1. Managing Sharps Waste In Cambodia SIGN Meeting, 25 October 2002 Cambodiana Hotel, Phnom Penh Dr. Chea Kim Ly, Deputy Director National Immunization Program

2. Current safe injection interventions in Cambodia Relatively new still in Cambodia – since 1999 Ensuring safe injection and waste management is a collaborative effort in Cambodia, involving: Safe Injection Committee HIV Prevention Programme Essential Drugs National Immunization Programme Reproductive Health Health System – National, Operational District, Province, Health Centres, Village and Commune levels Ministry of Environment

3. 1 2 3 456 Cambodia management of sharps waste by proper use of safe injection equipment in all levels of the health system 7

4. Three key safe injection equipment: A-D syringes

5. Three key safe injection equipment: Local safety boxes

6. SICIM – 13 in CAMVULCAIN DISTRICT REFERRAL HOSPITAL BURNERS - Safety boxes not burned here, only medical waste Three key safe injection equipment: Incinerators

7. Overview: NIP goals for safe injection interventions Every immunization is done with a sterile needle and syringe All used injection material is properly disposed of in an appropriate way The program discourages the use of disposable equipment that can be re-packaged without proper sterilization The NIP will transition to auto-disable syringes and safety boxes for all immunization by the end of 2002

8. NIP has implemented the national safe injection policy by developing the following into its strategic plan: Introduction and distribution of donated A-D syringes and safety boxes into immunization programme activities Supplementary immunization activities (SIAs) Routine immunization activities Training for SIAs and routine A-D syringes Safety boxes Incinerators Distribution: Exchange system Monitoring and supervision into integrated supervision activities NIP role

9. Safe injection equipment introduction plan A-D syringes and safety boxes are already being used for all supplementary immunization activities (SIAs) – since 1999 A-D syringes and safety boxes have been introduced to the routine program in Kg. Chhnang OD with the DPT-Hep B introduction – since 4Q 2001 A phased introduction of A-D syringes and safety boxes will follow after Kg. Chhnang so that all areas will have A-D syringes by the end of 2002! First shipment of A-D syringes arrived in May, 1998 Training for A-D syringes were provided from August to October 2002 A-D syringes will be expanded for use to all provinces in November and December Incinerators in all provinces

10. Includes syringes used in all SIA activities and SIAs and routine activities in K. Chhnang (data from K. Chhnang from January to June 2002) Includes both 0.5 cc and 0.1 cc syringes All A-D syringes were sent to incinerators Number of A-D syringes used higher than number of injections given due to: Staff new to use A-D syringes System to use safety boxes new Some A-D syringes were of not good quality A-D syringes used from 1999 - 2002

11. Safety boxes are now used in supplementary immunization activities, hospitals, blood collection sites, and HIV/AIDS Treatment Centers Average number of A-D syringes in safety boxes: 120 Safety boxes: 5-litre capacity Safety boxes used from 1999 - 2002

13. Distribution system of A-D syringes and safety boxes Referral Hospitals – only disposable syringes Central level distributes safety boxes to district pharmacists for use at referral hospitals District pharmacists store new and used safety boxes Each department of referral hospitals collects and change old safety boxes from district pharmacists when safety boxes are full Full safety boxes are sent to the incinerator K. Chhnang – Bundling of A-D syringes & exchange system Health centre workers take full safety boxes from the health centre to the district centres during monthly meetings at the district centres Full safety boxes are exchanged for new A-D syringes and new safety boxes SIAs – Bundling of A-D syringes & exchange system For provinces with incinerators Safety boxes are burned every day during the campaign For provinces with no incinerators Safety boxes are stored at one place, the designated sub-district site, until transported to the nearest incinerator at the end of the campaign

14. Training materials Injection safety movie produced Immunization safety movie (in progress) Posters (see pictures) Guidelines for injection safety in routine immunization and SIAs and for referral hospitals Training materials

15. Conduct training activities to assemble, use and prevent recapping of A-D syringe to all health workers Training for use and assembly of A-D syringe

16. Training for assembly and use of safety boxes and A-D syringes is provided to all health workers Training is also given on the exchange system – full safety boxes are exchanged for new safety boxes and A-D syringes (when available) Training for use and assembly of safety boxes

17. Training on operational use and maintenance of incinerators is provided to the appropriate incinerator operator (one for each incinerator) Training of preparation, use and maintenance of incinerators

18. Problems still encountered…

19. …however, much better than before… View of waste before safety boxes were introduced before the waste management system in 1998

20. View of waste from a typical medical waste disposal pit – prior 1998 …however, much better than before…

21. Ongoing improvement through monitoring and supervision

22. Future activities Conduct national assessment of injection safety system to include: Assessment of operational capacity and conduct any necessary maintenance of incinerators in each province Ongoing training Ongoing monitoring and supervision of use of safe injection equipment, and distribution and exchange system

23. Final note: Waste management system for the first five year time period in K. Chhnang – Overview of costs *Data Source: Estimates based on information provided by the WHO Cambodia Country Office, Ministry of Health EPI Department and field visits to Kompong Chnang and Takeo