Safe Management of Health Care Waste in Liberia

Transcription

1 REPUBLIC OF LIBERIA Safe Management of Health Care Waste in Liberia Guidelines for the Safe Management of Health Care Waste from the Health Care Sector in Liberia. HEALTH SYSTEM RECONSTRUCTION PROJECT (HSRP) Financed through: International Development Association (IDA) Page i

2 The effective management of health care waste is of vital importance to the health care sector and the people in Liberia, who need to be assured that such wastes are managed and disposed of properly. The guideline has been produced by the Ministry of Health & Social Welfare and the International Development Association within the Health System Reconstruction Project (HSRP). The guideline is considered as a tool to support health care facilities to implement the National Health Policy and the National Health Plan as well as the National Policy on Healthcare Waste Management. Therefore it is part of the Basic Package of Health Services (BPHS). Whilst the guidance set out in this guideline document should help those responsible for the management of health care waste, it does not remove their obligations to comply with other legislation and good practice. Other Liberian laws and regulations such as the National Environmental Policy of the Republic of Liberia and the Environment Protection and Management Law of Liberia are also included. International agreements and conventions Liberia signed and/or ratified such as the Stockholm Convention on the Persistent Organic Pollutants and the Basel Convention on the Control of Transboundary Movements of Hazardous Waste and their Disposal where considered when compiling this document. Management s responsibilities include the requirement to understand relevant statutes and legislation. Senior personnel who determine waste management policies and allocate resources for their implementation are also responsible for ensuring that good waste management practices are maintained. Some, but certainly not all, of these responsibilities can be delegated. The requirement for risk assessment in the context of the protection of workers engaged in health care and waste management must be recognised. There are also clear policy and legal obligations detailing responsibility for the protection of the environment. All those responsible for the management of health care waste should ensure that they know their obligations. The guideline shall be understand as not only to be specially set up for the social and physical conditions prevailing in post-conflict affected Liberia, but as a tool for the long term implementation of sustainable health care waste management solutions in Liberia. Nevertheless it provides also a guide for the national government, for the local authorities and international donors how to implement a sustainable system under consideration of the existing health care system in rural areas. A public consultation process with national and international organizations and agencies involved in Healthcare Waste Programs was begun in October 2009 with the initial distribution of the first draft guideline. Jan-Gerd Kühling (ETLog Health), Team Leader, Monrovia 2009 Prepared by: IDA/HSRP in cooperation with other organization - 2 -

3 Table of Contents 1 Introduction Relevant Legislation and Guidance Terminology Recommendations Overview Waste management principles Organisational issues Containers, storage and transport Treatment and disposal methods Classification and Segregation General classification system for health care waste General HCW segregation system Domestic waste Highly infectious waste Infectious waste Sharp waste (Sharps) Hazardous pharmaceutical waste Chemical waste Cytotoxic waste Radioactive waste Pathological and anatomy waste Pressurized containers Waste with high heavy metal content Recommended segregation strategies Recommended segregation strategy system for County Hospitals Recommended segregation strategy system for Health Center Recommended segregation strategy system for Clinics Logistics for health care waste Collection of health care waste Internal transport of health care waste Central Interim Storage for health care waste External transport of health care waste Recommended logistic systems Recommended logistic systems for county hospitals Recommended logistics systems for Health Centers Recommended logistic system for Clinics Treatment and disposal of health care waste Treatment of infectious waste and sharps Treatment of other kind of hazardous waste...37 Prepared by: IDA/HSRP in cooperation with other organization - 3 -

4 7.3 Recommended treatment & disposal systems Recommended treatment & disposal systems for county hospitals Recommended treatment & disposal systems for Health Center Recommended treatment & disposal systems for Clinics Management Aspect for Health Care Waste Organization and responsibilities The health care waste officer system Role of housekeeping / water & sanitation department Role of County Health Team (CHT) Documentation of the health care waste system Human resource management Functional planning National HCW Training system Physical assets management (Maintenance) Financing of health care waste management New installations financed by external sources...44 Prepared by: IDA/HSRP in cooperation with other organization - 4 -

5 List of Abbreviations CHO CHT HC HCF HCW HCWM HWO IEC NGO OHS PAM PPE SOP WHO County Health Officer County Health Team Health Center Healthcare Facilities Healthcare Waste Healthcare Waste Management Healthcare Waste Officer Information, Education, Communication Non-Governmental Organization Occupational Health & Safety Physical assets management Personal Protective Equipment Standard Operating Procedure World Health Organization List of Tables: Tab. 1: Overview Domestic waste Tab. 2: Overview Highly infectious waste Tab. 3: Overview Infectious waste Tab. 4: Overview Sharp waste Tab. 5: Overview Hazardous pharmaceutical waste Tab. 6: Overview Chemical waste Tab. 7: Overview Cytotoxic waste Tab. 8: Overview Radioactive waste Tab. 9: Overview Pathological waste Tab. 10: Overview Waste with heavy metal content List of Figures: Figure 1: HCW classification system Figure 2: HCW Three Bin System Figure 3: HCW Overview, logistic system Figure 4: HCW function area for county hospitals Figure 5: HCW function area for Health Center Figure 6: Hazardous HCW disposal scheme Figure 7: Decision making path for the treatment of infectious waste Figure 8: Level based training system Prepared by: IDA/HSRP in cooperation with other organization - 5 -

6 1 Introduction The provision of health care services, by default, creates waste. Some specifically from diagnosis and treatment, and most just general household-type waste.. In this National Guidelines Document health care wastes are taken to mean those wastes which arise in diagnosis and treatment, and from the immediate care of patients. Healthcare waste also arise in the homes of patients, in residential and nursing homes, in clinics, in the premises of health centers, in county hospitals and in tertiary hospitals, indeed in any place where people are cared for. The adequate management of health care waste (HCW) is still a new subject in Liberia. Integrated waste management concepts hardly exist. The main treatment method, if at all existent, is the burning of the waste in small incinerators. While in Monrovia and other main cities first efforts to improve the situation are underway, in the rural areas a large portion of the HCW stream is still disposed of without any treatment. During the last cholera epidemics, the outbreak of haemorrhagic fevers and the thread of avian influenza and H1N1, shortcomings in the management of infectious waste in Liberia became apparent. Transmission of disease occurs mainly through injuries from contaminated sharps and through inhalation of bio-aerosols. Besides tuberculosis (TB), blood borne diseases - like hepatitis B (HBV), hepatitis C (HCV), and the human immunodeficiency virus (HIV) - are infections of particular concern. Toxic risks arise among others from reagents (particularly laboratory reagents), drugs, and mercury thermometers (CEC, 1993). The different categories of waste normally generated from a health care setting are non-risk/non-hazardous, solid waste (household waste) as well as risk/hazardous waste such as infectious waste, sharps, pharmaceutics, chemicals and other potential dangerous waste streams. Included in the domestic waste is also green waste from maintenance of grounds, and construction and demolition wastes from building activities. The Environment Protection and Management Law defines different hazardous waste streams, the National Policy on Health Care Waste Management has introduced a classification system which should be followed. The health care waste categorisation is discussed further in the section on classification and segregation. The personnel responsible for health care waste management, i.e. for waste minimisation, collection, transport, storage, treatment and disposal, will require access to relevant professional advice and the implementation of a sound management system adequate for the purpose. Risk assessment is required in the contexts of the protection of staff and the protection of the environment. Due to the changes in health care processes, the volume of waste generated is steadily raising. Those responsible for health care waste are increasingly challenged to investigate further the management of health care wastes. The aim, where possible, should be to substantially reduce the volume of waste. Special consideration should be given to hazardous waste, because of its higher risks and the cost intensive specialist treatment and disposal. In particular, sound and practical systems of segregation are required. Prepared by: IDA/HSRP in cooperation with other organization - 6 -

7 Good waste management principles in Liberia shall include: full responsibility of the waste producer for the management of waste; re-orientation and training of personnel on separate waste collection and motivating them to ensure that waste segregation is effective; establishment of separate waste collection system which ensures that wastes intended for different means of treatment and disposal are segregated into different streams ; establishment of appropriate treatment and disposal system for each waste stream; maintaining records of waste generation; costs of it management; and accidents related to waste handling; monitoring the performance of the segregation and disposal arrangements; taking corrective action if necessary. Establishing and monitoring robust separate waste collection system is likely to be severe tests of management skills, particularly since many health care workers see waste handling as an unimportant minor activity. It is crucial to good waste management practice that health care workers know what is expected of them in waste segregation and that they are motivated and trained to act properly. The arrangements made should be sufficiently robust to accommodate both changes in personnel and, should it be necessary, changes in the means of waste treatment and disposal used. In choosing the means of final treatment and disposal, health care services management should achieve following objectives: to comply with relevant legislation; to follow established guidance; to use means which, while consistent with the above, are costeffective. In that choice, technical and commercial judgement will play a major part, as will knowledge of what is consistent with legislation and good practice. It is the responsibility of all staff within health care premises to ensure that wastes are entered into the correct disposal stream. Abuse or misuse of the system could lead to a significant increase in the hazards and risks associated with health care waste management. Health care facilities should also, as a matter of course, have clear arrangements for ensuring that their waste management policies work in practice and, if they do not, for taking early and effective corrective action. Prepared by: IDA/HSRP in cooperation with other organization - 7 -

8 2 Relevant Legislation and Guidance Article 7 of the Liberia Constitution (6 January 1986) states: The Republic shall, consistent with the principles of individual freedom and social justice enshrined in this Constitution, manage the national economy and the natural resources of Liberia in such manner as shall ensure the maximum feasible participation of Liberian citizens under conditions of equality as to advance the general welfare of the Liberian people and the economic development of Liberia. This article forms a constitutional basis for the set up of an active National Policy on Health Care Waste Management and for the preparation of national development plans that are environmentally sustainable - including plans for the future management of health care waste. For the environmental side, two main acts exist: An act creating the Environmental Protection Agency which empowers the agency with the principal authority in Liberia for the management of the environment and to coordinate, monitor, supervise, and consult with relevant stake-holders on all activities in the protection of the environment and sustainable use of natural resources; An act adopting the Environmental Protection and Management Law with sections on air quality standards and domestic waste management as well as a draft legislation on Persistent Organic Pollutants, and Waste Management The relevant law is the public health law from In Part III, environmental sanitation is covered specifies that improper management of waste can result in nuisance which is prohibited in accordance with Chapter 24 regulates liquid waste (water pollution control). Prepared by: IDA/HSRP in cooperation with other organization - 8 -

9 3 Terminology These guidelines are valid for all entities - private and public - involved in the management of health care waste in Liberia. Waste means any substances or objects which are disposed of or are intended to be disposed of or are required to be disposed of. Waste includes product left over at the end of a process or action and is a resource out of place. Health care waste includes all the waste (solid, liquid or gaseous) generated by health care facilities, research facilities, and laboratories. In addition, it includes the waste originating from minor or scattered sources, such as that produced in the course of health care undertaken in the home (dialysis, insulin injections, etc.). Waste can be considered as non-hazardous if the risks are similar to those caused by domestic (or household) waste - if it does not contain products or potential properties that are known to have either a reactive or toxic or biological effect, either to humans or the environment. Hazardous health care waste is waste containing substances or compounds which are directly harmful or indirectly harmful to environment and health by interacting with other substances. Waste can be considered as hazardous if it is: Explosive Oxidizing Highly or extremely flammable Irritant Harmful Toxic or very toxic Infectious Teratogenic Mutagenic Carcinogenic Ecotoxic Corrosive Radioactive Health care waste management is concerns all efforts to eliminate or minimize wastes including: Identification of waste and the sources of generation, Selecting and implementing of the most appropriate techniques: with respect to cost, with respect to environmental reasons in the frame of the hierarchy of waste management practices, through process optimization or redesign in developing cleaner processes. The main objective of waste management is the cost effective handling, minimization, treatment and disposal of waste under the key constraint of legislation and its enforcement. Prepared by: IDA/HSRP in cooperation with other organization - 9 -

10 Health care facilities have a duty of care for patients and for the public health. This includes that they also have a particular responsibility for health care waste management as they are the producer and owner of this waste. Any failure in classification, collection, storage, treatment and disposal processes will create potential risks to human health and the environment. Waste minimisation: A fundamental principle of any waste management system is that the generation of waste be minimised. Appropriate classification and segregation will minimise costs and volume in certain waste stream categories. Volume reduction in real terms requires life-cycle-analysis of products used in clinical practice, and consideration/implementation of reuse/reusables, and recycling. Occupational health and safety: The system must ensure that all waste is handled and disposed of safely. This applies particularly to hazardous waste such as discarded sharps, cytotoxic pharmaceuticals, microbiological cultures and radioactive waste. The waste management plan and procedures should be readily available to all workers involved. Legislative requirements: The recommendations in this document are not meant to override any special conditions imposed by the relevant authorities. Rather, they provide a basis for the development of any current and future strategy for health care wastes management in Liberia. There is a need for a national, uniform strategy for health care wastes management, and therefore the terminology used in this document is recommended. National standardisation will help to improve safety and optimise resources. Prepared by: IDA/HSRP in cooperation with other organization

11 4 Recommendations The following are the basic recommendations. However, some local authorities may adopt more stringent measures with respect to waste management options. 4.1 Overview These guidelines should be used as the basis for a national uniform strategy for waste management. Health care waste generators must ensure the safe identification, packaging/containment, labelling, storage, transport, treatment and disposal of wastes. A large proportion of health care waste is no more dangerous than household like waste, and waste generators should lead the way in educating all personnel, and particularly disposal contractors, to approach waste management with this in mind. 4.2 Waste management principles Independent of size, waste amount, hazards, etc., every natural or juristically body which is generating waste is committed to manage the generated waste in a responsible way under consideration of hygienically, ecological, economical and safety aspects. One of the main keys for an effective waste management and for waste minimization is a strict segregation of waste into different waste streams as otherwise the entire waste mixture (e.g. mixed infectious and household like waste) must be handled as hazardous infectious waste, resulting in extremely high treatment costs. The expenditure for waste management should stand in proportion to the quantity and quality of the produced waste. Out of this it occurs that small, specialized hospitals, producing small amounts of highly hazardous waste may have higher expenditures and must take more efforts as a large health facility, producing large amounts of non-hazardous HCW. General principles to be followed for the health care waste management are: The Duty of Care principle it stipulates that any person handling or managing hazardous substances or related equipment is ethically responsible for using the utmost care in that task. The Proximity principle it recommends that treatment and disposal of waste should take place at the closest possible location to its source in order to minimize risks linked to the transport of waste. The Precautionary principle it governs health and safety protection. When the magnitude of a particular risk is uncertain, it should be assumed that this risk is significant, and measures to protect health and safety should be designed accordingly. The Polluter Pays principle it implies that all producers of waste are responsible for the safe and environmentally sound disposal of the waste they produce. Prepared by: IDA/HSRP in cooperation with other organization

12 4.3 Organisational issues Appropriate waste management plan and policy should be developed and implemented with the full support of the facility management. Public health and environment protection, provision of information, education and training, performance monitoring are essential elements that need to be included in the management plan. Statistical analysis of data collected on waste type, weight, volume, manner and frequency of removal, cost and associated injuries, should be undertaken. Every health care facility should designate a responsible person for health care waste management and large health care facilities should format a waste management group. A waste audit should be conducted prior to developing a waste management plan and subsequently repeated to monitor effectiveness of the implemented plan. The correct segregation is the clear responsibility of every waste generator, independent of the organisational position of the generator ( duty of care principle). Separate waste collection should be carried out by the producer and close as possible to the place of waste generation, that means segregation must take place at source, e.g. on the ward, at the bedside, operating theatre, laboratory, etc. and must be carried out by the person generating the waste e.g. nurse, physician ( proximity principle ). Health care facilities should seek to implement recycling programs for materials where a viable market exists. 4.4 Containers, storage and transport All waste containers/bags should be colour-coded and identified according to these guidelines. Wherever practicable, in the containment of waste, rigid-walled containers should be preferred in place of waste bags, to reduce the risk potential to waste handlers. Such rigid containers should preferably be lined with tie-off plastic bags. Sharps, including retractable items/sharps safety devices, must be collected and transported in watertight, puncture proof, sealable and strong cardboard or plastic containers. Central storage areas should be lockable, hygienic, appropriately signposted and kept secure at all times. Containers with mixed categories of waste must be managed according to the component with the highest level of risk. 4.5 Treatment and disposal methods Infectious waste must be disposed of by an approved method. Recognisable anatomical parts should be safely buried on a cemetery or combusted in a crematory. High-temperature incineration should be used for the disposal of cytotoxic and hazardous pharmaceutical waste. The incineration temperature in the secondary combustion chamber must be 1100 degrees Celsius, with a minimum residence time for volatile gases of 1.0 second. Prepared by: IDA/HSRP in cooperation with other organization

13 Waste pits are a viable alternative to incineration for the bulk of infectious wastes generated in geographical areas where approved incineration facilities are not readily accessible. Where landfill disposal of health care waste is intended, recognisable pathological waste, pharmaceuticals and cytotoxic waste should be excluded at source and the landfill site should be confirmed as suitable. The performance of treatment facilities for health care wastes must be monitored. All health care waste treatment facilities must meet the standards for flue gas emissions. Radioactive waste must be handled, stored and disposed of in accordance with relevant legislation. Non-hazardous waste generated in health care facilities can be disposed of in the same manner as domestic waste. Prepared by: IDA/HSRP in cooperation with other organization

14 5 Classification and Segregation 5.1 General classification system for health care waste In accordance to the Liberian regulations hospital or health care waste (HCW) is divided in 12 different groups. Ten of the twelve groups are considered as medical or hazardous health care waste. In the following figure, a schematic diagram of the classification system and information about the colour coding system can be found. A detailed description of the definition of the different waste groups can be found in the segregation section (Chapter 5.2). Health Care Waste (HCW) Non-medical Waste Medical Waste Domestic Waste (Black) Recyclables Highly Infectious Waste (Yellow) Infectious Waste (Yellow) Sharps (Yellow) Pathological Waste (Yellow) Pharmaceuticals (Brown, if hazardous) Chemical Waste (Brown, if hazardous) Cytotoxic Waste (Purple) Radioactive Waste (Red) Pressurized Containers Waste with high content of heavy metals Figure 1: HCW classification system Prepared by: IDA/HSRP in cooperation with other organization

15 5.2 General HCW segregation system Independent of the kind of waste, the segregation of waste in different waste streams (classes) has to be carried out at the point of generation. Based on the type of waste, the waste might be later on reused, recycled, treated or disposed of. The segregation of waste is the duty of every waste generator, independently of the position in the health care system. Waste has to be segregated directly after generation Domestic waste Domestic waste is comparable to waste generated by households. This waste class is graded as non-hazardous. Examples of this type of waste are: Kitchen waste, office waste, packing materials, left over food and fruit pellets, etc. Other non-risk waste: garden waste, construction waste. Recyclables like glass, paper, cardboard, aluminium, scrap metal and various kinds of plastics are considered as a subgroup of non-medical HCW. Specification Colour Code Packaging: Symbol / Marking Health care waste with similar composition to household and municipal waste Black Black PP or PE plastic bags of good quality and sufficient capacity. Domestic Waste Recyclables: The international recycling sign should be placed on the bins/bags. Wording: Non-contaminated XXX (kind of waste), to be recycled is recommended. Labelling During normal operation not necessary, only during times of research (e.g. waste audits: name of the producer, department, etc.) Tab. 1: Overview Domestic waste Highly infectious waste Highly infectious waste includes all viable biological and pathological agents artificially cultivated in cultures or stocks. It also includes items used for the transfer, inoculation and mixing or cultures of infectious agents. Place of origin of highly infectious waste is normally the laboratory but may also be in other places like in quarantine wards. Highly infectious waste must be treated close to the place of generation. After e.g. autoclaving of highly infectious waste this waste should be disposed off into the normal infectious waste bag (double security). Prepared by: IDA/HSRP in cooperation with other organization

16 Specification Colour Code Packaging: Symbol / Marking Media and cultures from the microbiological laboratory. Yellow Autoclavable (e.g. made from PP), strong, leak proof bags. If bags shall be autoclaved, they should not be hermetically closed. International bio-hazard symbol in black / yellow and wording: Danger! Bio-hazardous medial waste Recommended Labelling Name of the generator (department, ward) Waste class, date of generation Recommended is a chemical indicator which indicates if the waste was successfully sterilized Waste volume and waste destination Tab. 2: Overview Highly infectious waste Infectious waste Infectious waste consists of discarded materials that are contaminated with communicable pathogens that have the potential of transmitting infectious agents to humans. These waste include: waste from isolation wards, tissues (like swabs), waste contaminated with potentially infectious excreta, body fluids and blood, infectious waste from the laboratory as long this waste is not considered as highly infectious waste, waste from the pathology department and from the dialysis (yellow dialysis), waste from the operating theatre. Specification Colour Code Packaging: Symbol / Marking Health care waste contaminated with pathogens which are known or clinically assessed to have the potential of transmitting infectious diseases to humans or animals. Yellow Strong PP or PE plastic bags of good quality and sufficient capacity. Should be placed in a container, such as a pedal bin, or suspended from a bag holder with a lid. International bio-hazard symbol in black / yellow and wording: Danger! Bio-hazardous medial waste Labelling Name of the generator (department, ward) Waste class, date of generation Special remarks Waste volume and waste destination Tab. 3: Overview Infectious waste Prepared by: IDA/HSRP in cooperation with other organization

17 5.2.4 Sharp waste (Sharps) Sharps are all objects and materials which pose a potential risk of physical injury (stick, cuts, etc.). Typical items are needles, blades, broken glass and vials, infusion sets with butterflies, etc. Specification Colour Code Packaging: Symbol / Marking All sharp items, whether contaminated with infectious material or not. Yellow Water tight, puncture-proof, sealable and strong cardboard or plastic containers. A sharps container should, once assembled, have a lid which cannot be removed, have a handle (not part of the closure device) and a lid so designed as to enable items to be dropped in by one hand. Should be resistant to penetration and leakage. International biohazard symbol in black / yellow and wording: Danger! Contaminated Sharps Recommended Labelling The container should bear a horizontal line together with the words `WARNING - DO NOT FILL ABOVE THE LINE'. Name of the generator (department, ward) Waste class, date of generation Waste volume and waste destination Tab. 4: Overview Sharp waste Hazardous pharmaceutical waste Hazardous pharmaceutical waste includes expired, unused, unwanted, spilled and contaminated pharmaceutical products, drugs and vaccines. It also includes all sera and bottles, boxes and vials used to contain pharmaceuticals, which are no longer required. It does not include non-risk pharmaceuticals like vitamins, sugars, amino acid and certain salts. Waste streams should never be mixed, and should always be collected in the original packaging where possible. If the original packaging is no longer available, the wastes should be collected and packed separately according to the trade names and/or chemical and physical properties. A list of drug trade names should be made available to the disposal companies. Specification Colour Code Packaging: Symbol / Marking Hazardous pharmaceutical waste Brown To be packed in specific cardboard boxes, containers or other safe packaging, depending on the specific characteristics and hazards. Depend on the type of the waste, such as: toxic, noxious, corrosive, oxides, flammable, mixed hazards, environmental Prepared by: IDA/HSRP in cooperation with other organization

18 polluting materials etc. Recommended Labelling The wording: Danger! Hazardous pharmaceutical waste Name of the generator (department, ward) Waste class, date of generation Special remarks Waste volume and waste destination Tab. 5: Overview Hazardous pharmaceutical waste Chemical waste All discarded solid, liquid and gaseous chemicals, for example from diagnostic and experimental work, and cleaning, housekeeping and disinfecting procedures. There is a wide variety of dangers and different procedures within this group. Special care must be taken during segregation and collection as these materials can be highly toxic, irritant, corrosive, ignitable, harmful, explosive or carcinogenic. Used packaging must be designed for the specific chemical waste. If no special packaging is available, the waste should be collected in the original packaging. Different kind of chemicals should be only collected if it is ensured that they will not react with each other. If possible, chemical waste should be given back to the supplier for final disposal. Chemical waste should only be handled when Personal Protective Equipment (PPE) is available. Specification Chemical waste Colour Code Packaging: Symbol Formaldehyde, oxide ethylene, X-Ray fixing and developing solutions, solvents, chemical mixtures. Brown Sealable, robust containers, appropriately for their content and for normal conditions of handling and transportation. Different types of hazardous waste should not be mixed to eliminate undesirable reactions, and elevated costs of waste treatment. Depend on the properties of waste, such as: oxidizing, corrosive, explosive, flammable, toxic, mixed hazards, dangerous for the environment, etc. Prepared by: IDA/HSRP in cooperation with other organization

19 Additional Labelling Name of the Producer, if applicable: department Waste class, date of production Special remarks Waste volume-waste destination Tab. 6: Overview Chemical waste Cytotoxic waste A highly hazardous sub-group of pharmaceutical waste is cytotoxic waste. Cytotoxics are pharmaceuticals used for cancer treatment and can be mutagenic, carcinogenic and teratogenic. Cytotoxic waste -also known as genotoxic waste- is potentially highly hazardous if not carefully handled. For this reason it is considered as a separate waste category. Specification Colour Code Packaging: Symbol / Marking Waste from the reconstitution of cytotoxic pharmaceuticals Purple Sealable, robust containers, appropriately for their content and for normal conditions of handling and transportation. Different kind of hazardous waste should not be packed together to eliminate undesirable reactions. Cell in telophase, Wording: Cytotoxic waste Recommended Labelling Name of the generator (department, ward) Waste class, date of generation Special remarks Waste volume and waste destination Tab. 7: Overview Cytotoxic waste Radioactive waste In tertiary health facilities, radioactive waste is generated during diagnostic, therapy and research processes. Radioactive waste has to be handled in accordance to the national regulations. Specification Waste with radio-nuclides whose ionizing radiation has genotoxic effects e.g. Cr-51, Ga 67, I-125, I-131, In-111, P- 32, Rb-86, RD 222, S-35, Tc-99m Prepared by: IDA/HSRP in cooperation with other organization

20 Colour Code Packaging: Symbol / Marking Red Sealable, robust containers, appropriately for their content and for normal conditions of handling and transportation. International radiation symbol and wording: Caution! Radioactive Waste Required Labelling Name of the generator (department, ward) Kind or radionuclide Radiation on given date (start storage time) Period of storage time required Further safety remarks (e.g.: Danger! Contains Biohazardous materials) Waste volume and waste destination Tab. 8: Overview Radioactive waste Pathological and anatomy waste Pathological and anatomical waste includes all waste, recognizable as human body parts and placentas. Anatomical waste is not necessary infectious but needs special requirement out of ethical and religious reasons. Specification Colour Code Packaging: Symbol / Marking Recommended Labelling Anatomical, pathological waste as body parts. Yellow Water tight and sealable strong plastic bags, containers or other collection items None Recommended wording: Pathological waste - Handle with care Name of the generator (department, ward) Waste class, date of generation Special remarks Waste volume and waste destination Tab. 9: Overview Pathological waste Pressurized containers Gases like compressed air, liquids or powdered materials are often stored in pressurized cylinders, cartridges, and aerosol cans. Full pressurized containers must be stored in an upright position. Most of these containers are reusable and should be returned to the supplier when empty. Whether containing inert or potential harmful materials, containers may explode if incinerated or accidentally punctured hence they should be collected separately and handled with care. Prepared by: IDA/HSRP in cooperation with other organization

21 Waste with high heavy metal content Waste with high heavy-metal content is potentially highly toxic and represent a subcategory of hazardous chemical waste but needs special consideration during treatment. Cadmium is used in batteries, and mercury in amalgam fillings, thermometers or manometers. Mercury is present also in small quantities in fluorescent light bulbs and lamps. Lead is still used in radiation proofing of X-ray and diagnostic departments. Specification Colour Code Packaging: Symbol / Marking Recommended Labelling Waste with heavy metal content NON Sealable, robust containers, appropriately for their content and for normal conditions of handling and transportation. Different kind of hazardous waste should not be packed together to eliminate undesirable reactions. Skull and crossbones, Wording: Heavy Metal Waste containing XXX (Mercury or Cadmium.) Name of the generator (department, ward) Waste class, date of generation Special remarks Waste volume and waste destination Tab. 10: Overview Waste with heavy metal content 5.3 Recommended segregation strategies A to be introduced segregation system depends on the kind of waste generated in a specific health care facility. While in secondary and tertiary level health care facilities a much wider spectrum of hazardous wastes must be expected, the classes of medical waste generated in primary health care settings is limited. In general, the Three-Bin System shall be introduced for all health care facilities from Health Center level and above. This shall include the provision of segregation possibilities for infectious waste, sharp waste and domestic waste throughout the medical areas of a health care facility. If needed, additionally possibilities for other type of health care waste shall be provided. Entire Healthcare Waste Stream Chemical / Pharmaceuti cal Waste Infectious Waste Sharp Waste Domestic Waste Figure 2: HCW Three Bin System Prepared by: IDA/HSRP in cooperation with other organization

22 5.3.1 Recommended segregation strategy system for County Hospitals The three bin system has to be set up in all medical areas throughout the hospital. Additionally, the following segregation possibilities shall be provided if required: Segregation of pharmaceutical waste at ward level (nursing station) and in the pharmacy Segregation of chemical waste in the medical support areas such as laboratory and radiology department Collection points for pathological waste at the operation theatres, pathology and at the maternity. One or more collection points for heavy metal waste, especially amalgam (dentist), batteries, fluorescent lamps. In Liberia the following segregation possibilities will be only needed on an exceptional basis and will normally not be required: Radioactive Waste Cytotoxic Waste Recommended segregation strategy system for Health Center The three bin system has to be set up in all medical areas throughout the Health Center. Additionally the following segregation possibilities shall be provided: Segregation of non-risk waste for recycling, especially for cardboard, plastic, glass throughout the hospital and especially at the nonmedical areas, but only if it can be sold. One segregation point for the collection of pharmaceutical waste at a secured area in the Health Center One segregation point for the collection of chemical waste at a secured area in the Health Center Recommended segregation strategy system for Clinics The set up of the three bin system is not needed at Clinic level as only very limited amounts of infectious waste can be expected. Segregation possibilities shall be mainly available for domestic waste and for sharps. Expired pharmaceuticals shall be collected in their original package. Prepared by: IDA/HSRP in cooperation with other organization

23 6 Logistics for health care waste The internal disposal logistic system for health care waste consists of the collection of the segregated waste, the internal transport and the interim storage. In some health care facilities the treatment and also the disposal of specific wastes like sharps, placentas or incinerator ash might be part of the internal logistic system. Another possibility is the external transport, treatment and final disposal. In the following, an overview of a typical internal logistic system and the relevant interfaces and responsibilities is provided. Segregation Point A Segregation Point B Segregation Point C Segregation Point D Segregation Point E Collection by Ward Cleaner Local Collection Point Interface Ward Level Transport by central services Check Packaging/Label Ok? Yes NO Inform responsible Person Interface Waste treatment / storage Area Transport to central interim storage Central Interim Storage Place Acceptance by storage manager Check Packaging/Label OK? Yes NO Inform responsible Person Internal or External: Treatment / Disposal Figure 3: HCW Overview, logistic system The transport of waste can be divided into: Direct transportation: o Direct transportation of the waste from the segregation point to the central interim storage place (normally used in smaller health care facilities such as Health Center, Clinic, Clinics). Local collection points are not considered for direct transportation. Two-step transportation system. o First step: transport of waste from the segregation point to the local collection point (by the staff of the respective ward); o Second step: pick up of the waste from the local collection and transport to the central interim storage place (by logistic staff). Prepared by: IDA/HSRP in cooperation with other organization

24 Under consideration of hygiene, ease and economical aspects, following systems should be introduced for different waste streams: Domestic waste: Recyclables: Highly infectious waste: Infectious waste: Sharps: Pathological waste: Pharmaceuticals: Chemical waste: Radioactive waste: Pressurised containers: Heavy metal waste: Regular collection, direct transportation for small hospitals. Two step transportation for larger hospitals. Regular collection, direct transportation for small hospitals. Two step transportation for larger hospitals. Regular collection, to be collected together with infectious waste after disinfection. Regular collection, direct transportation if no dirty rooms are available, two step transportation if dirty rooms are available (recommended). Regular collection, to be collected together with infectious waste. Direct transportation, on demand collection (Note: normally carried out by staff of the respective department). Direct transportation, on demand collection (Note: normally carried out by staff of the respective department). Two step transportation (usage of local collection points in laboratory, pathology or radiology department), collection on demand. Direct transportation, on demand. Direct transportation, on demand (collection by supplier). Direct transportation, on demand. 6.1 Collection of health care waste Segregated waste shall be collected by the ward cleaner and shall be transported to the local collection point. Containers for the collection of waste shall be made from solid, relatively light, stainless and waterproof materials. Container for the collection of infectious and cytotoxic solid medical waste shall be cleaned and disinfected before reuse. Plastic bags must not be reused. Infectious waste, pathological waste and general waste has to be collected regularly. The waste must be collected at least daily, but as soon as the bins are for 2/3 full. Other type of waste (e.g. sharps) can be collected with a lower frequency (after containers are for 2/3 full). Pharmaceutical waste and chemical waste can be collected on demand and after notice to the responsible person. Prepared by: IDA/HSRP in cooperation with other organization

25 6.2 Internal transport of health care waste Medical and non-medical waste shall be collected from the local collection points and transported to the interim storage place by designated staff and not by ward cleaners. For the transport, appropriate transport equipment is required. The personnel in charge for the transportation of the waste shall be equipped and wear the necessary personal protective equipment (PPE) such as gloves, mask and overall. Non-medical and medical waste must be transported separately. For the transport of domestic waste, infectious waste, sharps and pathological waste, only specially designed, closed and easy to be disinfected trolleys shall be used. These trolleys shall not be used for any other purpose. If other hazardous materials such as chemicals or pharmaceuticals shall be transported, it must be packed in a way that no risk during transportation will be created. 6.3 Central Interim Storage for health care waste Each health care facility has the duty to establish and operate at least a basic central interim storage point. The central interim storage point shall act as waste function area and it shall be possible to carry out the following tasks at this area: Maintenance (cleaning) and repair place for waste logistic equipment (place with water and sewage connection), Interim storage and transfer place (interface) for domestic waste, Post-sorting and storage place for valuable materials (waste for recycling) if recycling is carried out (simple shed attached to existing buildings), Documentation and record keeping of the waste streams, Storage place in case that the waste will be treated in a central facility e.g. county hospital. Healthcare waste, wherever it arises, should be disposed of as soon as it is practicable to do so, but within 24 hours after storage. This requires that waste for disposal has to be picked up at least 3 times per week. In all instances, storage arrangements should: be robust and secure; allow for the safe handling of waste containers exclusively for health care waste. Any clean unused containers must be distinctly separate from used/full containers; allow clear distinctions to be maintained between wastes intended for different disposal methods; allow storage of wastes in designated and delineated areas, in a safe environment without offensive odour; be provided with safety instructions (e.g. spillage procedures and blood and body fluids precautions); be of sufficient size to allow for delays in the onward transportation of the waste. Prepared by: IDA/HSRP in cooperation with other organization

26 The location, size and type of construction of the storage area will depend upon specific circumstances: what is required in a hospital and in a Clinic will be very different. In all cases, it should be secure from unauthorised entry, animals, birds or other infestation. Storage areas for hazardous waste should be located near to any on-site treatment facility, sited on a well drained impervious hard base, and have available wash-down facilities, adequate lighting, ventilation and clear warning signs. The local circumstances and the nature and volume of the waste to be stored should be taken into account when determining storage conditions. 6.4 External transport of health care waste It will be a duty for each health care facility, independent of its size, to sign an external transport and disposal arrangement at least for domestic waste. Arrangements for the collection and transport of health care waste should: be compatible with the arrangements made for storage of the waste; be made, in the context of the duty of care under the sub law on Healthcare Waste Management to permit ready delivery to the means of treatment or disposal which has been arranged; comply with legislation and good practice, especially regarding the health and safety of patients, health care and waste management personnel, and others, and protection of the environment. Arrangements for the storage, collection and transport of waste may involve the personnel of different health care employers, of waste collection and disposal authorities and of waste contractors. In the common interest of smooth operation, and indeed to assist in compliance with legal requirements, there should be standing arrangements for monitoring the duty of care at regular frequencies, to include operational performance and liaison with all designated points of contact. Arrangements for transport by road, rail or sea ensure that: medical solid waste container shall be stored in strong, closed container before transferred to transport vehicle; the waste carrier is registered under the scheme implemented by the sub law on health care waste management; medical solid waste container shall be safe and out of reach from people or animals; Transport personnel shall wear necessary PPE, consisting of: Helm, masker, eye protector, overall, apron for industry, foot protector/boots, and special gloves. The vehicles used to transport health care waste should: permit the safe and easy loading, securing and unloading of waste; contain any leakage from damaged containers; be constructed to avoid entrapment of particles of waste and harbourage of insects or vermin; Prepared by: IDA/HSRP in cooperation with other organization

27 permit, where appropriate, the use of secondary containment of the waste; allow ready disinfection or steam cleaning; be subject to regular inspection for cleanliness and a programme of cleaning appropriate to the extent and nature of usage. Where a vehicle, that is not solely designated, is used to transport waste (for example general purpose vans or cars), particular care should be taken to avoid contamination of personnel, of the vehicle itself or of subsequent loads. That care might well involve special arrangements for extra containment and for regular examination of the vehicle and cleaning as required. 6.5 Recommended logistic systems The complexity of a logistic system depends naturally on the quantity and quality of to be managed waste. Therefore the logistic system in a Clinic can be of quite easy nature. In a county hospital it is often more complex and often requires to be managed by special trained persons Recommended logistic systems for county hospitals For county hospitals, the set up of local collection points for domestic waste, waste for recycling and for infectious waste is recommended. It shall be the task of each ward and department to ensure that waste bins in the department will be regularly emptied and that the bins will be cleaned and disinfected. Sharps and disinfected highly infectious waste shall be collected together with the infectious waste. The emptying and maintenance of the local collection point containers shall be the task of the technical services (e.g. to be carried out by the sanitation department). The cleaners will have to transport the waste in a secured way to the central interim storages. Pharmaceutical waste shall be collected at the nursing station and shall be brought back to the pharmacy. At the pharmacy the pharmaceuticals shall be sorted and stored in original packaging. Hazardous pharmaceutical waste shall be brought to the interim hazardous waste storage place for disposal. Hazardous chemical waste shall be collected at the laboratory, radiology, pathology and other places and shall be brought to the interim hazardous waste disposal place for interim storage. At the hazardous waste storage place, a receive area for heavy metal contaminated waste (batteries, etc.) shall be installed. The set up of a central waste function area is recommended. For the interim storage of domestic waste, waste skips (4-10 m³) shall be used if available by the municipality. For the central treatment of the own and, if applicable, collected infectious waste from other health care facilities, as well as for the management of other hazardous waste from the county hospital, a functional building designed under consideration of logistic aspects will be needed. Based on general waste management aspects, the following main areas will be needed: Prepared by: IDA/HSRP in cooperation with other organization

28 A) Non-infectious, hazardous waste storage B) Receive, storage and treatment area for infectious waste C) Multipurpose HCW management office D) Multipurpose storage area for waste for recycling E) Cleaning and maintenance area for waste logistic equipment Sample building design: In the following sketch, a sample layout for a possible building can be found: 1 Ground scale 9 Loading/Unloading area 2 Office Desk 10 Contaminated container area 3 Storage area for domestic 11 Container washing & disinfection hazardous waste 4 Storage area for liquid 12 Container pick up area hazardous waste 5 Storage shelves 13 Parking station for hospital trolleys 6 Medium height cabinets 14 Storage area glass 7 Incinerator 15 Storage area plastic 8 Space for possible future waste 16 Storage area paper/cardboard treatment (autoclave) Figure 4: HCW function area for county hospitals Prepared by: IDA/HSRP in cooperation with other organization

29 Building requirements for different areas: A) Non-infectious, hazardous waste storage Task: Non-infectious, hazardous waste has to be interim stored until pick-up for final treatment and disposal. To be expected storage time will be up to one year. Possible necessary pre-treatment of hazardous chemical waste (e.g. de-silvering of photo chemicals) will be carried out here. Structural requirement: Size: 3 x 5 m = 15m², minimum height 2,5 m; Floor: with flood concrete and epoxy coating; Equipped with a tiled, water proof sump (0.7x3x0.5m) for the storage of liquid, chemical waste. 1 x Window (1600x1000 mm) 1 x Ventilation 1 x Lockable outside door with ventilation 1 x Inside door B) Receive, storage and treatment Area for infectious waste Task: Infectious waste from the hospitals and possible from surrounding Health Center will arrive here. The incoming waste will be registered, weight and placed ready for treatment. The waste will be disinfected by steam (autoclaving) or will be incinerated. Afterwards the ash or the disinfected waste will be placed ready for disposal. Structural requirement: Size: 5 x 5 m = 26m², height 3 m. Floor: with flood concrete and epoxy coating; Equipped with a washbasin for hand-washing With 2 x fan for the removal of steam and hot air 1 x Window (1600x1000 mm) 1 x Lockable outside door with ventilation 1 x Inside door C) Multipurpose HCW management office Task: Carrying out of administrative activities, storage for more expensive waste management equipment, staff room. Structural requirement: Size: 3 x 5 m = 15 m², minimum height 2.5 m. Floor: with hard concrete and epoxy coating 1 x Window (1600x1000 mm) 1 x Ventilation 1 x Lockable outside door with ventilation 1 x Inside door Prepared by: IDA/HSRP in cooperation with other organization

30 D) Multipurpose storage area Task: For the storage of different kinds of non-hazardous waste (i.e. plastic, paper/cardboard, glass). Structural requirement: Attached to the main building Size: 2 x 5 m = 10m², divided in three compartments, minimum height 2 m. Floor: with flood concrete 3 x lockable door (padlock) E) Maintenance area Task: In front of the area (outside) a washing and disinfection place for the cleaning and disinfection of waste collection and transport equipment such as bins or trolleys shall be set up. Structural requirement: 1 x outside washing place (1000x750x150) Tiled, waterproof Connected to the sewage system of the hospital Recommended logistics systems for Health Centers As the waste generation in most Health Centers is comparably small, transporting filled waste bins (infectious waste, domestic waste, waste for recycling) from the segregation point to the central interim storage place will be possible. Infectious waste, and sharps in containers can be collected at the same time. To enable Health Center to manage generated health care waste (hazardous and non-hazardous waste) in an appropriate manner, necessary infrastructure must be available. The set up of a small building (shed) for the carrying out of basic waste management functions is recommended. Of special consideration must be the maintenance of the logistic assets (cleaning and disinfection of waste bins). If hazardous waste cannot be treated in an external facility (e.g. other Health Center or county hospital), an own small scale treatment facility must be available. In the following sketch, the general layout of the shed can be found: Prepared by: IDA/HSRP in cooperation with other organization

31 Legend: (A) Storage for infectious waste (B) Storage for chemical & pharmaceutical waste (C) Storage for domestic waste (D) Storage for waste for recycling Figure 5: HCW function area for Health Center Description of requirements for different areas: A) Infectious & hazardous waste storage Task: Infectious waste and sharps have to be interim stored until pick-up for treatment and disposal. The waste shall be stored in closed transport containers. The storage area is protected to not allow strangers and mammals (stray dogs, etc.) to have access to the waste. Pharmaceutical waste and chemical waste shall be also stored here in closed containers until pick-up. Structural and plumbing requirements: Size: 2 x 3 m = 6m², minimum height 2 m; Floor: with flood concrete; 1 x lockable outside door with padlock Floor drain and connection to the sewage system B) Supply & material store Task: The waste management will need to have space to store supplies, materials, etc. The store area must be protected against burglars. Structural and plumbing requirements: Size: 2 x 3 m = 6m², minimum height 2 m; Floor: with flood concrete; 1 x lockable outside door with padlock Prepared by: IDA/HSRP in cooperation with other organization

32 C) Non-infectious waste storage Task: Non-hazardous, household like waste has to be interim stored until pick-up for final disposal. The waste shall be preferably stored in closed containers. The storage area is protected to not allow strangers and mammals (stray dogs, etc.) to have access to the waste. Structural and plumbing requirements: Size: 1,5 x 3 m = 4,5m², minimum height 2 m; Floor: with flood concrete; 1 x lockable outside door with padlock Floor drain and connection to the sewage system D) Valuable waste storage Task: Valuable waste as plastic, paper, cardboard has to be stored until a sufficient amount of waste for pick up is existent. The waste shall be preferably stored in closed containers. The storage area is protected to not allow strangers and mammals (stray dogs, etc.) to have access to the waste. Structural and plumbing requirements: Size: 3 x 1,5 m = 4,5 m², minimum height 2 m; Floor: with flood concrete; 1 x lockable outside door with padlock Floor drain and connection to the sewage system E) Maintenance place for disposal logistic equipment Task: Reusable waste containers must be regularly cleaned and disinfected. A washing place must be existent where this task can be carried out. Structural and plumbing requirements: Size: 0,7 x 1 m = 0,7 m²; Concrete floor with tiles; 150 mm bordering Water connection: 1 x tap (½ ), flow 25 l/min Recommended logistic system for Clinics Clinics generate only minor amounts of domestic and medical waste and nearly no other kind of hazardous waste. Domestic waste shall be collected in a closable, large container and shall be regularly be picked up and disposed of. Infectious waste will normally not be generated. If it is generated, it shall be disinfected on-site with adequate chemicals and disposed of afterwards together with the domestic waste. Sharps waste, expired pharmaceuticals and other hazardous waste shall be separately collected in safe containers and transported to the next Health Center. Prepared by: IDA/HSRP in cooperation with other organization

33 Prepared by: IDA/HSRP in cooperation with other organization

34 7 Treatment and disposal of health care waste Overriding rule for the treatment and disposal of generated waste shall be the duty of care and the polluter pays principle. Each waste generator shall be fully responsible for the safe treatment and disposal of the generated waste. 1. Disposal of domestic waste: Each health care facility, independent of it size and location shall be responsible to organize the external transport and disposal of the generated domestic waste. The onsite burning or burying of domestic waste shall be in no way permitted. If no general waste disposal service is offered by the municipality, arrangements shall be made with local transport companies for the disposal of the waste in the nearest dump. 2. Treatment of hazardous waste: The treatment of hazardous waste is a complicated and often costly process. If possible, it only should be carried out at secondary hospital level and above. Pharmaceutical waste, chemical waste and other hazardous waste shall be only collected, stored and regular transported for final treatment to facilities at national level. For the regular collection and treatment the MOH&SW in cooperation with NDS, etc. office will be responsible Infectious waste and sharps might be treated at Health Centre and or (preferably) at county hospital level. No regular treatment of hazardous waste shall be carried out in Clinics with the exemption of the disinfection of generated infectious waste on a case by case basis. In the following, the general system for the treatment of hazardous waste in Liberia displayed. Valuable Material Recovery Valuable. Materials Haz. Waste National Level Receive Area Special Treatment (Export) Household Waste Landfill Further Treatment Pharmaceutical Waste Chemical Waste Other Hazardous Waste <5 Vol.% County Hospital Interim Storage Infect. Waste Sharps Autoclave / Incinerator Household Waste Landfill All Hazardous W. (100 Vol.%) Pharmaceutical W. Chemical Waste Other Hazardous W. Health Center Clinic Health Center Infectious Waste Small Scale Incinerator Clinic Other Source Figure 6: Hazardous HCW disposal scheme Prepared by: IDA/HSRP in cooperation with other organization

35 7.1 Treatment of infectious waste and sharps In general, health care facilities at county level and below should avoid treating waste by themselves; the waste should be handed over for treatment to a facility with more specialised treatment and disposal capabilities. Considering the environmental impact of different treatment solutions, and the public health and occupational health risks, the following hierarchy of treatment systems shall be followed in Liberia: 1. Co-Incineration or steam treatment (autoclaving) 2. High Thermal, medium-scale oil fired incinerator 2. High Thermal, small-scale bio-mass incinerators 3. Controlled sanitary landfilling without treatment but with at least daily coverage of the waste The burning of the infectious waste in primitive incinerators or barrels shall only allowed on an exceptional, temporary basis with the written permit of the local Environmental Protection Agency, issued in consultation with the County Health Officer. The disposal of infectious waste and sharps mixed together with the domestic waste shall be in no way allowed. Compared with steam treatment, co-incineration also offers a solution for other hazardous waste streams such as pharmaceuticals or chemicals. Out of technical and economical reasons, it requires however quite large amounts of to be treated waste. Based on the before carried out considerations, following path of decision making for the treatment of bio-hazardous waste shall be followed. Hazardous Waste Transport to Monrovia possible? Yes Treatment: Centralized No Transport to county level hospital possible? No Transport to a Health Center possible? Yes Yes Treatment: Incinerator (WDU) Treatment: Sharing Incinerator No On-site disposal Figure 7: Decision making path for the treatment of infectious waste Prepared by: IDA/HSRP in cooperation with other organization

36 Treatment of infectious waste and sharps by incineration: Traditional incineration was the most commonly used treatment method for health care waste in Liberia and other African countries. However small and medium scale incinerators have come under criticism due to environmental impact concerns regarding emissions (flue gas, bottom ash, contaminated fly ash and waste water from the flue gas treatment). From the practical point of view, the high fuel consumption of medium scale incinerators (about l fuel per kg of waste) is often the main problem. Incineration of hospital waste oxidizes pathogenic agents.. State of the art incinerators are normally two chamber systems, equipped with a wet or dry flue gas treatment system and a Continuous Emission Monitoring (CEM)-System. Gasification of the waste takes place in the first chamber, then the gas is combusted in the second chamber at a temperature of C where pathogens are destroyed. One problem of the incineration of hospital waste is the high content of PVC. PVC incineration leads to the creation of highly corrosive HCl, and the formation of cancer causing substances like dioxins and furans. Incineration further creates the problem of the disposal of the generated ash. This incinerator ash must often be classified as potential toxic due to high contents of heavy metals, etc. Therefore incinerator ash should not be disposed of on an unsecured landfill without prior inertization and stabilization. A modern alternative to the traditional oil-fired incinerator is the bio-mass fuelled, small scale incinerator. The main disadvantage of these incinerators are the high maintenance demand, the high work load for the operators and possible emission problems. If incinerators shall be operated, they must be installed and operated in accordance to installation manuals and permits issued by EPA. Treatment of infectious waste and sharps by steam treatment: Different kinds of thermal (steam based) treatment systems are today available. All these technologies have one thing in common which is steam. As heat is applied to water, its temperature rises until it reaches its boiling point or saturation temperature at which point water is turned into steam. At atmospheric pressure the saturation temperature of water is 100 C. At higher pressures (e.g. in the pressure vessel of an autoclave), the saturation temperature is higher. For example, at a pressure of 3.2 bar, water boils at 134 C. Steam based systems are inactivating micro organism by heat (coagulation of the proteins). The inactivation process however combines effects of moisture, heat, and pressure. If steam treatment is chosen for the treatment of waste, the parameters recommended by WHO, and Basel Convention must be followed. Note: The sterilization of infectious waste and sharps by chemicals or by hot air is not recommended for Liberia. All treatment and disposal facilities require a licence from the Environment Protection Agency. Prepared by: IDA/HSRP in cooperation with other organization

37 7.2 Treatment of other kind of hazardous waste Highly infectious waste, if generated in county hospitals, shall be treated by thermal (steam) treatment methods close to the place of generation or directly in the laboratory. After treatment, the waste shall be handled as infectious waste. Fixing bathes used for the photo-graphical processes in the radiology shall be de-silvered (recovery of silver) prior disposal. The recovery shall either be carried out in the one premise or the fixing bath shall be sold to specialized companies. Liquid hazardous waste shall be neutralized prior it is disposed of via the waste water system. Liquid hazardous waste which cannot be neutralized, such as solvents or halogenated liquids, shall be stored and then transported to more specialized treatment facilities. Non-infectious but hazardous waste such as heavy metal containing waste, pharmaceutical waste or chemical waste shall be stored in the hazardous waste store of the county hospital and shall be regularly transported to central collection point for further treatment. 7.3 Recommended treatment & disposal systems Recommended treatment & disposal systems for county hospitals Infectious waste shall be treated by steam treatment or incineration. After sterilization the residues can be disposed of as normal domestic waste. Ash from the incineration process shall be collected and either disposed of in an ash pit or shall undergo an inertization / stabilization process prior disposal on an landfill. Highly infectious waste requires a pre-disinfection or sterilization and afterwards disposal as infectious waste Sharp waste shall be packed in puncture proof containers and afterwards can be treated together with the infectious waste Hazardous pharmaceutical waste shall be sorted, packed and stored in the hazardous waste storage place for pick up and treatment on national level Cytotoxic waste and radioactive waste are not expected to be generated. If this kind of waste is generated, the MoH&SW shall be contacted for further instruction Chemical waste shall be separately collected and stored in the hazardous waste storage room. The chemical waste will be periodically picked up and transported to Monrovia for further treatment. Pathological waste and anatomical waste: Minor and unrecognizable parts might be treated together with the infectious waste. Larger parts and anatomical waste shall be disposed of under consideration of religious requirements. Prepared by: IDA/HSRP in cooperation with other organization

38 If a county hospital is operating an on-site incinerator or steam sterilization plant for waste treatment, the hospital is required to offer the treatment of infectious waste and sharps also to other health care facilities in the surrounding. The county hospital has the right to expect payment for the service from the waste delivering institution Recommended treatment & disposal systems for Health Center Infectious waste and sharp waste shall be packed in safe containers and shall be transported to the next incinerator or autoclave for treatment. If an external treatment is not possible, a small incinerator shall be set up. The incinerator shall be housed in a small building which shall include a storage place for the infectious waste and a storage place for the combustibles. Further ash pits shall be available for the disposal of the generated ash If a Health Center is operating an on-site incinerator, they are required to offer the treatment of infectious waste and sharps also to other Health Center in the surrounding. The Health Center has the right to expect payment for the service from the waste delivering Health Center. Hazardous pharmaceutical waste shall be sorted, packed and transported to the hazardous waste storage room of the county hospital. Chemical waste shall be shall be sorted, packed and transported to the hazardous waste storage room of the county hospital. Pathological waste and anatomical waste shall be treated together with the infectious waste. Larger parts and anatomical waste shall be disposed of under consideration of religious requirements. Health Center will have the duty to accept hazardous waste from related Clinic for further treatment Recommended treatment & disposal systems for Clinics Sharps waste shall be collected in sharps containers and shall be transported If chemical waste and pharmaceutical waste is generated, these shall be separately packed and transported to the next Health Center. If infectious waste is generated, it shall be disinfected by soaking for 12 hours in a 0,5% bleach solution. Afterwards it shall be disposed of together with the domestic waste Prepared by: IDA/HSRP in cooperation with other organization

39 8 Management Aspect for Health Care Waste Previous health care waste projects in Liberia showed that the most common weak point were not technical but even more organizational and management problems. In the following, the core aspects for a sustainable health care waste management system are introduced. To be introduced system shall be adapted to the specific needs of the health care institutions. 8.1 Organization and responsibilities The awareness on environmental infection control issues and by this on health care waste is generally too low in Liberia at the management level. To ensure sustainability, a transparent management system is needed. Central point will be clear responsibilities and a close cooperation between housekeeping and infection control The health care waste officer system In county hospitals, at least one person shall be appointed by the management board of the health care facility as the responsible person for the management of health care waste (Healthcare Waste Officer - HWO). The HWO shall be fully trained and certified by the MoHSW. The Healthcare Waste Management Officer will have the overall responsibility for waste management practices and will report to the Health Institution management team on waste management matters. The Healthcare Waste Monitoring Officer will act as the control, information and contact point for all staff. It is the responsibility of the Infectious Control Committee to ensure that an adequate number of Health Care Waste Monitoring Officers are identified and that they are trained as necessary to fulfil their duties. The duties and responsibilities of the Healthcare Waste Officer can be summarized as follows: 1. Information and Motivation: Informing stakeholders, staff, patients and the public about waste management activities in hospitals Carrying out health care waste training and awareness program in institutions Sensitization and motivation of hospital staff in health care waste matters 2. Initiative and Innovation: Stimulation of the new and better waste management and treatment methods Make recommendations and give advice on purchasing of environmentally- friendly disposables and investment goods Introduction of environmental friendly procedures, replacement of disposables, mercury, collection of valuable waste, etc. 3. Monitoring and Supervision: Prepared by: IDA/HSRP in cooperation with other organization

40 Supervision of the internal waste logistics including segregation, collection, storage and disposal Supervision of the supply of waste collection materials Monitoring the environmental capacity building in the hospital 4. Reporting and Documentation: Reporting on accidents and incidents related to hospital waste Documenting waste activities in an institution, setting up of waste balance sheets and waste stream analysis Carrying out waste audits 5. Operational waste management: Organization and management of daily waste services Responsibility for setting up and carrying out waste collection schemes Responsibility for safe treatment and disposal of collected health care waste The Healthcare Waste Monitoring Officer shall monitor the health care facility based on checklists. The checklist shall include all critical areas of HCW management that need monitoring such as: hospital staff practices of proper HCW segregation, availability of and consistent use of protective gear by HCW handlers, post exposure prophylaxis follow-up for those pricked by sharps, training needs for new staff and refresher for other staff. The checklist shall be used regularly (at least once per month) and the filled checklist shall be signed by the director of the health care facility. The latest checklist must be provided to the County Health Team on request. The duties and responsibilities can be assigned to the appointed persons based on the specific situation in the hospital Role of housekeeping / water & sanitation department The housekeeping or the water & sanitation department shall be responsible for the practical aspects of the HCWM. Their task shall include but shall not be limited to: 1. Collection and transport of the health care waste from the wards and departments to the interim storage; 2. Management of the interim storage facilities; 3. Operation of waste treatment plants if applicable; 4. Organization of the external transportation and final treatment/disposal of the waste; 5. Record keeping of relevant data; 6. Waste tracing system (documentation) from generation to final disposal; 7. Spillage and accident response and management. The head of the department shall be the responsible Healthcare waste management officer of the institution. Prepared by: IDA/HSRP in cooperation with other organization

41 The Healthcare waste management officer shall be responsible for having records at the source of production of hazardous HCW. The documentation should show the number of hazardous waste containers collected, 2 nd the number of containers which were transported and 3rd records showing that the HCW has reached the hazardous waste treatment place. Once per month, an overview of generated hazardous waste (in kg) and the way of treatment and disposal; shall be provided to the CHT Role of County Health Team (CHT) The CHT shall have the overall responsibility for the supervision of the HCWM system in the specific county. At least two persons of the department shall have the qualification of health care waste officer (HWO). The task of the CHT shall include but shall not be limited to: 1. Supervision and monitoring of the health care institution in the county in regard to HCWM; 2. Supporting Health Center in the set up of health care waste management system and providing of HCW training courses 3. Supporting health care facilities in the organization of the treatment and disposal of hazardous waste. 4. Organization of the transport, treatment and disposal of special health care waste streams such as pharmaceutical waste or chemical waste. 5. Collection of relevant data and information such as waste generation rates, accidents, etc. 6. Monitoring the health care provider by regular inspecting of checklist and monitoring waste generation and waste treatment 7. Evaluation of data and preparation of an annual report of the actual HCW situation in the county. 8. Coordination of all activities with the MoH&SW to ensure a coherent system throughout Rural areas Documentation of the health care waste system To document the waste management system and the related tasks, the following documents shall be introduced on Health Center and higher level: Waste Management Policy Waste Management Plan Standard Operating Procedures (SOP) for HCWM Job description for person working in the HCW field Sharps accident reporting system Record keeping for hazardous waste streams The to be set up waste management plan shall be based on this guideline, relevant laws and regulations and the specific needs of the health care facility. Prepared by: IDA/HSRP in cooperation with other organization

42 8.2 Human resource management Functional planning The operation and management of the new health care waste management system will require that the following new functions are fulfilled 1. Operational management of the new health care waste system; 2. Operation of the interim storages and treatment plant, including supporting activities; 3. Monitoring the health care waste system A training program to enable staff to carry out these functions will be provided and is described in the following. The monitoring of the new system, which shall also include the task of information providing and on-site training, shall be carried out by either the infection control committee or, if the committee is not set up, by the nursing sector. 8.3 National HCW Training system The sophistication and appropriateness of various disposal logistics systems depends greatly on what services the health facility offers, and subsequently what waste streams are produced.. It is recommended to adjust the demands relating to the qualification of a person responsible for HCW to adapt to real needs. It is proposed to set up a training system which can serve three levels of health care facilities: Health Centers and private hospitals with up to 50 beds (primary health care level) County hospitals and larger private hospitals with >50 beds (secondary health care level) Tertiary level hospitals and hospitals with more than 150 beds. In order to force health care facilities to employ at least one trained person (full or part-time) or to send their employees to training sessions to obtain this qualification, health care institutions should have a clear duty to employ at least one qualified and registered person to be responsible for HCW. In Liberia this duty is defined in the National Policy and the National Guideline for Health Care Waste. Typically environmental technician shall be responsible for HCW management. Note: According to the proposed minimum planning in the NHP, for Clinics it is not expected to employ and Environmental technician. It is however expected that the officer in charge will cooperate with an environmental technician from the next referral health care facility. As mentioned above, the training duration, content as well as the implemented responsibilities should be adjusted depending on the level of the hospital. It is recommended to form and train following responsibilities depending on the service level: Prepared by: IDA/HSRP in cooperation with other organization

43 Primary level health care facilities: Healthcare Waste Technician (HWT) Secondary level health care facilities: Healthcare Waste Officer (HWO) Tertiary level health care facilities: Healthcare Waste Manager (HWM), Trainees will have to start with the HWT training and, after passing this level, can follow another training to become a HWO and after this a HWM. (Step-by-Step training approach) Figure 8: Level based training system It is expected that especially HWO and HWM will act as in-house trainer and also as support trainer / supervisor for clinics and health care centers. Successful participants will be registered by the MoHSW and will receive an official certificate which will allow the work as waste manager for two years. After this time, the trainee will have to participate in a refreshment course (1 day for waste technicians, 2 days for health care waste officer / manager). After attending this course, the enrolment in the register will be automatically prolonged for another two years. It is the duty of each health care facility and CHTs to send staff for qualification to the training. It is further a clear duty for health care institutions to have employed at least one qualified and registered responsible person for HCW. 8.4 Physical assets management (Maintenance) Healthcare waste management is part of the physical assets management system of the health care facility, especially in regard to the maintenance of the infrastructure of the health care facility. It shall be the task of the health care waste officer to develop in close cooperation with the engineering department and gardening department a maintenance plan which shall include: 1. Maintenance of the infrastructure: a. Waste management / cleaning system for the health care facility compound; b. Preventive maintenance strategy for waste management related buildings. 2. Maintenance of the equipment: a. Operation plan for the health care waste logistic and treatment equipment; b. Preventive maintenance strategy for waste logistic and treatment equipment (including cleaning planning for waste segregation equipment); Prepared by: IDA/HSRP in cooperation with other organization