1. WHO Health Care Waste Management Protection of the Human Environment (PHE) Richard M. Carr

2. WHO Health Care Waste Management Protection of the Human Environment (PHE) Content of Presentation Needs Assessment National Action Plans Relative Risks Technology Options

3. WHO Health Care Waste Management Protection of the Human Environment (PHE) Needs Assessment WHY Needed? Identifies health risks Describes current management practices Raises awareness Provides information on amounts and types of waste generated Supports development of a National Action Plan

4. WHO Health Care Waste Management Protection of the Human Environment (PHE) Needs Assessment How? Assess HCWM at representative facilities of all sizes and in typical settings Interview facility staff at all levels Interview staff from key government agencies, NGOs, and municipalities Evaluate curriculums at School of Public Health, Medicine Nursing, etc. Assess current laws governing HCWM

5. WHO Health Care Waste Management Protection of the Human Environment (PHE) Needs Assessment Tools/Resources WHO Rapid Assessment Tool (RAT) Aide-Memoire Safe health-care waste management Websites: www.healthcarewaste.org www.safeinjection.orgwww.healthcarewaste.orgwww.safeinjection.org Technical option database on website

6. WHO Health Care Waste Management Protection of the Human Environment (PHE) National Action Plan Successful HCWM Strategies Include: National policy for safe HCWM Comprehensive system of HCWM Awareness and training Selection of options for HCWM

7. WHO Health Care Waste Management Protection of the Human Environment (PHE) National Action Plan National policy for safe HCWM Designate responsible authority Regulatory framework & guidelines Assessment of status & problems Overall waste management plan Monitoring & evaluation

8. WHO Health Care Waste Management Protection of the Human Environment (PHE) National Action Plan Comprehensive system for HCWM Assign waste management responsibilities to staff Allocate Resources Minimization of waste (procurement) Segregation of waste Safe collection, handling and storage Safe treatment and disposal

9. WHO Health Care Waste Management Protection of the Human Environment (PHE) National Action Plan Awareness and Training Add waste management to the curricula for health-care personnel Develop national training package Develop train the trainers programmes Education on health risks Education on safe practices Increase community awareness

10. WHO Health Care Waste Management Protection of the Human Environment (PHE) National Action Plan Management Options for HCW Review available options for different size facilities and different settings Evaluate safety and environmental aspects Ensure worker’s safety Evaluate sustainability Assess acceptability Monitoring of safety and efficiency

11. WHO Health Care Waste Management Protection of the Human Environment (PHE) Relative Health Risks Reuse of needles and syringes pose the greatest health risks to patients, staff and the community Risks to health-care workers and the community can still be significant even without reuse Burning HCW at low temperatures produces dioxins: persistent toxins which effect human health and the environment Burning HCW can release mercury and other heavy metals which effect human health and the environment Risks from dioxin and mercury due to burning HCW are unknown

12. WHO Health Care Waste Management Protection of the Human Environment (PHE) Risk: Reuse Staff & Community Dioxin Mercury Relative Health Risks Strategies for reducing risk: AD syringes, Over-supply needles and syringes, Good management and disposal, Hepatitis B vaccination of staff and children Sharps boxes, protective clothing, training, Community awareness programmes, good management and disposal Hepatitis B vaccination of staff and children Non-incineration disposal options, high temperature Incineration, procurement Waste segregation, non-incineration disposal options, procurement

13. WHO Health Care Waste Management Protection of the Human Environment (PHE) Managing Waste No one-size-fits-all solution Solutions do exist for many situations “non-availability” of technologies is often a “wrong problem” - or not a technical one Allocated resources ? Regulatory compliance ? Social acceptance ? Environmental concerns, pressure groups, Kyoto, bans on burning in some countries “polluter pays” principle ---

14. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Safety boxes - first line of defense Bundled with vaccines Work well in vaccination campaigns and for some routine programme needs Reusable plastic sharps boxes can be used for routine needs Disposable boxes require frequent re-supply Disposal requires burning or incineration – limits options

15. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Needle Cutters and Destroyers Reduce risks by removing the sharp before disposal Prevent reuse and community exposure Reduce most dangerous waste significantly Manual needle cutters may still pose health risks from splashing Expensive Needle destroyers very expensive and require electricity

16. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Burning – Low temperature Open pit Brick enclosures and open brick incinerators “Drum” incinerators Low costs Create maximum pollution Incomplete combustion does not destroy all sharps Least desirable option

17. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Burning – High temperature Locally built brick incinerators e.g. “De Montford” Small factory built pre-fabricated steel incinerator Other industrial incinerators

18. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Burning – High temperature Appropriate for medium to large facilities – better for less densely populated areas Reduce harmful emissions by high temperature incineration Complete combustion of all sharps Moderately expensive to build US$ 1500 – 5000 May require fuel to operate Requires training to operate and maintain Requires waste segregation – heavy metals

19. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Burning – High temperature De Montford Locally built brick Incinerator US $1500 Installed

20. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Burning – High temperature Factory built Prefabricated Incinerator US $5000 Installed

21. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Steam Sterilizers e.g. “Hydroclave” Appropriate for medium to large facilities Essentially no emissions Good for densely populated areas Complete destruction of all sharps Expensive Requires training to operate and maintain Requires waste segregation – heavy metals

22. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Waste Burial Pit Suitable for small clinics Easy to build, operate and maintain Requires space on-site Proper segregation of sharps can increase life May not be suitable for areas with high water tables

23. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Waste Burial Pit

24. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Other Options Encapsulation Melting ovens Professional recovery and recycling

25. WHO Health Care Waste Management Protection of the Human Environment (PHE) Technical Options for Managing Waste Waste Minimization Reduce injection overuse New delivery systems Biodegradable syringes and needles Reduce packaging Eliminate use of toxic components

26. WHO Health Care Waste Management Protection of the Human Environment (PHE) Conclusion Safe HCWM requires a comprehensive system Lack of resources can be overcome with creativity and the will to manage HCW safely Technology is only part of the solution Raising staff and community awareness are keys to success