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Handbook of Environmental Materials Management pp 1901–1923 Cite as

Sustainable Biomedical Waste Management

• Sukanchan Palit 2 &
• Chaudhery Mustansar Hussain 3  
• Reference work entry
• First Online: 21 May 2019

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The domain of waste management and pollution control is today undergoing rapid and drastic changes. Human civilization and human scientific endeavor are moving toward a newer era of scientific regeneration. In the similar manner, biomedical engineering is surpassing visionary scientific frontiers. Solid waste management and biomedical engineering are the forerunners toward scientific regeneration and deep scientific vision. The present state of waste management is deeply challenged and is replete with scientific imagination. Industrial pollution today is the need of the hour. In this treatise, the authors deeply discussed the scientific success, the vast scientific potential, and the vision to move forward in the field of biomedical waste management. Human scientific research pursuit in waste management today needs to be re-envisioned and redefined. The challenge and the vision of this treatise are immense and far-reaching. The authors also in this well-researched treatise successfully elucidate the need for sustainable development in present-day human civilization. Waste management and environmental sustainability are the challenges of environmental engineering science today. This treatise opens up a new chapter in human scientific research pursuit in biomedical sciences and engineering with the sole aim and objective toward the furtherance of engineering science. Technological validation and the vast scientific ingenuity in the field of waste management are the other hallmarks of this treatise. The authors pointedly focus on the human scientific ingenuity and deep profundity in the field of biomedical engineering and waste management. Environmental sustainability is another vast area of research pursuit in this widely researched treatise.

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Palit, S., Hussain, C.M. (2019). Sustainable Biomedical Waste Management. In: Hussain, C. (eds) Handbook of Environmental Materials Management. Springer, Cham. https://doi.org/10.1007/978-3-319-73645-7_123

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Biomedical Waste Management: A Study on Assessment of Knowledge, Attitude and Practices Among Health Care Professionals in a Tertiary Care Teaching Hospital

Divya Rao 1 , M. R. Dhakshaini 2 , Ameet Kurthukoti 3 and Vidya G. Doddawad 4

1 Department of Health System Management Studies, JSS University, Mysuru.

2 Department of Prosthodontics, Vice Principal, JSS Dental College, JSS University, Mysuru.

3 Dental Health Officer, Department of Health and Family Welfare, Government of Karnataka.

4 Department of Oral Pathology and Microbiology, JSS Dental College, JSS University, Mysuru.

Corresponding Author E-mail:  [email protected]

DOI : https://dx.doi.org/10.13005/bpj/1543

Biomedical waste (BMW) generated in our nation on a day to day basis is immense and contains infectious and hazardous materials.  It is crucial on the part of the employees to know the hazards of the biomedical waste in the work environment and make its disposition effective and in a scientific manner. It is critical that the different professionals engaged in the healthcare sector have adequate Knowledge, Attitudes and Practices (KAP) with respect to biomedical waste management. Many studies across the country have shown that there are still deficiencies in the KAP of the employees in the organizations and hence it is necessary to make the appraisal of the same. To ascertain the levels of and the expanse of gaps in knowledge, attitudes and practices among doctors, post graduates, staff nurses, laboratory technicians and house-keeping staffs in a tertiary care teaching hospital in Mysuru, Karnataka. A cross sectional study was carried out using questionnaire as the study tool among the health care professionals in a tertiary care teaching hospital. The study demonstrated gaps in the knowledge amongst all the cadres of the study respondents. The knowledge in relation to BMW Management including the hospital BMW protocols was more desirable among doctors, but practical facets were better in nurses and the lab technicians. Knowledge, Attitude and Practice amongst the different cadres of staff members were found to be significant statistically.

Attitude; Biomedical Waste; Healthcare personnel;   Knowledge; Practice

Introduction

Health care waste is a unique category of waste by the quality of its composition, source of generation, its hazardous nature and the need for appropriate protection during handling, treatment and disposal. Mismanagement of the waste affects not only the generators, operators but also the common people too. 1

‘Bio-medical waste’ (BMW) means any solid and/or liquid waste including its container and any intermediate product, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research pertaining thereto or in the production or testing thereof. 2

Due to the increase in the procedures that are carried out at the various health care setups, excessive amounts of waste have been generated at the centers of care.

India approximately  generates 2 kg/bed/ day 3 and this biomedical waste encompasses wastes like anatomical waste, cytotoxic wastes, sharps, which when inadequately segregated could cause different kinds of deadly infectious  diseases like Human immunodeficiency virus(HIV) hepatitis C and B infections, etc, 4   and also cause disruptions in the environment, and adverse impact on ecological balance. 5,6

Adequate knowledge amongst the health care employees about the biomedical waste management rules and regulations, and their understanding of segregation, will help in the competent disposal of the waste in their respective organizations. 7

Acceptable management of biomedical waste management begins from the initial stage of generation of waste, segregation at the source, storage at the site, disinfection, and transfer to the terminal disposal site plays a critical role in the disposal of waste. Hence adequate knowledge, attitudes and practices of the staff of the health care institutes play a very important role. 8,4,9

Teaching institutes play a critical role in the health care setup as it is from these places that the future health care professionals and all those persons involved in the care giving to the community are trained. 10

Studies documented from different parts of the country; still convey that there are gaps in the Knowledge, lacunae in the attitudinal component and inconsistency in the practice aspects which are matters of concern among the health care professionals. 8,11-15  With this background, the study was carried out to assess the current knowledge, attitude and practices of the health care workers like doctors, post graduates, interns, staff nurses, laboratory technicians and house-keeping staff in a tertiary care teaching hospital with regard to the management of BMW.

To assess the levels of knowledge, attitudes and practices among doctors, post graduates, interns, staff nurses, laboratory technicians and house-keeping staff in the different departments of a tertiary care teaching hospital.

To assess the gaps in knowledge, attitudes and practices among these health care workers in the different departments of a tertiary care teaching hospital.

Methodology

Study design

Cross-sectional study.

Study setting

Tertiary care teaching hospital

Study population

Staff working in the different departments of the hospital.

Eligibility Criteria

All consenting individuals amongst the different cadres of staff were included into the study. There were 2056 eligible participants, which was taken as the sampling frame.

Sample Size

Expecting that 50% of the study population had precise knowledge (considering the outcome variable) about the rules and legislation of biomedical waste management, 16  with an allowable error of 10%, at 95% confidence interval, and accounting for the finite population correction for 2,056 participants, a minimum sample size of 472 was calculated.

Sampling Strategy

The study population was classified according to the different strata based on their designation as doctors, postgraduates (junior residents), interns, staff nurses, laboratory technicians and house-keeping staff. Allocation of the population according to the strata.

Ethical Approval

The ethical clearance for the study was obtained from the Institutional Ethics Committee.

Materials and Methods

The tool used for the study was a pre-tested, semi-structured closed ended questionnaire which encompassed 42 questions on Knowledge, Attitudes and Practices.

The questions on knowledge appraised the participant’s knowledge on attributes related to the colour coding and their implications, identification of biomedical hazard symbol, waste categories, and hospital policies for biomedical waste management.

The questions on attitude were related to matters like, was biomedical waste hazardous, its management additional burden on their work or if their appropriate management burden on the finances of the hospital, and also on legislative measures for waste management.

The questions on practice appraised if the study respondents had received any training on biomedical waste management, if they were immunized against hepatitis B and if disinfection of sharps were carried out at the point of generation.

The literature review was done based on which the questionnaire was formulated according to the requirements of the study. The questionnaire was pretested and validated by a post-test and a pilot survey was conducted with a sample of 60 respondents, with representations from the various strata of the study respondents. The study tool consisted of 12 questions assessing the knowledge with yes/no/not sure responses, 10 questions assessing the attitude with agree/disagree/no comment as answers and 20 questions assessing the practices with yes/ no responses.

The participants filled up the self-administered questionnaires without scope for undue help.

The questionnaire was adapted from English to local language by an experienced professional who is involved in translating of health survey questionnaires to accommodate the housekeeping staff. The questionnaire was also back translated to English for checking of possible discrepancies and incorporating if any changes were required. The identity of the study respondents were maintained anonymous   at various stages of the study.

The results were evaluated across 3 domains for all the cadres of the study population.

The results are Displayed as Under

Statistical Methods

Data was analysed using MS-Excel and R version 3.4.3.  Percentages (with 95% confidence intervals) were calculated and the same are presented graphically. Chi-square test was performed to test the association between the different cadres related to their knowledge, attitude and practices towards BMW

Knowledge Score

The knowledge regarding general information about HCW was assessed, the mean score was highest in doctors (10) followed by nursing staff (9.3) and least in housekeeping staff (7.5). This is found to be statistically significant.

Table 1: The participant’s knowledge on biomedical waste management.

Overall, the study respondents showed satisfactory knowledge regarding biomedical waste management. The knowledge about BMW among doctors was the distinctively better, followed by that of nurses, technicians, post graduates, interns and housekeeping staff (in order). The gaps in knowledge were in the areas regarding the fate of the waste after it was segregated, and as well as who was the regulator for the safe transportation of biomedical waste from the hospital.

Table 2: The participant’s attitudes towards biomedical waste management.

The mean attitude score was 9.20 for the nurses and 9.18 out of 10 for the doctors. Favourable attitude was shown by most of the study respondents towards biomedical waste management. The best attitudes were displayed by the nurses showed, subsequently by doctors, interns, postgraduates, the laboratory technicians, and house keeping staff (in order). It was concerning that the lacuna in this domain was that biomedical waste management was considered as additional burden on work.

Table 3: The participant’s practices regarding biomedical waste management.

The mean practice score was 17.30 for the nurses and 16.50 for the housekeeping staff and 15.27out of 20 for the doctors, in the study. Though greater number of the study respondents displayed favourable biomedical waste management practices, it was noted that the nurses had the best practices, followed house keeping staff, doctors, technicians, interns and junior residents (in order). It was noted that the staff ware following the preventive measures of immunisation against Hepatitis B, and also routine health check-ups were conducted for the staff. Explicit training on BMW management was desired by most of the staff.

Chi-Square Test

The null hypothesis which was to be tested here was “The two attributes were independent”. Here three hypotheses were there to be tested:

Cadre and knowledge are independent.

(Chi-square = 160.8,  Degrees of freedom=10, p-value < 0.0001)

Cadre and attitudes are independent.

(Chi-square = 95.6, Degrees of freedom=10, p-value < 0.0001)

Cadre and practices are independent.

(Chi-square = 538.45, Degrees of freedom=15, p-value < 0.0001)

The present cross-sectional study recognized certain inadequacies in the knowledge component amongst the different cadres of health care workers, though greater than 50% of the study respondents, across cadres, demonstrated satisfactory or good knowledge, attitudes and practices. The knowledge component of the doctors was more desirable compared to their practices whereas visa versa was true for nurses and lab technicians. The knowledge component was low amongst the housekeeping staff; which was identical to the results from other similar studies conducted previously. 10,13,16 

The attitude towards BMW management of housekeeping staff was low. Low level of knowledge was mainly attributed to new staff coming on rotation to the hospital and also to comparably low educational levels of the housekeeping staff. Training of all cadres of staff will help in the analytical evaluations for suitable and applicable management of biomedical waste. 10,13,16 

The practice of recapping the needles was very low across cadres. Recapping of needles is one of the important risk factor for needle stick injuries; the prevalence was very low in the organization. This may be associated to the awareness of the staff and also due to the adequate number of needle cutters in the various patient care areas of the hospital.

Higher practice scores found in the house keeping staff and nursing staff in the present study may be due to higher responsibilities assigned to them in handling of BMW which was similar to findings of previous studies. 1,17 Overall 8.1 % of the study respondents attended the external training programmes on BMW management on their own accord, but others too (~ 59%) of them communicated their willingness to do the same if opportunities arose in the future. 10,13,16

Conclusions

Overall, the knowledge, attitudes and practices towards biomedical waste management among the study respondents was satisfactory.

Knowledge, attitudes and practices toward biomedical waste management were better among the nurses and doctors than the other cadre of staff.

Knowledge, Attitudes and Practices of the study respondents are dependent on the cadre that they belong too.

This study was a modest attempt to evaluate the KAP of the health care workers towards BMW. We recommend further studies on a larger stratum across hospitals to evaluate the awareness of health care workers towards BMW.

Recommendations

Training programs need to focus on empowering the healthcare professionals on biomedical waste management with broad scope and practical knowledge in all aspects. The ethical requirements and the institutional level policies form the directional pathway for the practical components in the organization. The right practices and other activities of BMW management and its ramifications in the form of avoiding of injuries, importance of vaccinations and following of universal precautions can be achieved when adequately supported by IEC (information, education and communication) strategies like handouts, stickers, charts, celebrations of various days like hand hygiene day and other days etc can help in bettering the practices of the employees of the organizations. Training the staff with checklists and regular inspections can bring about accountability in the staff.

All health care professionals regardless of their designation, experience and qualification , designation must be included in these interventions, so that it can avoid  cross infections among the professionals and patients in the health care sector.

Conflicts of Interest

There is no conflicts of interest.

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Biomedical waste disposal practices among healthcare workers during COVID-19 pandemic in secondary and tertiary care facilities of Tamil Nadu

Associated data.

The ongoing COVID-19 crisis has drastically changed the practice of biomedical waste (BMW) generation and management. Studies venturing into the facility level preparedness at various levels of healthcare delivery during pandemic situation is the need of the hour. Hence, we did this study to assess the BMW disposal practices amongst secondary and tertiary health facilities during COVID-19 pandemic in Tamil Nadu.

Materials and methods

This cross-sectional survey was conducted amongst doctors, nurses and allied healthcare staffs across various departments in 18 public health facilities across six districts of Tamil Nadu. Multivariable logistic regression analysis was done based on the random-intercept model to assess the determinants of BMW disposal practices. The effect size was reported as adjusted odds ratio (aOR) with 95% confidence interval (CI).

In total, 2593 BMW disposal observations were made. During nearly three-fourth of the observations (73%), the BMW was disposed of appropriately. Nurses (aOR ​= ​1.54; 95%CI: 1.06–2.23) and doctors (aOR ​= ​1.60; 95%CI: 1.05–2.45), healthcare workers in Paediatrics department (aOR ​= ​1.77; 95%CI: 1.13–2.76), healthcare workers in inpatient department (aOR ​= ​2.77; 95%CI: 1.95–3.94) and injection outpatient department (aOR ​= ​2.69; 95%CI: 1.59–4.47) had significantly better odds of having appropriate BMW disposal practices.

Our study shows that nearly during three-fourth of the observations, healthcare workers performed appropriate BMW disposal practices. However, measures should be taken to achieve 100% compliance by healthcare workers especially the target groups identified in our study by allocating appropriate resources and periodically monitor the BMW disposal practices.

1. Introduction

Wastes generated in health care facilities are often regarded as the most hazardous form along with the radiation wastes [ 1 ]. Healthcare wastes are unique in generation, composition, handling and disposal [ 2 , 3 ]. Improper management of healthcare wastes can prove detrimental not just for the operators and waste handlers but also for the general public. Improper disposal of hazardous healthcare wastes can result in several hospital-acquired and blood-borne infections and poses serious occupational hazards [ [4] , [5] , [6] ].

Biomedical waste (BMW) refers to “any waste including solid or liquid generated as a final or intermediate product generated during diagnosis, treatment, or research on animals or human beings” [ 7 ]. Disparities in knowledge and practice towards BMW management across the globe, even amongst the healthcare personnel, has emerged as an important challenge in patient safety and hospital management. Limited interest and priority, lack of formal training and surveillance by the hospital administration has further heaped on this challenge [ 8 ]. With around 1.6 million health care workers employed in more than 28,000 health facilities, India is never an exception to this challenge [ 9 ]. Data suggest that approximately around 2 ​kg of biomedical wastes are generated per bed per day in India [ 10 ].

WHO has proposed the core principles to achieve such safe & sustainable BMW management in the year 2007. The proposal has stressed up on the necessity of right investment in resources with complete commitment to reduce level of harmful effects for the people and environment due to BMWs [ 11 ]. WHO also released the second edition of “The Blue Book” in the year 2014, adopting newer practices compared to the first edition published in 1999 [ 11 ]. Government of India has also released the first BMW management guidelines around the same timeline (in the year 1998), which was subsequently amended in 2000, 2003 and 2011 [ 12 , 13 ]. The latest BMW management guidelines was published in the year 2016 [ 14 ]. Despite these, vast majority of the health facilities in India fail to operationalize the existing BMW management guidelines.

In addition, the ongoing COVID-19 crisis has drastically changed the practice of BMW generation and management. Everyone has started using various forms of PPE. Masks, gloves, face shields, visors, full body suits, and splash-proof aprons, are available for use to general public also [ 15 ]. The waste generation is bound to increase due to such practices and hence, the assessment of BMW practice is essential more than ever to determine whether the public health facilities are in line with the standard guidelines and has the ability to withstand the paradigm shift during the ongoing COVID-19 crisis. Although several studies have explored the attitude and practice of healthcare workers towards BMW management, majority have focused only on the private sectors, older guidelines and only tertiary care institutions [ [16] , [17] , [18] ]. Studies venturing into the facility level preparedness at various levels of healthcare delivery during pandemic situation is the need of the hour. To bridge this knowledge gap, we did this cross-sectional survey to assess the BMW disposal practices amongst secondary and tertiary care institutes during COVID-19 pandemic in Tamil Nadu, South India.

2.1. Study design and setting

This cross-sectional survey was conducted as a part of large-scale mixed methods study on patient safety practices across public health facilities in Tamil Nadu. Healthcare services in the state of Tamil Nadu are provided by a three-tier structure delivery system. We have conducted this survey amongst secondary and tertiary care facilities in Tamil Nadu.

2.2. Sampling strategy

A two-stage stratified random sampling was performed for the selection of public health facilities ( Supplementary Fig. 1 ).

2.2.1. Stage 2

In the first stage, all the districts were stratified into three categories (low, medium and high) based on their human development index (HDI) scores [ 19 ]. The HDI was chosen to stratify the districts because its indicators reflected the key demand-side factors that explain health status, healthcare seeking behaviour, and service consumption. Two districts from each of these strata were selected randomly. Selection of districts was done randomly using lottery method.

2.2.2. Stage 2

In the second stage, a total of 18 public health facilities were selected covering the secondary and tertiary care levels of healthcare delivery. The selected facilities were 6 tertiary care hospitals/medical colleges in each selected district, 12 Government Hospitals (two GHs from each district) summing up to 18 public healthcare facilities in Tamil Nadu ( Supplementary Table 1 ).

2.3. Sample size

Sample size was calculated based on the assumption that at least 20% of the observations will be non-compliant to appropriate BMW disposal practices, 10% relative precision and design effect of 1.75, the minimum number of BMW disposal opportunities to be observed will be 2685 (to round it off and gather equal number of observations across each facility, the required sample size was 2700 observations). Since we have a sample of 18 facilities, we must observe 150 BMW disposal opportunities from each facility (150 ​× ​18 ​= ​2700).

2.4. Data collection process

Research assistants were recruited as data collectors for this survey. Before starting the data collection process, a week-long training was provided to familiarize them on data collection methods, tools, and the observations at the facility level. The research assistants were then asked to conduct a direct non-participant structured undisguised observation of the BMW disposal practices by healthcare professionals.

HCWs of varying cadres such as doctors, nurses, laboratory technicians, pharmacists were observed from the selected secondary and tertiary care facilities. The observations were done in the following departments: General Medicine, General Surgery, Obstetrics & Gynaecology, Orthopaedics and Paediatrics. In each of these departments, the observations were conducted in the out-patient department (OPD), in-patient department (IPD), injection OPD, Procedure room and intensive care unit (ICU). The data collection process was monitored periodically by the Principal Investigator and Co-Investigators.

Observation checklists were made after consensus with the subject experts and literature search. The observation was considered as appropriate BMW disposal practice if the wastes were disposed of in the appropriate colour coded bins as per the latest BMW management guidelines ( Supplementary Table 2 ) [ 13 ]. Information related to BMW management practices such as presence of separate BMW committee, standard operating procedures, training and management facilities were also obtained in the individual facilities as part of the patient safety study.

2.5. Statistical analysis

Data was entered into EpiCollect5, and analysis was performed using STATA software version 14.2 (StataCorp, CollegeStation, TX, USA). Continuous variables were summarized as mean and standard deviation (SD) and categorical variables as frequency and percentages. Outcome variable (appropriate BMW disposal practice) were reported with 95% Confidence Interval (CI). Appropriate BMW disposal practice was considered as the dependent variable and type of HCWs, department, section of the department, BMW management practices in the individual facility were considered as explanatory variables. Logistic regression model was done to assess the determinants of appropriate BMW disposal practices. Factors with p-value less than 0.20 in the univariable analysis were included in the multivariable analysis.

Multilevel modelling was performed to adjust for the multiple levels involved in the sampling strategy. The effect of clustering at the level of healthcare facility was evaluated using a random-intercept model [ 20 ]. Likelihood ratio test (LR test) was done to compare this model with the naïve model (the final model in multiple logistic regression). Multivariable logistic regression analysis was done based on the random-intercept model for the outcomes reporting significant LR test. The effect size was reported as adjusted Odds Ratio (aOR) ratio with a 95% confidence interval. Variables with p-value less than 0.05 were considered statistically significant.

In total, 2593 BMW disposal observations were made across the surveyed healthcare facilities. Majority of the observations were made amongst the nurses (66.3%) followed by doctors (22.2%) and other allied staffs (11.5%). More than half of the observations were made in general medicine department. Almost half of the observations were made in IPD (44.7%) followed by general OPD (28.3%) and injection OPD (19.2%) ( Table 1 ).

Table 1

Biomedical waste management observations across public health facilities in Tamil Nadu (n ​= ​2593).

Majority of the facilities (15 out of 18 facilities – all 6 surveyed medical colleges and 9 ​GHs) had a separate BMW management committee. Regarding the BMW practices, all the 18 facilities provide PPE for BMW handlers, BMW storage facility and availability of bins and trolleys for transporting of BMW. Majority of the facilities (15 out of 18) had SOP for BMW practices, conducted training for staffs on BMW practices (14 out of 18), mechanism for reporting needle stick injuries to the hospital administration (14 out of 18) and linkage to common treatment facility (13 out of 18).

During nearly three-fourth of the observations (73%), the BMW was disposed of appropriately. Table 2 shows the determinants of appropriate BMW disposal practices amongst HCWs in public healthcare facilities of Tamil Nadu. First, we checked the clustering at the level of healthcare facility and found a significant LR test (p ​< ​0.001), depicting a significant effect of clustering at the facility level on the BMW disposal observations. Intra-class correlation coefficient (ICC showing between cluster variability) was found to be 0.20. Hence, the logistic regression was run with a random intercept model at healthcare facility level.

Table 2

Determinants of appropriate BMW disposal practices amongst HCWs in surveyed public healthcare facilities of Tamil Nadu (N ​= ​2593).

Ref - Reference value.

In the unadjusted analysis, designation, department, section of department, presence of separate committee and SOP for BMW management were significant determinants and all of these factors were included in the adjusted analysis. In the multivariable model, designation, department and section were statistically significant. Nurses (aOR ​= ​1.54; 95%CI: 1.06–2.23) and doctors (aOR ​= ​1.60; 95%CI: 1.05–2.45) had significantly better odds of having appropriate BMW disposal practices when compared to other allied healthcare staffs. HCWs in Paediatrics department had significantly higher odds of complying to appropriate BMW disposal practices (aOR ​= ​1.77; 95%CI: 1.13–2.76) when compared to HCWs in General Medicine department. HCWs in IPD (aOR ​= ​2.77; 95%CI: 1.95–3.94) and Injection OPD (aOR ​= ​2.69; 95%CI: 1.59–4.47) had significantly better odds of having appropriate BMW disposal practices when compared to HCWs in general OPD.

4. Discussion

4.1. bmw management policies and their implementation.

The safe & sustainable management of the BMWs is a legal and social responsibility of all the people involved in provision or utilization of healthcare services (i.e., patients, families, HCWs, hospital administration and health system). The BMW Rules, 2016 (further amended in 2018 & 2019) is a joint product of research made by agencies such as Centre for Chronic Disease Control, Health Care without Harm, and Centre for Environmental Health under Public Health Foundation of India [ 21 ]. This guideline was introduced to bring out a stringent and elaborate set of rules and bring a change in the way BMWs are managed in India. Monitoring the activities in health facility and its compliance to the standard guidelines is important as proper compliance to BMW practices ensures safety to patients and HCWs.

Most of the surveyed facilities were better performing in terms of almost all the BMW management practices (except reporting of needle stick injuries to NACO). Similar findings were reported in previous survey conducted in an Indian setting regarding the satisfactory adoption of latest BMW guidelines in secondary and tertiary care setting [ 22 ]. The possible reason for such positive finding could be the ongoing COVID-19 crisis which might have influenced a positive change in the waste disposal practices as most facilities has conducted training to HCWs on BMW disposal practices and management. Compliance to these practices was also heavily scrutinized during this period, which might have also influenced the positive finding with respect to these indicators. This shows that the public health facilities in Tamil Nadu are working towards the positive direction in handling BMW management practices. One major area of concern with many facilities were the non-reporting of needle stick injuries to NACO. This again makes it difficult to determine the impact of BMW management practices implemented across the public health facilities in Tamil Nadu, as the ultimate aim or objective of any intervention is to achieve the desired outcome.

4.2. Improper BMW disposal practices

We have conducted a direct observational survey of BMW disposal practices amongst various set of HCWs in the surveyed public health facilities. BMW disposal practices was significantly better as nearly three-fourth of the observations followed appropriate BMW disposal practices. Similar finding was found in previous studies assessing the BMW disposal practices across various cadres of HCWs [ 17 , 22 , 23 ]. Such positive findings is encouraging given that the COVID-19 pandemic has raised the amount of BMW generated and ability of the virus to remain active on different surfaces for a variable period of time has made them hazardous [ 24 ]. In addition, fomite transmission has also been described as one of the modes of COVID-19 transmission [ 25 ]. However, there is always a scope for improvement despite the positive findings obtained in our survey, as some of the facilities had compliance as low as 40%. All the HCWs handling BMW across all the facilities should take utmost care and training or additional interventions should be targeted towards these facilities with compliance less than 50%.

Depending on the type of HCWs, nurses and doctors had better compliance when compared to other allied staffs. This finding was also similar to previous studies in Southern India and other similar setting, as the doctors and nurses had almost similar BMW disposal compliance or slightly better compliance amongst nurses [ 17 , 22 , 26 , 27 ]. Possible reason for such finding could be high amount of responsibility on BMW management practices are assigned to nurses and doctors in public health facilities of Tamil Nadu. In addition, doctors and nurses have better access to BMW management training, guidelines and equipment compared to other allied staffs. However, such practice should be changed and all the HCWs are equally important in preventing the transmission of infection in health facility. Though, training programs are conducted for every HCWs in the health facility, not all HCWs are motivated enough to attend the training as reported during the qualitative interviews. Hence, the training on BMW management should be made as a strict mandate for all the hospital staffs. Attendance of staffs during the training programs should be considered for the annual appraisal or promotion of staffs.

We also found that HCWs in IPD/Injection OPD had better compliance to BMW disposal practices compared to those working in the general OPD. The possible reason for such finding could be the hectic nature of work in the OPD especially in the government healthcare facilities. This makes the HCWs allocate less time to each patient and prone to inappropriate disposal of BMWs. However, measures should be taken to ensure proper compliance by HCWs even in OPDs by allocating appropriate resources and periodically monitor the BMW disposal practices in general OPDs.

4.3. Strengths and limitations

Our study has certain strengths. We have utilized a standard framework/guideline (released by Government of India) for assessing the BMW management policy implementation. We have also conducted the survey on BMW disposal practices across 18 secondary and tertiary care facilities across different settings (OPD/IPD/Procedure room/Injection OPD/ICU/OT) and type of HCWs (doctors/nurses/allied staff). Despite these strengths, our survey had some limitations. Observer bias was possible during the BMW disposal observations, as the Dean/MS/RMO were informed that such observations will be made on the HCWs in a defined period of time. Hence, the communication of this information to all the HCWs in the facility might have influenced their practices during the survey. Finally, primary healthcare facilities were not included in our survey.

5. Conclusion

This study was conducted as a part of an Operations Research project with grant from the Tamil Nadu Health Systems Reforms Program, to study the patient safety practices in public health facilities of Tamil Nadu. The grant was awarded to Dr. Yuvaraj Krishnamoorthy.

Ethical approval

This study was approved by Institutional Ethics Committee of ESIC Medical College & PGIMSR, Chennai dated 04.05.2021 with IEC No. IEC/2021/1/12.

Conflict of Interest

None declared.

Acknowledgments

The authors would like to acknowledge the contributions of Dr. Deivasigamani Kuberan, Dr. Aruna B Patil, Dr. Kala M, Dr. Vijayaprasad Gopichandran, Dr. Venmathi E, who gave their valuable inputs during the conduct of the research. We thank the members of the Operation Research Team for their support throughout the study.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijmmb.2022.08.011 .

Appendix A. Supplementary data

The following is the Supplementary data to this article:

The Role of Environmental NGOs: Russian Challenges, American Lessons: Proceedings of a Workshop (2001)

Chapter: 14 problems of waste management in the moscow region, problems of waste management in the moscow region.

Department of Natural Resources of the Central Region of Russia

The scientific and technological revolution of the twentieth century has turned the world over, transformed it, and presented humankind with new knowledge and innovative technologies that previously seemed to be fantasies. Man, made in the Creator’s own image, has indeed become in many respects similar to the Creator. Primitive thinking and consumerism as to nature and natural resources seem to be in contrast to this background. Drastic deterioration of the environment has become the other side of the coin that gave the possibility, so pleasant for the average person, to buy practically everything that is needed.

A vivid example of man’s impact as “a geological force” (as Academician V. I. Vernadsky described contemporary mankind) is poisoning of the soil, surface and underground waters, and atmosphere with floods of waste that threaten to sweep over the Earth. Ecosystems of our planet are no longer capable of “digesting” ever-increasing volumes of waste and new synthetic chemicals alien to nature.

One of the most important principles in achieving sustainable development is to limit the appetite of public consumption. A logical corollary of this principle suggests that the notion “waste” or “refuse” should be excluded not only from professional terminology, but also from the minds of people, with “secondary material resources” as a substitute concept for them. In my presentation I would like to dwell on a number of aspects of waste disposal. It is an ecological, economic, and social problem for the Moscow megalopolis in present-day conditions.

PRESENT SITUATION WITH WASTE IN MOSCOW

Tens of thousand of enterprises and research organizations of practically all branches of the economy are amassed over the territory of 100,000 hectares: facilities of energy, chemistry and petrochemistry; metallurgical and machine-building works; and light industrial and food processing plants. Moscow is occupying one of the leading places in the Russian Federation for the level of industrial production. The city is the greatest traffic center and bears a heavy load in a broad spectrum of responsibilities as capital of the State. The burden of technogenesis on the environment of the city of Moscow and the Moscow region is very considerable, and it is caused by all those factors mentioned above. One of the most acute problems is the adverse effect of the huge volumes of industrial and consumer wastes. Industrial waste has a great variety of chemical components.

For the last ten years we witnessed mainly negative trends in industrial production in Moscow due to the economic crisis in the country. In Moscow the largest industrial works came practically to a standstill, and production of manufactured goods declined sharply. At the same time, a comparative analysis in 1998–99 of the indexes of goods and services output and of resource potential showed that the coefficient of the practical use of natural resources per unit of product, which had been by all means rather low in previous years, proceeded gradually to decrease further. At present we have only 25 percent of the industrial output that we had in 1990, but the volume of water intake remains at the same level. Fuel consumption has come down only by 18 percent, and the amassed production waste diminished by only 50 percent. These figures indicate the growing indexes of resource consumption and increases in wastes from industrial production.

Every year about 13 million tons of different kinds of waste are accumulated in Moscow: 42 percent from water preparation and sewage treatment, 25 percent from industry, 13 percent from the construction sector, and 20 percent from the municipal economy.

The main problem of waste management in Moscow city comes from the existing situation whereby a number of sites for recycling and disposal of certain types of industrial waste and facilities for storage of inert industrial and building wastes are situated outside the city in Moscow Region, which is subject to other laws of the Russian Federation. Management of inert industrial and building wastes, which make up the largest part of the general volume of wastes and of solid domestic wastes (SDW), simply means in everyday practice their disposal at 46 sites (polygons) in Moscow Region and at 200 disposal locations that are completely unsuitable from the ecological point of view.

The volume of recycled waste is less than 10–15 percent of the volume that is needed. Only 8 percent of solid domestic refuse is destroyed (by incineration). If we group industrial waste according to risk factor classes, refuse that is not

dangerous makes up 80 percent of the total volume, 4th class low-hazard wastes 14 percent, and 1st-3rd classes of dangerous wastes amount to 3.5 percent. The largest part of the waste is not dangerous—up to 32 percent. Construction refuse, iron and steel scrap, and non-ferrous metal scrap are 15 percent. Paper is 12 percent, and scrap lumber is 4 percent. Metal scrap under the 4th class of risk factor makes up 37 percent; wood, paper, and polymers more than 8 percent; and all-rubber scrap 15 percent. So, most refuse can be successfully recycled and brought back into manufacturing.

This is related to SDW too. The morphological composition of SDW in Moscow is characterized by a high proportion of utilizable waste: 37.6 percent in paper refuse, 35.2 percent in food waste, 10 percent in polymeric materials, 7 percent in glass scrap, and about 5 percent in iron, steel, and non-ferrous metal scrap. The paper portion in commercial wastes amounts to 70 percent of the SDW volume.

A number of programs initiated by the Government of Moscow are underway for the collection and utilization of refuse and for neutralization of industrial and domestic waste. A waste-recycling industry is being developed in the city of Moscow, mostly for manufacturing recycled products and goods. One of the most important ecological problems is the establishment in the region of ecologically safe facilities for the disposal of dangerous wastes of 1st and 2nd class risk factors.

Pre-planned industrial capacities for thermal neutralization of SDW will be able to take 30 percent of domestic waste and dangerous industrial waste. Construction of rubbish-burning works according to the old traditional approach is not worthwhile and should come to an end. Waste-handling stations have been under construction in the city for the last five years. In two years there will be six such stations which will make it possible to reduce the number of garbage trucks from 1,156 to 379 and to reduce the amount of atmospheric pollution they produce. In addition the switch to building stations with capacity of briquetting one ton of waste into a cubic meter will decrease the burden on waste disposal sites and prolong their life span by 4–5 fold. Trash hauling enterprises will also make profit because of lower transportation costs.

Putting into operation waste-segregation complexes (10–12 sites) would reduce volumes of refuse to disposal sites by 40 percent—that is 1,200,000 tons per year. The total volume of burned or recycled SDW would reach 2,770,000 tons a year. A total of 210,000 tons of waste per year would be buried. So, in the course of a five year period, full industrial recycling of SDW could be achieved in practice.

Collection of segregated waste is one of the important elements in effective disposal and utilization of SDW. It facilitates recycling of waste and return of secondary material into the manufacturing process. Future trends in segregation and collection of SDW will demand wide popularization and improvement of the ecological culture and everyday behavior of people.

In recent years the high increase in the number of cars in Moscow has brought about not only higher pollution of the atmosphere, but also an avalanche-like accumulation of refuse from vehicles. Besides littering residential and recreation areas, cars represent a source for toxic pollution of land and reservoirs. At the same time, automobile wastes are a good source for recycled products. In the short-term outlook, Moscow has to resolve the problem of collection and utilization of decommissioned vehicles and automobile wastes with particular emphasis on activities of the private sector. Setting up a system for collection and utilization of bulky domestic waste and electronic equipment refuse is also on the priority list.

In 1999 in Moscow the following volumes of secondary raw materials were produced or used in the city or were recycled: 300,000 tons of construction waste, 296,000 tons of metal scrap, 265 tons of car battery lead, 21,000 tons of glass, 62,500 tons of paper waste, 4,328 tons of oil-bearing waste, and 306 tons of refuse from galvanizing plants.

Such traditional secondary materials as metal scrap and paper waste are not recycled in Moscow but are shipped to other regions of Russia.

The worldwide practice of sorting and recycling industrial and domestic wastes demands the establishment of an industry for secondary recycling. Otherwise segregation of waste becomes ineffective.

There are restraining factors for the development of an effective system of assorted selection, segregation, and use of secondary raw resources, namely lack of sufficient manufacturing capacities and of suitable technologies for secondary recycling.

The problem of utilization of wastes is closely linked with the problem of modernization and sometimes even demands fundamental restructuring of industries. The practical use of equipment for less energy consumption and a smaller volume of wastes and a transition to the use of alternative raw materials are needed. Large enterprises—the main producers of dangerous wastes—are in a difficult financial situation now, which is an impediment for proceeding along these lines.

Private and medium-size enterprises are becoming gradually aware of the economic profitability in rational use of waste. For example, the firm Satory started as a transportation organization specialized in removal of scrap from demolished buildings and those undergoing reconstruction. It now benefits from recycling of waste, having developed an appropriate technology for the dismantling of buildings with segregation of building waste. So, as it has been already mentioned above, the first task for Moscow is to establish a basis for waste recycling.

HOW TO CHANGE THE SITUATION WITH WASTE

Transition to modern technologies in the utilization of wastes requires either sufficient investments or a considerable increase in repayment for waste on the part of the population. Obviously, these two approaches are not likely to be realized in the near future.

The recovery of one ton of SDW with the use of ecologically acceptable technology requires not less than $70–100.

Given the average per capita income in 1999 and the likely increase up to the year of 2005, in 2005 it will be possible to receive from a citizen not more than $14 per year. This means that the cost of technology should not exceed $40 per ton of recycled waste. Unfortunately, this requirement can fit only unsegregated waste disposal at the polygons (taking into account an increase in transportation costs by the year 2005).

Such being the case, it looks like there is only one acceptable solution for Russia to solve the problem of waste in an up-to-date manner: to introduce trade-in value on packaging and on some manufactured articles.

In recent years domestic waste includes more and more beverage containers. Plastic and glass bottles, aluminium cans, and packs like Tetrapak stockpiled at disposal sites will soon reach the same volumes as in western countries. In Canada, for example, this kind of waste amounts to one-third of all domestic waste.

A characteristic feature of this kind of waste is that the packaging for beverages is extremely durable and expensive. Manufactured from polyethylene terephthalate (PTA) and aluminum, it is sometimes more expensive than the beverage it contains.

What are the ways for solving the problem? Practically all of them are well-known, but most will not work in Russia in present conditions. The first problem relates to collection of segregated waste in the urban sector and in the services sector. A number of reasons make this system unrealistic, specifically in large cities. Sorting of waste at waste-briquetting sites and at polygons is possible. But if we take into account the present cost of secondary resources, this system turns out to be economically unprofitable and cannot be widely introduced.

The introduction of deposits on containers for beverages is at present the most acceptable option for Russia. This system turned out to be most effective in a number of countries that have much in common with Russia. In fact this option is not at all new for us. Surely, all people remember the price of beer or kefir bottles. A system of deposit for glass bottles was in operation in the USSR, and waste sites were free from hundreds of millions of glass bottles and jars. We simply need to reinstate this system at present in the new economic conditions according to new types and modes of packaging. Deposits could be introduced also on glass bottles and jars, PTA and other plastic bottles, aluminium cans, and Tetrapak packing.

Let us investigate several non-ecological aspects of this problem, because the ecological impact of secondary recycling of billions of bottles, cans, and packs is quite obvious.

Most of the population in Russia lives below the poverty line. When people buy bottles of vodka, beer, or soft drinks, they will have to pay a deposit value (10–20 kopeks for a bottle). The poorest people will carry the bottles to receiving points. A system of collection of packaging will function by itself. Only receiving points are needed. Millions of rubles that are collected will be redistributed among the poorest people for their benefit, and a social problem of the poor will be solved to a certain extent not by charity, but with normal economic means.

A second point is also well-known. In a market economy one of the most important problems is that of employment. What happens when the trade-in value is introduced?

Thousands of new jobs are created at receiving points and at enterprises that recycle glass, plastics, etc. And we don’t need a single penny from the state budget. More than that, these enterprises will pay taxes and consume products of other branches of industry, thus yielding a return to the budget, not to mention income tax from new jobs.

There is another aspect of the matter. Considerable funding is needed from budgets of local governments, including communal repayments for waste collection and disposal at polygons and incinerators. Reduction of expenses for utilization of waste can be significant support for housing and communal reform in general.

It is practically impossible to evaluate in general an ecological effect when thousands of tons of waste will cease to occupy plots of land near cities as long-term disposal sites. Operation costs of receiving points and transportation costs could be covered by funds obtained from manufacturers and from returned packaging. Besides, when a waste recycling industry develops and becomes profitable, recycling factories will be able to render partial support to receiving points.

Trade-in value can be introduced on all types of packaging except milk products and products for children. It could amount to 15 or 30 kopecks per container, depending on its size. If all plastic bottles with water and beer are sold with trade-in value only in Moscow, the total sum will reach 450 million rubles a year. If we include glass bottles, aluminum cans, and packets, the sum will be one billion rubles. This sum will be redistributed at receiving points among people with scanty means when they receive the money for used packaging and jobs at receiving points and at recycling factories.

The bottleneck of the problem now is the absence in Russia of high technology industries for waste recycling. It can be resolved rather easily. At the first stage, used packaging can be sold as raw material for enterprises, including those overseas. There is unrestricted demand for PTA and aluminum on the part

of foreign firms. When waste collection mechanisms are established, there will be limited investments in this branch of industry.

With regard to the inexhaustible source of free raw material, this recycling industry will become one of the most reliable from the point of view of recoupment of investments. The Government, regional authorities, the population, and of course ecologists should all be interested in having such a law.

The same should be done with sales of cars, tires, and car batteries. Prices of every tire or battery should be higher by 30–50 rubles. These sums of money should be returned back to a buyer or credited when he buys a new tire or a new battery. For sure, such being the case we will not find used batteries thrown about the city dumps. In this case the task is even simpler because there are already a number of facilities for the recycling of tires and batteries.

In fact, a law of trade-in value can change the situation with waste in Russia in a fundamental way. Russian legislation has already been prepared, and the concept of an ecological tax has been introduced in the new Internal Revenue Code. Now it needs to be competently introduced. The outlay for waste recycling has to become a type of ecological tax. To realize this task much work has to be done among the deputies and with the Government. Public ecological organizations, including international ones, should play a leading role.

ACTIVITY OF PUBLIC ORGANIZATIONS IN THE SPHERE OF WASTE MANAGEMENT IN THE MOSCOW REGION

We know examples of the ever increasing role of the general public in the solution of the problem of waste utilization, first of all in those countries that have well-developed democratic institutions. “Fight Against Waste” is one of the popular slogans of public organizations abroad. Public opinion has brought about measures of sanitary cleaning in cities, secured better work by municipal services, shut down hazardous industries, and restricted and prohibited incineration facilities. Nevertheless, the struggle against wastes in the economically developed countries, being a manifestation of an advanced attitude towards the environment, has in the long run brought about a paradoxical result. Transfer of hazardous industries to countries with lower environmental standards and inadequate public support—Russia, as an example—has made the world even more dangerous from the ecological point of view.

Russia has just embarked on the path of formation of environmental public movements by the establishment of nongovernmental organizations. Representatives of nongovernmental organizations from Russia took part in the international gathering in Bonn in March 2000 of nongovernmental organizations that are members of the International Persistent Organic Pollutants (POPs) Elimination Network. A declaration against incineration was adopted in

Bonn by nongovernmental organizations, which called for elaboration of effective alternative technologies for utilization of waste and safe technologies for elimination of existing stockpiles of POP.

Quite a number of environmental organizations are operating now in Moscow. First to be mentioned is the All-Russia Society for the Conservation of Nature, which was established in Soviet times. There are other nongovernmental organizations: Ecosoglasiye, Ecolain, Ecological Union, and the Russian branches of Green Cross and Greenpeace. All these organizations collect and popularize environmental information and organize protest actions against policies of the Government or local administrations on ecological matters. A new political party—Russia’s Movement of the Greens—is being formed.

Laws currently in force in the Russian Federation (“On Protection of the Environment,” “On State Ecological Examination by Experts,” “On Production and Consumption of Waste”) declare the right of the public to participate in environmental examination of projects that are to be implemented, including those on the establishment of facilities for elimination and disposition of waste. Public examinations can be organized by the initiative of citizens and public associations. For example, under the law of Moscow “On Protection of the Rights of Citizens while Implementing Decisions on Construction Projects in Moscow,” public hearings are organized by the city’s boards. Decisions taken by local authorities, at referenda and public meetings, may be the very reason for carrying out public examinations. Such examinations are conducted mainly by commissions, collectives, or ad hoc groups of experts. Members of public examination panels are responsible for the accuracy and validity of their expert evaluations in accordance with the legislation of the Russian Federation. A decision of a public environmental panel has an informative nature as a recommendation, but it becomes legally mandatory after its approval by the appropriate body of the State. Besides, the opinion of the public is taken into account when a project submitted for state environmental review has undergone public examinations and there are supporting materials.

Public environmental examination is supposed to draw the attention of state bodies to a definite site or facility and to disseminate well-grounded information about potential ecological risks. This important facet of public environmental organizations in Moscow and in Russia is very weak. To a large extent, it can be explained by an insufficient level of specific and general knowledge of ecology even on the part of the environmentalists themselves. Lack of knowledge on the part of ordinary citizens and public groups and inadequate information (for various reasons) produce alarm-motivated behavior by those who harm the organization of environmental activity in general and waste management in particular.

There are nevertheless positive examples of public participation in designing policies of local authorities in the waste management sphere.

Speaking about the Moscow region we can point to the very productive work of the Public Ecological Commission attached to the Council of Deputies in Pushchino, in Moscow Oblast.

The population of Pushchino is 21,000. The polygon for solid biological wastes (SBW) has practically exhausted its capacities. In 1996, in order to find a way out, the Administration of the town showed an interest in a proposal made by the Austrian firm FMW to support financially the construction of an electric power station in the vicinity of the town that would operate using both fuel briquettes and SBW of the town. The briquettes would be manufactured in Turkey and would contain 70 percent Austrian industrial waste with added oil sludge. It was also envisaged that during the construction period of the electric power station, 300,000 tons of briquettes would be shipped and stockpiled. The original positive decision was annulled due to an independent evaluation of the project organized by the Public Ecological Commission.

The general public of Puschino put forward a counter proposal before the Administration in order to reduce volumes of SBW disposal at the polygon and to prolong its operation—segregation of SBW (food waste, paper refuse, fabrics, metal, glass, used car batteries). As a result, a new scheme for sanitary measures in the town was worked out in 1998, which on the basis of segregation of waste provided for a considerable decrease in refuse flow to the polygon. Unfortunately, for lack of finances in the town budget, the scheme has not been introduced to the full extent. But in spite of severe shortages of special containers for segregated wastes, a network of receiving points for secondary materials was set up.

One of the pressing tasks for greater public activity is wide popularization of environmental knowledge on waste management, especially among the young generation. There is a very important role for public organizations to play in this domain when enlightenment and education are becoming a primary concern of nongovernmental organizations. Referring again to the example of the Public Ecological Commission in Pushchino, I have to underline that this organization is taking an active part in the enlightenment of the population through organizing exhibitions, placing publications in the press, and spurring school children into action to encourage cleaning of the town by means of environmental contests, seminars, and conferences. Children help the Commission organize mobile receiving points for secondary material. They even prepare announcements and post them around the town calling on the citizens to take valuable amounts of domestic wastes and car batteries to receiving points.

There are other examples of a growing influence of public organizations on the policy of administration in the sphere of waste management in the Moscow region. The Moscow Children’s Ecological Center has worked out the Program “You, He, She and I—All Together Make Moscow Clean,” which is being introduced with the support of the Moscow Government. In the framework of this program, children collect waste paper at schools, and they are taught how to

be careful about the environment and material resources. The storage facilities agreed to support the initiative. They buy waste paper at a special price for school children. Then, the schools spend the earned money for excursions, laboratory equipment, books, and plant greenery.

Another example of an enlightened activity is a project realized in 1999 by the firm Ecoconcord on producing video-clips for TV about the adverse effects of waste incineration and the illegality of unauthorized storage of waste.

The name Ecoconcord speaks for the main purpose of this organization—to achieve mutual understanding between the general public and governmental organizations, to encourage public involvement in decision-making, and to promote the formation of policy bodies that would not let public opinion be ignored.

Proceeding from the global task of integrating the activities of interested parties in lessening adverse waste pollution, public organizations have to cooperate with authorities and not stand against them. Cooperation and consensus between governmental and nongovernmental organizations in working out strategies and tactics in waste management should become a prerequisite in successful realization of state policy in this sphere in the Russian Federation.

An NRC committee was established to work with a Russian counterpart group in conducting a workshop in Moscow on the effectiveness of Russian environmental NGOs in environmental decision-making and prepared proceedings of this workshop, highlighting the successes and difficulties faced by NGOs in Russia and the United States.

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