Dentistry, 2013, Vol. 7(1), pp.1-7. 25. MC Yadavannavar, Aditya S Berard, PB Jagrdar. Bio-medical Waste Management: A study of knowledge, attitude, practices in a tertiary health-care institution in Bijapur. Indian Journal of Community Medicine, January 2010 / Volume 35 / Issue I. 26. Mohd Shafee, Kasturwar NB, Nirupama N. study of knowledge, attitude and practices regarding Biomedical Waste among Paramedical Workers. Indian Journal of Community Medicine, January 2010 / Volume 35 / Issue 2. 27. 27. Pandit NB, Mehta HK, Khartha GP, Chodary SK. Management of Biomedical Waste; Awareness and practices in a district of Gujarat. Indian Journal of Public Health 2005. 28. 28. Kumar M, Singh RK, Varshney U, Rawat V. Awareness and practices about bio-medical waste among Health care workers in Tertiary care hospital of Haldwani, Nainital. Natl J Med Res. 2015;5(1):47-51.