RISK OF POTENTIAL EXPOSURE INCIDENT IN NON-HEALTHCARE WORKERS 
IN CONTACT WITH INFECTIOUS AND MUNICIPAL WASTE
Sanja KANISEK1,2*, Rudika GMAJNIĆ1, Ivana BARAĆ1
1Health Centre Osijek, Park kralja P. Krešimira IV/6, 31000 Osijek, Croatia 
2J.J. Strossmayer University of Osijek, Faculty of Medicine, Cara Hadrijana 10e, 31000 Osijek, Croatia 
Received: Apr 8, 2017
Accepted: Jan 17, 2018
Original scientific article
Introduction: The proper classification of sharp and infectious waste in situ by the healthcare workers is an 
important measure of prevention of sharps and other exposure incidents in non-healthcare workers, who handle 
such waste. The aim was to examine the practice of classifying sharp and infectious waste in family and dental 
practices. 
Methods: An analysis of 50 bags of infectious and 50 bags of municipal waste from five family and five dental 
practices for five days in October 2016 at the Health centre Osijek.
Results: Healthcare workers in 70% of the practices deposited sharps in infectious waste. In 56% of infectious 
waste bags, sharp object were found. More risky bags of infectious waste were produced by family practices 
(64%), but with no significant differences in relation to dental practices (48%), (P=0.143). Disposing of infectious 
into municipal waste was the case in 90% of the practitioners, where in 60% of municipal waste bags, infectious 
waste was disposed. Dental practices produced more risky bags of municipal waste (76%) in relation to family 
practices (44%), but with no significant difference (P=0.714). 
Conclusions: The results of this research point to importance of performing audits of proper disposal of sharps 
and infectious waste to reduce the risks of injury to non-healthcare workers who come into contact with the 
said waste. Given results could be used for framing written protocols of proper disposal of sharps and infectious 
waste that should be visibly available in family and dental practices and for education of healthcare workers.
Uvod: Pravilno sortiranje ostrih predmetov in infektivnih odpadkov, ki ga izvajajo zdravstveni delavci, 
je pomembno za preprečevanje opozorilnih nevarnih dogodkov, posebej vbodov z ostrimi predmeti pri 
nezdravstvenih delavcih, ki z odpadki prihajajo v stik. Cilj je bil raziskati ločevanje ostrih in infektivnih 
odpadkov v ambulantah družinske medicine in ambulantah zobne medicine.
Metode: Analiziranih je bilo 50 vreč infektivnih in 50 vreč komunalnih odpadkov iz petih ambulant družinske 
medicine in petih ambulant zobne medicine v petih dneh v oktobru 2016 v Domu zdravlja Osijek.
Rezultati: Zdravstveni delavci so v 70 % ambulant odlagali ostre predmete v infektivne odpadke. V 56 % vreč 
z infektivnimi odpadki so bili najdeni ostri predmeti. Ordinacije družinske medicine so ustvarile več rizičnih 
vreč infektivnih odpadkov (64 %), vendar brez pomembne razlike glede na ambulante zobne medicine (48 %) 
(P=0,143). Odlaganje infektivnih odpadkov v komunalne je bilo v praksi dokazano v 90 % ordinacij, infektivni 
odpadki pa so bili dokazano prisotni v 60 % vrečah komunalnih odpadkov. Ordinacije zobne medicine so imele 
več rizičnih vreč komunalnih odpadkov (76 %) kot ordinacije družinske medicine (44 %), vendar brez pomembne 
razlike (P=0,714).
Zaključki: Rezultati tega raziskovanja nam kažejo pomembnost izvajanja testiranj o pravilnem odlaganju 
ostrih in infektivnih odpadkov, da bi se zmanjšalo tveganje za poškodbe nezdravstvenih delavcev, ki prihajajo 
v stik z navedenimi odpadki. Dobljeni rezultati bi lahko bili uporabljeni za oblikovanje pisanih protokolov za 
pravilno odlaganje ostrih in infektivnih odpadkov, ki naj bi bili vidno dostopni v družinski in zobni medicini, in 
za edukacijo zdravstvenih delavcev.
ABSTRACT
Keywords: 
medical waste, 
injuries, primary 
healthcare
IZVLEČEK
Ključne besede: 
medicinski odpadki, 
poškodbe, primarna 
zdravstvena zaščita
*Corresponding author: Tel. + 385 9 590 830 72; E-mail: sanja.kanisek@gmail.com
10.2478/sjph-2018-0009 Zdr Varst. 2018;57(2):65-71
65
TVEGANJE ZA IZPOSTAVLJENOST NEZDRAVSTVENIH DELAVCEV, 
KI SO V STIKU Z INFEKTIVNIMI IN KOMUNALNIMI ODPADKI V AMBULANTAH 
DRUŽINSKE IN ZOBNE MEDICINE
Kanisek S, Gmajnić R, Barać I. Risk of potential exposure incident in non-healthcare workers in contact with infectious and municipal waste. 
Zdr Varst. 2018;57(2):65-71. doi: 10.2478/sjph-2018-0009.
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
In Croatia, waste management and its individual segments 
are regulated by numerous legal documents, which are 
fully compliant with European regulations (1), where 
medical waste management was regulated as a separate 
category of waste (2). The largest producer of medical 
waste is the health system, i.e., it is the by-product of 
the health service delivery (3). Most medical waste in 
Croatia consists of non-hazardous waste, which in its 
composition, corresponds to municipal waste, and only a 
small portion (14%) consists of hazardous medical waste 
(4), which requires special methods of disposal and 
treatment (2). In Croatia, hazardous medical waste, in 
respect with the hazardous properties and the methods 
of management, is divided into infectious waste, sharps, 
pharmaceutical waste, chemical waste, cytotoxic and 
cytostatic waste, amalgam waste from dental care and 
other hazardous waste – any waste that has some of the 
hazardous properties listed in Appendix III of the Act on 
sustainable waste management (1). Despite significant 
progress in the medical waste management in recent 
decades, errors are still present, and their consequences 
can be disastrous (5). Among the many potential health 
hazards from contact with hazardous medical waste are 
HIV infection, hepatitis B and C, gastroenterological, 
respiratory, skin, and numerous other infections (3). All 
persons who come into close contact with hazardous 
medical waste are exposed to a potential risk of injury, 
including those that produce such waste and those who 
handle it (3). The main groups of people at risk of injury in 
health institutions are nurses and support staff, where the 
highest rate of injury through medical waste is present in 
the staff responsible for cleaning and workers involved in 
the transport and disposal of waste (3). Although hospitals 
are the largest producers of medical waste, we should 
not neglect its production at the level of primary health 
care, which deals with 80–85% of health problems in the 
community (6) and is the input filter into higher levels of 
health system (7). In Croatia, there is no data on behaviour 
patterns of healthcare workers in family practice (FP) 
and dental practice (DP) when disposing of components 
of sharps and infectious waste. The aim was to examine 
the practice of classifying sharps and infectious waste 
of healthcare workers in FP and DP, and to examine the 
existence of risks for potential sharps injury and other 
exposure incidents in non-healthcare workers (cleaning 
staff, municipal workers) in contact with the said waste. 
These results would contribute to clarifying the pattern 
of behaviour of healthcare workers in FP and DP, when 
disposing of sharps and infectious waste, and point to 
the possible need for interventions that would enhance 
the said practice to reduce the risks of injuries in non-
healthcare workers.
2 METHODS 
In the area of Osijek – Baranja County in the year 2015, 
there were a total of 169 contracted FP teams and 123 
DP teams. Of the total number of contracted teams, in 
six health centres in Osijek-Baranja County, there were 
64 contracted FP teams and 47 contracted DP teams, 
where the Health centre Osijek had the largest number 
of contracted teams in these sectors (31 FP teams and 
22 DP teams) (8). FP and DP teams in Health Centre 
Osijek were chosen for medical waste analysis, as they 
are the most numerous among all services provided by 
all health centres and are the largest producers of sharps 
and infectious waste. In order to select practitioners 
that constitute a representative sample, categories of 
family and dental practitioners in Health Centre Osijek 
were determined based on their levels of activity and 
the annual patient visits in 2015 (8). Three categories 
of FP have been determined, namely: up to 12000 visits, 
from 12001 to 15000 visits and more than 15000 visits, 
as well as three categories of DP: up to 2000 visits, from 
2001 to 2500 visits and more than 2500 visits. Based on 
these categories, five FP teams (16.1%) and five DP teams 
(22.7%) from Health Centre Osijek were selected with 
the purpose of analysing infectious and municipal waste 
(Table 1). Given the relatively small daily amount of 
waste production in practice (in relation to the hospital), 
the overall, i.e., 100% daily production of infectious 
and municipal waste during 8 working hours per day, in 
selected 10 practices, over five average working days 
(weekends and holidays are excluded) in October 2016, 
was included for analysis of the types and quantities of 
waste components. Healthcare workers in the selected 
practices were unaware of the waste analysis.
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2.1 Waste Analysis
The waste was collected by the staff in charge of cleaning 
and analysed the same or the following day in order to 
avoid inaccurate results due to shrinkage of waste (9). 
When handling the waste during the analysis, personal 
protective equipment, a gripper for sorting and a 
protective pad on which the waste was sorted, were used. 
The sorted waste was weighed according to the groups 
and was later returned to the previously prepared new 
bags (9). Weighing was conducted on a moderate scale, 
with test spacing of 1 g, with the maximum value of 3000 
g. In order to save the data anonymity, all practices were 
numbered during monitoring according to the order of 
waste analysis on the first day of monitoring, i.e., the 
name of the practice was replaced by a number (i.e. FP-1, 
FP-5, FP-9 etc.). Waste analysis of other practices (i.e., 
paediatric, pulmological, occupational medicine, etc.) 
has been conducted as well, but due to the small number 
of these practices and a small waste production, was 
not included in this analysis. Waste analysis was photo-
documented. 
2.2 Statistical Analysis
Categorical data are presented in absolute and relative 
frequencies. Numerical data are presented in the median 
and limits of interquartile range. The differences of 
categorical variables were tested by Fisher’s exact test. 
The normality of the distribution of numerical variables 
was tested by the Shapiro-Wilk test. The differences of 
normally distributed numerical variables between the two 
independent groups were tested by the Mann-Whitney U 
test. All P values are double-sided. The level of significance 
was set at alpha=0.05. The statistical program MedCalc 
Statistical Software version 14.12.0 (MedCalc Software 
bvba, Ostend, Belgium; http://www.medcalc.org; 2014) 
was used for the statistical analysis. 
3 RESULTS
Two healthcare workers in each practice, where one 
worker had a high school education (nurse/technician) 
and the other a university degree (medical doctor/
dentist), or a total of 20 healthcare workers, were 
involved in the production of medical waste. Given the 
fact that every practice produced one bag of infectious 
and one bag of municipal waste daily, an analysis of the 
quantity and composition of 50 bags of municipal and 
50 bags of infectious waste was conducted. A few years 
ago, containers for sharps (1.5 l) and infectious waste 
(25 l), marked by the type of waste, were set beside 
the municipal waste container in every practice (25 l). 
Although the Ordinance of waste management in Health 
Centre Osijek was adopted a few years ago, no written 
protocols were available to the healthcare workers 
until after the implementation of this waste analysis. 
Improper disposal of sharps waste (needles, ampoules) 
into infectious waste was found in 70% of the practices, 
i.e., in four FPs and three DPs. The proportion of sharps 
waste into infectious waste in FP ranged from 4 to 20% of 
the total of infectious waste over five days and in DP from 
1 to 2% (Table 2).
Table 2. Five-day production of components of sharps in 
infectious waste in family and dental practices in 
Health Centre Osijek.
FP - family practice; DP - dental practice
FP-1
FP-5
FP-9
FP-12
FP-13
DP-3
DP-4
DP-8
DP-10
DP-11
30 (4)
94 (20)
29 (5)
55 (10)
0
11 (1)
29 (2)
0
19 (1)
0
815 (100)
478 (100)
548 (100)
531 (100)
626 (100)
1864 (100)
1387 (100)
2252 (100)
2141 (100)
3111 (100)
The proportion of 
sharps in infectious 
waste/5 days (%)
TOTAL infectious 
waste/ 5 days (%)
Table 1. The method of selection of FP and DP for waste analysis in Health Centre Osijek. 
FP - family practice; DP - dental practice
FP
DP
≤12000
12001-15000
>15000
≤2000
2001-2500
>2500
12
12
7
8
8
6
2 (16.6)
2 (16.6)
1 (14,2)
2 (25)
2 (25)
1 (16.6)
Health centre Osijek Categories of practices according to the 
annual number of patient visits in 2015
Number of practices 
within a category 
Number of selected practices 
from a particular category (%)
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The production of infectious waste in DP was significantly 
higher in relation to FP (P=0.009). Although the proportion 
of sharps in infectious waste was higher in FP, there were 
no significant differences in relation to DP (P=0.090) 
(Table 3). 
Table 3.
Table 4.
The average five-day production of sharps in infectious waste in family and dental practices in Health Centre Osijek.
The type and frequency of sharps in infectious waste over five days in family and dental practices in Health Centre Osijek.
*Mann Whitney U test
FP - family practice; DP - dental practice; IW - infectious waste; * Fisher’s exact test
The proportion of sharps in infectious waste/ 5 days (g)
Total infectious waste/ 5 days (g)
FP-1
FP-5
FP-9
FP-12
FP-13
DP-3
DP-4
DP-8
DP-10
DP-11
30 (14.5-74.5)
548 (505-721)
0/5
0/1
0/1
0
0
2/0
1/0
0
1/2
0
1/3
0/2
0/1
0
0
3/0
1/1
0
1/0
0
0/1
0/8
0/2
0
0
1/0
0
0
0/1
0
0/6
0/5
0/5
0/1
0
1/0
2/1
0
0/1
0
0/3
0/1
0/2
0
0
0
4/2
0
0
0
11 (1-18)
2141 (1626-2682)
0.090
0.009
0.143
16
12
5
5
5
1
0
4
4
0
4
0
Family practice
Day 1 Day 2 Day 3 Day 4 Day 5
The median (interquartile range)
Number of needles/ ampoules in infectious waste
Dental practice P*
P*
Total number 
of risky bags
IW
Number of 
risky bags 
IW
Given the number of bags of infectious waste produced over 
five days in all practices in which incorrectly disposed of 
sharps (needles, ampoules) were found, 28 (56%) of a total 
of 50 bags of infectious waste represented the potential 
risk for sharps injuries for other persons who come into 
contact with infectious waste. Although FP produced a 
larger number of high-risk infectious waste bags, 16 (64%) 
of the total 25 bags, no significant differences in relation 
to DP were found (12 (48%)) (P=0.143) (Table 4).
Improper disposal of infectious waste in municipal waste 
was established in 90% of the practices, that is, only one 
FP has not deposited infectious waste into municipal 
waste. The proportion of infectious waste in FP ranged 
from 2 to 4% of the total of municipal waste over five 
days, and in DP, from 5 to 25%. No sharps in municipal 
waste bags have been established (Table 5). 
10.2478/sjph-2018-0009 Zdr Varst. 2018;57(2):65-71
69
Although DPs produced a larger amount of municipal waste, 
there were no significant differences of production of 
municipal waste in relation to FPs (P=0.602). Significantly 
more of infectious waste in municipal waste in relation to 
FP was deposited by DP (P=0.009) (Table 6). 
Due to disposing of infectious waste into municipal waste, 
30 (60%) of the bags of the total of 50, presented a risk 
for potential exposure incident for other persons who 
came into contact with them (cleaning staff, municipal 
workers). Although DP produced a larger number of high-
risk municipal waste bags, 19 (76%) of the total of 25, 
compared to FP (11 (44%)), no significant differences have 
been determined (P=0.714) (Table 7). 
Table 5. Five-day production of components of infectious waste 
in municipal waste in family and dental practices in 
Health Centre Osijek.
FP - family practice; DP - dental practice
FP-1
FP-5
FP-9
FP-12
FP-13
DP-3
DP-4
DP-8
DP-10
DP-11
40 (2)
34 (4)
3 (0)
61 (4)
0
149 (18)
297 (10)
308 (25)
89 (6)
75 (5)
1652 (100)
767 (100)
1030 (100)
1637 (100)
898 (100)
841 (100)
2951 (100)
1252 (100)
1374 (100)
1607 (100)
The proportion of 
infectious in municipal 
waste/ 5 days (%)
TOTAL municipal 
waste/ 5 days 
(%)
Table 6. The average five-day production of infectious waste in municipal waste in family and dental practices in Health Centre Osijek.
*Mann Whitney U test
The proportion of infectious in municipal waste/ 5 days (g)
Total municipal waste/ 5 days (g)
34 (2-51)
1030 (833-1645)
149 (82-303)
1374 (1047-2279)
0.009
0.602
Family practice
The median (interquartile range)
Dental practice P*
Table 7. The amount and frequency of infectious waste in municipal waste over five days 
in family and dental practices in Health Centre Osijek.
FP-family practice; DP-dental practice; MW- municipal waste; * Fisher’s exact test
FP-1
FP-5
FP-9
FP-12
FP-13
DP-3
DP-4
DP-8
DP-10
DP-11
10
0
0
17
0
100
58
25
0
20
0
21
0
15
0
7
44
6
25
55
7
13
0
13
0
15
63
62
30
0
6
0
0
0
0
18
53
79
34
0
17
0
3
16
0
9
79
0
0
0
0.714
11
19
4
2
1
4
0
5
5
4
3
2
Day 1 Day 2 Day 3 Day 4 Day 5
Infectious waste in municipal waste (g)
P*
Total number 
of risky bags 
MW
Number of 
risky bags 
MW
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4 DISCUSSION
Sharp objects, such as used ampoules, should be disposed in 
situ into the sharps container (3, 10). Sharp objects which 
primarily are not contaminated, if stored in the infectious 
waste, get contaminated as a result of contact with other 
content of infectious waste (11). Sharps injury analysis 
in Croatia in the year 2015 (12) shows an increase in the 
number of reported accidental sharps injuries compared 
to the year 2014 (13). The largest number of incidents 
(63%) is related to the injuries with different kinds of 
needles. The most commonly injured were nurses (50%), 
followed by medical doctors (25%) and in high third place 
were the cleaning staff (10%) (12). From this analysis, the 
circumstances in which the cleaning staff members were 
injured, the frequency of which is quite high, considering 
that they are not in direct contact with patients, are 
not clearly visible (12). Sharps injury analysis in Croatia 
in 2015, states that a high number of sharps injuries of 
cleaning staff possibly results from improper sorting of 
waste in situ (12). The given assumption is supported 
by results of this research, which shows that healthcare 
workers in 70% of the practices, deposited primarily non-
contaminated sharps waste (mostly empty ampoules) into 
infectious waste by mistake. Research on the analysis of 
the sharps injuries in non-healthcare workers in health 
facilities have shown that 60–80% of such injuries are due 
to improper disposal of sharp objects in infectious waste 
(11, 14–16), and that more than 30% of such injuries were 
caused by sharp objects, such as glass (15). The fact that 
more than a half of the infectious waste bags were risky, 
where FP produced a larger number of high-risk bags of 
infectious waste, shows the frequency of such improper 
conduct of healthcare professionals and the consequent 
exposure to accidental sharps injuries of other people 
who come into contact with infectious waste, such 
as the cleaning staff. These results can indicate a lack 
of knowledge of the majority of healthcare workers 
from this research on the methods of disposal of sharps 
waste in situ and the lack of awareness of the potential 
dangers of such practice on the health of other workers 
who come in contact with infectious waste. In addition, 
it is possible that the said defect is more present with 
FP healthcare workers. Despite a number of preventive 
measures, such as education and design of protective 
mechanisms, proper sorting and disposal of waste in situ 
represents the most effective measure to prevent injuries 
(14). Infectious waste, disposed of in municipal waste, 
contaminates its entire content (17, 18), which, primarily, 
was not like that. Results of this research have shown 
that healthcare workers in almost all practices (90%) 
mistakenly deposited infectious waste (gloves, material 
for dental impression...) in the municipal waste, and 
almost two thirds of municipal waste bags represented 
risks for potential exposure incidents for other persons 
who come into contact with that kind of waste, where 
the DP prevailed in the number of produced contaminated 
municipal waste bags. Through such improper conduct of 
healthcare workers, the risk of endangering the health 
of others extends to an even greater number of people 
(e.g. municipal workers). Although the risk of infection 
in people exposed to exposure incidents through mucous 
membranes or injured skin is smaller than with injuries 
by contaminated sharp object, it is necessary to prevent 
these types of incidents, because the repetition of such 
exposure incidents increases the risk of transmission of 
infection (15). Based on the assessment method of disposal 
of medical waste, it is possible to identify activities 
where the improper sorting of waste in situ is conducted 
(19), and to determine the existence of risk of injury 
for non-healthcare workers (cleaning staff, municipal 
workers) who come into contact with the waste. While 
in literature, most attention is given to prevention of 
sharps injuries and other exposure incidents in healthcare 
workers, little attention is given to well-being and safety 
of non-healthcare workers who come in contact with 
hazardous medical waste (15). The results of waste 
analysis from this research emphasize the uncomfortable 
truth that the fundamental problem of exposure to 
harm of non-healthcare workers is a consequence of 
the improper conduct of healthcare workers when 
disposing of hazardous medical waste in situ (5). The 
results of this research confirm the recommendation on 
the need to conduct periodic surveys on sharps waste 
disposal with purpose of identifying incorrect procedures 
in practice (19), as well as the necessity for municipal 
waste surveillance, for a fuller insight into the practice 
of disposal of hazardous medical waste (5), all with the 
goal of preventing the sharps injuries and other exposure 
incidents of non-healthcare workers as well as all persons 
who come into contact with waste from health facilities. 
Characterization of medical waste is an essential tool 
not only to assess the production of waste within the 
institution, but also to accurately identify other types of 
problems (20). The results of this study reflect the paradox 
of the health care system in which healthcare workers on 
one hand ‘cure,’ but on the other hand ‘endanger’ the 
health. Although the results of this research cannot be 
generalized because of the small sample of monitored 
practices, they point to one aspect of risks for potential 
sharps injuries and other types of exposure incidents 
caused by the improper conduct of healthcare workers 
when disposing of sharps and infectious waste in situ.
5 CONCLUSION
The results of this research point to the importance 
of performing audits of proper disposal of sharps and 
infectious waste in outpatient settings, in order to reduce 
10.2478/sjph-2018-0009 Zdr Varst. 2018;57(2):65-71
71
the risks of injury to non-healthcare workers who come 
into contact with the said waste. Given results could be 
used for framing written protocols of proper disposal 
of sharps and infectious waste that should be visibly 
available in family and dental practices, as well as for 
education of healthcare workers, with an emphasis on the 
consequent dangers of improper conduct on the health of 
other people who come into contact with the said waste.
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
For the purpose of implementing this medical waste 
analysis, Health Centre Osijek has provided the nurse 
for control and prevention of infections with personal 
protection equipment as well as time needed within her 
working hours. 
ETHICAL APPROVAL
Received from the Commission for Ethical and Status 
Issues of Health Centre Osijek before the implementation 
of the research.
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