hcwm guidelines ethiopia final

Health Care Waste Management for Ethiopia

Guidelines

Prepared by:Fikru Tessema (BSc, MSc), Senior Public Health Professional

M&E Specialist

May 2006

Table of contents

Page

Abbreviations 4

Preface 5

Section 1

1.1 Introduction 6

1.1.1 Overview of Health Facilities (HFs) Hazards and Infections 6

1.1.2 Overview of HCWM Programmes for HCFs 7

1.1.3 Overview of the Need for Developing Comprehensive HCWM

Programmes 8

1.2 Objectives 12

1.3 How to use these guide lines 13

Section 2. Definition 14

Section 3. Public Health Importance, Risks and Management of

Health-Care Wastes

3.1 Public Health Importance 19

3.2 Risks of Health-Care Wastes 19

3.3 HCW Management 21

Section 4. Health-Care Waste Management Guidelines

4.1 Segregation of Health-Care Waste Guidelines 23

4.2 Guidelines for Colour coding system 25

4.3 Guidelines for HCW recycling and reusing

26

4.4 Guidelines for Recycling of non-contaminated plastic items 26

4.5 Guidelines for Packaging 28

2

4.6 Waste storage guidelines 29

4.7 Waste handling guidelines

31

4.8 Waste transportation guidelines 31

4.9 Waste treatment guidelines

34

4.10 Guidelines for steam sterilization 36

4.11 Guidelines for incineration

37

4.12 Guidelines for thermal inactivation

38

4.13 Guidelines for gas/vapor sterilization 39

4.14 Guidelines for chemical disinfection 40

4.15 Guidelines for accidents and spillage 41

4.16 Guidelines for Ultimate Disposal 41

4.17 Guidelines for maintenance workers 42

4.18 Guidelines for occupational risks 42

4.19 Guidelines for Training 43

Section 5. Specific Guidelines Associated With HCW Categories

5.1 Class 1: non-risk health-care waste 44

5.2 Class 2: clinical waste 44

5.3 Class 3: sharps 45

5.4 Class 4: anatomical waste and placentas 46

5.5 Class 5: hazardous pharmaceutical waste and cytotoxic waste 46

5.6 Class 6: highly infectious waste 47

5.7 Class 7: radioactive waste 48

5.8 Class 9: Waste with high contents of heavy metals 48

5.9 Class 10: Effluents 50

3

Section 6. Guidelines for Implementation of HCWM Plan in HCFs

6.1 Guidelines for waste management plan 52

6.2 Guidelines for duties and responsibilities 53

4

6.3 Guidelines for allocation of resources and equipment for

health-care waste handling

59

6.4 Guidelines for Awareness and Training 61

6.5 Guidelines for monitoring system and reporting

procedures for HCWM at all levels 62

6.6 Guidelines for private sector involvement

63

References 64

5

Abbreviations

HCF : Health-Care Facility

HCW : Health-Care Waste

HCWM : Health-Care Waste Management

WHO : World Health Organization

EPA : Environment Protection Authority

MoH : Ministry of Health

DHEH : Department of Hygiene & Environmental Health

RHB : Regional Health Bureau

PREFACE

The purpose of the health-care waste management guidelines is to

ensure safe and healthful working conditions for every working man

and woman in the health-care facility by providing guidelines that will

ensure, insofar as practicable, that no workers will suffer diminished

health, functional capacity, or life expectancy as a result of their work

experience.

This document does present guidelines for reducing the incidence of

injury and disease among health care workers of health care facilities

and the population at large.

Every effort was made to address all major health and safety hazards

that might be encountered in hospitals or other health care centers.

The document is not intended to affect patients directly, but

implementing the guidelines will generally benefit patient care.

National Guidelines for Health-Care Waste Management 9

Section 1 Introduction

1.1 Overview of Health Facilities (HFs) Hazards and Infections

Safe management of Health-Care Waste (HCW) is a key issue to control

and reduce nosocomial infections inside a hospital, health centres,

clinics and health posts and to ensure that the environment outside is

well protected. Health-Care Waste Management (HCWM) should be

part of the overall management system of a Health-Care Facility (HCF)

and reflect the quality of the services provided by the facilities.

Ethiopia has poor health status relative to other low-income countries,

even within Sub-Saharan African countries. This is largely attributed to

preventable infections and nutritional problems. Infectious and

communicable diseases account for about 60-80% of the health

problems in the country. Therefore, the recommendations that are

contained in this document should be applied in all the HCFs of

Ethiopia. In case these recommendations cannot be rapidly applied in

certain HCFs, due to financial or institutional constraints, a minimum

HCWM programme should always be set up.

According to the Ministry of Health report, there are a total of 126

hospitals, 519 health centers, 1797 health stations, and 2899 health

posts run by the government (over 90%), private institutions, and

NGOs. 5627 public health service facilities that include hospitals,

health centers, health stations, health posts, and clinics; and 2489

pharmaceutical retail outlets are owned by the government, private

owners, OGA and NGOS. Health-care services inevitably generate

wastes that may be hazardous and infectious to health as well as have

harmful environment. Some of them, such as sharps and pathogenical

10

wastes, carry a higher potential for infection and injury than any other

type of wastes. An integrated effort is necessary in Ethiopia to set-up

safe health-care waste management practices.

1.2 Overview of HCWM Programmes for HCFs

Health-care waste is a management issue (and not only a technical

one) that should become and integral feature of health-care services. It

is essential that clear individual and group responsibilities and

monitoring procedures should be established at each level of the

health-care establishments. Additionally, awareness and training

programmes for medical and ancillary staff should be strengthened in

health-care establishments. Specific administrative procedures should

be defined and adequate resources allocated at all levels to ensure a

proper management of health-care waste. Appropriate, environmental-

friendly and affordable technologies should be selected for the

treatment and the disposal of health-care waste, taking into

consideration the resources of each health-care facility.

A policy statement on hazardous waste exist at the national level,

specifics that deal with hazardous waste management, in general, and

health care waste, in particular, does not exist at the national level.

Given the rapid expansion of health-related infrastructures, which

implies a rapid growth of hazardous waste generation, the need for

policies, directives, and a strategic plan as well as their

implementation based on prioritized problems is a forthcoming

challenge. Studies that are contributing to the appreciation of the

depth and breadth of health care waste management problems

currently become important.


This document is prepared to provide guidelines for the persons

involved in health-care waste management at central, regional, district

and local levels. Some HCFs have started to establish safety and

health care waste management committees. The committees have

made important contributions by identifying safety and health

problems and by educating the workforce about safety and health

issues. Such committees can help to ensure safe work environments in

HCFs.

1.3 Overview of the Need for Developing Comprehensive

HCWM Programmes

A comprehensive HCWM programmes are needed to:

1.3.1 Address Diverse Needs: The diverse HCWM concerns in HCFs

are traditionally divided into HCW that pose an immediate threat

and HCW that cause long-term health problems. These

conditions may result in an immediate illness or in the long-term

development of disease.

Developing an appropriate and useful safety and health program

for a health care facility requires the involvement of a safety and

HCWM committee that represents workers and supervisors from

all departments in the HCFs. To be effective, committee

members should be knowledgeable in HCWM and have explicit

responsibilities and appropriate authorities.

1.3.2 Identify Hazards and interventions: Hazard and infections

identification involves not only recognizing the hazards and

infections themselves but also learning their specific

characteristics and identifying the population at risk so that

control programs can be designed.


The HCFs safety and health committee should assist with this in

consultation with workers from each department. The most

important step in identifying hazards is usually a physical

inspection called a walk-through survey. Persons conducting the

survey actually walk through the unit and note as many hazards

as possible.

1.3.3 Conduct Medical Evaluations: Medical evaluation is usually on

the extent of exposure to the agent, the severity of the adverse

effects, the complexity of the work process, and protective

measures. Complex work procedures (e.g. operating-room

practices) should be analyzed carefully, noting products and

byproducts formed during the procedures.

The signs and symptoms that workers experience should be

evaluated medically, taking care to avoid preconceptions about

which ones are work related. An occupational history should also

be maintained for each worker to help evaluate the long-term

effects of exposures. This history should contain at least the

worker’s prior occupations and job titles, the duration of

employment at each job, and the name of any substance or

agent to which the worker may have been exposed.

1.3.4 Provide Personal Protective Equipment: Personal protective

equipment for health woprkers includes gloves, goggles, aprons,

respirators (not surgical masks), and boots. Although the use of

such equipment is generally the least and last desirable way to

control workplace hazards and infections because it places the

burden of protection on the worker, the equipment should be

available for situations when an unexpected exposure to

chemical substances physical agents, or biologic materials could

have serious consequences.


1.3.5 Keep Records: No sufficient data is available on the amount of

health care waste generated and how that waste is handled.

Adequate recordkeeping is very important:

(1) To track the safety and health of individual workers and work

groups over time,

(2) To provide documentation on quantity of waste generated

and disposed off for future evaluations, planning for

management,

(3) To help the HCFs’ administrations and the safety and health

committee identify problem areas, and

(4) To measure the effectiveness of safety and health programs.

The employer must maintain these records and provide access to

concerned body. Workers and their representatives also have the

right to access these records.


1.4 Objectives

1.4.1 The overall aim is at providing guidelines for HCWM methods

that can be applied in the HCFs of Ethiopia.

More specifically, it attempts to:

o Provide a better knowledge of the fundamentals of HCWM

planning and a better understanding of the hazards linked to HCW;

o Develop HCWM plans and standards which are protective for both

the human health and the environment, in compliance with the

current environmental and public health legislations of Ethiopia

taking into consideration the financial possibilities of each

institution;

o Set priority actions in order to tackle the most sensitive problems

related to HCWM (e.g. disposal of sharps) and to present these

actions as part of a more global framework;

o Review appropriate and sustainable technologies to treat and

dispose of HCW;

o Facilitate the analysis of HCWM problems and develop strategies

for the safe management of HCW at district level.


1.4.2 It is also targeting the provision of both conceptual and practical

information on HCWM.

More specifically for:

o The medical staff members having a "duty of care" at all levels in

public or private HCFs, namely: Medical Directors in Charge, Heads

of all Hospital Departments, Administrators, Doctors, Matrons,

Nurses, Medical attendants and all other staffs;

o National policy makers, regional and district health management

teams in charge of developing, implementing and devaluating

HCWM plans at central, regional and district levels as well as

health officers in charge of their implementation monitoring;

o Members of the health training institutions;

o International Organisations or NGOs involved in the backstopping

of health care services delivered in Ethiopia.


1.5 How to use these guide lines

These guidelines are divided into five sections and have bee structured

to be as practical as possible.

o The two first sections have been written for all people involved

in health-care waste management at any level. They provide

key information on HCW and the potential harmful effects that

can result from its mismanagement;

o The third section gives the procedures for health-care waste

manipulation and disposal that should be applied and followed in

all the HCFs of the country;

o The instructions contained in the fourth section have been

written for personnel involved in the organisation of HCWM plans

in major hospitals and minor HCFs;

o The fifth section has been written for personnel of central,

regional and district Health Services that should deal with HCWM

to ensure a smooth implementation of the instructions contained

in this document;


Section 2 Definition

The definitions and the classification hereafter are adapted from the

international classification provided by the World Health Organisation.

2.1 Health-Care Waste

Health-Care Waste (HCW) includes all the waste, hazardous or not,

generated during medical activities. It embraces activities of diagnosis

as well as preventive, curative and palliative treatments in the field of

human medicine. In other words, are considered as health-care waste,

all the waste produced by a medical institution (public or private), a

medical research facility or a laboratory.

2.2 Non-Risk Health-Care Waste

Non-risk Health-Care Waste comprises all the waste that has not been

infected. They are similar to normal household or municipal waste and

can be managed by the municipal waste services. They represent the

biggest part of the HCW generated by a medical institution. It includes

paper, cardboard, non-contaminated plastic or metal, cans or glass,

left over food, etc... and can also be included in this category of waste,

all items that have been used for medical care but are visually not

contaminated with blood or body fluids of the patient, this only being

applicable if the patient is not confined in an isolation ward.


2.3 Pathological Waste

Pathological Waste groups all organs (including placentas), tissues as

well as blood and body fluids and follows the precautionary principle

stipulated by WHO.

2.4 Anatomical Waste

Anatomical waste comprises recognizable body parts. It is primarily for

ethical reasons that special requirement must be placed on the

management of human body parts. They can be considered as a

subcategory of Pathological Waste.

2.5 Infectious Waste

Infectious waste comprises of all biomedical and health-care waste

known or clinically assessed by a medical practitioner to have the

potential of transmitting infectious agents to humans or animals.

Waste of this kind is typically generated in the following places:

Isolation wards of hospitals; centres caring for patients infected with

hepatitis viruses; pathology departments, operating theatres and

laboratories.

2.6 Highly Infectious Waste

Highly infectious waste includes all viable biological and pathological

agents artificially cultivated in significant elevated numbers. Cultures

and stocks, dishes and devices used to transfer, inoculate and mix

cultures of infectious agents belong to this category of waste. They

are generated mainly in Diagnostic Medical Laboratories.


2.7 Sharps

Sharps are all objects and materials that pose a potential risk of injury

and infection due to their puncture or cutting properties (e.g. syringes

with needles, blades, broken glass...). For this reason, sharps are

considered as one of the most hazardous categories of waste

generated during medical activities.

2.8 Pharmaceutical Waste

Pharmaceutical Waste embraces a multitude of active ingredients and

types of preparations. This category of waste comprises expired

pharmaceuticals or pharmaceuticals that ate unusable for other

reasons

2.9 Cytotoxic Waste

Cytotoxic Waste may be considered as a sub-group of hazardous

Pharmaceutical Waste, due to its high degree of toxicity. The potential

health risks for people who handle cytotoxic Pharmaceuticals results

above all from the mutagenic, carcinogenic and teratogenic properties

of these substances, which can be split into six main groups: alkylated

substances, antimetabolites, antibiotics, plant alkaloids, hormones and

others.

2.10 Radioactive Waste

Radioactive Waste includes liquids, gas and solids contaminated with

radio nuclides whose ionizing radiations have genotoxic effects. The

ionizing radiations of interest in medicine include X-any. An important


difference between these types of radiations is the X-rays are emitted

from X-ray tubes only when generating equipment is switched on.

2.11 Special Hazardous Waste (Waste with high contents of

heavy metals)

Waste with high contents of heavy metals should normally be treated

in specific recovering industries. Alternatively, as for chemical waste,

it may be encapsulated. Waste with high contents of mercury or

cadmium shall never be incinerated because of the risk of atmospheric

pollution with toxic vapours.

Special Hazardous Waste includes gaseous, liquid and solid chemicals,

waste with a high contents of heavy metals such as batteries,

pressurized containers, out of order thermometers, blood-pressure

gauges, photographic fixing and developing solutions in X-ray

departments, halogenated or non-halogenated solvents... this

category of waste is not exclusive to the health-care sector. They can

have toxic, corrosive, flammable, reactive, explosive, shock sensitive,

genotoxic properties.

2.12 Effluents

Effluents and more particularly, effluents from isolation wards and

medical diagnostic laboratories should be considered as hazardous

liquid waste that should receive specific treatment before being

discharged into the sewerage/drainage system, if such a system exists.

2.13 Miscellaneous wastes

These types of wastes are wastes include those from surgery and

autopsies, contaminated laboratory wastes, dialysis unit wastes and

contaminated equipment.


2.13.1 Wastes from surgery and autopsies include soiled

dressings, sponges, drapes, lavage tubes, drainage sets, under

pads, and surgical gloves.

2.13.2 Contaminated laboratory wastes include specimen

containers, slides and cover slips, disposable gloves, laboratory

coats, and aprons.

2.13.3 Dialysis unit wastes include contaminated disposable

equipment and supplies such as tubing, filters, disposable

sheets, towels, gloves, aprons, and laboratory coats.

2.13.4 Contaminated equipment refers to discarded equipment and

parts that are used in patient care, medical research, and the

production and testing of certain pharmaceuticals.


Section 3 Public Health Importance, Risks and

Management of Health-Care Wastes

3.1 Public Health Importance

Nowadays, health care wastes generation is significantly large

amounts by volume and diverse by types that require proper handling

and disposal. Much of the waste is hazardous and must therefore be

packaged, transferred, and disposed of properly to protect both the

persons handling it and the environment

All individuals exposed to hazardous HCW are potentially at risk of

being injured or infected. They include:

1. Medical staff: doctors, nurses, sanitary staff and hospital

maintenance personnel

2. In-and out-patients receiving treatment in HCFs as well as their

visitors;

3. Workers in support services linked to HCFs such as laundries,

waste handling and transportation services;

4. Workers in waste disposal facilities, including scavengers;

5. The general public and more specifically the children playing

with the items they can find in the waste outside the HCFs when it is

directly accessible to them.

3.2 Risks of Health-Care Wastes

3.2.1Occupational Risks

HCFs’ work environment, during handling of wastes, the medical and

ancillary staff as well as the sanitary laborers can be injured if HCW

has not been handled safely. In this respect, sharps are considered as

23

one of the most dangerous categories of waste. Many injuries occur

because syringe and needles or other sharps have not been collected

in safety boxes or because these have been overfilled.

On dumpsites, scavengers during their reusing or recycling activities

may also come in contact with infectious waste if it has not been

properly treated or disposed of.

Maintenance workers serve in all patient and non-patient areas and are

thus potentially exposed to all of the health hazards found in drainage

system, chemical stores, etc of the HCFs’ environment. Maintenance

personnel are frequently exposed to pathogens.

3.2.2Risks to the Population

The general public can be infected by HCW either directly or indirectly

through several routes of contamination. Dumping HCW in open areas

is a practice that can have major adverse effects on the population.

The ''recycling'' practices, the reuse of syringes are certainly the most

serious problem in some of the developing countries. The WHO

estimates that some millions infections of Hepatitis B, C and HIV occur

yearly from the reuse of discarded syringes needles without prior

disinfection.

3.3 HCW Management

It is not often understood why HCW should be managed in a different

way than the other categories of wastes, and particularly why HCW

should be segregated on the spot, where it is generated. Furthermore,

the constraints related to their management as well as the funds


required to set up a proper management system discourage many

medical institutions to undertake the necessary steps to improve their

current HCWM practices.

However, HCWM is an integral part of hygiene and infection control

within a HCF and proper management should help control of

nosocomial infections.

HCWM is not only compliance with Federal and local regulations, but it

should carefully consider the development of an infectious waste

management plan to minimize the overall risks of HCWs. Each HCF

should develop an infectious waste management plan that provides

for:

(1) Designation of the waste that should be managed as HCWs,

(2) Segregation of infectious waste from the noninfectious waste,

(3) Packaging of infectious waste to reduce contacts and exposure,

(4) Storage of HCW for proper transport,

(5) Treatment of infectious waste to avoid contaminations,

(6) Disposal of infectious waste to eliminate risks,

(7) Measures for emergency situations, and

(8) Staff training on HCWM.

Implementing adequate procedures to minimize the overall risks

associated with HCWM remains the prior objective of these National

Guidelines. Waste management and treatment options should first


protect the health-care workers and the population and minimizes

indirect impacts from environmental exposures to HCW.

The instruction contained in theses guidelines for the handling and the

disposal of sharps, and more specifically used syringes, attempt first to

minimize the risks of cuts or needle stick injuries that may occur after

an injection:

Some treatment options - such as low-cost incinerators that emit

pollutants - may be used in certain situations (e.g. low density

populated areas) where the overall health benefits from preventing

infections are likely to outweigh the risks from exposure to toxic

pollutants in the air. Nevertheless, environmental-friendly practices,

like the recycling of plastics are recommended when they are in

accordance with the precautionary principle.


Section 4 Health-Care Waste Management Guidelines

The implementation of safe HCWM guidelines aims at containing

infections and reducing public health risks both within and outside the

HCF. The guidelines should always contain the following measures:

1. Segregation and identification of hazardous HCW from non-risk

HCW;

2. Recyclingof HCW to minimize the quantity of HCW generated by

the HCF;

3. Adequate packaging and safe storage of the different categories

of HCW;

4. Proper treatment and disposal of hazardous and non-risk HCW.

4.1 Guidelines for Segregation of Health-Care Waste

A proper segregation must follow rigorous and standardized

procedures to enable and reduce the risks of infecting workers and

control the economical incidence of hazardous HCW disposal by

decreasing the treatment costs. It must be:

1. Simple to implement for medical and ancillary staff;

2. Safe and guaranty the absence of infectious HCW in the

domestic waste flow;

3. Stable and homogeneously applied in all the HCFs;

4. Regularly monitored to ensure that the procedures are

respected.

The following guidelines should be included in HCW Segregation:

27

1. Segregation of HCW should consist in separating the different

waste streams based on the type of treatment and disposal

required at economical cost.

2. The segregation should identify waste according to source and

type of disposal or disinfections.

3. Segregation of HCW practices should provide coloured waste

receptacles specifically suited for each category of waste.

4. Segregation shall take place at the source or at the site, that is

at the ward bedside, Operation Theatre, Medical Diagnostic

Laboratory, or any other room or ward in the hospital and

health center where the waste is generated.

5. Seven categories of waste shall be considered in the

segregation of HCW: HCW of classes 1, 2, 3, 4 and 9 are

commonly generated in major and minor medical institutions.

HCW of classes 5, 6, 7 and 8 are generated only in some

institutions and in small quantities.

Class1: non-risk waste comprises the non-hazardous waste generated

within the medical institutions as defined in section 2, as well as the

non-hazardous pharmaceutical waste;

Class 2: clinical waste comprises pathological waste and infectious

waste as defined in section 2. It includes also all items that are visually

contaminated with blood or body fluids;

Class 3: sharp waste includes all items that can case cuts or puncture

wounds as defined in section 2 sharps shall be considered as highly

hazardous waste and collected in rigid safety boxes;


Class 4: anatomical waste and placenta comprises recognizable body

parts as specified in section 2. Due to their physical characteristics,

similar to anatomical waste, placentas are grouped in the same class;

Class 5: Hazardous pharmaceutical and cytotoxic waste include

pharmaceuticals (cytotoxic drugs and toxic chemicals), which pose a

potential hazard when used improperly by unauthorized persons, and

unidentifiable pharmaceuticals heavy-metal-containing disinfectants,

which owing to their composition require special management and

cytotoxic waste as defined in section 2.

Class 6: highly infections waste comprises waste as defined in section

2. This category of waste is generated in medical Diagnostic

laboratories or in isolation wards;

Class 7: radioactive waste includes waste as defined in section 2.

Class 8: Wastes with high contents of heavy metals include wastes as

defined in section 2. This category of wastes is wastes with high

contents of heavy metals such as mercury or cadmium.

Class 9: Effluents comprises waste as defined in section 2. This

category of waste is non-solid waste of all liquid infectious waste.

4.2 Guidelines for Colour coding system

The colour coding system aims at ensuring an immediate and non-

equivocal identification and segregation of the hazards associated with

the type of HCW that is handled or treated. In this respect, the colour


coding system shall remain simple and be applied uniformly

throughout the country.


All health- care facilities shall apply the following colour coding system:

1. Black: all bins or bags containing non-risk HCW of class 1;

2. Yellow: any kind of container filled with HCW from class 2 –

7;

3. Red: any kind of container filled with HCW from class 8 and 9.

4.3 Guidelines for HCW Recycling and Reusing

The implementation of recycling procedures in HCFs to minimize the

quantity of HCW generated is highly sensitive. Recycling procedures

complicate the overall segregation scheme by increasing the

segregation criteria and multiplying the number of waste streams in

the HCF. It is a potential source of error.

However, considering the specific recycling practices in Ethiopia, the

necessity to implement an environmental-friendly process of HCW

disposal and the financial resources of each HCF, a simple and safe

recycling practice should be implemented whenever it is possible. In

these situations the instructions hereafter should be followed.

4.3.1Guidelines for Recycling of non-contaminated plastic

items

The following guidelines should be included in recycling of non-

contaminated plastic items:

1. All non-contaminated plastic items (e.g. bags of sodium chlorine,

etc) should be collected, packed in separate boxes.

2. They should be delivered to or picked-up local collectors capable

of recycling them with environmental-friendly techniques.


4.3.2Guidelines for Recycling of glassware inside the

Diagnostic Laboratories

The following guidelines should be included in glassware inside the

Diagnostic Laboratories:

7 All non-contaminated and non-broken glassware (flasks of inject

able penicillin for instance) should be collected separately.

8 They should be put in a disinfectant solution not less than 30

minutes, carefully washed, rinsed and dried before being reused.

9 The disinfected glassware should be reused only for specific

medical Diagnostic (blood, urine) carried out inside the Diagnostic

laboratory.

10 After having been used once, they shall be considered as

contaminated and infectious.

11 Broken glassware shall always follow the stream of sharp waste

(class 3) while non-broken glass flasks shall be reused only after

disinfections in a disinfectant solution, carefully washed with a

brush and soap, rinsed.

12 During the disinfection process, hands shall always be protected

with gloves. It is further recommended to autoclave the glassware

after washing at 1210C for at least 30 minutes to ensure complete

disinfection.

4.3.3Guidelines for Reuse of specific equipment

The following guidelines should be included in recycling of non- specific

equipment:

1. In general, to encourage reuse, each hospital and health center

shall collect separately, wash and sterilize, either thermally or

chemically in accordance with approved procedures, surgical


equipment and other items which are designed for reuse and are

resistant to the sterilization, disinfection or disinfection process.

2. Pressurized materials as cylinders shall be returned to suppliers

for refilling and reuse.

4.4 Guidelines for pharmaceuticals management

The following guidelines should be included in pharmaceuticals

management:

1. Drug stores in each HCF shall be rigorously managed on a base

of first in first out to avoid wastage.

2. Stock positions should be recorded on a regular basis.

4.5 Guidelines for Packaging

The following guidelines should be included in packaging:

1. Infectious wastes should be contained from the point of origin to the

point at which they are not longer infectious.

2. The packaging should be appropriate for the type of waste involved

3. It should consider tear-resistant packaging materials in the process

of handling, storage, transportation, and treatment.

4. Liquid infectious wastes should be placed in capped or tightly

stopper bottles or flasks and large quantities may be placed in

containment tanks.

5. Solid or semisolid wastes should be placed in plastic bags, but the

following recommendations should be observed:


5.1 Selection of tear-resistant bags: use plastic bags that are

judged by their thickness or durability and the most

important considerations are tear-resistance.

5.2 Placement of sharps (sharp items, or items with sharp

corners) in the bags: place sharps in impervious rigid,

puncture-resistant containers made of glass, metal, rigid

plastic, or wood.

5.3 Loading a bag beyond its weight or volume capacity: load

bags up to its limit.

5.4 Keeping bags from coming into contact with sharp external

objects: keep away bags from contacts with sharp objects.

5.5 Double bagging: Consider double bagging to ensure tear-

resistance.

6. There should be special packaging characteristics for some

treatment techniques: incineration required combustible containers,

and steam sterilization requires packaging materials such as low-

density plastics that allow steam penetration and evacuation of air.

4.6 Waste storage guidelines

The following guidelines should be included in waste storage:

1. In each room where HCW is generated, an adequate place shall

be dedicated for storing HCW bag-holders, bins or containers.

2. Waste storing places in each room of HCF should be easily

accessible for the sanitary staff and instruction shall be

displayed.

3. In all HCFs, separate central storage facilities shall be provided

for hazardous HCW, except radioactive waste that shall be stored

specifically.

4. It shall clearly be mentioned that the facility stores hazardous

HCW and no materials other than yellow bag waste.


5. No waste shall be stored for more than two days before being

treated or disposed of.

6. The designated central storage facility shall be located within the

hospital premises close to the treatment unit but away from food

storage or food preparation areas.

7. The designated central storage facility should be large enough to

contain all the hazardous HCW produced by the hospital during

one week, with spare capacity to cope with any maintenance or

breakdown of the treatment unit.

8. The designated central storage facility shall be totally enclosed

and secured from unauthorized access.

9. The designated central storage facility shall be inaccessible to

animals, insects and birds.

10. The designated central storage facility shall be easy to clean

and disinfect with an impermeable hard-standing base, good

water supply, drainage and ventilation: The following procedures

area recommended:

10.1 Infectious waste should be stored for a minimum amount

of time and should be packaged securely enough to ensure

containment of the waste and to prevent penetration by

rodents and vermin.

10.2 Limited access to the storage area is recommended.

10.3 The universal biological hazard symbol should be posted

on the storage area door, waste containers, freezers, or

refrigerators.

10.4 Containers for bio-hazardous material should be a

distinctive red or orange color.


4.7 Waste Handling guidelines

The following guidelines should be included in Waste Handling:

1. All HCW or disposal of medical equipment shall be discarded at

the point of use by the person who used the item to be disposed

off in case any such used equipment or supplies are found or are

handed over to another person, it should be discarded by that

person.

2. All the specific procedures of HCW segregation, packaging and

labeling shall be explained to the medical and ancillary staff and

displayed in each department on charts located on the walls

nearby the HCW containers.

3. When handling waste, sanitary staff and sweepers shall wear

protective clothing at all times including face masks, aprons and

boots, heavy duty gloves, as required.

4. Carts and recyclable containers that are used repeatedly for

transport should be disinfected after each use. Single-use

containers should be destroyed as part of the treatment process.

4.8 Waste Transportation guidelines

4.8.1Transport to Central Storage

4.8.1.1 The waste collection trolley should be easy to load, unload

and. The trolley shall not be used for any other purpose. It

shall be cleaned regularly, and especially before any

maintenance work is performed on it.


4.8.1.2 Yellow bags of hazardous HCW and black bags of non-risk

HCW shall be collected on separate trolleys that shall be

painted marked with the corresponding colours and washed

regularly.

4.8.1.3 The collection route shall be the most direct one from the

collection point to the central storage.

4.8.1.4 The collected waste shall not be left even temporarily

anywhere other than at the designated central storage.

4.8.1.5 Containers should be covered with lids during storage.

4.8.1.6 Instead of chutes or dumbwaiters, carts should be used for

transporting bags of infectious waste within the facility.

4.8.2Transport to Final Disposal Site

4.8.2.1 When the waste is to be moved about for treatment or

storage, special handling or packaging may be necessary to

keep bags intact and to ensure containment of the waste. The

following procedures are recommended:

1. Single-bagged waste and containers of sharps and liquids

should be placed within a rigid or semi-rigid container such

as a bucket, box, or carton lined with plastic bags.

2. Containers should be covered with lids during

transportation.

3. When transporting plastic bags of infectious waste, care

should be taken to prevent tearing the bags.

4. Infectious waste should not be compacted before

treatment. This process could damage the packaging and

disperse the contents, or it could interfere with the

effectiveness of treatment.


5. Outside the hospital and health centers or all HCFs,

infectious waste should be transported in closed, leak-proof

dumpsters or trucks.

6. The waste should be placed in rigid or semi-rigid, leak-

proof containers before being loaded onto trucks.

7. In case off-site transportation is required to treat

hazardous HCW at treatment facilities, the local

Government shall approve the off-site transportation plan

before any transit occurs.

8. All yellow bags shall be collected and transported at least

every second day.

9. The transportation shall be properly documented, and all

vehicles shall carry a consignment note from the point of

collection to the treatment facility.

10.Vehicles used for the carriage of yellow bags shall not be

used for any other purpose.

11.The vehicles shall be free of sharp edges, easy, to load and

unload by hand, easy to clean/disinfect, and fully enclosed

to prevent any spillage in the HCF premises or on the road

during transportation.

12.All vehicles shall be cleaned and disinfected after use.

13.The vehicles shall carry adequate supply of plastic bags,

protective clothing, cleaning tools and disinfectants to

clean and disinfect in case of any spillage.

14.All staffs handling yellow bags shall wear protective

clothing.

15.Staffs shall be properly trained in the handling, loading and

unloading, transportation and disposal of the yellow bags.

16.Staffs shall be fully aware of emergency procedures for

dealing with accidents and spillage.


4.9 Waste treatment guidelines

The following guidelines should be included in waste treatment:

1. Amongst all the current existing technologies for treating and

disposing of HCW, the most appropriate technology shall be

applied, that is:

1 The most reliable, affordable and sustainable technology in

accordance with the technical, human and financial

resources of each HCF;

2 The technology that minimizes the immediate public health

risks associated with HCWM with the lowest impact on the

environment.

2. Incineration may be considered as the technology that most

reliable disposal of hazardous and properly buried in an

appropriate pit. Nevertheless, in highly densely populated areas

large quantities of hazardous HCW shall not be incinerated at

temperatures lower than 12000C.

3. Several methods are used for infectious waste treatment,

depending on the type of waste material. These treatment

methods shall include one of the following options or

combination of options: steam sterilization, incineration, thermal

inactivation, gas/vapor sterilization, chemical disinfection, or

sterilization by irradiation.

4. After treatment, the wastes or their ashes should be disposed of

by discharge into sanitary sewer systems (for liquid or ground-

up waste) or burial in sanitary landfills.

5. Acceptable treatment methods for the various types of wastes

are listed in Table 3-1.


Recommended techniques for treatment of infectious wastes

Type of

infectious

waste

Recommended treatment techniques

Steam

sterilizatio

n

Incineratio

n

Thermal

inactivatio

n

Chemical

disinfectio

n

Other

Isolation wastes X X

Cultures and

stocks of

infectious

agents and

associated

biologicals

X X X X

Human blood

and blood

products

X X X X

Pathological

wastes X X X

Contaminated

sharps X X

Carcasses and

partsX X

Bedding X


4.9.1Guidelines for Steam Sterilization (Autoclaving)

Steam sterilization, autoclaving, involves the use of saturated steam

within a pressure vessel at temperatures high enough to kill infectious

agents in the waste. Sterilization is accomplished primarily by steam

penetration. Steam sterilization is most effective with low-density

material such as plastics.

The following guidelines should be included in Steam Sterilization

(Autoclaving):

1. An alternative treatment method, e.g. incineration, should be

used on high-density wastes such as large body parts or large

quantities of animal bedding or fluids because they inhibit direct

steam penetration and require longer sterilization times.

2. Containers that should be used effectively in steam sterilization

are plastic bags, metal pans, bottles, and flasks. High-density

polyethylene and polypropylene plastic should not be used in

this process because they do not facilitate steam penetration to

the waste load.

3. Heat-labile plastic bags allow steam penetration of the waste,

but they may crumble and melt. If heat-labile plastic bags are

used, they should be placed in another heat-stable container

that allows steam penetration, such as a strong paper bag, or

they should be treated with gas/vapor sterilization.

4. The following precautions should be taken when using steam

sterilization:

4.1 Plastic bags should be placed in a rigid container before

steam treatment to prevent spillage and drain clogging.


4.2 To facilitate steam penetration, bags should be opened and

caps and stoppers should be loosened immediately before

they are place in the steam sterilizer.

4.3 Care should be taken to separate infectious wastes from

other hazardous wastes.

4.4 Infectious waste that contains noninfectious hazards

should not be steam-sterilized because of the possibility

that the equipment operator will be exposed to toxic,

radioactive, or other hazardous chemicals.

4.5 Waste that contains drugs, toxic chemicals, or chemicals

that would be volatilized by steam should not be steam-

sterilized.

4.6 Persons involved in steam sterilizing should be trained in

handling techniques to minimize personal exposure to

hazards from infectious wastes. Some of these techniques

include:

4.6.1 Use of protective equipment

4.6.2 Minimization of aerosol formation

4.6.3 Prevention of waste spillage during autoclave loading

and unloading

4.6.4 Prevention of burns from handling hot containers

4.6.5 Management of spills

4.7 The autoclave temperature should be checked with a

recording thermometer to ensure that the proper temperature

is being maintained for a long enough periods during the

cycle.

4.8 Steam sterilizers should be routinely inspected and serviced,

and the process should be routinely monitored to ensure that

the equipment is functioning properly.

4.9.2Guidelines for Incineration


Incineration converts combustible materials into noncombustible

residue or ash. Gases are ventilated through the incinerator stacks,

and the residue or ash is disposed of in a sanitary landfill. If

incinerators are properly designed, maintained, and operated, they are

effective in killing organisms present in infectious waste.

The following guidelines should be included in Incineration:

1. Incineration should be used for anesthetic disposal of

pathological wastes such as tissues and body parts.

2. Incineration should be used to render contaminated sharps

unusable.

3. The principal factors affecting incineration like variations in

waste composition, the waste feed rate, and the combustion

temperature should be considered to maintain efficiency of

incinerating infectious wastes.

4. Infectious wastes containing drugs should be disposed of in an

incinerator that provides high temperatures and enough time for

the complete destruction of these compounds.

5. The incinerator’s effectiveness in disposing of chemical wastes

should be documented before such use.

6. Persons involved in Incineration should be trained in handling

techniques to minimize personal exposure to hazards from

infectious wastes. Some of these techniques include:

6.1 Use of protective equipment

6.2 Prevention of waste spillage during incinerators loading

6.3 Management of spills


4.9.3Guidelines for Thermal Inactivation

Thermal inactivation involves the treatment of waste with high

temperatures to eliminate the presence of infectious agents. This

method is usually used for large volumes of infectious waste.

Liquid waste is collected in a vessel and heated by heat exchangers or

a steam jacket surrounds the vessel. The types of pathogens in the

waste determine the temperature and duration of treatment. This

method requires higher temperatures and longer treatment cycles

than steam treatment.

The following guidelines should be included in Thermal Inactivation:

1. After treatment, the contents should be discharged into the

sewer or landfills in a manner that complies with Federal and

local requirements.

2. Solid infectious waste should be treated with dry heat in an oven,

which is usually electric.

3. Persons involved in Thermal Inactivation should be trained in

handling techniques to minimize personal exposure to hazards

from infectious wastes. Some of these techniques include:


3.2 Prevention of waste spillage during Thermal Inactivation

loading and unloading

3.3 Prevention of burns from handling hot containers


4.9.4Guidelines for Gas/Vapor Sterilization


Gas/vapor sterilization uses gaseous or vaporized chemicals as the

sterilizing agents. Ethylene oxide is the most commonly used agent.

The following guidelines should be included in Gas/Vapor Sterilization:

1. Gas/Vapor Sterilization should be used with caution since it is a

suspected human carcinogen, because ethylene oxide may be

adsorbed on the surface of treated materials, the potential exists

for worker exposure when sterilized materials are handled.

2. Persons involved in Gas/Vapor Sterilization should be trained in


from infectious wastes and handling of sterilized materials. Some

of these techniques include:


2.2 Prevention of waste spillage during Gas/Vapor Sterilization




4.9.5Guidelines for Chemical Disinfection

Chemical disinfection is the preferred treatment for liquid infectious

wastes, but it can also be used in treating solid infectious waste.

The following guidelines should be included in Chemical Disinfection:

1. The following factors should be considered and labeled with

wastes to be treated when using chemical disinfection:

1.1 Type of microorganism

1.2 Type of disinfectant

1.3 Contact time


1.4 Other relevant factors such as temperature, pH, mixing

requirements, and the biology of the microorganism

2. Ultimate disposal of chemically treated waste should be in

accordance with Federal and local requirements.

3. Persons involved in Chemical Disinfection should be trained in


from infectious wastes and handling of sterilized materials.

Some of these techniques include:


3.2 Infections from exposure to pathogenic organism

3.3 Prevention of waste spillage during Chemical Disinfection




4.9.6Guidelines for Accidents (emergency) and spillage

The following guidelines should be included in Accidents and spillage:

1. All HCF staff members shall be properly trained and prepared for

emergency response, including procedures for treatment of

injuries, cleanup of the contaminated area and prompt reporting

of all incidents of accidents.

2. The following actions shall be taken:

2.1 Evacuation of the contaminated area if required;

2.2 Decontamination or disinfection, rinsing and wiping dry

with absorbent cloth by personnel wearing adequate

protective clothing;

2.3 Decontamination or disinfection of the protective

clothing if necessary;

2.4 Cuts with sharps or needle stick injuries shall be

immediately disinfected;


2.5 Accident shall be reported to the infection control

officer/staff;

2.6 All cases shall be registered by the management Team

of the HCF and annually reported to the District Health

Authorities.

2.7 It is highly recommended to perform blood tests

following such an injury to ensure that the injured staff

has not been contaminated by any pathogen.

4.10 Guidelines for Ultimate Disposal

The following guidelines should be included in Ultimate Disposal:

1. The recommended types of disposal options in accordance with

the type of HCW are:

1.1 Conventional sewer system for discharge of treated liquids

and grounded solids.

1.2 Landfill disposal of treated solids and incinerator ash.

2. EPA and MoH shall control that only treated infectious wastes

are buried in landfills.

3. Facilities should secure the services of reputable waste handlers

to ensure, to the extent possible, that ultimate disposal of

hazardous wastes is performed according to applicable Federal

and local regulations.

4.11 Guidelines for Maintenance Workers

The following specific guidelines should be included in a HCWM for

maintenance workers:


1. Workers should be instructed to use gloves during working in

contaminated areas and materials, and wash their hands

thoroughly after removing work gloves.

2. Workers should be aware that other persons may not have

followed proper procedures for disposing of needles, knives, and

glassware.

4.12 Guidelines for occupational risks

The following guidelines should be included in HCWM for central store,

food, laundry & other services and office workers:

1. Desks and countertops should be free of sharp.

2. Needles and other sharp instruments should be discarded in

designated puncture-resistant containers and not in trash cans or

plastic bags.

3. There should be no recapping of needles.

4. Rules for safe disposal and collection of sharp instruments or

other hazardous materials should be reviewed regularly.

5. Workers should examine and handle soiled linens and similar

items as if they contained hazardous items.

6. Workers should receive periodic instruction to keep them aware

of the specific hazards of HCW of HCFs.

7. Worker should follow instructions issued by the infection control

personnel for reporting infections.

8. Workers should take appropriate measures to limit further

contagion from HCWs by practicing universal precautions of self-

protection from exposure to infectious wastes.

4.13 Guidelines for Training


All workers who handle infectious waste should receive infectious

waste management training that includes:

(1) Explanation of the infectious waste management plan.

(2) Assignment of roles and responsibilities for implementation of the

plan.

(3) Refresher courses should also be given periodically.


Section 5 Specific Guidelines Associated With HCW Categories

Class 1: non-risk health-care waste

1. Non-risk HCW of class 1 shall be placed in black containers.

2. Non-contaminated items that are designated for recycling shall

be packed in specific black containers marked ''Non-

contaminated plastic, to be recycled'' or ''Non-contaminated

glassware, to be recycled''.

3. All non-risk HCW not designated for recycling shall be collected

with the other municipal waste.

Class 2: clinical waste

1. All class 2 clinical waste shall be placed in yellow polyethylene

bags of minimum 300 microns gauge marked ''Danger!

Hazardous medical waste'' and indicated with the international

Biohazard symbol.

2. Preferably, the bags shall be placed in bag-holders.

3. Bags shall be sealed with appropriate adhesive tape, removed

and replaced immediately when they are no more than three-

quarters full.

4. If not available, yellow bins or containers shall be used; they

must nevertheless be systematically disinfected in a solution of

10% of sodium hypochlorite or Lysol once emptied.

5. All class 2 clinical HCW shall be incinerated in double chamber

incinerators.

6. In highly densely populated areas centralized pyrolytic

incinerator, reaching 1'2000C shall be preferably used.

7. In minor HCFs, i.e. in health centers and Dispensaries, class 2

clinical HCW may be incinerated in a simple pit hole land

50

disposal is an alternative solution when there is no risk of

contaminating underground water.

Class 3: sharps

1. All class 3 sharps shall be placed in specific cardboard or plastic

safety boxes, resistant to punctures and leak-proof, designed so

that items can be dropped in using one hand and no item can be

removed.

2. The safety box shall be coloured yellow, marked ''Denger!

Contaminated sharps''.

3. It shall be closed when three-quarters full and then placed in a

yellow plastic bag or containers with the other hazardous HCW

of class 2.

4. In particular all disposable syringes and needles shall be

discarded immediately following use.

5. The needle shall not be recapped or removed from the syringe;

the whole combination shall be inserted in to the safety box.

6. Under no circumstances are used syringes or needles, or safety

boxes, to be disposed of in normal garbage or dumped randomly

without prior treatment.

7. Sharps are destroyed together with the hazardous HCW of class

2. The method of choice for destruction of full safety boxes is

incineration, preferably in an appropriate double-chamber

incinerator.

8. If such an incinerator is unavailable, alternative methods may be

used like the use of sharp pits.

9. Under exceptional circumstance, full safety boxes may be

incinerated in small numbers by open burning in a pit hole.

10. The residues of incineration shall be safety buried at sufficient

depth (> 1m).


Class 4: anatomical waste and placentas

13 In operation theatres, all class 4 anatomical waste and placentas

shall be collected separately.

14 When a centralized incinerator is available they shall be incinerated.

15 Nevertheless, when low-cost incinerators are used, anatomical

waste or large number of placentas can be difficult to incinerate and

will reduce drastically the performance of the system.

16 If incineration cannot be performed, class 4 anatomical waste and

placentas shall be dropped into a concrete lined pit or buried at a

sufficient depth (> 1m) inside the HCF compound1.

17 If transportation and disposal cannot be immediately ensured,

anatomical waste should be stored in the mortuary.

Class 5: hazardous pharmaceutical and cytotoxic waste

1. Hazardous pharmaceutical waste and cytotoxic waste shall be

repacked in specific cardboard boxes marked ''Danger!

Hazardous pharmaceutical and cytotoxic waste'' they shall be

sent to the medical store Department that shall ensure their

disposal at central level.

2. Class 5 wastes shall be incinerated in a pyrolytic incinerator at a

minimum of 1'2000C.

3. Class 5 hazardous pharmaceutical wastes and cytotoxic waste

containing heavy metals shall not be incinerated.

1 The area around the pit should be totally enclosed and secured from unauthorized

access and at least 100 m away from any underground fresh water borehole or well.


4. For this specific category of waste, inertization2 may be

foreseen.

Class 6: highly infectious waste

1. Highly infectious waste from the medical Diagnostic laboratory of

the HCF, such as media and culture plates, shall be collected

preferably in leak proof yellow bags suitable for autoclaving and

properly sealed.

2. It shall be autoclaved at a temperature of 1210C at 1 bars for at

least 20 minutes at source, i.e. in the medical Diagnostic

laboratory itself.

3. Disinfected waste shall be collected and treated with the

hazardous HCW of class 2.

4. If a distinct autoclave is not available at the medical Diagnostic

laboratory to ensure a thermal treatment, highly infectious waste

shall be disinfected in a solution of sodium hypochlorite in

concentrated form and left overnight.

5. It shall than be discarded in a specific yellow bag properly sealed

and itself discarded with the hazardous HCW of class 2.

6. If none of the above treatment options can be ensured, ensured,

highly infectious waste should at least be packed in a specific

yellow bag that shall be sealed and directly discarded with the

hazardous HCW of class 2 and this option shall remain

exceptional.

2 Inertization consists in mixing pharmaceutical waste with cement and lime before

burying too minimize the risk that toxic substance migrate in to the surface water or

groundwater. The packaging should previously be removed.


7. Class 6 wastes from isolation wards or permanent treatment

centers (cholera) shall always be incinerated on-site.


Class 7: radioactive waste

1. All radioactive waste of class 7 shall be stored to allow decay to

background level.

2. They shall be placed in a large container or drum and labelled

with the radiation symbol showing the radio-nuclide's activity on

a given date, the period of storage required, and marked

"Caution! Radioactive waste".

3. Containers or tanks with radioactive waste that has not decayed

to background level shall be stored in a specific marked area,

with concrete walls 25 cm thick.

4. Non-infectious radioactive waste, which has decayed to

background level, shall follow the non-risk HCM stream (class 1)

while infectious radioactive waste which has decayed to

background level shall follow the clinical HCW stream (class 2).

5. Liquid radioactive waste shall be discharged into the sewerage

system or into a septic tank only after it has decayed to

background level in adequate tanks.

Class 8: Waste with high contents of heavy metals

1. Wastes with high contents of heavy metals should normally be

treated in specific recovering industries.

2. Alternatively, as for chemical waste, it should be encapsulated

for handling and disposal.

3. Wastes with high contents of mercury or cadmium shall never be

incinerated because of the risk of atmospheric pollution with

toxic vapours.


Class 9: Effluents

1. All liquid infectious waste shall be discharged into the sewerage

system only after being treated according to WHO standards.

2. Wastewater from HCFs should not be released to the

environment with out treatment because they may contain

various potentially hazardous components such as

microbiological pathogens, hazardous chemicals,

pharmaceuticals and radioactive isotopes.

3. The proper treatment of wastewater from HCFs is very expensive

and cannot be currently foreseen in every HCF of Ethiopia,

however, basic steps described above (1 & 2) should be applied

to contributes to the reduction of the public health risk

associated with liquid waste and wastewater.


Section 6. Guidelines for Implementation of HCWM Plan in

HCFs

6.1 Guidelines for waste management plan

The following guidelines should be included in HCWM plan:

6.1.1 Each HCW generating organizations should have a

comprehensive waste plan as part of an overall health care

strategy.

6.1.2 Implementation of HCWM plan shall be coordinated by the

DHEH of the MoH, in concordance with other stakeholders

who will participate in a range of activities - from

implementation to supervision.

6.1.3 There should be a designated individual and/or waste

management committee responsible for HCWM plan

implementation.

6.1.4 The HCWM plan shall contain:

a) Duties and responsibilities for each of management level

and different categories of HCF staff members.

b) An estimation of the quantities of HCW generated and the

annual needs for the implementation of the HCWM

procedures/plan.

c) A manual describing all the procedures for the management

of HCW in the premises with special explanation for those

HCWs requiring specific management.

d) Monitoring procedure to track and a day-to-day activities

inside the HCF and ensure that HCWM rules are respected.


e) Information on procedures, display and location of HCF

staffs, receptacles, storage at strategic points.

f) Training courses and programmes for all categories of HCF

staff members.

g) A plan for storage and disposal of hazardous HCW in cases

of emergency in the events of a breakdown of the

incinerators or autoclave, and emergency procedures.

6.2 Guidelines for duties and responsibilities:

6.2.1 HCWM in HFs shall involve clarifying who is responsible for

what functions and identifying the fields of competencies

of each actor involved in this process.

6.2.2 The following guidelines should be included in Duties and

Responsibilities at National level:

a) The Federal MoH, Department Hygiene and Environmental

Health (DHEH), shall take the lead in coordinating

implementation of the HCWM plan.

b) The Federal government, DHEH, shall ensure that Regional

Health Bureaus (RHB) prepare and implement a proper

HCWM plan.

c) The DHEH shall support the RHB in the definition and the

implementation of the HCWM plan by providing technical

advice.

d) The DHEH shall set up periodic training programmes

review in all the training institutions to ensure that

adequate training on HCWM is given.

e) The DHEH shall be responsible give supportive supervision

on HCWM activities at all levels and Federal EPA at local


landfills to ensure that treatment and disposal facilities

comply with guidance and regulations.

f) The DHEH and Federal EPA shall watch over the means of

collection, transportation, destruction and disposal of the

wastes.

g) The Federal MoH, Health Extension and Education

Department, shall play a role with activities of public

information and awareness raising on HCWM.

h) EPA shall watch over the respect of environmental norms

and procedures, particularly as they are contained in the

Environmental Impact Assessment guidelines for

hazardous wastes and health-care wastes.

i) EPA shall be responsible for developing norms and

standards for soil, water and air protection, mainly as they

relate to the use of landfill sites for HCW disposal. In these

conditions, the EPA should develop norms and standards

for landfills so that they could receive HCW in a safe

manner.


Responsibilities at regional/district level:

6.2.3.1 The local (regional/district) governments shall:

a) Design their landfills according to the norms and standards

defined by Federal EPA, in order to avoid soil, water and air

pollution in case of reception of HCW.

b) Ensure that safe disposal of HCW accomplishment by

reserving specific areas.

c) Enact regulations to refuse receiving mixed HCW with non

infectious wastes at local landfills; forbid uncontrolled HCW

disposal; and set up strong waste management controls in


their landfills (materials for covering, restriction for non

authorized public access, equipment protection, etc.)

6.2.3.2 The Regional/District health and environmental

bureaus/offices shall:

a) Need to put in place arrangements to make sure that HCW

are not mixed with general wastes in their public landfills.

b) Give their opinion about the HCWM plan activities proposed

for health facilities in their jurisdiction, in case some may

have negative impacts on the local population's health.

c) Ensure that coordination of the monitoring and reporting

on implementation of the HCWM should be exercised by

the HCWM Committee.

d) Prepare and implement a proper HCWM plan.

e) Support the HCFs in the definition and the implementation

of the HCWM plan by providing technical advice.

f) Set up periodic training programmes in all the HCfs to

ensure that adequate training on HCWM is given to their

staffs.


Responsibilities at health facility level:

1. The medical director of the health facility shall:

a) Be responsible for HCWM plan in his/her HF.

b) Ensure that a HCWM plan is prepared and then watch to

ensure that procedures and regulations are respected.

c) Designate a committee in charge with supervising HCW

segregation, storage, collection, transportation,

treatment and disposal.


d) Assign duties and responsibilities to all medical and non-

medical staff.

e) Allocate sufficient financial and manpower resources for

the implementation of HCWM plan.

f) Ensure adequate training and refresher courses for the

concerned hospital staff members.

2. The HCWM committees shall:

a) Make important contributions by identifying safety and

health problems and by educating the workforce about

safety and health issues.

b) Get a full support and commitment of the hospital

administration to have a strong and effective HCWM in

the HCFs.

c) Be a committee with no informal tasks for the members

but a regular part of their job responsibilities.

d) Represent workers and supervisors from all departments

in the HCFs.

e) Comprise the following members:

i)Medical director or Deputy, who shall be the

chairperson.

ii) The Head of administration

iii) The Head of units/nurses

iv) The Matron

v) The HCWM officer/expert

vi) The Head of operation and maintenance

vii) The Head of pharmacy

f) Include the following major functions:

i) Inspecting workplaces regularly to identify safety and

health hazards and infections


ii) Regularly reviewing needle injury rates and results

from prevention activities, and other relevant

workplace data

iii) Preparing information for workers on identified

hazards and infections

iv) Organizing educational classes

v) Reviewing safety and health aspects when planning

new construction or renovating facilities

vi) Establishing motivational programs (e.g. recognition,

awards, and dinners) to stimulate worker participation

in HCWM activities.

3. The HCWM officer/expert shall:

a) Be responsible for the daily implementation and monitoring

of the HCWM plan.

b) Ensure internal collection of bags and waste containers and

their transport to the central storage facility of the HF on a

daily basis.

c) Liaise with the medical and supply units to ensure that an

adequate supply of waste bags, containers, protective

clothing and collection trolleys are available at all level.

d) Ensure that cleaners and sweepers immediately replace

used bags/containers with a new bag/ container of the

same type and where a waste bin is removed from one

container, that the container is properly cleaned before a

new bag is fitted in.

e) Ensure that cleaners and sweepers are not involved in

waste segregation and that they only handle waste bags

and containers, in the correct manners.


f) Ensure correct use of the central storage facility and that it

is kept secured from unauthorised access. He should also

prevent unsupervised dumping of waste nags and waste

containers on the hospital premises, even for short periods

of time

g) Coordinate and monitor all disposal operations, and for this

purpose meet regularly with the concerned representative

of the local council.

h) Ensure that the correct methods of transportation and

disposal of waste are used.

i) Ensure the emergency procedures exist and can be taken.

He shall investigate record and review all incidents

reported regarding hospital waste management.

4. The Heads of administration shall:

a) Ensure that all the logistics and human resources needs

are adequately fulfilled to implement the HCWM plan.

b) Ensure that a proper budget to the implementation of the

HCWM plan.

c) Liaise with the medical director and the HCWM

officer/expert to estimate the specific costs and to request

the proper budget to the waste storage, treatment and

disposal facilities and health services.

5. The Matron shall:

a) Liaise with the medical director and HCWM committee.

b) Be responsible for the application of HCWM procedures by

the nursing and the cleaning staffs.

c) Be responsible for the recording and the reporting of all

cuts or puncture wounds associated with sharps and


manipulations such as needle stick injuries of medical and

non-medical staff members.

d) Ensure that the staff members know the immediate

disinfection measures to be taken during spilling

emergencies.

6. The Head of units/nurses shall:

a) Be responsible for the proper management of the HCW

generated in their respective units.

b) Head of units/nurses shall:

c) Ensure that al, the medical and ancillary staff working in

their unit respect the HCWM procedures.

d) Ensure that the HCWM procedures are clearly displayed at

strategic locations.

e) Liaise with the HCWM officer/ expert for effective

monitoring reporting of mistakes and errors in the

implementation of the HCWM plan.

7. The Head of operation and maintenance shall:

a) Liaise with the head administration and HCWM

officer/expert.

b) Be responsible for the application of HCWM procedures by

the maintenance staffs.

c) Be responsible for the recording and the reporting of all

cuts or puncture wounds associated with sharps and

needle stick injuries of maintenance staffs.

d) Ensure that the maintenance staff members know the

immediate reporting of all cuts or puncture wounds

associated with sharps and needle stick injuries.


e) Ensure that the maintenance staff members know the

immediate corrective maintenance measures to be taken

during spilling emergencies wastes from drainage lines.

f) Be responsible for the installation, maintenance and safe

operation of waste storage facilities as well as the waste

handling and treatment equipment.

g) Ensure that the concerned HF staff members are properly

trained for these purposes.

8. The Pharmacist shall:

a) Ensure that all logistics and pharmaceutical commodities

are stored properly to minimize wastage due mishandling.

b) Ensure that a proper records for logistics and

pharmaceutical commodities.

c) Ensure that the application of first-in first-out dispensary

for pharmaceutical commodities.

d) Liaise with the medical director and the HCWM

officer/expert to handle expired pharmaceutical

commodities and to request the proper method of handling

and disposing off.

6.3 Guidelines for allocation of resources and equipment

for health-care waste handling

6.3.1Guidelines for waste audits and needs estimate

a) A waste management baseline audit and needs estimate

should be conducted before developing a waste

management plan of the HCF.

b) The following information HCW for waste audit should be

collected and assessed in accordance with the guidelines:


i) Types, volume and/or weight, quantities and

composition of waste generated;

ii) Incidence and severity of waste handling injuries;

iii) Incidence and nature of spills and leakages of

hazardous wastes;

iv) Sources of solid and liquid wastes;

v) Points of generation, collection and storage sites;

vi) Types and number of waste containers;

vii) Loading, transport and disposal methods;

viii) Transportation and disposal records;

ix) Costs of waste handling, transport, treatment and

disposal;

c) The number of safety boxes, yellow, black and red bags as

well as bag-holders, containers, collection trolleys and

protective clothing annually required for HCW handling shall

be estimated.

d) A contingency margin of 5% shall always be applied for

safety boxes, yellow, black and red bags.

e) The quantities of disinfectants, necessary spare parts for

HCW treatment and disposal shall be estimated.

f) The number of staff members required for HCW collection

and disposal.

6.3.2 Guidelines for selection of the technology for HCW

treatment/disposal

The technology for HCW treatment /disposal shall:

a) Be selected according to the types of HCW generated in

the HCF.

b) Be sized according to the quantities of HCW generated in

the HCF.


c) The operation and maintenance procedures shall be

carefully estimated and documented in the HCWM plan.

d) A contingency plan shall be included in the HCWM plan in

case of breakdown of the disposal/treatment facility.

6.3.3 Guidelines for allocation of resources and provision

of equipment

a) Equipment and materials (safety box, bags, disinfectant,

protective clothing) should be supplied regularly with out

any shortage in stock.

b) Health facility heads should promote material recovery for

reuse under supervision from national, regional and district

health offices.

c) Sufficient annual running costs shall be dedicated in the

budget for the safe management of the HCW.

6.4 Guidelines for Awareness and Training

Training and awareness efforts with regards to HCWM shall be made at

all levels:

6.4.1 To raise awareness amongst the public about HCW health

risks and safe practices.

6.4.2 To make sure that medical staff refresher training is given on

HCWM.

6.4.3 To make sure that the new staff member is familiarized with

HCWM of the HCF.

6.4.4 To ensure that of waste management is included in the

curricula of health-care personnel in the National training

package.


6.4.5 To ensure that waste management operators (transporters,

treatment plant and landfill operators…) get appropriate

training and support.

6.4.6 For public education on risks, waste segregation, or waste

disposal practices by using the following methods:

a) Displaying posters at strategic points in HCFs such as waste

bin locations, giving instructions on waste segregation.

Posters should be explicit, using diagrams and illustrations

to convey the message to as broad an audience as possible,

including illiterate people.

b) Conveying simple messages outside HCFs through schools,

radio or television programmes, raising awareness about the

risks involved in scavenging discarded syringes and

hypodermic needles, etc…

c) Applying attractive manner for all information displayed or

communicated to be at a maximum effectiveness in holding

people’s attention.

6.5 Guidelines for monitoring system and reporting

procedures for HCWM at all levels:

6.5.1 Monitoring system shall be set up to track hazardous HCW

and sharps along the waste stream until final disposal.

6.5.2 Monitoring should include incident and accident reporting and

recording.

6.5.3 Monitoring data should be analyzed and reviewed at regular

intervals and compared with the host country regulatory limits

so that any necessary corrective actions can be taken.

6.5.4 Records of monitoring results should be kept in an acceptable

format.


6.5.5 Periodic survey shall be performed in waste generators,

storages and transportation, treatment and disposal facilities.

6.5.6 All responsible bodies should submit annual HCWM

performance monitoring reports to their respective bodies.

6.5.7 The annual reports shall contain quantitative data of the

performance of the facility illustrating compliance with

national guidelines.

6.6 Guidelines for private sector involvement

6.6.1 All contracts with private contractors for collection, on-site or

off-site transportation, treatment or disposal of HCW shall be

approved by regional health and environment bureaus.

6.6.2 A private contractor shall be licensed for HCWM operation by

regional health bureaus for competency and regional

environment bureaus for operation.

6.6.3 The MoU with private contractor shall include duties and

responsibilities of ach party regarding HCWM procedures

and handling, transportation and final disposal of HCW.

6.6.4 All workers of the private enterprise dealing with HCW shall be

supplied adequate protection clothes and equipment.


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