Training structure EFFO Safety and good quality work Module 1: Ebola Virus Disease Module 2: Epidemic control on different levels Module 3: Standard precautions & disinfection Module 4: Screening & isolation Module 5: Personal protective equipment Module 6: Waste management & cleaning Support from the community Support from the hospital administration Support from the population 01.08.2017

Waste management & cleaning Module 6 01.08.2017

Learning objectives module 6 General objectives To know the principles of general waste management To be able to apply waste management in the red area Specific objectives To name the different types of waste and to be able to apply waste separation To understand the adequate management of highly infectious waste To know when and how to clean and disinfect contaminated areas To be familiar with the procedures and the responsibilities in the event of death Note - In the first part of this module, the general waste management in everyday hospital operations is presented. The second part explains the handling of highly contagious waste in the red zone. Participants should understand the differences! 01.08.2017

Waste management Adequate waste management = Ensuring hygiene in the hospital and preventing infections  reduce nosocomial infections  ensure the safety of all actors Know the national specifications with the technical guidelines Good waste management depends on the commitment of the entire staff. Group discussion Who is «the entire staff»? → health workers (doctors, nurses, assistants), janitors, technical staff (cleaners, waste management personnel, laboratory personnel, pharmacists), administrative staff, security guards, ...... but also think of people outside off the hospital: transport personnel, infrastructure staff Personnel trained in waste management have the responsibility to also supervise other persons who are part of the waste management. → Continuing education and continuous supervision of the staff is essential! Literature ICRC, « Manuel de gestion des déchets médicaux », 2011 01.08.2017

Domestic waste also is produced in hospitals! accounts for 75 - 90 % of the waste generated by health-care activities Office waste, paper, packaging, magazines, non-contaminated dressing material, bottles, food leftovers, ...  Follows the recycling chain such as municipal waste Additional information No specific treatment of domestic waste on hospital level necessary Group discussion Other examples of domestic waste can be collected with the group. Literature « Préparation des Plans Nationaux de Gestion des Déchets de soins médicaux en Afrique Subsaharienne », OMS 2004 01.08.2017

Infectious waste in hospitals can potentially transmit infectious agents to humans Used material that is contaminated with blood (laundry, aprons, gloves, ...), used bandages, ...  Follows the chain for infectious waste Group discussion Collect further examples of infectious clinical waste with the participants, e.g.: Solid waste: single-use hospital clothing that is soiled with bodily fluids Liquid waste: blood products, vomit, diarrhea Organic waste: placentas, organs removed, amputated body parts Sharp and pointed waste: Needles, catheters, ampoules, syringes, glass objects, tweezers, scalpel, ... (Sharp and pointed waste must be disposed of in a designated container immediately after use. 01.08.2017

Management of clinical infectious waste Collect all solid infectious waste in a watertight garbage bag that is in a trash can with a lid Ethical aspects: Collect organic waste in dedicated sacks, separate from other waste Put sharp and pointed objects in suitable puncture-proof containers Solid waste Anatomic parts Sharp and pointed objects Note At this point, it should be pointed out that this slide shows the management of infectious clinical wastes (the management of HIGHLY infectious waste will be dealt with in the second part of the presentation) Literature « Une meilleure gestion des déchets d’activités de soins », OMS, 2005  Disposal according to local legislation 01.08.2017

Initial sorting of waste = most important stage for an adequate waste management The initial sorting of waste must be done the moment it is produced: this is the responsibility of all actors! It should be avoided to mix different types of waste: waste separation! Safe transport of waste: in garbage cans / wheelbarrows  not close to the body! Group discussion Discuss important elements of initial waste sorting: « The initial waste sorting should: always take place at the place where the waste is produced be easy and consistent put into practice for the staff be sure and guarantee the absence of infectious waste in household waste Be well understood and known to the hospital staff be regularly inspected to ensure standards are met » Literature « Préparation des Plans Nationaux de Gestion des Déchets de soins médicaux en Afrique Subsaharienne », OMS 01.08.2017

Waste management – general points Always try to reduce the waste volume: waste separation during sorting Recycling / reuse of certain objects (if possible) Never fill the safety containers or garbage bags more than 2/3 → secure closure & adequate weight → safe transport If the waste is further processed → adequate equipment (work clothes, adequate gloves, ...) Waste must be sorted and separated where it is produced! Group discussion What happens if the garbage bags are filled to more than 2/3? Become aware of the problems that can be caused: no secure closure possible, difficult transport (weight!), Increased risk of injury (especially with sharp and pointed objects) 01.08.2017

Storage of waste Area for the storage of waste: Fenced / closed Protected from rain, animals and unauthorized persons (especially children) Marked with the international symbol of biological hazards Limited storage time Additional information The storage time of waste depends on the climate (moderate temperatures: up to 72 hours / hot temperatures: up to 24 hours); the local conditions must also be considered! (WHO) Purpose of waste elimination: Inactivation of pathogens ... while negative consequences for health and the environment are minimized. First choice according to WHO: autoclave (= sterilization under pressure with steam at high temperatures) Advantage: low pollution Disadvantages: little volume reduction of the waste, dependence of a permanent and reliable power supply Literature «  Safe management of wastes from HCF », WHO, 2014 (http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1) 01.08.2017

Incineration of waste Inactivation of pathogens Significant reduction of volume and weight of the waste Different types of incinerators: Efficiency depends on the maximum temperature reached Complete incineration of waste is important Emission of pollutants and toxic ash Necessity of a final storage possibility of the ashes Additional information Incineration = transformation of organic and combustible waste by fire in ashes Literature « Ash from incineration is conventionally considered to be hazardous by virtue of its likely heavy metal content and the dioxins and furans it may contain » (WHO, 2014, Safe management of wastes from HCF) 01.08.2017

Waste disposal - minimal approach In crisis situations: Isolation of waste = elementary to protect public health Open incineration with gasoline - No safe complete incineration guaranteed (e.g., cannulas) - Attention: risk of burning by not wearing adequate PPE (e.g. adapted gloves) Controlled and safe disposal = elimination of hospital waste in a pit Note These approaches are not recommended by the WHO and should only be used in crisis situations! Literature « Une meilleure gestion des déchets d’activités de soins », OMS, 2005 « Manuel de gestion des déchets médicaux », CICR, 2011 01.08.2017

Adequate waste management – key points Waste sorting (where produced!) Responsibility of all actors in the hospital Management of waste according to the local legislation Safe elimination by e.g. incineration Group discussion Summarize the most important aspects with participants: Responsibility of all actors in the hospital Waste management according to local legislation, as well as the elimination Distinction between household waste and infectious hospital waste, both incurred in the hospital Attention: sharp and pointed objects Initial waste sorting (where the waste is produced) = essential step Controlled and safe transport and storage Questions? / Further discussion: What is the local procedure? Which categories of waste are sorted / separated? How is waste further processed? Controlled and safe transport and storage Attention: sharp and pointed objects 01.08.2017

Learning objectives module 6 General objectives To know the principles of general waste management To be able to apply waste management in the red area Specific objectives To name the different types of waste and to be able to apply waste separation To understand the adequate management of highly infectious waste To know when and how to clean and disinfect contaminated areas To be familiar with the procedures and the responsibilities in the event of death Note: Make clear that the following slides concern the management of HIGHLY infectious waste 01.08.2017

Introduction: Highly infectious waste Essential elements for preventing the transmission of infections: Standard precautions Disinfection PPE Note - We have already learned the importance of PPE and standard precautions in preventing the transmission highly infectious diseases and other infections. - The role of health agents: Rigorously applying the standard precautions to all patients and at all times. Source: RKI 01.08.2017

What is highly infectious waste? Certain laboratory waste (certain culture media or blood tubes,…) All waste being produced in contact with a patient with VHF (Ebola, Lassa,…) All waste from the red area of an isolation unit When dealing with highly infectious waste wear full PPE. Similarly, when cleaning the red zone and laundry from the red zone, at the funeral of corpses, .... Source: RKI 01.08.2017

Dealing with waste in the red zone (I) All waste produced in the red zone is a highly infectious waste! Paper, packaging, kitchen utensils, laundry, reusable parts of PPE, cleaning utensils, ... Attention: sharp and pointed objects ! Always use sharp and pointed objects in puncture-proof containers This container should be positioned as close as possible to where the sharp and pointed objects are being used Group discussion Collect with the participants further elements that occur in the red zone and are accordingly classified as highly infectious waste 01.08.2017

Dealing with waste in the red zone (II) Solid waste → collect in a liquid proof garbage bag with the symbol for biological hazards and the mark «highly infectious» which is located in a trash can with lid Collect liquid waste → in a bucket (one bucket / patient) → dispose of it in the drain or latrine (without pretreatment) - Attention: splashes! Provide an intermediate storage zone for waste in the red zone → To distinguish the waste from others, highly infectious waste must be marked as “highly infectious" as well as being marked with the symbol for biological hazards. Group discussion There is a color code that you should know for each country. In any case, the highly infectious waste must be marked as such! This must not be mixed with "normal" infectious garbage outside the red zone. Discuss with the participants why (shorter storage time, faster elimination) When it comes to liquid waste, try to make it less liquid: put cellulose on it or a sheet and put it all in a watertight bag. Literature “pocket guide for front-line HCW: Clinical management of patients with VHF”; WHO, 02/16 Highly infectious 01.08.2017

How to discharge waste from the red zone? Preconditions: Garbage bags = max. 2/3 filled Before final closure of a garbage bag → have a new garbage bag / trash can ready (cleaning of the used garbage can) Use of 0.5% chlorine bleach for the disinfection of garbage bags / trash cans in the red zone Just like a laboratory test, waste from the red zone must be transferred to the green zone in several steps! Additional information The discharge of waste can take place in different ways. This also depends on the equipment; however the logic should always be maintained. Waste can thus be removed safely from the red zone even with less material. Once the waste is in the green zone, it is considered green. 01.08.2017

Storage & elimination of highly infectious waste Safe transport of waste: in wheelbarrows / garbage cans Provide a separate storage zone for highly infectious waste (do not mix it with other waste!) Elimination according to local specifications Note - The picture shows a person responsible for the incineration of the waste (during an exercise) Source: RKI 01.08.2017

Cleaning in the red zone For cleaning in the red zone (e.g. for wiping infectious material) → wear full PPE Red Zone 1) Put cellulose / towel on the infectious material 2) Disinfect with chlorine solution 0.5% Always clean from the "cleanest areas" to the "dirtiest areas" Additional information First: Clean - Then: Disinfect: To avoid the ineffectiveness of the disinfectant due to organic matter, remember never to mix soap with chlorine bleach! Always clean from the "cleanest areas" to the "dirtiest areas": to prevent contamination from being carried on. Replacement of cleaning solutions, because they are quickly polluted. Safe disposal in the sink or duct. Note - The picture shows the cleaning of the red zone during a simulation exercise. RKI Source: RKI 01.08.2017

Never sweep when it is dry! Cleaning – key points Never sweep or clean without liquids → Dusty towels should never be shaken Spray disinfectant only when needed Never sweep when it is dry! Regularly replace detergents → especially soiled bleach (chlorine solution) should not be used Additional information Never sweep or dry clean: Cleaning with a wet towel helps to prevent contamination of air and other surfaces by airborne particles. Source: RKI 01.08.2017

Laundry management Laundry from the red zone is thrown away and is treated as highly infectious waste. If laundry must be reused: Careful handling of the laundry from the red zone Avoid splashes, protect yourself with adequate equipment (full PPE) Never carry the containers with laundry directly on the body. Wash with detergent and water → rinse → disinfect for 30 minutes in 0.05% chlorine solution Literature “Pocket guide for front-line HCW: Clinical management of patients with VHF”; WHO, 02/16 01.08.2017

Water and purification Minimum requirements in health facilities: Sufficient supply of drinking water for the personnel, auxiliary staff and patients Separation of excreta (stools and urine) from sources of drinking water Effective isolation of excreta so as to prevent any human contact Separate toilets for suspected and confirmed cases of VHF Group discussion - What is the current situation in the health facilities where the participants come from 01.08.2017 24

Multidisciplinary response Bleach (chlorine solution) Standard precautions Cleaning Waste & Cleaning Elimination of waste Water and purification Note The fight against highly contagious diseases requires a multidisciplinary approach! Refer to Module 3 (Standard precautions) To remind the participants: We are talking about topics that are not solely the responsibility of the medical staff. However it is important to be aware so that we know what needs to be considered. Management of laundry 01.08.2017

Safe burial procedures The body of a patient who has died from VHF (e.g. Lassa, Ebola) is still highly contagious. Handling should be kept to a minimum! Inform the burial team for moving and burying deceased patients. If the corpse needs to be transported - e.g. to a secure site until the burial team arrives - wear full PPE! Do not wash or embalm human remains. 01.08.2017

Communication with the family of the deceased Offer your condolences Take account of cultural and religious practices Explain to the families of victims that corpses are contagious and explain the idea of disinfection Explain to them that they cannot wash or embalm the body Source: WHO 01.08.2017

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Exercise: Sorting waste What are the local practices? Which categories for waste separation are available? How is waste processed (burned, etc.)? → Sorting exercise with items written on cards Source: RKI 01.08.2017