PONE-D-20-06712

Awareness and Practice of Biomedical Waste Management among Healthcare Providers In

National Referral Hospital

PLOS ONE

Dear Ms yangden,

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

We would appreciate receiving your revised manuscript by Jun 21 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

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

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Itamar Ashkenazi

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

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

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for including your ethics statement: 

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

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

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

For additional information about PLOS ONE ethical requirements for human subjects research, please refer to " ext-link-type="uri" xlink:type="simple">http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research."

  

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

4. Please consider modifying your title to ensure that it is specific, descriptive, concise, and comprehensible to readers outside the field (for example by  including the name of the centre/location where you carried out this cross-sectional study)

5. Thank you for stating the following in the Acknowledgments Section of your manuscript:

"Fund was supported from JDWNRH"

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"The funders had no role in study design, data collection and analysis, decision to

publish, or preparation of the manuscript"

6. Please amend the manuscript submission data (via Edit Submission) to include author Chhimi Lhamo, Chandra Bdr Limbu, Sonam Yoezer, Thinley Jamtsho, Puja Chhetri and Dawa Tshering.

7. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

8. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: Partly

Reviewer #2: Partly

**********

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

Reviewer #1: I Don't Know

Reviewer #2: No

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

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

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

Research Summary:

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

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

General Reviewer comments:

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

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

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

Minor comments:

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

- lines 27-28: not clear sentence

- lines 29-30: not clear sentence

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

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

- line 129: “15 questionnaires”?

- lines 160-162: not clear sentence

**********

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

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

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

Reviewer #1: No

Reviewer #2: No

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

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

Attachments

Attachment

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

PONE-D-20-06712R1

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

PLOS ONE

Dear Dr. yangden,

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

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

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

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

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

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Carmen Melatti

Associate Editor

PLOS ONE

on behalf of 

Itamar Ashkenazi

Academic Editor

PLOS ONE

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

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

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

Reviewer #1: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

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

Research Summary:

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

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

General Reviewer comments:

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

Specific Comments:

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

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

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

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

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

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

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

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

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

**********

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

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

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

Reviewer #1: No

Reviewer #2: No

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

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

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

PONE-D-20-06712R2

Dear Dr. yangden,

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

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

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

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

Kind regards,

Itamar Ashkenazi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: