World Health Organization 11 November, 2018 Module 5 Health care waste management WASH FIT

Objectives Identify all types of healthcare waste Describe the steps of waste management Describe a waste management plan

Typical Healthcare Waste Compositions Between 75% and 90% of the waste produced is similar to domestic waste and usually called ‘non- hazardous’ or ‘general health care waste’ 10-25% of health care waste is regarded as ‘hazardous’ and may pose a variety of environmental and health risks Source: Safe management of waste from health-care activities, WHO, 2014

Non-hazardous / general waste Waste that does not pose any particular biological, chemical, radioactive or physical hazard Can be disposed of as household waste/garbage through the available landfills/waste disposal sites set by cities / municipalities or waste pits at the facility Examples Packaging materials (paper, cartons, sacks…) Plastic bottles and cans Food remains Dry grasses and fallen leaves Outdated equipment/furniture that does not contain hazardous elements (doors, office cabinets, sofa, etc.)

Hazardous waste Causes various health and environmental risks Requires special care from the point of generation until final disposal Requires treatment prior to final disposal Categories Infectious waste Sharp waste Pathological waste Pharmaceutical and cytotoxic waste Chemical waste Radioactive waste

Hazardous waste Category Examples Sharps waste Infectious waste Used or unused sharps (i.e. hypodermic, intravenous or other needles; auto-disable syringes; syringes with attached needles; infusion sets; scalpels; pipettes; knives; blades; broken glass Infectious waste Waste suspected to contain pathogens and pose a risk of disease transmission (i.e. waste contaminated with blood and other body fluids; laboratory cultures and microbiological stocks Pathological waste Human tissues, organs or fluids; body parts; foetuses; unused blood products Pharmaceutical waste, cytotoxic waste Pharmaceuticals that are expired or no longer needed; items contaminated by or containing pharmaceuticals Cytotoxic waste containing substances with genotoxic properties, e.g. waste containing cytostatic drugs (often used in cancer therapy); genotoxic chemicals Chemical waste Waste containing chemical substances (i.e. laboratory reagents; film developer; disinfectants that are expired or no longer needed; solvents; waste with high content of heavy metals, e.g. batteries; broken thermometers and blood pressure gauges) Radioactive waste Waste containing radioactive substances (i.e. unused liquids from radiotherapy or laboratory research; contaminated glassware, packages, or absorbent paper; urine and excreta from patients treated or tested with unsealed radionuclides; sealed sources)

Waste management processes Waste minimization Segregation Handling Collection Transport Storage Treatment Final disposal

Waste minimization This is the first and best way to reduce healthcare waste quantities and costs Purchases of material and supplies should be made with waste reduction in mind Issuing of supplies should follow first expire, first out (FEFO) and first in, first out (FIFO) rules Encouraging the use of tablet medication as an alternative to injection to reduce sharps waste Encourage recycling and reuse of non-infectious materials (e.g. glass, plastic and cardboard) Example of purchases with waste reductions: quantity of syringe (box size; 1 box of 100 instead of 5 box of 20), most frequently use sizes of PPE items in larger quantity

Segregation Different types of waste require different handling, treatment and disposal Must start at the source All waste must be segregated into these categories: Basic (all patient care areas) = 3 bins Bin for general waste (black bag in a bin) Bin for infectious waste (yellow bag in a labeled pedal bin) Sharp container or needle cutter Special areas Anatomical or pathological (operating theatre and labor rooms) Chemical waste e.g. mercury containing waste or x-ray liquids Pharmaceutical waste (pharmacy, wards) Exceptional waste segregation Cytotoxic Waste (oncology, pharmacy), Radioactive (oncology – cancer treatment unit) Need to be review…

Three-bin System (Basic healthcare waste categories) Black Lined container Yellow Lined Container

Handling – basic principles Wear appropriate personal protective equipment (PPE) Handle waste with care Practice hand hygiene before and after handling waste Do not re-sort waste Never carry waste bags/containers against body Avoid heavy loads (use transport tools)

Collection A schedule should be available for reference Waste bags should be collected when 3/4 full or at least daily Sharp waste should be collected when the container is 3/4 full Tie bags securely After removing the waste bag, replace with a new one

Transport Wear appropriate PPE Transport waste with covered trolley, wheel barrow, wheeled bin, or a cart Separated transport of hazardous and non-hazardous waste Transport equipment should be dedicated for waste transportation only The equipment must be cleaned and disinfected at the end of each working day Add picture

Storage of Infectious and Sharp Waste Inaccessible to unauthorized persons, animals, insects and birds Sign with biohazard symbol Floor and walls are sealed or tiled to allow easy disinfection Keep well ventilated & protected from rain Restrict access-lock at all times Use for waste only Large enough to cater for over-flow waste due to collection and treatment breakdowns.

Storage Storage times for infectious waste (e.g. the time gap between generation and treatment) should not exceed the following periods: Temperate climate: 72 hours in winter 48 hours in summer Warm climate: 48 hours during the cool season 24 hours during the hot season Source: Safe management of waste from health-care activities, WHO, 2014

General waste storage areas Sized according to the quantities of waste generated and the frequency of collection Fenced and paved Easy access for municipal waste collection trucks In case of recycling activities separate areas for recyclables should be available

Treatment - Incineration An incinerator is the ideal method for burning infectious and sharp waste The incinerator should have two burning chambers The location of the incinerator should be away from the medical wards and public housing Wear heat-resistant gloves when handling flammable material It is essential to make sure that total incineration has taken place Basic waste treatment technology. WASH 28

Alternative treatment technologies Autoclaves (steam treatment technology) Gravity displacement autoclaves (with and without integrated shredder systems Pre-vacuum or high vacuum autoclaves Pressure pulse autoclaves Microwave treatment technologies Frictionated heat treatment technologies

Final disposal methods Ash pit: Disposal of incineration ash Landfill or waste burying pit: Disposal of general waste including the autoclaved waste Burning pit: Disposal of waste only during emergency in the absence of incinerators/autoclaves. It causes higher smoke pollution and other health risks Encapsulation: Disposal of expired vaccines, medications by adding immobilizing materials i.e. cement and seal the container Placenta pit: Disposal of placenta and body parts

Example drawings: Pits Source: Technical Specifications, Healthcare Without Harm / MSF

Final disposal methods - Landfill Lined to prevent leachate from contaminating the environment For liquid waste where do we dispose?? Cross-section of an active Landfill www.blueenvironmental.com/images/imgLandfillD

What is wrong in this picture? Waste is: Not segregated Exposed Not treated Not properly disposed

Risk assessment Think about your workplace, what can harm you, patients and their families? Which part of your body can be exposed to the harm? Which PPE items can protect you? Change questions

Healthcare Waste Officer A responsible person for the management of healthcare waste should be appointed (Healthcare Waste Officer – HWO) Roles and duties: Introduction of supervision of safe handling methods Data recording Regular training of medical and logistic staff Development and revision of a waste management plan Observing the legal regulations Supervision of safe waste treatment and disposal

Content of a Waste Management Plan Aims and Objectives Legal background and Responsibilities Generated waste and waste amounts Waste handling procedures Segregation, Collection, Transport, Storage, Treatment, Disposal Occupational Safety Education and Awareness Documentation and Recording Action Plan and budget

WASH FIT Indicators (1) ESSENTIAL 2.11 A trained person is responsible for the management of health care waste in the health care facility. 2.12* Functional waste collection containers for 1) non-infectious (general) waste, 2) infectious waste and 3) sharps waste in close proximity to all waste generation points. 2.13 Waste correctly segregated at all waste generation points. 2.14 Functional burial pit/fenced waste dump or municipal pick-up available for disposal of non-infectious (non-hazardous/general waste).

WASH FIT Indicators (2) ESSENTIAL 2.15* Incinerator or alternative treatment technology for the treatment of infectious and sharp waste is functional and of a sufficient capacity. 2.16 Sufficient energy available for incineration or alternative treatment technologies (mark if not applicable) ADVANCED 2.17 Hazardous and non-hazardous waste are stored separately before being treated/disposed of or moved off site. 2.18* All infectious waste is stored in a protected area before treatment, for no longer than the default and safe time.

WASH FIT Indicators (3) ADVANCED 2.19* Anatomical-pathological waste is put in a dedicated pathological waste/placenta pit, burnt in a crematory or buried in a cemetery (if applicable). 2.20* Dedicated ash pits available for disposal of incineration ash (if applicable). 2.21 Protocol or SOP (Standard Operating Procedure) for safe management of health care waste clearly visible and legible. 2.22* Appropriate protective equipment for all staff in charge of waste treatment and disposal.

WASH FIT Indicators 3.10 Dedicated ash pits available for disposal of incineration ash (mark if not applicable) 3.11 Protocol or SOP (Standard Operating Procedure) for safe management of health care waste clearly visible and legible. 3.12 Appropriate protective equipment for all staff in charge of waste treatment and disposal.

Questions?