1. HOSPITAL WASTE MANAGEMENTPROJECT TRAINING FOR MEDICAL OFFICER By: Alamgeer Memon Project Manager Mashriq Foundation Hyderabad 24 th March 2010

2. Mashriq Foundation Mashriq Foundation is an NPO and has a multi-dimensional focus on Environment and community health activities. Based in Hyderabad, Mashriq Foundation is currently executing following two projects 1. Hospital Waste Management (HWM) Project at 4 Taluka hospitals of Hyderabad District with collaboration of UNDP GEF SGP 2. Hospital Waste Management (HWM) Project at DHQ Hospital Sanghar with collaboration of BP Pakistan

3. How We conceived this project

4. Disposal Movie

5. Disposal End …..

6. Project Nexus ► Burning of HW – dioxin formation ► Exposure of hepatitis B & C through needle pricks

7. HOSPITAL WASTE HAZARDS (i) Occupational Risk ► Medical as well as sanitary workers & scavengers are at risk. Sharps are the most dangerous category. ► Scavengers at the municipal storage and dumpsites and those dealing with reuse/recycling activities (ii) Risk to the Population ► Through unauthorized reuse and recycling practice, particularly of disposable syringes (iii) Indirect Risk via Environment ► Contamination of drinking & irrigational water. ► Contamination of soil and underground waters. ► Air pollution through uncontrolled burning

8. Injection safety practices The reference definition of a safe injection ► In order not to harm the patient, the injection should be administered with a sterilized syringe and needle, using the right medication, etc. ► In order not to expose the provider to any avoidable risk, the needle should be placed in a puncture-proof container immediately after use. ► In order not to result in any waste that is dangerous for other people, sharps waste should be discarded appropriately

9. Why this project: ► According to WHO, contaminated needles and syringes represent a particular threat as these are scavenged from dump sites and be reused. ► WHO has estimated that, in year 2000, injections with contaminated syringes caused:  21 million hepatitis B virus (HBV) infections (32% of all new infections);  2 million hepatitis C virus (HCV) infections (40% of all new infections);  260 000 HIV infections (5% of all new infections) ► Epidemiological studies indicate that a person who experiences one needle- stick injury from a needle used on an infected source patient has risks of 30%, 1.8%, and 0.3% respectively to become infected with HBV, HCV and HIV.

10. HW MANAGEMENT – SELF ASSESSMENT S. No Statement Your score Is there a designated person in charge of waste management in the facility? Is there a written standard operating procedure (SOP) for waste management in the facility? Is there a system for segregation of waste in place? Are the staff aware of risks associated with improper waste handling? Are auto-disable syringes used for injection? Are syringes discarded with their needles attached? Is there a secured waste storage area on site? Is safety boxes, bins, waste bags transportation system safe? Do you see hospital waste littered outside? Is there a specific budget for waste management? There was an overall sense of increased safety from t he staff doing the injection. There was an overall sense of increased safety from t he staff doing the injection. They also reported a real saving in the time they spe nd in taking care of the used injection material. They also reported a real saving in the time they spe nd in taking care of the used injection material. Qw

11. Waste Transport

12. Hospital Waste Types:

13. Carriers

14. Segregation/collection ► The most important component of HWM is segregation. ► Segregation is the process of separating different waste streams while keeping in view the type of treatment and disposal options. ► Risk waste will be separated at source from non-risk waste at the ward bedside, operation theatre, laboratory etc. ► Risk waste includes all infectious waste e.g.. soaked bandages, pus, blood and bloody material, used syringe/needles etc ► Non-risk waste includes Paper, carton, used drips, empty glass bottles, used vials/ampoules and Garbage

15. Collection & Transportation ► Collection will be on daily basis from specific color coded waste bins ► Risk waste from Red-bins and non risk waste from Blue- bins placed at bed side, will be collected separately in the LARGE bins of same color scheme ► Transportation of waste from wards to Central Storage Facility will be done by covered drums

16. HW Storage ► Mashriq Foundation suggests Central storage room facility with Incinerator. ► CSF locations to store waste temporarily before Incineration and Land filling/Dumping ► These CSF will be covered and having large containers for the waste storage

17. HW Disposal: ► Incineration for Risk/ Infectious waste ► Land filling for Non-risk waste ► Packing papers, plastic bags, empty bottles and other pharmaceutical waste of non-infectious type back to supplier

18. Story of Incinerator

19. What is Incineration ► Technologies using high-heat thermal process generally operate at around 1000 °F to 15,000 °F or even higher. ► High heat process involves chemical and physical changes in both organic and inorganic materials resulting in total destruction of waste. ► Oxidation at high temperature converts organic compounds in the waste into their CO2 and water. ► Inorganic components are mineralized and converted into ash ► These conversions result in very significant reduction of waste volume and weight, at times up to 95-99%. ► Incineration is the oldest and still the most commonly-used method for the HWM in most of the countries

20. Dioxin ► Dioxin belongs to a family of 419 chemicals with related properties and toxicity, but the term “dioxin” is often used to refer to the 29 that have similar toxicity. ► Dioxin is one of the most toxic chemicals known to humankind. Its toxicity is measured in monograms ► WHO last year acknowledged dioxin’s cancer-causing potential when they classified it as a known human carcinogen ► The U.S. EPA has determined that airborne dioxins settle onto soil and plants. Dioxins enter the air from waste burning and other natural sources

21. Incinerator – Opposite arguments ► In the west, some environmental criticize incinerator on account of not meeting dioxin and furan limits

22. Disposal Methods

23. Infectious Wastes ► Infected HW can transmit diseases, especially if it finds portals of entry. ► Main concern of infectious hospital waste is the transmission of HIV/ AIDS virus and more often of Hepatitis B or C virus (HBV) through injuries caused by syringes contaminated by human blood. ► Potential risk of TB/ Throat infection, Typhoid, Dysentery, Diarrhea, Bacterial/ Viral diseases, ARV (Rabies), VDRL (Sexually transmitted disease), UTI/ all C/S, and Leprosy etc. as the pathological laboratories do all these analysis to diagnose the diseases

24. Waste not to be Incinerated ► Pressurized gas containers ► Large amounts of reactive chemical waste ► Radioactive waste ► Silver salts or radiographic waste ► Halogenated plastics (e.g. PVC) ► Mercury or cadmium ► Ampoules of heavy metals

25. HWM – Good and Bad practices

30. Color coding of Waste Bins ► Red colored waste bins for Risk/infectious waste ► Blue colored waste bins for Non-risk waste ► Black colored dust bins for Garbage (fruits/food)

31. Screening & Vaccination of staff ► There will be a regular program of Screening and Vaccination of Hepatitis B & C, for hospital staff ► Initially the Sanitary staff of Hospital is being given this facility ► Step by step, other categories will also be included

32. HW Regulations: ► The HWM Rules 2005 were notified by Pakistan EPA ► HWM Rules 2005 describes organizational process of hospital management along with prescribing n forming waste management responsibilities on the hospital administration ► In reality this is not being practiced in public sector hospitals but LUH is pioneer and has started by formation of WMT

33. What is Waste Management Plan EPA’s HWM Rules 2005 require all hospitals to develop and implement Waste Management Plan ► A map of the hospital showing  the waste generation points for every ward and department,  indicating whether each point is for risk waste or non-risks waste, and  showing the sites of the central storage facility for risk waste and  the central storage facility for non-risk waste; ► Details of the types, numbers and estimated costs of containers, waste bags and trolley required; ► Timetables including frequency of waste collection from each wards; ► Duties and responsibilities for people where waste is generated, and be involved in the management of the waste; ► Estimate of the number of staff members required for waste collection; ► Procedures for the management of waste requiring special treatment before final disposal; ► Contingency plans for storage or disposal of risk waste in the event of breakdowns of incinerators, or of maintenance or collection arrangements; ► Training courses and programs on waste management.

34. Monitoring & Ownership System ► This whole program will be looked after and owned by “Waste Management Team” ► The Ward-Administrator and Incharge of Labs and other departments will play key role ► Civil Surgeon, obviously, will be the head of whole activity

35. Sustainability: ► HWM system will be considered as a routine business of hospital rather than one-time project activity ► WMT will develop a comprehensive “Waste Management Plan” ► This Plan will be the actual document to achieve the desired goals under this HWM system

36. Email Distribution Group ► We suggest to start a email based discussion / information sharing group

37. Injection Safety

38. Are We ready for the change ??

39. Personal Commitment For the improvements of HW Management, I, Dr. …………… personally commit to do following 1. Nothing specific. I happy the way things are happening around me. It is administration's worry 2. Ensure that I always use syringe cutters wherever I use.. 3. Understand and preach for better HW management 4. To promise myself to leave at least one of the habits contributing in mismanagement of “Hospital Waste” 5. To adopt at least one measure of improving the “Hospital Waste Management”

40. The End