HEALTH CARE WASTE MANAGEMENT IN MACEDONIA Workshop on Waste and Healthcare Waste Management 24 October 2007 Ana Petrovska SLOVAK ENVIRONMENTAL AGENCY Basel Convention Regional Centre BRATISLAVA

Health care system in Macedonia Total of 101 major Healthcare Institutions (HIs) in the country comprising: Hospitals and specialised healthcare institutions at tertiary level (6) General Hospitals, specialised healthcare institutions and centres for rehabilitation at secondary level (47) Health centres at primary level (34) Total number of hospital beds at the tertiary and secondary level, including private hospitals, is approx. 10,000. There are also 745 private dentist ambulatories and 117 veterinary ambulatories and animal stations. Number of pharmacies is 498 and laboratories 54.

Survey on HCW management present practice A questionnaire survey has been carried out The overall response rate (41%) was satisfactory Based on results, the baseline data have been set, serving the purpose of stakeholder consultations and development of a platform (strategy) for future HCW management in the country

HCW Management baseline (I) Total HCW quantities are in the range of 900 - 1000 tons/year It is approximately 15% of the total waste quantities originating in Healthcare institutions Healthcare Institutions in Skopje and Kumanovo generate in total 450 tons/year; Absence of flue gas treatment at the "Drisla" incinerator causes significant risks for the human health and the environment Remaining quantities (500-550 tons/year) are disposed of mixed with other waste types at municipal dumpsites, although previous segregation takes place in majority of institutions

HCW Management baseline (II) Internal segregation up to dedicated storage point(s) is conducted in all health care centres Collection/transportation (external) system in Skopje is serviced by the Public Communal Enterprise "Komunalna Higiena"; the same company operates the incinerator; the company does not possess a license for transportation of hazardous waste External system in Kumanovo is organized by the General Hospital, enabling collection of HCW from all generators in the City and transporting total quantities once a week to the "Drisla" incinerator External transport for segregated HCW is not organised in other towns; the Kumanovo example may be followed by other General hospitals, however the incineration tariffs and transportation costs are the main obstacle at present

Internal HCW segregation and storage problems Absence of regularly appointed HCW managers proceeding upon written and acknowledged internal management plans/procedures Space constraints within treatment rooms and wards; No sufficient availability of elevators to safely move waste around hospital premises; Lack of space for secure temporary storage of infectious waste as well as lack of adequate ventilation and refrigerators in storage areas; Problems concerning availability of appropriate receptacles;

Typical internal HCW treatment procedure (I) Currently the only internal treatment of HCW is done in the Institutes for Health Protection as well as in Departments for Infectious Diseases located in the Clinical Centre-Skopje and in General Hospitals throughout the country. Internal treatment is done in small autoclaves and covers only HCW such as sharps, culture plates and small glass tubes with blood samples. Sharps are collected in yellow sharps boxes and disinfected using a low level disinfectant. When full, the sharps boxes are transferred into a transparent autoclave plastic bag (approx. 20 litres) mounted in a rack.

Typical internal HCW treatment procedure (II) When a plastic sharps box is used, this is often reused due to the relatively high costs of the boxes. Culture plates and blood tubes are collected in the same transparent autoclave plastic bag. The bags are marked with the infectious symbol. When a bag is full it is closed using a string and transferred to an on site autoclave. Following autoclaving the waste is without further treatment disposed into the municipal waste containers for disposal at the municipal landfill together with ordinary municipal waste. After sterilisation via the autoclave treatment, the sharps will pose a risk for the staff within the hospital, collection/transportation company and scavengers at municipal dumpsites

Legal framework and enforcement Present legal framework provides for the basis to implement sound management of the HCW in the future, while gaps being created under the intensive legal drafting process towards approximation are recognized by responsible authorities The institutional capacity to carry out policy formulation, monitoring / inspection, record keeping and reporting and enforcement is relatively low at present. Share of specific authorities among several institutions is neither clearly regulated, nor conducted in practice. No regular reporting of HCRW data are currently being conducted, neither by generators, transporters or treatment facilities.

Financing of the HCW management system Tariff paid for collection of HCW in the Skopje area is: MKD 56 per kg excl. VAT (18%). Tariff paid for delivery of HCW at the gate at Drisla Landfill is: MKD 45 (0,75 Euro) per kg excl. VAT (18%). Tariff paid for collection of yellow HCW boxes (25 litres) from private General Practitioners and ambulatories, etc. in the Skopje area, is: MKD 385 (6,4 Euro) per box (3 kg), or 128 MKD per kg. (2,0 Euro) excl. VAT (18%). Tariff paid for collection of yellow HCW boxes (25 litres) from private General Practitioners and ambulatories in Kumanovo MKD 130 (2,1 Euro) per kg excl. VAT (18%), to be paid to the Kumanovo Health Centre, which is organizing collection and transport to the "Drisla" landfill Transparency of setting the tariffs is not sufficient

Required improvements (I) Internal HCW management systems Setting clear internal procedures at hospital level Providing appropriate receptacles and transportation means within the premises, thus minimizing the manual handling and contact with HCW Improving the segregation at source aiming at reduction of total quantities for treatment/disposal Arranging for suitable storage conditions

Required improvements (II) External (collection/transportation) systems Organizing collection of segregated HCW from all generators Setting of collection points in bigger centres, serving as central storage facilities until transport to the disposal point is carried out; the central storage facilities at hospitals will be cooled with maximum temperature of 8 oC, while this is not necessary for storage facilities at the health centres. Appoint companies having the proper permit and license to carry out transport of hazardous waste.

Disposal options considered Treatment technologies Incineration Autoclaving Other methods being suitable for HCW types not covered by previous methods

Incineration It is considered as an all round treatment option. Mercury containing waste (e.g. amalgam waste from dentists), as well as the radioactive waste and waste containing significant amounts of heavy metals may not be incinerated. There isn't legislation in place regulating emission of hazardous substances originating from incineration in Macedonia Flue gas cleaning unit requires application of chemicals Ashes are considered hazardous waste, while in Macedonia there isn't any dedicated landfill accepting such waste Setting an Incinerator would require obtaining a stringent IPPC permit and regular monitoring upon operation

Autoclaving About 90 % of the yearly amount of HCRW can be treated in appropriate autoclaves. Chemicals, expired or unused drugs and pharmaceuticals including cytotoxic waste and mercury containing waste will remain problematic for disposal. Also the biological (pathological) waste may not be treated, depending on the selected autoclave type; The HCRW will after treatment be sterile and can be disposed of at a landfill together with ordinary municipal waste in compliance with the EU Landfill Directive; waste volume is reduced due to the shredding. Setting an autoclave would require less stringent IPPC permit, while monitoring is not as demanding as for incineration, due to lower emissions

Organisation A suitable management organisation must be established for the ownership and operation of the future medical waste management system. Authorities must decide on the split of responsibilities in all stages of HCW management: internal, external and treatment system(s) Public/private partnerships may be established for the external (collection/transport) and disposal (incineration and/or autoclaving) system(s) Transparent setting of tariffs must be taken into account at national level via relevant regulation, either by amendments of present laws, or by issuing a new regulation. Contracts must support linkage between all involved entities