MEDICAL WASTE MANAGEMENT

MEDICAL WASTE MANAGEMENT TRAINING MANUAL DIRECTORATE GENERAL OF HEALTH SERVICES MOHAKHALI, DHAKA

ADVISOR Dr. Md. Akhter Hossain Bhuiyan Director (Hospitals & Clinics), and Line Director (IHSM), DGHS, Mohakhali, Dhaka. EDITORIAL BOARD 1. Dr. Syed Abu Jafar Md. Musa, DPM (Training, Hospital), DGHS, Mohakhali, Dhaka 2. Dr. A. K. M. Saiedur Rahman, DPM (IHSM), DGHS, Mohakhali, Dhaka 3. Dr. Nasima Akhter, Environmental Research Unit, BRAC, Dhaka

LIST OF CONTRIBUTORS (Not according to position) 1. Dr. Md. Akhter Hossain Bhuiyan, Director (Hospitals & Clinics) and Line Director (Improved Hospital Services Management), DGHS, Mohakhali, Dhaka. 2. Dr. Farida Akhter, Deputy Director (Hospital-2), DGHS, Mohakhali, Dhaka. 3. Commander M.R. Chowdhury, CCO, DCC, Dhaka. 4. Dr. M. Manzurul Hossain, Professor, Geography and Environment, Jahangirnagar University. 5. Md. Ziaul Haque, Deputy Director, DOE, Dhaka. 6. Dr. Md. Nurul Islam, DCHO, DCC, Dhaka. 7. Dr. Syed Abu Jafar Md. Musa, DPM (Training, Hospital), DGHS, Mohakhali, Dhaka. 8. Dr. A. K. M. Saiedur Rahman, DPM (IHSM), DGHS, Mohakhali, Dhaka 9. Dr. Nasima Akhter, Environmental Research Unit, BRAC, Dhaka 10. Dr. Ali Miraj Khan, ICDDRB, Mohakhali, Dhaka. 11. A.K.S. Mahmudur Rahman, ICDDRB, Mohakhali, Dhaka. 12. Md. Asaduzzaman, Evaluation Officer, 13. Tarit Kanti Biswas, Coordinator (Medical waste management), PRISM Bangladesh

Table of content Sl. No. Subject Page No. 1. Introduction of Medical waste management 02 2. Classification of Medical waste 07 3. In-house Medical waste management 12 4. Medical waste management- WHO guiding principle, strategy and policy 24 5. Composition of medical waste, consequences, risk and hazard 20 6. Factors influencing external waste management, final disposal technology and element 37 7. Occupational Hazards: Bio-Safety, Prevention and Management 45 8. Medical Waste and Infection Control Measures 64 9. Temporary Waste Storage & Transportation 88 10. Supervision and monitoring in Medical waste management 94 11. Roles and responsibilities of concern personnel for implementation of MWM 102 12. Use of check list 108

MEDICAL WASTE MANAGEMENT TRAINING MANUAL Total duration : 14 hours Total Session No: 12 Sl no Name of the session Total time period Remarks 1 Introduction of Medical waste management 45 minutes 2 Classification of Medical waste 45 minutes 3 In-house Medical waste management 90 minutes 4 Medical waste management- WHO guiding principle, strategy and policy 5 Composition of medical waste, consequences, risk and hazard 6 Factors influencing external waste management, final disposal technology and element 7 Occupational Hazards: Bio-Safety, Prevention and Management 60 minutes 60 minutes 60 minutes 120 minutes 8 Medical Waste and Infection Control Measures 120 minutes 9 Temporary Waste Storage & Transportation 60 minutes 10 Supervision and monitoring in Medical waste management 11 Roles and responsibilities of concern personnel for implementation of MWM 60 minutes 60 minutes 12 Use of check list 60 minutes TOTAL TIME 840 minutes = 14hours 1

Session no 01 Introduction to Medical waste management Contents: Scenario of medical waste management Importance of medical waste management Concept and definition of Medical waste and need for effective waste management Objectives: At the end of the session the participants will be able to: Understand the importance of Medical waste management Different aspect of Medical waste management Definition of Medical waste management Need for effective waste management Teaching Methodology: Presentation, Questions and Answers, Group discussion, and demonstration Duration: 45 minutes Lesson Plan: Content Methodology Teaching aids Time Introduction to the session: Contents and objectives Importance of medical waste management Scenario of Medical waste management Definition of medical waste and need for effective waste management Summing-up and feed back Discussion OHP/Flip chart 10 minutes Question and Answer Discussion, Question and Answer Discussion and demonstration OHP/White board Flip chart/ White board OHP / White board 10 minutes 10minutes 10 minutes Question and Answer OHP 05minutes 2

Introduction to Medical waste management Introduction: The management of waste poses to be a major health problem in most of the countries, specially the hospital waste. It is an ongoing problem for many countries. Healthcare wastes pose a serious public health problem. The main purpose of any health care institution is to provide health care services to prevent the diseases and also to cure people who are suffering from various kinds of illness.when visiting health care facilities, patient should not become more ill then they already are. Hence it is very important to ensure patient safety by keeping the health centre clean and environmentally sound. On the other hand the service providers safety during providing health care also to look at meticulously. The scenario of medical waste management in different type and category of hospitals are not satisfactory and polluting the environment with toxic substances contributing public health problem. The country has public specialized hospitals, Medical college hospitals, district hospitals and upazilla health complexes. Moreover a good number of private hospitals and clinics are also providing health care. In the majority public and private hospitals there are no systemic approaches to medical waste disposal. The medical waste are simply mixed with the municipal waste in the collecting bins at road side and some percentage are buried without any measure or burn out under open sky. Improper disposal of healthcare wastes aesthetically damages to the environment. Public awareness of healthcare wastes has grown in recent years, especially with the emergence of acquired immunodeficiency syndrome (AIDS)). In addition, the possibility that healthcare wastes could transmit human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other agents associated with blood-borne diseases is also a major concern. Therefore, the disposal of healthcare wastes and their potential health impact are an important public health issue. Like other industries and institutes, healthcare facilities generate various kinds of wastes as a result of a variety of medical treatment and research. In the past 10 years, due to the increased number and size of healthcare facilities, medical services, and use of medical disposable products, the generation rate of healthcare wastes has increased rapidly. 3

The United Nations conference on the environment and development in 1992 led to the adoption of agenda 21, which recommends a set of measures for waste management. The recommendation may be summarized as follows: Prevent and minimize waste production Reuse or recycle the waste to the extent possible Treat waste by safe and environmentally sound methods Dispose of the final residues by landfill in confined and carefully designed sites Agenda 21 also stresses that any waste producer is responsible for the treatment and final disposal of its own waste.the regulatory mechanism for Medical waste management in the light of agenda 21 in Bangladesh is not in place.the MOH&FW already started to address the medical waste management as one of the priority program by including it as one of the critical area among the identified six critical areas under Health, Nutrition and population sector program. The draft rule on Medical waste management is also in the final stage of approval after the completion of scrutiny by the MOH&FW. The recent development of formation of National hospital waste management committee and also committees for City Corporation, district and upazilla to handle the out house management of medical waste will be regarded as major breakthrough for determining the roles and responsibilities in relation to the Medical waste management. We have a good number of stakeholders in respect of medical waste management but the coordination mechanism is not satisfactory. To streamline the medical waste management is not an easy task in the context of Bangladesh because of limited resources.so we need to develop a structured coordination mechanism among the relevant stakeholders of medical waste management. In accordance with the Basel convention recommendation we have to develop our medical waste management system. The recommendations are: Clearly define the problem Focus on segregation first Institute a sharp management system Keep focused on reduction Ensure workers safety through education,training and proper personal protective equipment Provide secure collection and transportation 4

Requires plan and policies Invest in training and equipment for processing of supplies Invest in environmentally sound and cost effective medical waste treatment and disposal technologies Develop infrastructure for the safe disposal and recycling for hazardous materials Develop infrastructure for safe disposal of municipal medical waste We have so many challenges like development of policy guideline, establishment of regulatory framework, structured coordination among the stake holders, capacity development of the service providers, accountability framework of different organization, development of community awareness, resource mobilization according to need and institutionalization of the process. So everybody has to work sincerely with commitment for effective medical waste management. Our vision is To ensure safe, cost effective, acceptable and sustainable management of medical waste in order to safeguard the community health, environment and also to minimize the occupational health hazard towards an environmental friendly hospital. Concept and definition of Medical Waste Waste is essentially anything, which someone no longer requires or wants. This term includes things we commonly describe as garbage, refuge, and trash. The U.S. Environmental Protection Agency s (EPA) regulatory definition of waste includes any discarded items; things destined for reuse, recycle, or reclamation; sludge s; and hazardous wastes. Any kind of anthropogenic activity generates some waste. Hospital is one of those kinds generate various types of wastes. A wide variety of waste components have always been generated by various sections of hospitals or medical establishments or healthcare services. Waste generated by health care activities includes a broad range of materials, from used needles and syringes to soiled dressings, body parts, diagnostic samples, blood, chemicals, pharmaceuticals, medical devices and radioactive materials. Medical waste stream is an extremely complex one including chemicals, which could be hazardous, as also normal kitchen or office waste similar to municipal solid waste, the definition of regulated medical wastes produced by hospitals, clinics, pathological 5

laboratories, diagnostic centers, doctors offices, and other medical and research facilities. These wastes include infectious, pathological, sharps, pharmaceuticals, hazardous, genotoxic, chemicals, heavy metals, radioactive and other general wastes. Definitions of medical waste vary in different countries and institutes as well, based on different categories of wastes. In general, medical wastes are wastes arising from diagnosis, monitoring and preventive, curative or palliative activities in field of the veterinary and human medicine. Broadly, medical waste is defined as any solid or liquid waste generated in the diagnosis, treatment or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals (BAN & HCWH, 1999). Millions of tons of medical waste are generated each year throughout the world. When talking about waste from hospitals or health facilities, different nomenclatures are in use: healthcare waste is the new European terminology; in the United States this types of waste is called medical waste, and in the text of Basel Convention for Hazardous waste it is called clinical waste. However, according to the draft medical waste management rules of Bangladesh it is termed as Medical Waste. Therefore, we will use medical waste term in all documents and training. Effective waste management needs: National Policy, Strategy, plan, guidelines and SOP; Legislation /Rules for waste management; Political commitment; committed manpower; Good management; Proper budgetary allocation; Application of local available technology and also according to resource; envelop; Involvement of NGOs; Community participation; Proper capacity development of the service providers; Development of information system in relation to MWM as a part of MIS; Supportive supervision and monitoring. 6

Session no 02 Classification of Medical waste Contents: Classification of Medical waste Type of Medical waste with example and source of medical waste Objectives: At the end of the session the participants will be able to: Understand the classification of Medical waste; Different type of medical waste with example Major source of Medical waste Teaching Methodology: Presentation, Discussion, Questions and answers, group discussion, and demonstration Duration: 45 minutes Lesson Plan: Content Methodology Teaching aids Time Introduction to the session: Contents and objectives Discussion OHP/Flip chart 10 minutes Classification of medical waste Different type of Medical waste define by WHO and EPA with example Summing-up and feed back Presentation, Discussion, Question and Answer Presentation, Discussion, Question and Answer OHP/White board /MM Flip chart/ White board/mm 15 minutes 15 minutes Question and Answer OHP 05minutes 7

Medical waste A large part of medical waste usually consists of clinical and non-clinical waste. Such pollutants can, therefore, be broadly classified into a) solid wastes, and b) liquid waste (wastewater). Solid waste means non-liquid wastes. It is a variety of materials, such as, dust, ash, food-waste, rags, paper, plastic, glass, metals (sharps, needles).. Liquid waste contains chemicals used in laboratory, pathogen containing urine, blood and other sample for testing disposed off to the wastewater. Both are important source of physical and natural environmental degradation and constitute a health hazard. Medical Waste classification There is no standard classification of Medical waste. Researcher mentioned that, every country can classify her own generated medical waste keeping views in final terminal treatment and disposal facility. Medical waste can be classified in a number of ways by different countries and different organization. Some common classifications are A. On the basis of contentment, basically all medical waste are i. Solid ii. Liquid iii. Gaseous and iv. Radioactive B. On the basis of Health impact i. General waste ii. Hazardous waste C. On the basis of WHO classification (for developing countries) i. General waste ii. Sharp waste 8

iii. Infectious waste iv. Chemicals and Pharmaceutical waste v. Other Hazardous waste D. On the basis of WHO classification (for developed countries) i. General waste vi. Infectious waste ii. Pathological waste vii. Chemicals iii. Sharp waste viii. Pharmaceutical waste iv. Radioactive waste ix. Pressurized containers v. Chemicals waste Type of Medical waste generated in Bangladesh A. General waste- These types of waste are non-infectious and non-hazardous. Some time these wastes are named as Municipal waste. Common examples are Paper, cloths, different bottle, packing boxes, carton, left over food etc. B. Hazardous medical waste- The medical waste that poses a substantial danger or potential to pose danger for human, animal or plant life or to the ecosystem. All hazardous waste may or may not be infectious but all infectious waste are hazardous waste. Waste is called hazardous as it contains infectious, sharps, chemicals, radioactive materials etc. Waste are considered hazardous if the waste exhibits one of the following character i. Ignitability- having the flash point greater than 140 degree ii. Corrosivity- having ph less than 2 or greater than 12.5 iii. Reactivity- a chemicals that are unstable or undergo rapid and or violent chemical reaction with water or other chemicals. iv. Toxicity- chemicals with high degree of toxicity. 9

B.1. B.2. Pathological waste- includes Human tissue, organ, feces, body parts, biopsy products and autopsy materials. Sharp waste- includes all types of needles, blades, scalpel, razors, broken glass etc. B.3. Radioactive waste- any solid or liquid waste contaminated with radioactive substances. B.4. B.5. Chemicals waste-includes reagents, developers, other chemicals may be toxic flammable, explosive and or carcinogenic. Infectious waste-includes blood, blood products, pus, body fluids, stool or items contaminated with blood, blood products, pus, body fluids, stool etc. B.6. Pharmaceutical waste- date expired medication, discarded residual medications used in chemotherapy etc. B.7. Pressurized containers-includes aerosol cane, empty gas cylinders etc. Different source of Medical waste Major Source Hospital Waste Dialysis center Medical research center Clinics waste Laboratories Minor source Dental clinics Physician chamber Acupuncture clinics 10

Diagrammatic classification of medical waste: Classification of Solid MW LIQUID SOLID GASEOUS RADIO General/Non - hazardous Hazardous Sharps Infectious Anatomical Pathological Non -infectious Chemicals Pharmaceutical 11

Session no 03 In-house Medical waste management Issues of medical waste management In-house medical waste management Temporary storage of medical waste Strategy and key consideration of medical waste management Record keeping Objectives: At the end of the session the participants will be able to: understand the different issue in relation to Medical waste management; Different areas of In-house medical waste management Strategy and key consideration of medical waste management Content and process of record keeping Teaching Methodology: Presentation, Discussion, Questions and answers, group discussion, and demonstration Duration: 90 minutes Lesson Plan: Content Methodology Teaching aids Time Introduction to the session: Contents and objectives Issue of medical waste management In-house medical waste management Discussion OHP/Flip chart 10 minutes Presentation, Discussion, Question and Answer Presentation, Discussion, Question and Answer OHP/White board Flip chart/ White board/mm 10 minutes 25 minutes Temporary storage of medical waste management Record keeping Strategy and key consideration of MWM Presentation/Discussion, demonstration, Question and Answer Discussion, demonstration, Question and Answer Discussion, demonstration, Question and Answer OHP / White board/mm Flip chart/ White board/mm Flip chart/ White board/mm 15 minutes 10 minutes 10 minutes Summing-up and feed back Question and Answer OHP 10 minutes 12

In- house Medical waste management Medical waste management means practice of minimizing, identifying, separating, collection, handling, carrying, storage, treatment and finally disposal of medical waste as per policy of the institution or government. Carefully management is required to minimize occupational health hazard and to develop environmentally friendly hospital. For effective waste management there is in need of formulation of objective and effective time bound planning. Planning requires the strategy and allocation of resources according to the identified priorities. Waste management may varies from institution to institution but should take account of three main issues, these are The risk involved, may be financial, technical and legal The cost of each management option The management skill and time required. Other related issues need to be address are Should waste management will be implemented independently or cooperative basis How should the institution or group of institution dispose the waste Set of measure for effective waste management:- Prevent and minimize waste production to the extent as possible Reuse and recycle the waste to the extent as possible Treat waste by safe and environment sound methods Dispose off final residues by land filling in confined and designated areas 13

According to WHO, effective waste management should follow some elements and that elements must be address in terms of personnel, materials cost and occupational risk and safety. Researcher now a day given more emphasis on 3R procedure, these are Reduce the production/generation of medical waste Procure more Reusable medical items Recycle the medical waste as much as possible under safety measure Broadly the total medical waste management can be divided into two parts, are - - In-house waste management- means management within the health care facility. - Out-house management- means management out side the health care facility. Elements of In-house waste management For effective in-house waste management the important elements are- Waste minimization- Care full management prevents the accumulation of large quantity of waste. Health care service providers and institutions administrator can play important role in reduction of waste volume. Waste minimization is directly proportional with waste management cost and related risk. Institution can adopt many policies and practices that might reduce the waste volume. Some policies are- o Source reduction- Purchasing and supplies materials which are less wasteful and or generate less medical waste. o Stock management- Frequent auditing; use oldest stock first and checking the expired date of products during receiving and supplies of goods. o Encourage use of Recyclable products- Use materials that can be recycled both off-site or on-site. o Control at institution level- Centralized purchase and monitoring the receipt and supply procedure of medical goods. Waste Segregation- The key of effective waste management is the waste segregation. The waste should be segregated on the basis of the category of 14

waste. The whole waste management depends upon effective waste segregation, because incorrect segregation creates lot of hassles in the down stream of waste management. If waste is properly segregated, small amount are needed for disposal instead of large quantity of waste, ultimately related manpower, related cost, related risk lowered. If segregation is not properly done, small quantity of hazardous waste has a chance to mix with large volume of non-hazardous waste making the whole volume into hazardous waste. Segregation of medical waste should always be the responsibility of waste producer and waste should be segregated at the point just after its generation. Once waste is segregated, staffs should never attempt to correct of wrong segregation by placing/transferring items from one container to another. Waste Identification- An appropriate way of identifying the waste is by sorting the waste into different COLOR CODE. Color code is easy for identification and thereby easy for safe handling, transportation and waste treatment. There is no specific color code for medical waste management. The color code varies from country to country, as it depends upon many factors, such as socioeconomic status, literacy rate, availability of local resources, countries classification of waste etc. WHO recommended Color Code for developing countries Type of waste Highly infectious Infectious, Pathological, Anatomical Sharp Chemicals, Pharmaceuticals Radioactive General waste Color code Red Yellow Yellow colored box Brown Silver Black 15

Recommended Color Code in Bangladesh Type of waste General or non-hazardous Infectious, Pathological, Anatomical Sharp Radioactive Recyclable waste Liquid Color code Black Yellow Red Silver color Green Blue Waste Handling- means the links between packing, storage and transportation of medical waste from every area of the institution by designated individual. 16

o Waste collection waste does not accumulate at the point of birthplace. The designated personnel should collect the waste containers by a routine program through the designated route as a part of the waste management plan. Guidelines for waste collection are - Collectors must wear protective materials. Collection of waste in colored bag or colored covered bins. Content of the container should not exceed three quarter of its capacity. If bag is used for waste collection, tie the neck tightly. Avoid throwing, dragging over floor or holding the bottom of the containers. No container should be used if damaged or licked. All ns should be covered with lid during collection and transportation of waste. Waste should not be collected more the ¾ of containers capacity. No container should be transported without labeling. During collection ach containers should be replaced with a new one. Collection of Sharp medical waste under maximum precaution. If there is spillage of waste from the container (Accidental/Damage of bin), gently collect the waste into a bin, soak the area with 2% Lysol solution, wait or 30 minutes, then wash and wipe. o Waste collection materials Character of the materials depends upon the type of generated medical waste. Its better that the materials should be domestic in origin, so that sustainability of supply could be ensured. The commonly used material for Bangladesh are Colored waste containers or bins, colored heat resistant bags, heavy duty gloves, rubber service gum boots, hand tray, Balcha, waste carrying trolley, rubber apron etc. o Placement of color bins Appropriate container should be placed at all important location where particular wastes are generated. Instruction on waste identification should be pasted over the containers. Placement of the container could be done at institutional level by local level planning. Say in case of patient waiting area General waste (Black color bin) could be placed at landing area of the staircase, in the straight long corridor bin could be placed at 50 meter distance, yellow colored bin could be placed out side of the toilet in female ward for collection of sanitary napkins. 17

During replacement of the bin, same colored another bin should be placed at the site. o Labeling- Waste container should be labeled with some basic information s, say about its waste category, weight of the waste materials, date of collection, and site of waste production. These information could be written on preprinted labels with irremovable or water resistance ink. All waste should be labeled and marked with international symbol especially during transportation. o Security- Security of medical waste throughout its lifecycle is significantly a challenge, as because there is chance of scavenging in every point of its lifecycle. Scavenging of medical waste especially at the generation site and disposal site must be recognized as threats to institutional infection control program, quality of patient care and community health hazard. 18

o Health and safety- To ensure the health and safety of the cleaner in waste management through continuous monitoring is important. An appropriate health and safety program includes Training of the worker about related risk. Timely issue and encourage wearing personal protective materials. Immunization of the worker under occupational safety program especially against Hepatitis-B virus and Tetanus. Ensure reporting and post exposure prophylactic treatment. Ensure periodical medical checkup system. Medical surveillance. o Personal hygiene- In medical waste management personal hygiene is very important. The working place should be provided with continuous water supply and soap/detergent. Hand washing should be ensured on arrival for work, before meal, before living the working area and whenever is necessary. o Response to injury and exposure- Service providers should be trained to deal with injury and exposure. This program may include In case of accident immediate reporting to the designated authority. Identify items involved in accident, deals with protection. Immediate first aid measure Giving medical attention as soon as possible. Record keeping. o Emergency response- Service providers should prepare or accident and or unexpected situation. Service providers should be trained to manage common emergencies, necessary equipment should be in hand and ready at all times. Some common emergencies are Accidental spillage Equipment failure Accidental tear or breakage of containers. Explosion and or fire. 19

In-house transportation Means transportation of waste from the site of origin or collection to temporary storage area within the institution. Waste should be transported by designated trolley, through the designated route according to time schedule given by the institutional authority. A consignment note should accompany the waste during transportation. The trolley or handcart should be easy to clean, loading and unloading, leak proof body, should not be used in any other case other then waste transportation. Temporary in-house storage The store will be a room or area or building within the health care facility depending upon the quantity and quality of waste production and frequency of waste collection. Waste should not be stored more then 24 hours but for emergency waste stored for more then 24 hours then it should informed to higher authority and ensure it should not be harmful for others. Selection criteria for Temporary in-house storage areao Should be properly located to prevent access of unauthorized person. o Should have an easy access for workers and collection vehicle. o Should be away from food preparation, processing and food store. 20

o Provided with sufficient light and sufficient water supply. o Should be inaccessible for scavenger, animal and rodents. o Adjacent to the store room, there should be sufficient space for washing and cleaning. o Should be equipped with sand, cleaning equipments and fire fitting equipments and reagents o Floor should be elevated and impervious with proper drainage facility and avoid being flooded. o There should be weighting and recording facility. o Unless a refrigerated room, the room should be properly ventilated. Record keeping Accurate record keeping is needed for effective medical waste management. Future progress, further investment and sustainability of the program depend upon analysis of the record and take necessary measures accordingly. Record keeping might give some important information s, which are needed for - Assess the recurrent expenditure Assess the quality and quantity of generated waste Assess the cost directly related with the man and materials Assess the cost related with waste treatment and disposal method Assess the risk involved with generated waste, amount and nature of accident, amount of damage, measure taken against accident etc. Assess the failures, problem and obstacle in waste management for better compliance of the program. 21

Transportation of medical waste to dispose in the constructed pit Transportation for out house management- means collection of stored waste (Except Radioactive waste) from the health care facilities according to the colour code to the final disposal site. Collection of waste (As per color code) from different institute should be in a covered Van. The driver area should be totally separated from waste carrying area. 22

Strategy of medical waste management: Development of awareness among the service providers by sensitization; Proper capacity development of the service providers by providing training and specially focusing hands on training; Development of in house management of waste; Development and adoption of option for the final disposal of waste depending upon the situation, type of hospital, amount of waste production, safety and resource envelop; Supply of logistics like different color bin, needle crusher, service gloves, boot, mask etc; Establishment of accountability framework; Formation of Local waste management committee and development of local level plan for implementation; Refresher training program for service providers; Effective Monitoring and supervision. Key consideration for the better management of medical waste: 1. Strongly believes the need of alternative approach of MWM. 2. Hospitals will bear the responsibility of safe management of its generated waste. 3. Need for attitude change of service providers, patients and community people. 4. Service providers can contribute positively in reducing waste volume and segregation. 5. Committed and well motivated hospital staff can adopts an effective strategy for proper MWM. 6. Government should take positive steps in making guideline Legislation and policy on HWM with ensuring monitoring and supervision. 23

Session no 04 Medical waste management-who guiding principle, strategy and policy Contents: Guiding principle of WHO activities Strategy Policy and hospital waste management plan Objectives: At the end of the session participants will be able to: Understand the developed WHO activities principle; Formulated strategy of WHO in relation to MWM Different term policy principle Teaching Methodology: Discussion, Questions and answers, Goup discussion and Presentation Duration: 60 minutes Lesson Plan: Content Methodology Teaching aids Time Introduction to the session: Contents and objectives Discussion OHP/Flip chart 10 minutes Guiding principle Presentation, Discussion, Question and Answer OHP/White board 10 minutes Strategy Presentation,Discussion, Question and Answer Flip chart/ White board 10 minutes Policy and steps for hospital waste management Discussion, Question and Answer Flip chart/ White board 10 minutes WHO Medical waste management cycle Presentation,Discussion, Question and Answer Flip chart/ White board 10 minutes Summing-up and feed back Question and Answer OHP 10 minutes 24

Waste Management - WHO policy and activities Guiding principles of WHO activities Preventing the health risks associated with exposure to health-care waste for both health workers and the public by promoting environmentally sound management policies for health-care waste; Supporting global efforts to reduce the amount of noxious emissions released into the atmosphere to reduce disease and defer the onset of global change; Supporting the Stockholm Convention on Persistent Organic Pollutants (POPs); Supporting the Basel Convention on hazardous and other waste; and Reducing the exposure to toxic pollutants associated with the combustion process through the promotion of appropriate practices for high temperature incineration. Strategy To better understand the problem of health-care waste management, WHO recommends that countries conduct assessments prior to making any decision as to which health-care waste management methods are chosen. Tools are available to assist with the assessment and decision-making process so that appropriate policies lead to the choice of adapted technologies. WHO proposes to work in collaboration with countries through the following strategies. Guiding policy principles In view of the challenge represented by health-care waste and its management, WHO activities are oriented by the following guiding principles: 25

preventing the health risks associated with exposure to health-care waste for both health workers and the public by promoting environmentally sound management policies for health-care waste; supporting global efforts to reduce the amount of noxious emissions released into the atmosphere to reduce disease and defer the onset of global change; supporting the Stockholm Convention on Persistent Organic Pollutants (POPs); supporting the Basel Convention on hazardous and other waste; and reducing the exposure to toxic pollutants associated with the combustion process through the promotion of appropriate practices for high temperature incineration. Short-term Production of all syringe components made of the same plastic to facilitate recycling; Selection of PVC-free medical devices; Identification and development of recycling options wherever possible (e.g. for plastic, glass, etc.); and Research and promotion on new technologies or alternatives to small-scale incineration. Until countries in transition and developing countries have access to health-care waste management options that are safer to the environment and health, incineration may be an acceptable response when used appropriately. Key elements of appropriate operation of incinerators include: effective waste reduction and waste segregation; placing incinerators away from populated areas; satisfactory engineered design; 26

construction following appropriate dimensional plans; proper operation; periodic maintenance; and staff training and management. Medium-term Further efforts to reduce the number of unnecessary injections thereby reducing the amount of hazardous health-care waste that needs to be treated; Research into the health effect of chronic exposure to low levels of dioxins and furans; and Risk assessment to compare the health risks associated with: (1) incineration; and (2) exposure to health-care waste. Support to allocate human and financial resources to safely manage health-care waste in countries Long-term Effective, scaled-up promotion of non-incineration technologies for the final disposal of health-care waste to prevent the disease burden from: (a) unsafe health-care waste management; and (b) exposure to dioxins and furans; Support to countries in developing a national guidance manual for sound management of health-care waste; Support to countries in the development and implementation of a national plan, policies and legislation on health-care waste; Promotion of the principles of environmentally sound management of healthcare waste as set out in the Basel Convention; and Ten Steps for a HCWM Plan (WHO) Raise awareness of the problem. Define a policy Set up a strategy Conduct and assessment of the current situation Draft a HCWM Plan 27

Consolidate the legal and regulatory frame work. Standardize HCWM Practices Strengthen the institutional capacity Setup waste management plans at relevant level. Establish a monitoring plan. Waste Management Cycle (WHO) Supervision & Monitoring Waste Minimization Training Waste Identification Record Keeping Waste Segregation Waste Treatment & disposal Waste Handling 28

Session no 05 Composition of medical waste, consequences, risk and hazard Contents: Composition of medical waste Problem and consequences of medical waste Potential risk and health hazard Group at risk Objectives: At the end of the session participants will be able to tell: The composition of medical waste; Consequences of medical waste The potential risk and related health hazard The exposed to risk Teaching Methodology: Discussion, Questions and answers, group discussion, demonstration Duration: 60 minutes Lesson Plan: Content Methodology Teaching aids Time Introduction to the session: Contents and objectives Composition of medical waste Problem and consequences of medical waste Potential risk and health hazard Group at risk Summing-up and feed back Discussion OHP/Flip chart 10 minutes Presentation, Discussion, Question and Answer Presentation, Discussion, Question and Answer Presentation, Discussion, Question and Answer Discussion, Question and Answer OHP/White board/mm Flip chart/ White board/mm Flip chart/ White board/mm Flip chart/ White board 10 minutes 10minutes 15 minutes 10 minutes Question and Answer OHP 05minutes 29

Nature and Composition of Medical Waste Clinics and hospitals are the main source of most hazardous and toxic waste. While as, only a small amount is from domestic or industrial sources. According to the WHO (2000), from the total wastes generated by health-care activities, almost 80% are general waste comparable to domestic waste. The remaining approximate 20% of wastes are considered hazardous materials that may be infectious, toxic or radioactive. Infectious and anatomic wastes together represent the majority of the hazardous waste, up to 15% of the total waste from health-care activities. Sharps represent about 1% of the total waste from health-care activities. Chemicals and pharmaceuticals amount to about 3% of waste from health-care activities (Figure 1). Genotoxic waste, radioactive matter and heavy metal content represent about 1% of the total waste from health-care activities. High-income countries can generate up to 6 kg of hazardous waste per person per year. In the majority of low-income countries, health-care waste is usually not separated into hazardous or non-hazardous waste. In these countries, the total health-care waste per person per year is ranges between 0.5 and 3 kg. Others 1% Infectious 15% Chemical 3% Medical Waste Composition (source: WHO, 2000) Sharps 1% General waste 80% The amount and composition of MW depend on the definition, service type, source of MW, size of the healthcare facilities, season, location, socio-economic condition, user pattern, and regional pattern etc. Such as developed countries usually generate more disposable and plastics items that contribute to increase the amount of MW. Infectious disease handling hospitals or facilities generates more infectious waste. In rainy season volume and weight of waste increased and in temperate countries waste decomposition occur very slowly. Composition of MW in developed country also differs from developing country. 30

Different kinds of MW have different kind of environmental implications. Examples of different types of medical waste composition and environmental considerations are shown in the following Table Medical Waste Composition Category Examples Environmental concerns General or Municipal Solid waste Paper, packaging, food, floor sweepings and other items not unique to medical waste, commonly managed by municipal collection and disposal Volume of the waste; Air emissions; Contamination of surface and ground water; Litter; Insects or other vectors; Odors; Infectious waste containing pathogens in sufficient quantity that exposure could result in disease Pharmaceutical waste Pathological waste containing human tissues or Chemical waste Lab cultures and stocks of infectious agents, wastes from isolation wards, tissues, materials or equipment that have been in contact with infected patients Expired or unnecessary pharmaceuticals and drugs Body parts, human fetuses, blood, and other body fluids. Injury; Exposure to Pathogens Land disposal of active pathogens Human health impacts Released to land or water Human health impacts Untreated waste released to land or water; Human health impacts Solid, liquid and gaseous chemicals from diagnostic and experimental work, cleaning materials Released of hazardous air pollutants and releases to land or water; Human health impacts Sharp wastes Needles, infusion sets, scalpels, broken glass Land disposal of active pathogens; Injury Radioactive waste Radioactive substances including used liquids from radiotherapy or lab work Releases to air, land or water; Human health impacts Pressurized containers Gas cylinders, cartridges and aerosol cans Potentially harmful; May explode High heavy metal content Genotoxic waste Source: WHO, 1999, EPA, 2000. Batteries, broken thermometers, blood pressure gauges Waste containing cytotoxic drugs (used in cancer therapy), genotoxic chemicals accidentally Releases to air, land or water; Human health impacts Releases to air, land or water; Human health impacts Potential Risks and Hazards Associate with Medical Waste 1. Injuries and accidents In healthcare establishments, nurses and housekeeping personnel are the main groups at risk of injuries and the example are cut-injury, punctured wound, laceration, strain and sprain of the joint of limbs and backache. There were several 31

incidents (10 cases out of 17) of injury due to exposure to medical wastes inside or outside of hospital premises (Akter et. al. 1998). These were as follows: Hands cut due to handling broken glass; Injured by needle and fingers permanently damaged/ became curved; Right hands became paralyzed by the injury by a needle; Two legs became paralyzed due to injury by the needle; Skin diseases on legs and hands/ body ; Pus due to injury sometimes; and Ulcer on legs. As BAN & HCWH (1999), sharps, which include syringes and needles, have the highest disease transmission potential amongst all categories of medical wastes. Almost 85% of sharp injuries are caused during their usage and subsequent disposal. More than 20% of those who handle them encounter stick injuries. The study also mentioned that needle-stick and sharp injuries occur frequently in developing countries, and that safer disposal facilities and routine hepatitis B vaccine should be adopted. It has been reported that (WHO, 1999b, in Nessa et al, 2001), in France, by 1992, eight cases of HIV infection were recognized as occupational infections, two of these, involving transmission through wounds, occurred in waste handlers. It has also been reported that, in the USA, by June 1994, 39 cases of HIV infection were recognized by the Centers for Disease Control and Prevention (CDC) as occupational infections. By June 1996, the cumulative recognized cases of occupational HIV infection had risen to 51, comprising nurses, medical doctors, and laboratory assistants. Showing in Japan, the risk of infection after hypodermic needle puncture is as follows: HIV is 0.3%, HBV is 3%, and HCV is 3-5%. 2. Infectious medical waste risk According to Litchfield and Phelan (1992), that infectious waste as any substance containing microorganisms, helminthes or viruses pose a threat to the health of human beings or any other beneficial user of the environment due to their volume or virulence. 32

Infectious medical waste represents only a small part of special waste; yet, because of ethical questions and infection risks, it is a focal point of public interest. Infectious waste contains different kind of pathogens or organisms that is potential for infection or disease. The table shows few examples of different pathogen and diseases caused by them. Pathogenic Organisms in Infectious Waste Bacterial Tetanus, gas gangrene and other wound infection, anthrax, cholera, other diarrhoeal diseases, enteric fever, shigellosis, plague etc. Viral Various hepatitis, poliomyelitis, HIV-infections, HBV, TB, STD rabies etc. Parasitic Amoebiasis, giardiasis, ascariasis, ankylomastomiasis, Fungal infections taeniasis, echinococcosis, malaria, leishmaniasis, filariasis etc. Various fungal infections like candidiasis, cryptococcoses, coccidiodomycosis etc. Contaminated sharps particularly syringe needles together with the concentrated cultures of pathogens are considered waste items that pose the greatest risk to human health. Sharps may not only cause physical damage to those coming into contact with them but may also infect the wounds so caused by the pathogens present on the contaminated sharps. The double risk of injury and the possibility of the transmission of disease place sharps in the category of being a very hazardous waste. The disease of greatest concern is those that are likely to be transmitted by subcutaneous injection for example viral blood infections. Syringe needles are often contaminated with patient s blood and hence are of particular concern since they form the largest quantitative item in the sharps waste category. 3. Hazardous medical waste risk This class of medical waste, while largely ignored, poses risk to workers handling them. Hazardous medical waste consists primarily of chemicals and discarded cytotoxin drugs. The medical laboratories examine blood, stool, urine, and sputum. The chemicals used for the staining and preservation of slides and for the sterilization and cleaning of equipment and surroundings are potentially harmful to the laboratory technician and the environment. Most of the chemicals are poured down the sink and drain out next to the clinic. Xylene, phenol, methylene blue, 33

hydrochloric acid, chlorine and carbol fuchsin are used in the laboratory, and some could have very damaging effects (Akter et. al. 1998). Other than these, a large number of chemicals also use in different diagnosis and treatment (e.g. chemotherapy). Some common hazardous chemicals, some of which are probable carcinogens or pose other health risks and effects, are summarized in the following Table Types of Chemicals Used in Medical Facilities, Pharmaceuticals Industries, and Their Uses and Effects (few available examples) Purpose of Chemical Use Xylene Removal of seederwood oil for TB slides Carbol Fuchsin Fixing of sputum slides Phenol Hydrochloric Acid Methylene Blue Disinfectant and sterilizer Fixing of sputum slides Fixing of blood & sputum slides Treatment Formaldehyde Pathology, autopsy, embalming Chemotherapy and Antineoplastic chemicals Glutaraldehyde (fixer, developer) Photographic (X-ray) Ethylene Oxide Sterilizers Properties Toxic Corrosive poisonous Corrosive combustible poisonous Corrosive poisonous Hazardous Toxic Hazardous Toxic Hazardous Toxic Hazardous Toxic Potential Effects Inhalation of vapors can cause: headaches; euphoria; light-headedness; dizziness, drowsiness; nausea; vapor can irritate skin, eyes, and lungs over exposure can lead to irregular heart beat, fainting, and eventually death Readily absorbed and can cause severe burning if brought into contact with skin/eyes/lungs inhalation results in chest pains, increased heart rate, coughing, nose and throat irritation, convulsions, and eventually death Can cause severe burning to skin, eyes or lungs if contact made can seriously affect lungs and respiratory system in inhaled (pulmonary edema, lung inflammation); potentially fatal; ingestion causes nausea, vomiting, gastro-intestinal irritation and bleeding; over exposure can lead to kidney and liver damage May cause burning sensation if brought into contact with skin/eyes; inhalation causes coughing/restricts breathing and damage to upper respiratory system Can cause damage if brought into contact with eyes, skin, clothing Carcinogenic; other health risk Health risk; suspected carcinogens; eye, nose and throat irritation Health risks Harmful to health 34

Chemical Acid gases (e.g. HCl, NOx, SO 2 ) Chlorine made material (e.g. PVC) PCBs(Polychlorinated biphenyls) Heavy metals (mercury, arsenic, and zinc, for example) Purpose of Use Properties Potential Effects Laboratory Hazardous Acute effects such as eye and respiratory irritation; may enhance the toxic effect of heavy metals Laboratory Hazardous Creates dioxin; animal carcinogen and considered human carcinogen Medicine industries Instruments, Treatment, Medicine industries Hazardous Toxic Toxic (neurotoxic) Harmful to fish and other aquatic forms of life because they interfere with reproduction; PCBs produce liver ailments and skin lesions in human; In higher concentration, they can damage the nervous system, and are suspected carcinogens Women and children are most vulnerable; have carcinogenic, mutagenic and teratogenic effects Exposure lead to pneumonitis, branchitis muscle tumor, irritability, gingivitis; nerve damage; enter to the food chain and concentrated; in humans, these metal can produce kidney and liver disorders, weaken the bone structure, damage the central nervous system; Cause blindness, and lead to death Source: Akter et. al. 1999; NWFSC MSDS Search; BAN & HCWH, 1999; Shaner, 1997. 4. Groups at most risk Potential occupational exposures include direct exposure to patients, visitors and workers who handle or come into proximity to waste. All personnel at the hospital are exposed to health hazards of contaminated or infectious waste, especially those involved in direct case (Fereres, 1991 in Wangsaatmaja, 1997). Nursing personnel and laboratory technicians are exposed to blood and blood soaked objects from patients and should beware of the health hazard of handling any kind of blood sample or object contaminated with blood, regardless diagnosis of the patients. Landfill and refuse incinerator operators attempt to segregate waste for recycling and other disposal route. Therefore, workers working at landfill and refuse incinerator are also at risk. Specific groups coming directly into contact with healthcare waste include: Waste pickers; Waste recyclers; Drug addicts (who scavenge for used needles and disposed medicines); and Hospital sweepers and other low-grade hospital staff. 35

They can be affected in two ways: through direct contact with waste of their daily working lives as a result of poor healthcare waste management practices; and through dependency on existing healthcare waste practices for their livelihoods. Scavenging 0f Medical Waste 36

Session no 06 Factors influencing external waste management, final disposal technology and element Contents: Components and factors influencing total external management system, Components of external management system, Treatment and final disposal technology with advantage and disadvantages Recommended suitable options for Bangladesh Objectives: At the end of the session participants will be able to understand: The components of external management Stakeholders involved in MWM system Different technical options of final treatment and disposal Advantage and disadvantage of those options Teaching Methodology: Discussion, Questions and answers, group discussion, demonstration Duration: 60 minutes Lesson Plan: Teaching Content Methodology Time aids Introduction to the session: Contents and objectives Discussion OHP/Flip chart 10 minutes Components and factors influencing total external management system Presentation/Discussion, Question and answer OHP/White board/mm 10 minutes Treatment and final disposal technology with advantage and disadvantages Presentation/Discussion, Question and answer Flip chart/ White board/mm 10minutes Major type of out house management Presentation/Discussion, Question and answer Flip chart/ White board 15 minutes Summing-up and feed back Question and answer Flip chart/ White board 10 minutes 37

External management and final disposal of MWM There are lots of other things need to be addressed for a well approached and functional medical waste management system. These factors are linked with the whole management system of a country. For example water supply and sanitation, food and safety, infrastructure, air-water and noise pollution, drainage and flooding, solid waste, health and education, national budget, population etc. Therefore, it would not be possible to give a simple solution for a well established and functional management system. Nevertheless, factor those are influencing and need immediate attention or priority for a functional medical waste management system for Bangladesh are outlined in the following Figure Inadequate Disposal Site Solid Waste Management Nonexistence of Regulations Inadequate Treatment Improper MWMS Lack of Awareness Inadequate Collection System Absence of Responsibility Unauthorized Waste Picking Step by Step Improvement Resource Constraint Disposal Outside Hospital (total system) In-house Management Public and Political Awareness Treatment Transport Collection Training Good house keeping Capacity building Health & environment Civic sense Above Figure outlined the factors Influencing Proper MWM and how to Overcome those obstacle. The figure indicated that the MWM is a part of total solid waste management. The reasons behind improper MWM system has been shown in upper portion of the 38

figure, middle and lower portion explained how step by step improvement could be achieved by improving external and internal (in and outside hospital) condition of total management system. Lack or non-existence of regulations, resource constrain, poor responsibilities and lack of public and political awareness has been resulted improper and/or inadequate MWMS (e.g. collection, disposal, treatment and waste picking). Therefore, step by step activities proposed in this figure are needed to make a functional MWMS. It includes total system, in-house management and public and political awareness building. This section emphasized outhouse/external management systems and options. The following figure explained the components and steps of activities to make total medical waste management system functional. Outside hospital (Total system) Management Institutional cooperation Collection Optimum and proper utilization of resources Municipality Transport Public participation Private company/ NGOs Big hospitals (public or private) Central Incineration General waste Infectious waste General waste Public-private partnership Ash Treatment Infectious waste Same car different time Protected landfill Disposal site 39

External Management: Collection, Disposal and Treatment The above figure outlined total management system outside hospital (e.g. collection, transport, treatment, and disposal) and what is needed for proper management. To improve total medical waste management that is linked with the whole waste management system of a country should ensure the institutional cooperation, optimum use of resources, public participation and public-private partnership. All agencies or institutes (i.e. city corporation, municipality, DOE, MOHFW, other ministries, NGOs) involved with this issue, should work together to bring up guidelines, policies, implementing those and use and upgrade existing systems and available resources and infrastructure. A management plan should includes all stack holders in planning process. Such as local authority, local community, public and private institutes, NGOs and all other relevant institutes should work together to find an appropriate option feasible for that area. Specific work should be distributed to the relevant institutes or organization. Public and political awareness Organizational involvement Government Community Organization NGOs Health & environment Civic sense Campaign Conference Open forum Dialogue Mass media Meeting 40

External Management: Public and Political Awareness The above figure explained activities for public and political awareness and who should be involved to make it successful. This awareness should focus on health and environmental aspects and attitude and civic sense of people and commitments to the country and environment. Government is to take initiative and involve other agencies as well as share/ distribute responsibilities among them. Community organization and NGOs can organize training and awareness program at local level. Government and national/private institutes, NGOs can organize nation wide program like campaign, dialogue, open forum meeting etc. Treatment technologies and final disposal options Most important part of external management is treatment and final disposal of MW. Overview of treatment and disposal methods for different categories of medical waste with appropriate options are given in the following Tables below. (Prescribed disposal and treatment methods suitable for all possible categories of medical waste) Overview of Disposal and Treatment Methods Suitable for Different Categories of Medical Waste Technology or Infectious Anatomic Sharps Pharmaceutical Cytotoxic Chemical Radioactive method waste al waste waste waste waste waste Rotary kiln Yes Yes Yes Yes Yes Yes Low-level infectious waste Pyrolytic incinerator Yes Yes Yes Small quantities No Small quantities Single-chamber incinerator Low-level infectious waste Yes Yes Yes No No No Low-level infectious waste Drum or brick Yes Yes Yes No No No incinerator No Chemical disinfection Yes No Yes No No No No Wet thermal Yes No Yes No No No treatment No Microwave irradiation Yes No Yes No No No No Encapsulation No No Yes Yes Small Small quantities quantities No Safe burial on Yes Yes Yes Small quantities No Small hospital premises quantities No Sanitary landfill Yes No No Small quantities No No No Discharge to sewer No No No Small quantities No No Low-level liquid waste 41

Technology or Infectious Anatomic Sharps Pharmaceutical Cytotoxic Chemical method waste al waste waste waste waste Inertization No No No Yes Yes No No Other methods Return expired drugs to supplier Assessment of technology Source: WHO, 1999. Return expired drugs to supplier Return unused chemicals to supplier Radioactive waste Decay by storage It has been found that, a variety of technologies have been developed for the storage, collection, treatment and disposal of medical wastes particularly for those wastes generated in industrialized countries. Several types of treatment and disposal processes have been applied (incineration, micro waving, chemical treatment, melting etc.), with varying degrees of safety, cost and impact on the environment. None of the available low-cost treatment devices are however safe and environmentally friendly. As WHO mentioned that, in developing countries, a tradeoff has to be made between direct health risks from absence of waste management leading to reuse of syringes, and indirect health risks created by environmental pollution (e.g. by production of dioxins from inadequate incineration). Progress could be made in waste minimization practices, in particular in the development of materials and products leading to less waste, or less harmful waste when disposed off. overview of the various technologies used for the treatment and final disposal of different categories of medical wastes highlighted in the tables.. Advantages and/or disadvantages with suitable condition and influencing parameters have been discussed along with the selected technology. Information on various technologies may help to select a specific technology for each type of waste and/or each country that is suitable considering the socio-economic and environmental condition of that country. 42

Technologies for Treatment and Final Disposal Technology Description Advantages Disadvantages Incineration Chemical disinfection Render inert Wet thermal treatment (inc. autoclaving) Microwave irradiation A high temperature dry oxidation process that reduces organic and combustible waste to inorganic matter. Many different types of incinerator ranging from the sophisticated to the basic; however, basic incinerators often cause serious emissions problems. Chemicals added to the waste to kill/inactivate the pathogens. Shredding is usually necessary before disinfection, as only the surface of intact solid waste will be treated. The waste is then disposed of in a conventional way, e.g. landfill. Mixing the waste with cement in order to prevent migration of toxic substances from waste into ground water etc. Exposure of shredded waste to high temperature, highpressure steam. If temperature and contact time is sufficient, most micro-organisms are inactivated. Waste can subsequently be disposed of as municipal waste. Waste shredded, humidified and then irradiated by microwaves. The heat generated destroys microorganisms. Requires no pre- treatment. Good disinfection efficiency. Efficient disinfection when operated well. Some chemical disinfectants are low cost. Shredding reduces volume of waste. Relatively low cost. Lowtechnology Relatively low capital and operating costs. Low environmental impact. Very efficient disinfection when operated well. Environmentall y sound. Reduction in volume of waste. If not operated effectively may pollute atmosphere High capital and operational costs. Low cost incineration is possible by using a drum or brick incinerator, however, these present large emission problems and are not as effective in the destruction of hazards. Disinfectants may themselves be hazardous to operators & pose risks in the case of leakage and subsequent disposal. Needs highly trained operators. Shredder liable to mechanical failure. Bulky and heavy final waste product to be disposed of. Shredder liable to mechanical failure. Efficiency of disinfection very sensitive to operational conditions. Relatively high capital and operating costs. Potential operation and maintenance problems. Suitable condition >60% combustible Moisture content < 30%. Not suitable for pressurized gas canisters, reactive chemical waste, PVC, wastes with high heavy metal content, photographic or radiography wastes. Best for liquid or sewage Inadequate for pharmaceutical, chemical and some types of infectious waste. Especially suitable for pharmaceuticals. Not suitable for infectious waste. Not suitable for anatomical, pharmaceutical or chemical wastes. Not suitable for pharmaceutical or chemical wastes Not suitable for large metal objects. 43

Technology Description Advantages Disadvantages Landfill (Sanitary) (Encapsulate) Landfill isolates waste from the environment; it requires appropriate engineering preparation, staff to control operations, organized deposition and covering of waste. Waste may be pre-treated (see above). Ideally, healthcare waste is separated from municipal waste. Pre-treatment involving filling containers with waste, adding an immobilizing material and sealing the container e.g. bituminous sand, cement mortar. Simple, low cost & safe when operated properly. Preventing access to HC waste by scavengers. Relatively simple, low cost & safe Source: WHO, 1999 If not operated properly scavengers may access the waste and it may cause pollution of environment etc. Not recommended as sole method for nonsharp infectious waste. Bulky and heavy final waste product to be disposed of. Suitable condition Generally suitable Appropriate for establishments using minimal programs for disposal of sharps, chemical or pharmaceutical residue. 44

Session no 07 Occupational Hazards: Bio-Safety, Prevention and Management Contents: Health care, related occupational hazards Bio-safety measures Sharps injury and other exposure incidence procedure Prevention and management of occupational hazards Objectives: At the end of the session participants will be able to understand: The importance of health-care occupational hazards; Identify and explain different types of hazards; Acquaint themselves with common bio-safety precautions and practice at work; undertake necessary measures for accidents or other exposure incidence promptly; Follow preventive measures to reduce the risk of occupational hazards. Teaching Methodology: Discussion, Questions and answers, group discussion, demonstration Duration: 120 minutes (02 hours) Lesson Plan: Content Methodology Teaching aids Introduction to the session: Discussion OHP/ Flip Contents and objectives chart Health care, related Presentation, Discussion, OHP/White occupational hazards Question and answer board/mm Bio-safety measures Discussion, Question and Flip chart/ answer White board/mm Sharps injury and other Presentation, Discussion, Flip chart/ exposure incidence procedure Question and answer White board/mm Prevention and management Discussion, Question Flip chart/ of occupational hazards and answer White board/mm Response to accidental injury Discussion, Question Flip chart/ and Accidental report form and answer White board Summing-up and feed back Question and answer Flip chart/ White board Time 10 minutes 20 minutes 20 minutes 20 minutes 20 minutes 20 minutes 10 minutes 45

Occupational Hazards: Bio-Safety, Prevention and Management Medical waste includes materials sufficiently contaminated with blood or body fluid that is capable of transmitting mainly infectious diseases. Biohazardous waste is produced from a wide array of clinical settings: hospitals and laboratories, physician offices, dental offices, clinics, research facilities, surgery centers, nursing homes, and settings where health care is delivered. All theses settings are socially obligated to maintain a clean environment and to dispose of medical waste, in order to prevent pollution and infection among themselves and also among the general public. Doctors, nurses, pharmacists, radiologists, laboratory technician, dentists, physical therapist, ward boys, ayas, cleaners, sweepers, porters, ambulance drivers and other personnel working in this field, all run the risk of direct contact with potentially infectious or other harmful waste that are generated from patient care activities. Therefore, administrators of health care facilities will realize the need and importance of careful handling of hazardous health care waste for the safety of their staff and the environment at large. They shall be particular to take necessary actions to correct the poor waste handling practices in their respective health care facilities. Thus, clinical waste management and infection control measures are inter related and both are important for prevention of biohazards because health care providers are at constant risk of exposure to blood borne pathogens such as human immunodeficiency virus (HIV the virus that causes AIDS), the hepatitis B virus (HBV), and the hepatitis C virus (HCV) and many other bacteria. 46

1. Types of Hazards related to medical waste The exposure to hazardous health care waste may lead to disease or injury. The significant characteristics of hazardous medical waste are as follows: it contains infectious agents; it involves sharps items ; it contains toxic and hazardous chemical or pharmaceutical products; it is genotoxic; it is radioactive. Universal Precautions & Potentially Infectious Materials Causing Biohazards These are a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other blood borne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious. In the workplace, universal precautions should be followed where workers are exposed to blood and certain other body fluids including Semen, Vaginal secrétions, Synovial fluid, Cerebrospinal fluid, Pleural fluid, Peritoneal fluid, Pericardial fluid, Amniotic fluid etc. Universal precautions do not apply to Nasal secretions, Sputum, Sweat, Tears, feces, Urine, Vomits, saliva etc (except in the dental setting, where saliva is likely to be contaminated with blood). Universal precautions should be applied to all body fluids when it is difficult to identify the specific body fluid or when body fluids are visibly contaminated with blood. Any unfixed tissue or organ from a human (living or dead); and HIV-containing cell or tissue cultures, organ cultures, and HIV-or HBV/HCV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV/HCV are also considered infectious. Hazards from infectious waste and sharps Infectious waste usually contains pathogenic microorganisms. Pathogens in infectious waste may enter to the human body mainly through the following routes: 47

Puncture, abrasion or cut in the skin; Splashing of blood or other body fluids on the mucous membranes particularly on the mouth. eyes or nose; Inhalation; and Ingestion. It is important to know that almost all cases of hepatitis B and C viruses and HIV transmission to health care personnel occurred through preventable accidental puncture injury and handling health care waste. Hazards from chemical and pharmaceutical waste Many of the chemicals and pharmaceuticals used in health care establishments are hazardous such as toxic, genotoxic, corrosive, flammable, reactive, explosive, and shock-sensitive. This problem gives rise to serious consequences when large quantities of unwanted or outdated chemicals and pharmaceuticals are disposed of. They may cause intoxication and injury including burns. Intoxication can result from absorption of chemical and pharmaceutical through skin or the mucous membranes, or from inhalation or ingestion. Injuries to the skin, the eyes, or the mucous membranes of the airways can be caused by contact with flammable, corrosive or reactive chemicals such as formaldehyde and other volatile substances. Poorly stored and disposed of these substances can directly or indirectly affect the health of anyone who comes into contact with them. This also creates a gross environmental pollution through contaminating groundwater, air or other products including foods. Chemical residues discharged into the sewage treatment plants exert toxic effects on the natural ecosystems of wastewater. Similar problems may be caused by pharmaceutical residues such as antibiotics and other drugs, heavy metals such as mercury, phenols and other disinfectants and antiseptics. Hazards from genotoxic waste The severity of the hazards for health care workers who are responsible for the handling or disposal of genotoxic waste is mainly depend on the substance toxicity itself, and the extend and duration of exposure. It may also occur during the preparation of or treatment with particular drugs or chemicals. The exposure usually occur through inhalation of dust or aerosols, absorption through skin, ingestion of 48

food accidentally contaminated with Cytotoxic drugs, chemicals, or other waste, and ingestion due to improper practice such as mouth pipe ting. This also can happen through contact with body fluids and secretions of patients undergoing chemotherapy. The cytotoxicity of many antineoplastic drugs including alkylating agents is carcinogenic and mutagenic. In addition they are extremely irritant and have harmful local effects after direct contact with skin or eyes. They may also cause dizziness, nausea, headache or dermatitis. Therefore, genotoxic waste should be specially handled with extreme care. Hazards from radioactive waste Hazards due to radioactive waste range from headache and vomiting to more serious problems such as destruction of tissues. The hazards may arise from contamination of external surfaces of containers or improper mode or duration of waste storage. Health care workers and waste handling or cleaning personnel exposed to this radioactivity are most at risk. 2. Safe Guards against Biohazards: How can workers prevent exposure to blood and body fluids? Barriers are used for protection against occupational exposure to blood and certain body fluids. These barriers consist of: Personal protective equipment (PPE) Engineering controls Work practice controls Personal Protective Equipment (PPE) PPE includes gloves, lab coats, gowns, shoe covers, goggles, glasses with side shields, masks,etc. The purpose of PPE is to prevent blood and body fluids from reaching the workers' skin, mucous membranes, or personal clothing. It must create an effective barrier between the exposed worker and any blood or other body fluids. The type of protective clothing use should be depending upon the extent of the risk associated with the health-care waste. The following should be made available to all personnel who collect or handle health-care waste: 49

Helmets with to without visors - depending on the operation; Face masks depending on operation; Eye protectors (safety goggles) - depending on operation; Disposable gloves for medical staff and heavy-duty gloves for waste handlers obligatory; Leg protectors or industrial boots obligatory; Industrial aprons obligatory; Overalls (coveralls) obligatory. Personal protective equipment is also recommended for health care waste transportation in small hospital. 50

Engineering Controls Engineering controls refer to methods of isolating or removing hazards from the workplace. Examples of engineering controls include: sharps disposal containers, safe carrying, incineration etc. Work Practice Controls It refers to practical techniques that reduce the likelihood of exposure by changing the way a task is performed. Examples of activities requiring specific attention to work practice controls include: hand washing, handling of used needles and other sharps and contaminated reusable sharps, collecting and transporting of fluids and tissues according to approved safe practices. Personal hygiene Basic personal hygiene is important for reducing the risks from handling health care waste and convenient washing facilities with water and soap should be available for personnel involved in the tasks. Staff immunization Immunization against hepatitis B infection is recommended. Tetanus immunization is also recommended for all personnel handling waste. Golden Rules of Universal Precautions 1. Wash hands before and after every patient contact, and immediately if in direct contact with blood or body fluids. 2. Wear gloves when contact with blood or body fluids, mucous membranes or non-intact skin is anticipated and wash hands after their removal. 3. Take precautions to prevent puncture wounds, cuts and abrasions in the presence of blood 4. Protect skin lesions and existing wounds by means of waterproof dressings and/or gloves 5. Avoid invasive procedures if suffering from chronic skin lesions on hands. 6. Avoid use of or exposure to sharps and sharp objects, but when unavoidable, take particular care in their handling and ensure approved procedures are followed for their disposal. 51

7. Never re-sheath/recap needles. Always dispose of needles directly into sharps bins 8. Protect the eyes and mouth by means of a visor, goggles or safety spectacles and a mask whenever splashing is a possibility. 9. Wear rubber boots or plastic disposable overshoes when the floor or ground is likely to be contaminated. 10. Control surface contamination by blood and body fluids through appropriate decontamination procedures. 11. Use approved procedures for sterilization and disinfection of instruments and equipment 12. Use approved procedures for sterilization and disinfection of instruments and equipment. 13. Dispose of all contaminated waste and linen safely. 14. Use the agreed procedure for the safe procedure of contaminated wastes. Application of these precautions, particularly with regard to necessary protective clothing, will vary accordingly to the degree of anticipated contact with blood, body fluids or tissues. The risk of exposure must be assessed for each procedure and the appropriate action taken. 3. Sharps Management and Incidence Procedure Procedure to be followed in the event of a contamination incident A "sharps" or "needle stick" injury is one in which blood or body fluid from one person is inoculated into another on the point of a needle, scalpel or other sharp object. However, the following advice also applies to spillage of blood or body fluids on to skin, especially broken or eczematous skin, mucous membranes or the eye. If you are in any doubt seek advice. The major health risks to someone exposed to such event are Hepatitis B, Hepatitis C, and HIV infection. Needle stick Injuries Causing Biohazards A needle stick injury is the result of an accident with a needle. Several studies show that needles cause injuries at every stage of their use, disassembly, or disposal. 52

Nursing and laboratory staff usually experiences such 30 to 50 percent of all injuries during clinical procedures. Chances of exposure Critical situations during clinical procedures include: Withdrawing a needle from a patient, especially if staff attends to bleeding patients while disposing of the needle. Having the device jarred by a patient. Pulling a needle out of the rubber stopper of a vacuum tube which can jab the hand in a rebound reflex. Work conditions that might contribute to an increase in the number of needle stick injuries include: Difficult patient care situations. Working with reduced lighting. Staff Experience: New staff tends to have more needle stick injuries than experienced staff. Recapping: - Recapping can account for 25 to 30 percent of all needle stick injuries of nursing and laboratory staff. Often, it is the single most common cause. Injuries commonly occur when workers try to do several things at the same time, especially while disassembling or disposing of needles in crowded conditions on the way to the disposal box. to protect themselves when disassembling a non-disposable needle device with an exposed contaminated needle. from exposed needles when several items were carried to a disposal box in a single trip. to store a syringe safely between uses if its contents were to be administered in two or more doses at different times in crowded conditions on the way to the disposal box. Guidelines from the Centre for Disease Control (USA) recommend that workers should not recap (or bend or cut) needles but dispose of them directly into approved, puncture-proof containers. Recapping: Injuries occur in three different ways: The needle misses the cap and accidentally enters the hand holding it. The needle pierces the cap and enters the hand holding it. The poorly fitting cap slips off of a recapped needle and the needle stabs the hand. 53

Disposal Needle stick injuries commonly occur when workers dispose of needles. They also occur when needles are disposed of improperly in regular garbage or lost in the workplace. Special Containers: Up to 30 percent of needle stick injuries of nursing and laboratory staff occur when workers attempt to dispose of needles into sharps containers. Accidents occur at every step: While carrying the needle to the disposal container, especially when the needle is uncapped and mixed with other trash. While placing the needle into the disposal container, especially if the container is overfilled. While emptying disposal containers instead of sealing them for disposal. Improper Disposal: Virtually all needle stick injuries of domestic and portering staff are from needles that have either been lost in the workplace or thrown into regular garbage. Janitors and garbage handlers can also experience needle stick injuries or cuts from "sharps" when handling trash that contains needles or scalpels. Some attribute the problem to forgetfulness or lack of motivation or training on the part of people who work with and dispose of needles. Others feel that inconvenient disposal systems contribute to these incidents. Maintenance staffs have also experienced needle stick injuries when they have been cleaning ducts or other areas with their hands and have found hidden needles and syringes. These injuries have usually happened when they are reaching into areas where they cannot see and were not wearing leather gloves. Response to accidental injury and exposure incidence All staff members who are responsible for handing health care waste should be educated to deal with the management of injuries and exposures. These include: Initiation of immediate first aid measures; Reporting of the accident to the designated authority; Identification of items involved in the accident and take appropriate protective measures; Sought medical attention for the accident management; Establishment of medical surveillance; Participation of periodic blood and other examinations as indicated; Maintaining record keeping. 54

Response to other exposures or emergencies All health staff members should be educated for emergency response to the following situations: accidental spillage of waste equipment failure accidental tear or breakage of containers; interruption or delay in collection, treatment and disposal; explosion and fire; any other accident that needs immediate action or decision. Necessary equipment should be made readily available at hand in all times for dealing with any emergency situation. In case of emergency situation or accidents immediately report the incident to the designated authority. Reporting of incidence When any accident occurs at any institution, facility or any other site where hazardous health care waste is handled or during treatment of such waste, the authorized person should report the incidence using the accidence form to the designated authority for record keeping and taking appropriate preventive measures. First Aid and Immediate Help Encourage bleeding where skin is punctured Wash thoroughly with copious amounts of soap and warm water. DO NOT USE A SCRUBBING BRUSH. If eyes are involved, wash immediately with water (use tap water or sterile water if tap water not available). If the mouth is contaminated rinse with plenty of water Where massive contamination of unbroken skin has occurred, remove contaminated clothing and wash all affected areas with copious amounts of water. Ensure that your manager or immediate senior is informed promptly of the incident. The injured person should complete an incident reporting form and report to designated person 55

Post exposure Prophylaxis (PEP) After exposure, if the source patient is known to be infected with HIV or is considered to be at risk but there is no facility for testing, then approved guidelines on post exposure prophylaxis (HIV) for health care workers need to follow. The following points to be considered for PEP (HIV): The choice of anti-retrovial drugs; To ensure that all health care workers after exposure should have immediate access to PEP; Supply availability of drugs and appropriate laboratory investigations Appropriate counseling Setting up of local PEP policies and protocols. 56

Accident Report Form 1. Date and time of incident: / 2. Date and time of report: / 3. Name of the staff exposed/injured: 4. Age: 5. Sex: 6. Job title/occupation: 7. Place (Location) where the incident took place: 8. The area in the body injured: 9. Type of accident (Material involved): 10. How the incident occurred (Details of the incident): 11. Main reason for the incident: 12. Is any person directly responsible for the incident? (Yes/No): If yes, mention: 13. Hepatitis B vaccine taken before the injury (Yes/No): 14. In case of needle stick injury, what immediate measure has been taken by the injured person? (Yes/No) a) let the wound bleed freely: b) wash the affected area/skin with soap and water: c) rinse the affected area/skin with spirit: d) the wound is covered with water proof dressing: e) report to the respective supervisor and infection control officer for recording: f) report to staff clinic for further medical advice: 15. In case of exposure to blood or body fluids incident, what immediate measure has been taken? (Yes/No) a) wash the area with copious amount of water: b) report to the respective supervisor and infection control officer for recording: c) report to staff clinic for further medical advice: * Note: Needle stick or sharps injury and exposure to blood or body fluids incident include the following accident: an injury from a used needle or sharp instrument; splashing of these fluids into the face, especially the mouth and eyes; and Spillage of these fluids on to open skin cut, including areas affected by eczema. Date: Place: Signature: Designation: 57

4. Preventive Measures 4.1 Prevention of Needle Stick Injuries Preventing needle stick injuries is the most effective way to protect workers from the infectious diseases that needle stick accidents transmit. A comprehensive needle stick injury prevention program would include: Employee training. To follow recommended guidelines. Safe recapping procedures if essential. Effective disposal systems. Surveillance programs. Improved equipment design Employee Training To reduce needle stick injuries, an effective program must include employee training. Workers need to know how to properly use, assemble, disassemble, and dispose of needles. Workers need to understand the risks associated with needle stick injuries and know the proper means to prevent them. Specifically, the training programs should address. Risk of injury. Potential hazards. Recommended precautions for use and disposal of needles. Procedures for reporting injuries. The importance of hepatitis B vaccination where appropriate. Recommended Guidelines: Needles, scalpel blades and other sharp instruments- Workers should consider these as potentially infectious and handle them with care to prevent accidental injuries. Disposable needles and syringes, scalpel blades, and other sharp items-- workers should place these in puncture-resistant containers located near the area of use. They should avoid overfilling the containers because accidental needle stick injuries may occur. Workers should not recap needles by hand or purposely bend, break, or remove them from disposable syringes or otherwise manipulate them by hand 58

Safe Recapping Procedures: In situations where recapping is considered necessary, develop safe approaches which workers can follow. Workers should never move an exposed needle tip towards an unprotected hand. Single-Handed Scooping: Recapping can be safe when people lay the cap on a flat surface and scoop it onto the tip of a syringe held in one hand. They must keep the free hand away from the sheath and well behind the exposed needle. Disposal Effective system: Having disposal containers readily available can greatly prevent needle stick injuries and eliminate the need for recapping needles. Containers should be puncture-proof. Replace the containers before they are completely filled. Make sure they are sealed, collected, and disposed of in accordance with local regulations for biomedical waste. All staff should report every incident in which they find needles left at the bedside or thrown into the regular garbage. Surveillance There is still a serious lack of information about the various factors that cause accidents with needles. Surveillance programs that provide in-depth analysis of needle stick accidents are an important tool for obtaining this information. The goals of these programs should include: Determining the rate of needle stick injuries. Investigating the factors that cause the injuries. Ensuring that injured workers receive proper treatment. Identifying areas in which the prevention program needs improvement. Eventually providing practical strategies for dealing with the problem. 59

4.2 Other Preventive Measures Cytotoxic safety: Chemical and pharmaceutical waste safety Less hazardous chemicals should be substituted whenever possible and appropriate personal protective equipment should be used to minimize the occupational risks due to exposure to chemical and pharmaceutical waste. Premises where chemical hazardous chemicals are used should be properly ventilated. The senior pharmacist of the health care facility should be designated to ensure safe use of cytotoxic drugs. The following key measures are essential in minimizing exposure: Written procedure with specifying safe working methods for each process; Information of supplier s specifications on potential hazards; Established procedure for emergency response in case of spillage or other occupational accident; Appropriate education and training for all personnel involved in the handling of cytotoxic drugs. In hospitals where cytotoxic drugs are used, established specific guidelines for safe handling of cytotoxic products. The guidelines should include rules on the following waste handling procedures for the protection of personnel who are responsible for handling cytotoxic products: separate collection of waste in leak-proof bags or containers and put labeling for identification; return of outdated drugs to suppliers; separately keep them in safe storage from other health care waste; provision for the disposal of contaminated material, for the decontamination of reusable equipment, and for the treatment of spillages; provision of the treatment of infectious waste contaminated with Cytotoxic products. 60

Radioactive Safety Users of radiation materials must keep records of surveys, inventories, order and packing slips for the safety of the workers as well as inspections and investigations by nuclear safety and radiation control division of the Atomic Energy Commission. Individuals must keep themselves away from sources of radiation and use remote handling tools to prevent high dose. Appropriate radiation shield, protective clothing and dosimeter must be worn where indicated. Radioactive waste should be stored by encapsulation for decay of action. Radioactive containers such as bottles glass wear should be destroyed before disposal for avoidance of public access. Important Considerations to Avoid Biohazards While Dealing with Medical Waste: The waste should be separated at the source of its generation and high-risk waste should be labeled properly. For smooth functioning of hospital waste management, a colour-coding policy should be adopted. The different coloured waste containers should be provided throughout the hospital so that waste can be segregated at its source. Place waste containers close to where the waste is generated and where convenient for users. Carrying waste from place to place increases the risk of infection for handlers. Use plastic or galvanized metal containers with cover lids for contaminated waste collection and use separate containers for collection of sharps materials which should ideally be puncture-proof. 61

Use personal protective equipment when handling waste for example, heavyduty utility gloves, and protective shoes. Reusable waste containers should be emptied at least once daily or when three-quarters full and wash properly with vim or 0.5% chlorine solution and rinse with water before replacing them to its place. The used container should be closed on the top firmly and tightly, and the container should be taken to a pre-designated area for collection and transportation for at least once daily or as frequently as needed. The waste collection staff should ensure that the waste is segregated properly according to the colour-coding policy procedure and then carry it to the appropriate disposal area. The waste containers should be carried by holding on the top and avoiding touching to the body as well as avoiding jar king, throwing or dragging waste over floor. The waste collection staff may have reserved the right to refuse to remove the waste if sharps or items liable to cause injury are found in the wrong containers. The waste containers should be stored in a safe area until the transportation to the designated disposal destination. However, the storage time should not exceed 24 hours during summer and 48 hours in the winter season. If general waste or hazardous waste is mixed together, the mixed waste should be considered as hazardous waste and dispose of as clinical waste. Under any circumstances no staff members should put their bare hands into any waste containers. Special care should be taken when handling and transporting damaged and leaked waste container. During the collection of such a container, it should be replaced with a new one. No container should be collected if damaged or leaked. In case, if there is a leakage of the waste container, or there is a spillage of infectious waste, gently collect the spillage into a new container, soak the 62

area with hypochlorite solution and leave the area for 15-30 minutes. Then wash and wipe the area with soap and water. No waste containers should be collected without proper labeling from the source site. The waste container should contain maximum 100kg for solid waste and 50 liters for liquid waste. Equipments that are used to hold and transport waste must not be used for any other purpose in the hospital. Wash hands or use alcohol based hand-rub after removing gloves when handling waste. Hospital staff members including doctors, nurses should be trained and made aware about the segregation of waste and the use of colour-coding waste disposal system. Housekeeping staff and waste collection staff should also be adequately trained about safe way of handling and transporting of waste as well as the accident and spillage management procedures. Hepatitis B immunization should be offered to all concerned hospital staff members and proper recording of such immunization should be maintained by the authority. 63

SESSION NO 08 Medical Waste and Infection Control Measures Contents: Disease transmission at health care settings Standard precautions for prevention of infection Hand hygiene: Hand washing technique Decontamination of equipment Cleaning, disinfection and sterilization procedures Objectives: At the end of the session participants will be able to: Understand and explain how disease spread at health care facilities; Follow and practice standard precautions for the prevention of infections at health care settings; Understand the importance of hand washing and practice the right technique for hand washing; Follow safety procedures when handling contaminated items, and notify and take necessary actions in case of any incidence; Prepare disinfecting solutions (chlorine solutions) and decontaminate equipment or other items correctly; Define and explain the methods of cleaning, disinfection and sterilization. Teaching Methodology: Presentation, Question and Answers, discussion, and demonstration Duration: 2 hours 64

Lesson Plan: Content Methodology Teaching aids Time Introduction to the session: objectives and contents Discussion OHP/Flip chart 10 minutes Disease transmission at health care setting Question and answer OHP/Flip chart/mm 15 minutes Practice of standard precaution for prevention of infections Presentation/Discussion, demonstration OHP/Flip chart/mm 25 minutes Correct hand washing Discussion and demonstration, Question and answer OHP/Flip chart/mm 20 minutes Decontamination of equipment and other items Presentation, Discussion and demonstration OHP/Flip chart/mm 20 minutes Procedure for cleaning, disinfection and sterilization Discussion, Question and answer OHP/Flip chart/mm 20 minutes Summing-up and feed back Question and answer Flip chart 10 minutes 65

Medical Waste and Infection Control Measures Hospital acquired infection is a world wide problem. In developing countries including Bangladesh, the magnitude of this problem is greater. Most surveys revealed that hospital acquired infection rates range from 5-20%. Hospital acquired infections are also known as nosocomial infections. These are acquired during hospital stay which is not present or incubating at admission. Infections occurring 48 hours after admission are usually considered nosocomial.there is two forms of this infection: Endogenous infection, self-infection, or auto-infection: The causative agent of the infection is present in individual at the time of admission to hospital but there are no sign of infection. The infection develops during the stay in hospital. Exogenous infection or cross-infection: When patients come into contact with new infective agents during hospital stay, may develop infections. All individuals including health care workers are susceptible to bacterial infections and also to most viral agents. The dose of organisms (inoculum) necessary to produce infection in a susceptible host varies with the locations of the body and host factors. When the organisms come in contact with bare skin, infection risk is quite low but when the organisms come in contact with mucous membranes or non-intact skin, the risk of infection is high. Age, nutritional status, severity of illness, duration of antimicrobial therapy, procedures performed such as intubation or mechanical ventilation, prolonged antibiotic therapy and insertion of nasogastric tubes increase the risk for nosocomial infections. Rectal thermometer usually used for recording temperature of children, use of oxygen inhalation masks, nasal catheters for oxygen inhalation, nebulisation, venepuncture, intramuscular injection, spinal tap, varied surgical procedures etc are also risk factors for development of nosocomial infections. The spread of infections in health care settings can be better explained through disease transmission cycle. 66

1. Disease Transmission Cycle Infections are transferred from one person to another through disease-transmitting microorganisms, known as pathogens. There are six steps in disease transmission: the infectious agent, the reservoir, the place of exit, the mode of transmission, the place of entry and the susceptible host. Infectious agents are the microorganisms, such as bacteria, viruses, fungi, or parasites that can cause infection or disease. The reservoir is the place where the agent (microorganism) lives. Reservoirs can be people, animals, plants, soil, air, water, instruments and other items used in clinical procedures. The place of exit is the route by which the infectious agent leaves the reservoir. The bloodstream, broken skin (e.g. puncture, cut, surgical site, or rash), mucous membranes (e.g. eyes, nose, mouth), the respiratory tract (e.g. lungs), genitourinary tract (e.g. vagina, penis), gastrointestinal tract (e.g. mouth, anus), or placenta can be exit routes. The mode of transmission is the way in which the infectious agent moves from the reservoir to a susceptible host. Infectious agents can be transmitted by contact, through a vehicle, via a vector, or in the air. Contact: the agent can be transmitted by touch (e.g. staphylococcus), by sexual intercourse (e.g. gonorrhea, HIV), or in airborne droplets (e.g. influenza, tuberculosis). Vehicle: The infectious agent can be transmitted by such vehicles as food (e.g. salmonella), blood (e.g. Hepatitis B, HIV), water (e.g. cholera, shigella), or contaminated instruments (e.g. Hepatitis B, HIV). Vector: The agent can be transmitted to a person by insects and other invertebrate animals (e.g. mosquitoes spread malaria and dengue fever). Airborne: The agent can be carried by air (e.g. measles, ARI). 67

The place of entry is the route by which the infectious agent moves into the susceptible host. It can enter the host through the same places it can exit. A susceptible host is a person who can become infected by an infectious agent. For the purpose of this guide, susceptible hosts include clients, service providers, ancillary staff, and members of the community. The Disease Transmission Cycle Susceptible Hosts - Clients - Community - Service providers - Ancillary staff - Community members Reservoir - PEOPLE - Water, soil, air - Instruments - Equipment Places of Entry - Broken skin - Puncture wound - Surgical site - Mucous membranes Infectious Agent - Bacteria - Viruses - Fungi - Parasites Places of Exit Skin, respiratory, genitourinary, and vascular systems, Modes Transmission - Contact - Vehicle - Air - Vector of 68

2. Standard Precautions: The key elements of infection control Every one working at health care facility should be committed to prevent infection. They are definitely at risk of infection as they handle and come across different types of infectious medical waste. Health care providers are not only at risk of infection but also partly responsible for spread of infection in the population if they do not maintain standard hygiene practice. Examples are inadequate hand washing, inappropriate use of hand-gloves; recapping of needles; lack of appropriate decontamination etc. The only way to prevent infections is to stop the transmission of microorganisms. The best way to prevent infections at health care facilities is to follow standard precautions. These are a set of recommendations designed to minimize the risk of exposure to infectious materials. 2.1 Personal Hygiene: Hand washing Hand washing is the most effective and simple way of prevention of infection. Hands must be washed thoroughly and frequently. The use of gloves does not preclude the need for hand washing between procedures. 2.2 Personal Protective Equipment (PPE) Use of personal protective equipment prevents the health care workers from becoming contaminated with blood or other body fluids. All health care workers must routinely use appropriate personal protective equipment to avoid contact of skin and mucous membranes with blood or other body fluids. PPE must always be available for use and employee should be responsible for its appropriate use. PPE include gloves, masks, face shield, gowns, shoes / boots. 2.2.1 Gloves Disposable gloves should be worn when there is a risk of contamination with patient's body fluids or handling hazardous substances. Gloves are not always a 69

complete impermeable barrier, however, they reduce the transfer of microorganisms and in addition subsequent hand washing protects the individual. Hand-gloves should be used in the following events: Contact with blood or other body fluids; Touching mucous membranes; Touching non-intact skin of all patients; Performing venipuncture or others procedures involving vascular access; Handling vascular access; Performing surgical procedures; Conducting or assisting childbirths Handling items or surfaces soiled with blood or body fluids and other infectious items. Some necessary instructions for hand-gloves: Wear the correct size gloves because poorly fitting gloves can limit the performance and may be damaged easily. Gloves must be discarded after individual activity Hands must be washed thoroughly after removal of gloves Keep fingernails trimmed short to reduce the risk of tear or pinholes Types of gloves There are three types of gloves used in healthcare facilities. They are surgical, examination and utility or heavy-duty household gloves: Surgical gloves should be used when performing invasive medical or surgical procedures. Examination gloves provide protection to healthcare workers when performing many of their routine duties. 70

Utility or heavy duty household gloves should be worn for processing instruments, equipment and other items; for handling and disposing of contaminated waste; and when cleaning contaminated surfaces. The best surgical gloves are made of latex rubber, because of rubber s natural elasticity, sensitivity and durability and it provides a comfortable fit. Because of the increasing problem of latex allergy, a new synthetic rubber-like material called nitrile, which has properties similar to latex, has been developed. Nitrile gloves are less likely to cause allergic reactions. In many countries the only type of examination gloves usually available are made of vinyl, a synthetic material that is less expensive than latex rubber. Because vinyl is inelastic (does not stretch like latex), the gloves are loose fitting and can tear easily. Utility gloves are made of thick rubber, which is much less flexible and sensitive, they provide maximum protection as a barrier. All types of examination gloves are very thin and should not be reprocessed for reuse. Where utility gloves are not available, putting on two pairs of examination (double gloving) provides some protection for cleaning staff and for staff handling and disposing of contaminated medical waste. ````````````````````````````` 71

2.2.2 Eye and mouth protection: Masks and eye wear and face shield Eye and mouth protection is necessary where there is a risk of blood or other body fluid splashing over these areas. The use of masks is not routinely advised however there may be circumstances when masks will be required. In that case local policy should be followed. 2.2.3 Gowns or aprons Plastic aprons should be worn to protect uniforms when there is risk of contamination from blood or body fluids; Plastic aprons should be disposed of correctly after single use or it may be properly decontaminated if the local policy permits. 2.2.4 Shoes or footwear Footwear is worn to protect feet from injury by sharps or heavy items. Sandals or shoes made of soft materials (cloth) should be avoided. Leather shoes or rubber boots provide more protection. It should be kept clean and free of contamination from blood or other body fluid. 2.3 Care of hand, skin and mucous membranes Health care providers who have skin lesions should not be involved in medical waste care activities until the condition is resolved. Any cuts or lesions on hands or arms should be covered with waterproof dressing at all times when working with medical wastes. An emollient hand cream should be applied regularly to protect skin from the drying effects of hand-rub or repeated use of soap for hand washing. If a particular soap, antimicrobial hand wash or alcohol product causes skin irritation; an employee/occupational health team should be consulted. If mouth, nose or eyes are splashed with blood or other body fluids immediately wash the area with copious amounts of water. 72

2.4 Sharps The major cause of work place exposure to blood borne pathogens is through injuries from used sharps including used needles. Most of the documented cases of HIV and hepatitis B and C infections acquired at the work place are due to these types of preventable accidents. Therefore, all staff must handle and dispose of sharps safely to reduce the risk of exposure to blood borne viruses. Always take extreme care when disposing of used sharps. Avoid handling used sharps items whenever possible. Do not re-sheath a used needle - if this is necessary, a safe method such as one- hand technique of re-sheathing/recapping device must be used. Clinical sharps should be used for single time only where feasible. Discard sharps directly into a sharps container immediately after use and at the point of use. Keep sharps container on a stable surface to prevent displacement. Sharps container must be emptied when it is three quarter full. Opening of the sharps container must be closed when carrying for disposal Sharps containers should be temporarily stored in a secure place before sending it for final disposal. Finally dispose sharps on a regular basis preferably daily and incinerate, or dispose through other recommended methods. Needle stick Injury Incidence Procedure If any one is injured with contaminated sharps including needles should follow the procedure (first aid) mentioned below: The injured area should be encouraged to bleed freely but not by sucking; Immediately wash the area thoroughly and gently with copious amounts of soap and water; 73

The wound should be covered with a water proof band aid; Report the incident to the supervisor and complete an accident report form for recording and taking actions for remedial measures; Attend the concerned department or contact the occupational/employee health department as soon as possible for further medical assistance such as vaccination or post-exposure prophylaxis. Note: Person involved injury should be aware of his/her hepatitis B and tetanus vaccination status. Skin should not be scrubbed and disinfectant chemicals should not be used directly on the skin. 2.5 Safe working environment Maintaining of safe and hygienic work environment prevents the spread of infection. Contaminated hospital surface and equipment should be adequately decontaminated. Appropriate methods for cleaning, disinfections and sterilization must be done as per indications. Handle soiled equipment in a manner to prevent contact with skin or mucous, membranes as well as prevent contamination of clothing or the environment. Equipment or other contaminated items can be decontaminated by using 0.5% sodium hypochlorite (chlorine solution). Routinely clean and disinfect equipment and furniture in patient care areas for the promotion of environmental safety. Sinks, basins, toilets etc. must be cleaned and well maintained. Care should be taken to avoid spills. Careful disposal of used sharps and other clinical waste prevents infections not only for health care workers but also patients and community people. General Procedure for dealing with spillage Spillages of surface contaminated with blood or other body fluids should be decontaminated and cleared-up immediately. In some cases, immediate evacuation of the area may be necessary or secure the area to prevent further exposure to additional individuals. 74

Spillage Management Procedure Wear disposable latex gloves and plastic apron when clearing up spillages; Cover the spillage with disposable paper to sock-up for a while and discard the paper as clinical waste; Treat or saturate the contaminated surface with chemical disinfectant (0.5% chlorine solution) for at least two minutes; Clean away residue as clinical waste; Remove gloves and wash hands thoroughly. 2.6 Safe Disposal of health care waste All contaminated health care waste (if not indicated for incineration) should be decontaminated before disposal in order to protect the environment. Recommendations for classification and handling of different types of waste should be followed. Special precautions must be observed when disposing of clinical/biological waste and material that have become contaminated. Importance must be given to protect the environment. This can be done by following appropriate waste treatment and disposal techniques. The health care providers and waste handlers must follow the disposal of contaminated waste procedure. The procedure should include the following: Dispose of sharp waste in a puncture-resistant containers following colour coded segregation. Consider all biological waste as infectious Wear heavy duty gloves and handle all contaminated waste carefully to avoid direct contact. Do not load the container beyond its capacity or compact the contents. Specimens from patients with high risk infections (hepatitis viruses, HIV etc) should be conspicuously labeled with risk stickers and form s all should be transported in approved containers. Cytotoxic waste must be collected in strong, leak-proof containers clearly labeled "Cytotoxic waste". Remove health care waste routinely and frequently on regular basis and final disposal must be executed within 24 hours. Never put bare hands in the waste containers 75

Routinely decontaminate, wash and clean the re-usable waste containers after emptying. At the end of official hours, health care workers and waste handlers should ensure about the cleanliness of working place. They should wash hands and change the working dress before leaving for home. 3. Hand-Washing Transient bacterial flora of the hands potentially causes cross-infection. So, handwashing is important. The purpose of hand washing is to remove dirt and reduce the load of bacteria from the skin of the hands. Alcohol (spirit) is a powerful antiseptic that evaporates quickly. Its application to the skin rapidly kills transient and a portion of the resident bacteria, viruses, and even some fungus. Hands that are not obviously soiled, use of alcohol based hand-rub are a good substitute. Hands must be washed: Before and after each work shift or work break. Before and after physical contact with each patient. Before and after use of hand- gloves. Before and after administering injections (I/V or I/M) Before preparing or serving food. Before eating, drinking or handling food. After handling contaminated instruments or items such as dressings, bedpans, urinals and urine drainage bags, or body fluids. After using the toilet, blowing nose or covering a sneeze. When hands become soiled or dirty. Appropriate Hand Washing Technique Steps of routine hand washing are as follows: Thoroughly wet hands under running water Take 3-5 ml of liquid soap in the hands Vigorously rub all areas of hands and fingers together for at least 10 to 15 seconds, paying more attention to areas under fingernails and between fingers. Rinse hands thoroughly with running water. 76

Dry hands thoroughly with clean dry towel or in air. Important points to be remembered for hand wash: Running water is best for hand washing purpose because microorganisms grow and multiply in moisture and in standing water. When no running water is available, use a bucket with a tap that can be turned off to later hands and turned on again for rinsing or use bucket and mug. It bar soap is used provide small bars soaps and soap racks that drain. Do not add soap to a partly empty liquid soap dispenser. This practice of topping off dispensers may lead to bacterial contamination of the soap. Wet hands transfer microorganisms more efficiently than dry ones therefore, hands should be properly dried after washing. An emollient hand cream should be applied to protect skin from the drying effects of regular hand decontamination. Jewelries and rings should be removed before hand washing 77

Technique of Hand Washing (Non-surgical) Step-01 Step-02 Step-03 Step-04 Step-05 Step-06 Step-07 Step-08 78

4. Decontamination of Equipments Decontamination is a process which destroys micro to render medical device, instrument or environment surface safe. All infectious materials and contaminated equipment or apparatus should be decontaminated before being washed, stored or discarded. All individual working with bio-hazardous materials are responsible for proper handling of contaminated items during decontamination. It is important for staff to know how to decontaminate items. Usually chlorine solution (0.5%) or a solution made from another acceptable disinfectant can use for decontamination of items. A solution that contains less than 0.5% active chlorine may not adequately kill microorganisms during the recommended time. A solution that contains more than 0.5% active chlorine may increase the cost of supplies and may damage instruments, other items and environmental surfaces. 4.1 Steps of instrument decontamination Step I Immediately after use, decontaminate instruments and other items by placing them in a plastic container of 0.5% chlorine solution. A container with this solution should be kept in every operating theatre and procedure room. Step 2 After 10 minutes remove the sharp items from the chlorine solution and either rinse with water or clean immediately. Do not leave sharp items in solution for more than 10 minutes as excessive soaking in the solution can damage instrument and other items. Always wear utility gloves when removing instruments. How to make a 0.5% chlorine solution Chlorine solutions prepared from liquid or powdered bleach are recommended because of their low cost and wide availability. A chlorine solution can be made from: Liquid household bleach (Sodium hypochlorite) Bleaching powder (Calcium hypochlorite or chlorinated lime) Chlorine-releasing tablets 79

Liquid Household Bleach Chlorine in bleach is in different concentrations as available from market. One can use any type of bleach, but needs to make a 0.5% chlorine solution. One of the useful formulas (given below) that can be applied: *[% of active chlorine in liquid bleach 0.5%]-1 = parts of water for each part bleach. Examples: To make a 0.5% chlorine solution from bleach with 3.5% active chlorine, you must use 1 part bleach with 6 parts water. See calculation below: [3.5% 0.5%] -1 =[7]-1=6 parts water for each part bleach. *(AVSC International 2000, USA, Infection Prevention, p 27) Bleaching Powder If using bleaching powder, calculate the ratio of bleach to water using the following formula: [0.5% % active chlorine in bleaching powder] X 1000 = Grams of powder for each litre of water. Example: To make a 0.5% chlorine solution from calcium hypochlorite powder containing 35% available chlorine: [0.5% 35%] X 1000=[0.0143] X 1000=14.3 grams Therefore, one must dissolve 14.3 grams of calcium hypochlorite powder in 1 litre of water in order to get a 0.5% chlorine solution. *(AVSC International 2000, USA, Infection Prevention, p 27) Alternatively appropriate chlorine solutions can be prepared by dissolving 2.5 teaspoons of bleaching powder for each litre of water. While using bleaching powder it is important to remember that for effective disinfections, bleaching powder must be dry and in a powder form with a strong smell. Chlorine - releasing tables Follow the manufacturer s instructions since the percentage of active chlorine in these products varies. If the instructions are not available with the tablets from the supply source, ask for the product instruction sheet or contact the manufacturer. 80

4.2 Procedures for Equipment Process The choice of the decontamination method depends on a number of factors but chiefly the potential risk to patients. The risks are classified into following categories: Low risk Items in contact with normal and intact skin or the inanimate environment that are not in contact with patient, for example, walls, floors, ceilings, furniture, sinks and drains. Cleaning and drying is usually adequate. Intermediate risk Equipment that does not penetrate the skin or eater sterile areas of the body but is in contact with mucous membranes or non-intact skin or other items contaminated with virulent or transmissible organisms such as respiratory equipment, gastrointestinal endoscope, vaginal instruments, and thermometers. Cleaning followed by disinfection is usually adequate. High risk High risk items are that penetrate sterile tissues including body cavities and the vascular system such as surgical instruments, intra-uterine devices, vascular catheters. Cleaning followed by sterilization is required. Decontamination procedure includes cleaning, disinfections and sterilization. 4.2.1 Cleaning Cleaning is a physical process which removes foreign materials such as soil, organic material, microorganisms but does not necessarily destroys micro organisms from an object. If equipment not cleans before sterilization or high level disinfection, microorganisms trapped in organic material on the objects may survive. And also organic material and dirt can make the chemicals used in sterilization and high level disinfection less effective. Cleaning refers to scrubbing with a brush and wash with detergent and water. Detergent is important for effective cleaning, because water alone will not remove protein, oil and grease. When detergent is dissolved in water, it breaks up and dissolves grease oil and other foreign materials, making them easy to remove. Do not use hand soap for cleaning instruments and other items, because the fatty acids containing in the soap will react with the materials of hard water leaving a residue that is difficult to remove. Steps of cleaning Always wear utility gloves, a mask and protective eyewear when cleaning instrument and other items. Avoid using steel wool or abrasive cleansers such as vim. These products can scratch or pit on metal or stainless steel, resulting in grooves that can become a nesting place for microorganisms. This also increases the potential for corrosion of the instruments and others items. 81

Step 1 Scrub instruments and other items vigorously using a soft brush or old toothbrush, detergent and water to completely remove all blood, other body fluids, tissues and other foreign matter. Hold items under the surface of the water while scrubbing and cleaning to avoid splashing. Disassemble instruments and other items with multiple parts and be sure to brush in the grooves, teeth and joints of items where organic material can collect and stick. Step 2 Rinse items thoroughly with clean water to remove all detergent. Any detergent left on the items can reduce the effectiveness of further chemical processing. Step 3 Allow items to dry in air or dry them with clean towel. Note: Instruments that will be further processed with chemical solutions must dry completely to avoid diluting the chemicals; items that will be disinfected by boiling or steaming need not to be dried. 4.2.2 Disinfection Disinfection is a process that reduces the number of viable micro organisms but not necessarily inactivates all viruses and bacterial spores. Disinfection may not necessarily achieve the same reduction in microbial contamination levels as sterilization does. Disinfection can be carried out either thermal or chemical processes. Thermal disinfection is preferred whenever possible. It is generally more reliable than chemical processes, leaves residues, and is more easily controlled and is non toxic. Thermal Methods Moist heat Simple Boiling (100 C) for at least 5 minutes can inactivate micro-organisms including hepatitis B virus, HIV and mycobacteria. Chemical Methods Some instruments are better disinfected by chemical methods. Many of those items (e.g. Bronchoscopes, GI & other endoscopes etc) require high level disinfection. A limited number of disinfectants e.g. Glutaraldehyde 2% for 20 minutes, hydrogen peroxide 6% for 20 minutes, peracetic acid 0.2-0.3% for 5 minutes can be used for this purpose. If a Sporicidal action is required, immersion in 2% Glutaraldehyde for at least 3 hours required or 0.2-0.3% peracetic acid for 10 minutes is required. High-level disinfectants Chlorine, Glutaraldehyde, formaldehyde and hydrogen peroxide are most commonly used disinfectants for high-level disinfection. These chemicals can achieve high-level disinfection if the items being disinfected are thoroughly cleaned before immersion. 82

Chlorine solutions Chlorine solutions are effective against HBV, HCV and HIV/AIDS, and inexpensive and readily available. A major disadvantage is that the concentrated solutions (>0.5%) can corrode metal, however stainless steel instruments can be safely highlevel disinfected in 0.1% chlorine solution by soaking in a plastic container for up to 20 minutes. Glutaraldehyde (e.g., Cidex) It is commonly used for processing equipment that can not be sterilized by heat. It can be used for high-level disinfection by soaking for 20 minutes. Glutaraldehyde leaves a residue, so items should thoroughly be rinsed with boiled water or sterile water after disinfection. Glutaraldehyde can be irritating to the skin, eyes and respiratory tract. Therefore, staff and patients need to be protected from the fumes when mixing and using these solutions. Staff should wear gloves and protective eyewear to avoid skin contact, protect eyes from splashes, limit exposure time and use it only in a well ventilated area. Formaldehyde Formaldehyde is effective against vegetative bacteria, fungi and many viruses but only slowly effective against bacterial spores. It is highly toxic and extremely irritating to the skin, eyes and respiratory tract. It does not injure fabrics and metals. It may be used as a 2-3% solution (20 to 30 ml of 40% formalin in 1 litre of water) for spraying rooms, walls and furniture. Hydrogen peroxide (H 2 O 2 ) It is less expensive than other chemical disinfectants. It must be diluted to a 6% solution. The 3% H 2 O 2 solution is used as antiseptics. It is highly corrosive and should not be used to disinfect copper, aluminum, zinc or brass. 83

Other useful disinfectants Alcohol Ethyl and isopropyl alcohols are commonly used as antiseptics and disinfectants. Ethyl alcohol in the form of industrial methylated spirit is most commonly used for skin disinfection in the form of hand-rub. 70% alcohol is a good antiseptic but its activity decreases rapidly below 50% concentration. Idophors (Betadin) This is considered as an effective skin antiseptic but not suitable for disinfection because of their low levels of iodine. Phenol or Carbolic acid (Lysol) It is low-level disinfectant. These products are used to disinfect equipment. They can also be used to disinfect environmental surfaces such as floors, walls etc. Antiseptic solutions that should not be used as disinfectants Many antiseptic solutions are used incorrectly as disinfectants. Although antiseptics which are skin disinfectants could be used for cleansing skin before surgical procedures but they are not appropriate for disinfecting surgical instruments and gloves. They do not reliably destroy bacteria, viruses or endospores, For example, savlon (Chlorhexidine gluconate with or without cetrimide) which is readily available and often mistakenly used as a disinfectant. The following antiseptics should not be used as disinfectants Acridine derivates (e.g., Gentian violet or Crystol violet) Cetrimide (e.g., Cetavlon) Chlorhexidine gluconate (e.g., Hibiscrub, Hibitane) Chlorhexidine gluconate and Cetrimide in various concentrations (e.g., Savlon) Chlorinated lime and boric acid (e.g., Eusol) Hexachlorophene (e.g., phisohex) Mercury compounds 84

Characteristics of the main disinfectant Disinfectants Bactericidal activity Activity Against viruses Sporicidal activity Local human toxicity Applications Alcohol Very active Very active Not active Moderate Skin antisepsis Disinfection of small surfaces Chlorhexidine Less active against Gram negative bacilli Not active Not active Low Skin and wound antisepsis Chlorine compounds Very active Very active Less active Moderate Skin and wound antisepsis Water treatment Surface disinfection Formaldehyde Very active Very active Less active High Disinfection of inanimate objects and surfaces Glutaraldehyde Very active Very active Very active High Disinfection of inanimate objects Hydrogen peroxide Less active against staphylococci and enterococci Active Less active Low Wound antisepsis Iodophore Active Active Not active Moderate Skin and wound antisepsis Peracetic acid Very active Active Active High Disinfection of inanimate objects Phenolic compounds Very active Less active Not active High Disinfection of inanimate objects and surfaces Quaternary ammonium compounds Less active Less active Not active Low In combination with other compounds 85

4.2.3 Sterilization Sterilization is a process used to render the object free from viable micro-organisms including bacterial spares and viruses through destroying them. Sterilization is accomplished principally by steam under pressure (autoclaving), dry heat, by ethylene oxide gas or radiation. Steam Sterilization Steam sterilization is the most common and preferred method applied for sterilization of all items that penetrate the skin and mucosa. Providing they are not damaged by heat and moisture. Steam sterilization is dependable, non-toxic, inexpensive, sporocidal with rapid heating and good penetration of fabrics. Method The steam must be applied for a specified time so that the items reach a specified temperature. 121 C for 20 minutes for unwrapped items, 30 minutes for packaged items at 1.036 Bar (15.03 psi) above atmospheric pressure. 134 C for 4 minutes for unwrapped items in a gravity sterilizer or wrapped items in a vacuum assisted sterilizer at 2.026 Bar (29.41 psi) above atmospheric presser. As a possible alternative for unwrapped instruments or utensils a domestic pressure cooker may be used. Holding time should be at least 30 minutes. Dry Heat Dry heat is preferred for reusable glass syringes and ointments, powders, oils etc. Method At a hot air oven equipped with fan or conveyor which will ensure even distribution of heat. The recommendation temperature and time for sterilization of medical equipment is as follow: 170 C for 2 hours 180 C for 1 hour 86

Ethylene oxide gas (EO) This is used for low temperature sterilization of selected items in hospitals. Ethylene oxide gas is toxic, so manufacturers instructions for installation and use should be followed. There are four parameters that must be maintained to ensure EO sterilization, gas concentration, temperature, humidity and exposure time. Gas concentration should be 450 to 1200 mg/l temperature ranges 29 to 65 C, humidity from 45% to 85% and exposure times from two to five hours. The process has a long cycle as aeration of the items is required. Microbiological control of process is recommended. Radiation Gamma and X-ray are two principal types of ionizing radiation used in sterilization. Their application is mainly centered on the sterilization of prepackaged medical devices. Ultraviolet (UV) radiation is a practical method for inactivating viruses, mycoplasma, bacteria and fungi. UV radiation is successfully used in the destruction of airborne microorganisms. UV light sterilizing capabilities are limited on surfaces because of its lack of penetrating power. 87

Session no 09 Storage site, storage time & Transportation Contents: Storage site and storage time Salient feature for waste storage On-site transport, Regulation and control system of Off site transportation of waste Special packaging, Labeling, Transport vehicles or containers: Objectives: At the end of the session participants will be able to understand: Temporary storage site, storage time and criteria of storage room; Different aspect of waste storage; Proper method of on-site transport and off-site transport Different aspect of packaging, labeling of container and transportation Teaching Methodology: Presentation, Discussion, Questions and answers, group discussion, demonstration Duration: 60 minutes Lesson Plan: Content Introduction to the session: Contents and objectives Storage site and time Salient feature for waste storage Methodology Discussion Presentation/Discussion, Question and Answer Presentation/Discussion, Question and Answer Teaching aids OHP/Flip chart OHP/White board/mm OHP/Flip chart/ White board/mm Time 05 minutes 10 minutes 10minutes On-site transport, Regulation and control system of Off site transportation of waste Special packaging, Labeling, Transport vehicles or containers Presentation/Discussion, Question and Answer Discussion, Question and Answer OHP/Flip chart/ White board/mm OHP/Flip chart/ White board Summing-up and feed back Question and Answer Flip chart/ White board 10 minutes 15 minutes 10 minutes 88

Storage Site Store of the waste should be within the hospital. The store will be an area, room or building depending upon the quality and quantity of waste product and frequency of collection. The main storage site of the hospital should be accessible to vehicles so that the collection vans can reach it. This reduces the number of personnel handling the waste. The storage site should have a smooth surface so that it can be washed easily in case of spillage. The hospital should ensure that there are written instructions to handle spills, and that the personnel at the storage site are trained for such work. Storage within the hospital should be done in labeled, color-coded bins and bags in secured, balanced, easily washable covered containers that do not have any sharp edges. Storage Time Storage time is the time lag between the generation of waste and its treatment. Storage could be of different kinds: storage of waste within the hospital s wards/departments; storage outside wards but within the hospital premises; if the waste is taken to a treatment site, then storage in a vehicle; and finally storage at the central facility. Waste should not be kept untreated for more than 48 hours. One must remember that this is the maximum time limit. Keeping the Bangladeshi climate in mind (the hot and humid conditions in most part of the country) it is advisable to treat waste as soon as possible. According to WHO, unless a refrigerated storage room is available, storage times for Medical waste (i.e. the delay between production and treatment) should not exceed the following: Temperate climate: 72 hours in winter; 48 hours in summer. Warm climate: 48 hours during the cool season; 24 hours during the hot season 89

Salient feature for waste storage Supply of cleaning equipment waste bag equipment waste bag and containers Waste handlers should be immunized, especially for tetanus and Hepatitis B viruses Basic cleaning equipment sand, fire-fighting equipment should be available for accidental fire and for lickage of waste Radioactive waste should be stored in containers that prevent dispersion behind lead shield Reusable container should be smooth and should be washable both with water and chemicals Unless a refrigerated room, the storage time should not exceed the above mentioned time. On-site transport: Medical waste should be transported within the hospital or other facility by means of wheeled trolleys, containers, or carts that are not used for any other purpose and meet the following specifications: Easy to load and unload No sharp edge that could damage bags or containers during loading and unloading Easy to clean The vehicle should be cleaned and disinfected daily with an appropriate disinfectant. All waste-bag seals should be in place and intact at the end of transportation. Regulation and control system for off site transportation Medical waste producer is responsible for safe packaging and adequate labeling of waste to be transported off-site. Packaging and labeling should comply with national regulations governing the transport of hazardous wastes and with international agreements if wastes are shipped abroad for treatment. The control strategy for Medical waste should have the following components: 90

A consignment note should accompany the waste from the place of production to the site of final disposal. The transporting organization should be registered with, or known to the waste regulation authorities. Handling and disposal facilities should hold a permit, issued by a waste regulation authority, allowing the facilities to handle and dispose of healthcare waste The consignment note should be designed to take into account the waste control system in operation within the country. If a waste regulation authority is sufficiently established, it may be possible to notify the agency about the planned system of transport and disposal of the health-care waste and obtain the agency s approval. Anyone involved in the production, handling or disposal of Medical waste has a general duty of care, i.e. an obligation to ensure that waste handling and associated documentation complies with the national regulation. Special packaging requirements for off-site transport: In general the waste should be packaged according to the recommendations in sealed bags or containers, to prevent spilling during handling and transportation. The bags or containers should be appropriately robust for their content ( puncture-proof for sharps, for example, or resistant to aggressive chemicals) and for normal conditions of handling and transportation, such as vibration or changes in temperature, humidity or atmospheric pressure. In addition, radioactive material should be packed in containers whose surface can be easily decontaminated. For infectious wastes, it is recommended that packing should be design type-tested and certified as approved for use. Medical wastes that are known or suspected to contain pathogens likely to cause human disease should be considered as Infectious Substances and should comply with the packaging requirements. The packaging recommended for most health-care wastes, with a relatively low probability that infectious substances are present which are not likely to cause human disease. 91

Labeling before transporting the waste All waste bags or containers should be labeled with basic information on their content and on the waste producer. This information may be written directly on the bag or container or on preprinted labels, securely attached. The following indications should appear on the label: Symbol for infectious substances The total quantity (mass or volume) of waste covered by the description. The country authorizing the allocation of the label (identified by international code system used on motor vehicles) It is also recommended that the last two digits of the year of manufacture of the packaging specified by the competent authority are marked on the package, as well as a special code designating the type of packaging For health-care waste, the following additional information should be marked on the label: Waste category Date of collection Place in hospital where produced Waste destination In case of problems involving questions of liability, full and correct labeling allows the origin of the waste to be traced. Labeling also warns operative staff and the general public of the hazardous nature of the waste. The hazard posed by the container content can be quickly identified in case of accident, enabling emergency services to take appropriate action. Transport vehicles or container Waste bags may be placed directly into the transportation vehicle, but it is safer to place them in further containers (e.g. cardboard boxes or wheeled, rigid, lidded plastics or galvanized bins). This has the advantage of reducing the handling of filled waste bags but results in higher disposal costs. These secondary containers should be placed close to the waste source. 92

Any vehicle used to transport health-care waste should fulfill the following design criteria: The body of the vehicles should be of a suitable size commensurate with the design of the vehicle, with an internal body height of 2.2 meters. There should be a bulkhead between the driver s cabin and the vehicle body, There should be a suitable system for securing the load during transport. Empty plastic bags, suitable protective clothing, cleaning equipment, tools and disinfectant together with special kits for dealing with liquid spills, should be carried in separate compartments in the vehicles. The internal finish of the vehicle allows it to be steam-cleaned and the internal angles should be rounded. The vehicle should be marked with the name and address of the waste container as well as an emergency telephone number Vehicles or containers used for the transportation of health-care waste should not be used for the transportation of any other material. They should be kept locked at all times, except when loading and unloading. Articulated or demodulated trailers (temperature control required) are particularly suitable as they can easily be left at the site of waste production. The containers may be used for storage at the health-care establishment and replaced with an empty one collected. Refrigerated containers may be used if the storage time exceeds the recommendations or transportation times are long. The finish of these bulk containers should be smooth and impervious and permit cleansing or disinfection. The same safety measures should apply to the collection of hazardous health-care waste from scattered small sources.. 93

Session no 10 Supervision and monitoring in Medical waste management Contents: Definition of supervision and effective supervision Principle of supervision, function and responsibilities of a supervisor Techniques of supervision Definition of monitoring, conduction of monitoring activities Objectives: At the end of the session participants will be able to understand: Definition of supervision and monitoring; Principle,function and responsibilities in relation to MWM; Effective techniques of supervision for the effective management of MW Different aspect of monitoring Teaching Methodology: Discussion, Questions and answers, group discussion, demonstration Duration: 60 minutes Lesson Plan: Content Methodology Teaching aids Time Introduction to the session: Contents and objectives Definition of supervision and effective supervision Principle of supervision, function and responsibilities of a supervisor Techniques of supervision Definition of monitoring, conduction of monitoring activities Summing-up and feed back Discussion OHP/Flip chart 10 minutes Presentation/Discussion, Question and Answer Presentation/Discussion, Question and Answer Discussion, Question and Answer Presentation/Discussion, Question and Answer Question and Answer OHP/White board/mm OHP/Flip chart/ White board/ MM OHP/Flip chart/ White board OHP/Flip chart/ White board/mm Flip chart/ White board 05 minutes 10minutes 15 minutes 15 minutes 05 minutes 94

Supervision and Monitoring in Medical waste management Definition: Supervision means the act of watching over the work or task of another who may lack full knowledge of the concept at hand. Supervision does not mean control of another but guidance in a work, professional or personal context. Supervision is defined as the methods and procedures used to monitor the volume and quality of work performed by subordinate staff, as well as to provide necessary support to staff. Human resources are the key factor for any organization. Proper utilization of human resources is important especially in the medical waste management. The human resource management is the most crucial elements among all the elements of medical waste management. Effective supervision can bring successful change in the introduction of medical waste management in any hospital, clinics and laboratories but the supervision should have the following things: Supervision technique should influence staff to work positively with motivation to achieve the objectives of MWM Development of proper leadership, with aims to develop the individual staff to work effectively for achieving the task of MWM Providing support for the individual not only for the development of skill but also achieving the planned objectives of the organization in respect of MWM Supervisor should understand the basic elements of supervision and how to implement them. Assessing the knowledge and skill levels of staff members, providing necessary training and keeping staff informed about issues as well as their performance are crucial to successful supervision. Supervisor as teacher must clearly state the outcomes, and how they will be measured When working with a group of staff, supervisor needs to apply a variety of techniques of supervision to uphold the group interest. Supervision process should create an active learning environment The whole process of supervision need to direct with an aim to provide support the supervisee for the accomplishment of the job 95

Principle of supervision: The basic principle of supervision is To know his people To recognize the supervisee in terms of their strength and weakness. To provide clear understanding about the specific job of the supervisee and also translation of the job function if needed. To communicate the expectation of the supervisor from the supervisee. To provide opportunity to undertake more responsibilities for creating sense of confidence. To provide proper guidance in doing the job. To provide sense of achievement. To criticize constructively for poor work and encourage for improvement. To help the individual staff for the development of proper capacity on the basis of assessment findings. To acknowledge the individual staff or group for good work. To create proper environment for inviting the active participation of staff. Function of a supervisor: According to Professor John M.pfiffner of the University of Southern California, nine important function of a supervisor are as follows: The supervisor Provides leadership; Deals with incentives and motivation; Is teacher and trainer of his subordinate; Deals face to face with problems, both human and organizational, arising in the course of work; Is a key official in personnel administration; Evaluates employee performance; Handles questions of organization at his own level; Does a good deal of his own staff work; and Strives to provide adequate working facilities. 96

Responsibilities of supervisor A supervisor in the workplace has distinctly separates sets of responsibilities. The supervisor s first duty is to represent the management. It is the supervisor s job to organize his/her department and employees, visualize future impact and needs, energize the employees to get their tasks done and supervise their work ensuring that the productivity and quality standard are met. To ensure that this is done, the supervisor makes certain that his employee have the training, the tools and the material that they need to carry out their duties. Another important part of the job is to act as a middleman and buffer between the employees who actually do the job and the rest of the organization. The supervisor also has legal responsibilities to ensure that his area of responsibility is free of safety violation and simultaneously responsible for the health and safety of all subordinate staff. It is also the supervisor s responsibility to develop all the potential leaders that work under him. Some techniques of supervision: In the process of medical waste management supervision, there are many techniques, which can be applied. Some of them are as follows: In case of a problem: Acknowledge the problem Try to explore the reason, especially the root cause Fit the facts together Try to figure out different option for the solution Find the best and effective solution Give decision How to give directives: Determine the areas where directives are needed Analyze the situation Avoid command in providing directives Directives need to be realistic 97

How to criticize: Criticize in private, not in presence of fellow worker Start with positive and try to focus the weakness Try to express the expectation and objectives of the organization Say in friendly manner What to do about employees who are not working: Try to arrange in depth interview with the employee to find out the reasons Try to explore the potentiality Try to link the job description with the performance Make comparison of the performance with a good performing employee Provide extensive support for performance improvement Try to appraise the performance at a regular interval Monitoring with feedback Other important aspect of supervision Be consistent in words and deeds Be clear in instruction Delegation of work with proper authority Do not hesitate to admit own fault/mistakes Try to seek opinion from the juniors Do not show too much bossing Try to be supportive for the subordinate Establishment of better communication with the subordinate staff Regular visit of the working place However in order to complete the job or task, a good supervisor will know what needs to be done, how it should be done, how many workers and what kind of skills are required, what support is needed and how long it should take. The supervisor should coordinate all these to enable the job to be completed correctly and should give encouragement and recognition to those who successfully complete the job. 98

Monitoring: Monitoring is the systemic collection and analysis of information as a project/program progresses. Monitoring can also be defined as the continuous oversight of activities to ensure that they are proceeding according to plan and set standard. It is aimed at improving the efficiency and effectiveness of a program or activities. It is based on target set and activities planned during the planning phase of work and also help to keep the work on track. Monitoring is a managerial function. Purpose of monitoring: The purpose of monitoring is to keep track of: Ongoing activities Progress achieved Obstacle faced Personnel matter Supplies and equipment Money spent vs. budget allocation Supervision and monitoring are closely interlinked with each other. The findings of monitoring can indicate the specific need for supervision. Through monitoring we can review progress, identify problem in planning/or implementation and make adjustment on the basis of review findings. The monitoring involves: Establishing indicators, effectiveness and impact Setting up system to collect information relating to these indicators Collecting and recording the information Analyzing the information Using the information to inform day to day management Area of MWM monitoring: 1. Development of MWM plan in hospital 2. Monitoring of activities against the planned activities 3. Activities of the MWM committee 4. Supply of logistic and operational cost 99

5. capacity development of the different level service providers 6. In house management of Medical waste 7. Placement of colored bins in the different service area s according to the need 8. Identification and segregation of waste 9. Waste collection 10. Waste treatment and Waste transportation 11. Temporary storage of waste 12. Final disposal of waste 13. Wearing protective material 14. Incident reporting 15. Reports returned and documentation Conducting good monitoring The credibility of findings and assessments depends, to a large extent on the manner in which monitoring and evaluation in conducted. Good principles (also called minimum standards ) for monitoring are as follows: Good monitoring focuses on results and follow-up. It looks for what is going well and what is not progressing in terms of progress towards intended results. It then records this in reports, makes recommendations and follows-up with decisions and action. Good monitoring depends to a large measure on good design. If a project is poorly designed or based on faulty assumptions, even the best monitoring is unlikely to ensure its success. Particularly important is the design of a realistic results chain of outcome, outputs and activities. Offices should avoid using monitoring for correcting recurring problems that need permanent solutions. Good monitoring requires regular visits by GO staff that focuses on results and follow-up to verify and validate progress. In addition, the Program Manager must organize visits and/or bilateral meetings dedicated to assessing progress, looking at the big picture and analyzing problem areas. The Program Manager ensures continuous documentation of the achievements and challenges as they occur and does not wait until the last moment to try to remember what happened. 100

Regular analysis of reports is another minimum standard for good monitoring. Such reports, prepared by authority for the different stakeholders, serve as a basis for analysis by the UNDP Program Managers. Monitoring also benefits from the use of participatory monitoring mechanisms to ensure commitment, ownership, follow-up and feedback on performance. Participatory mechanisms include outcome groups, stakeholder meetings, steering committees and focus group interviews. 101

Session no 11 Roles and responsibilities of concern personnel for implementation of MWM Contents: Responsibilities of Institutional head Responsibilities of Professor/Associate Prof./ Assistant Prof./Consultant Responsibilities of Medical officer /Assistant registrar/emo Responsibilities of Senior staff nurse/paramedics Responsibilities of Ward Master Responsibilities of Ward boy/aya/cook Responsibilities of cleaner Objectives: At the end of the session participants will be able to understand: Roles and responsibilities of different category of personnel for the implementation of MWM; Proper translation of responsibilities; Linking of responsibilities as a part of job description Teaching Methodology: Discussion, Questions and answers, group discussion, demonstration Duration: 60 minutes Lesson Plan: Content Methodology Teaching aids Time Introduction to the session: Contents Discussion OHP/Flip chart 05minutes and objectives Roles and responsibilities of Institutional head, Professor/Associate Prof./ Assistant Prof./Consultant Presentation, Discussion, Question and Answer OHP/White board/mm 15 minutes Responsibilities of Medical officer /Assistant registrar/emo Senior staff nurse/paramedics/ward master Senior staff nurse/paramedics/cleaner Summing-up and feed back Discussion, Question and Answer Discussion, Question and Answer Discussion, Question and Answer Question and Answer OHP/Flip chart/ White board/mm OHP/Flip chart/ White board/mm OHP/Flip chart/ White board/mm Flip chart/ White board 10minutes 10 minutes 15 minutes 05 minutes 102

Roles and responsibilities of concern personnel for implementation of MWM Responsibilities of Institutional head 1. Forming a waste management team /committee to develop a written waste management plan and also for routine performance appraisal 2. Development of Waste management plan 3. Selection of focal person for coordinating medical waste management activities 4. Allocating sufficient financial and personnel resources to ensure efficient operation of the plan 5. Implementation of activities on the basis of developed plan 6. Ensuring that monitoring procedures are incorporated in the plan 7. Ensuring adequate training for key staff members 8. Determining the option for final disposal of Waste according to the existing facility and resource envelop 9. Establishing and maintaining coordination with the committee, for outhouse management of medical waste 10. Maintaining liaison with the central authority 11. Holding of regular meeting of the waste management committee 12. Performance appraisal of the activities at a regular interval 13. Extensive supervision and monitoring Professor/Associate Prof./ Assistant Prof./Consultant : 1. Active participation during the development of local medical waste management plan 2. Proper implementation of activities according to the developed plan 103

3. Ensuring the active participation of all category of staff working in his/her department /unit for proper practice of medical waste 4. Supervision and monitoring of the subordinate staff activities like minimization, identification, segregation and collection of medical waste 5. Identification and segregation of waste according to classification at the point of generation 6. Providing support for determining the need of the department /unit in relation to medical waste management 7. Providing technical support to the officer and staff for developing capacity in respect of medical waste management 8. Supervision of record keeping in respect of medical waste management 9. Monitoring of the health safety measure 10. Performance appraisal of the activities at a regular interval and also providing feedback to the subordinate officer and staff 11. Proper coordination with the waste management committee Medical officer /Assistant registrar/emo: 1. Active role during the development of local level plan on medical waste management plan 2. Proper implementation of activities according to the developed plan 3. Supervision and monitoring of the in house management activities like minimization, identification, segregation, waste treatment and collection of medical waste 4. Identification and segregation of waste according to classification at the point of generation 5. Maintenance of records in relation to medical waste 6. Maintenance of Incidence register 7. Conduction of Hands on training for the subordinate staff 8. Coordination of the different activities of medical waste management 9. Review of the performance at a regular interval 104

Senior staff nurse/paramedics: 1. Proper placement of different color waste Bin according to the need and type of service delivery in his /her working area 2. Identification and segregation of waste according to classification at the point of generation 3. Replacement of the bin during emptying of waste or any kind of damage 4. Supervision and monitoring of the activities of Aya, ward boy, cleaner in relation to waste management 5. Maintenance of safety measure for self and also for the workers working under him 6. Proper reporting of any incidence like needle or any kind of prick 7. Conduction of health education session for the patient and attendant on medical waste management 8. Playing active role for waste minimization and recycle 9. Monitoring of the use of protective material for the waste handlers 10. Ensuring regular cleaning of the different colour bin 11. Supervision and monitoring of the segregated waste emptying, collection, transportation, waste treatment and final disposal 12. Providing assistance in performance appraisal of waste management Ward Master: 1. Supervision of waste collection, transportation, temporary storage and final disposal 2. Proper placement and replacement of different color bin according to need 3. Ensuring cleanliness of the bins and its surrounding 4. Identification and segregation of waste according to classification at the point of generation 105

5. Supervision of the activities of Ward Boy, Aya and Cleaners in relation to waste management 6. Monitoring and supervision of the wearing of protective material by the cleaners/waste handlers 7. Providing assistance during development of plan on medical waste management 8. Ensuring the security of the temporary storage area 9. Taking proper step for any incident of needle prick of the waste handlers 10. Giving advice to patient and attendant for minimizing the waste and also use of bin 11. Ensuring the control of unwanted visitors 12. Supervision of handover of the segregated medical waste to city corporation / municipality waste handlers for final disposal Ward boy/aya/cook: 1. Following the directives for the placement of different colour waste bin 2. Ensuring the cleanliness of the bins and its surrounding 3. Identification and segregation of waste according to classification at the point of generation 4. Wearing protective material during handling of medical waste 5. Emptying of the waste from different colour waste bin for carrying to temporary storage area 6. Giving advice to patient and attendant for minimizing the waste and also use of bin 7. Reporting to higher authority for any needle prick or any incident 8. Providing assistance in the work of cleaners in respect of waste management 106

Cleaner: 1. Proper placement and replacement of different colour waste bin according to the directives of the authority 2. Ensuring the cleanliness of the bins and its surrounding 3. Identification and segregation of waste according to classification at the point of generation 4. Wearing protective material during handling, carrying and handover of medical waste 5. Emptying of the waste from different colour waste bin for carrying to temporary storage area 6. Giving advice to patient and attendant for minimizing the waste and also use of bin 7. Reporting to higher authority for any needle prick or any incident 8. Maintaining the security and cleanliness of the temporary waste storage area 9. Handover of medical waste to municipal/city corporation waste handlers 107

Session no 12 Use of check list in medical waste management Contents: Use of check list for in-house management Use of check list for out-house management Objectives: At the end of the session participants will be able to understand: The application of in-hose management checklist The application of out-house management check list Teaching Methodology: Discussion, Questions and answers, group discussion, demonstration Duration: 60 minutes Lesson Plan: Content Methodology Teaching aids Time Introduction to the session: Contents and objectives Discussion OHP/Flip chart 10 minutes Use of check list for in-house management Use of check list for outhouse management Roles and responsibilities in accordance with check list Presentation, Discussion, Question and Answer Presentation, Discussion, Question and Answer Discussion, Question and Answer OHP/White board/mm OHP/Flip chart/ White board/mm OHP/Flip chart/ White board/mm 15 minutes 15 minutes 10 minutes Summing-up and feed back Question and Answer Flip chart/ White board 10 minutes 108

CHECK LIST OF OUT-HOUSE MEDICAL WASTE MANAGEMENT Sl. No. Area Indicators / Variables / Activities Status Yes No Remarks Storage room Suitability of Room facilities Easy but Controlled Accessibility Presence of Ventilation Infection control system operating Water supply Duration of waste storage exceeds more than 24 hours Segregated waste stored in different color coded bin Waste storage Bin/ Container Labeling of waste according to its category Presence of replaceable colored bin Whether the bin/container easily washable & carry able System of cleaning bin after emptying exist Waste Transportation vehicle Whether the vehicle is covered Presence of available color coded container Record keeping system functioning Whether the bin/container easily washable & carry able Whether the waste previously weight Loading of waste for transportation Labeling of collected waste Record keeping for each HCE During loading all safety measure followed Hygiene practice followed Wearing of protective clothing of waste handler during loading of waste Unloading of collected waste Use of unloading equipment Wearing of protective clothing After unloading cleaning & infection control for vehicle /container done Personal cleanliness & Hygiene practice followed Burning Temperature : 1st chamber-850ºc 2nd Chamber-1250ºC 109

Sl. No. Area Final disposal,incineration Indicators / Variables / Activities Wearing of protective clothing of waste handler Status Yes No Remarks Proper procedure followed during incineration Residue of incineration disposed properly Personal cleanliness & Hygiene practice followed Autoclaving Temperature-140ºC Contact time-45 min Wearing of protective dress Final Management Autoclaving Proper procedure followed during autoclaving Personal cleanliness & Hygiene practice followed Cleaning & infection control after autoclaving Actual contact time procedure followed Wearing of protective Dress Personal cleanliness & Hygiene practice followed Cleaning & infection control of disinfection unit Security maintained during transportation Final management, Deep burial Use of trolley during transportation Proper arrangement of the bin in the trolley Wearing of protective clothing by waste handler during transportation and handling Personal cleanliness & Hygiene practice followed Segregated waste disposed in to pit according to type Cleanliness of the pit maintained Lid of the pit under lock and key 110

CHECK LIST OF In -HOUSE MEDICAL WASTE MANAGEMENT Sl. No. Area Placement of Bin Segregation of waste according to classification Collection of waste Transportation of waste to temporary waste storage room Indicators / Variables / Activities Bins are placed at the right site Bins are accessible for patient Placed bins are correct in number according to need(all places) Placed bins are correct in color according to type of service delivery(all places) Bins are closed with lid Labeling of bin number Surroundings cleanliness of the bins are maintained Placed bins are clean General waste segregated properly and placed in black color bin Infectious waste segregated properly and placed in yellow color bin Sharp waste segregated properly and placed in red color bin General waste but recyclable segregated properly and placed in green color bin Liquid waste disposed properly Collection of waste is done according to plan Same color bin is used for a specific type of waste collection Emptying of bins is done properly Record keeping system functioning in relation to waste collection Waste handlers are wearing protective materials during waste handling System of cleaning bins after emptying are in place Supervision and monitoring of collection of waste are done regularly Trolleys are available for carrying waste bin Waste bins are covered with lid during transportation Selected route is used for waste carrying Waste handlers are wearing protective materials during waste carrying Supervision and monitoring of waste transportation are done regularly Wearing of protective clothing Status Yes No Remarks 111

Sl. No. Area Temporary waste storage room management Safety measure Logistic management Health education on MWM Indicators / Variables / Activities Identified temporary waste storage room Impermeable, hard-standing floor with good drainage water supply for cleaning purpose Protection from the sun Accessible for unauthorized person, animals and insects Easy access for the waste transportation trolley Proper light, Passive ventilation Direct sun light Situation of the room within the proximity within the food preparation area Availability of protective material like Service gloves, Apron, Boot, Mask Service providers including waste handlers developed capacity on safety measures Proper hand washing is practicing by service providers especially for the waste handlers after waste handling Incidence reporting system is in place, especially for needle prick Safety measure discussed in the monthly waste management implementation coordination committee meeting Proper maintenance of incidence register Supply of Black, Green, Red, yellow bins and Blue plastic bowl are adequate in number Supply of protective material are sufficient in number Supply of needle crushers are sufficient in number Reserve stocks are available in the store for above mentioned material Soap/hand washing materials are sufficient in quantity Budgetary allocation available for logistic Proper inventory system for waste management logistic Sessions are organized by the staff nurses in the indoor on the roles and responsibilities of patients and attendants in waste management Sessions are organized by the health educator/paramedics/staff nurses in the outdoor on the roles and responsibilities of patients and attendants in waste management Status Yes No Remarks Maintenance of register 112

Sl. No. Area Capacity development on MWM Reporting system Indicators / Variables / Activities System of hands on training is in place for the staff nurse, paramedics and waste handlers System of performance reporting on MWM are practicing properly Status Yes No Remarks Accountability The responsibilities are distributed among the supervisor and staff for effective waste management The waste management implementation committee formed and sit at a regular interval for performance appraisal 113

REFERENCES 1. Akter N., & J. Tränkler (2003) An analysis of possible scenarios of medical waste management in Bangladesh, Management of Environmental Quality: An International Journal, Vol. 14 No.2. 2. Akter, N., Hussain, Z. Tränkler, J. and Parkpian, P. (2002) Hospital Waste management and it s probable health effect: a lesson learned from Bangladesh, Indian Journal of Environmental Health, National Environmental Engineering Institute. Nehru Marg, Nagpur 440020. India. Vol. 44, No 2. 3. Akter, N., Kazi, N. M. and Chowdhury, A. M. R. (1999) Environmental Investigation of Medical Waste Management System in Bangladesh With Special Reference to Dhaka City, BRAC, Research and Evaluation Division, 75 Mohakhali, Dhaka 1212, Bangladesh. 4. Akter, N., Kazi, N. M. and Chowdhury, A. M. R. (1999) Medical Waste Disposal in Dhaka City: An Environmental Evaluation, Publisher International Centre for Diarrhoeal Disease Research, Bangladesh. Mohakhali, Dhaka 1212 (GPO Box 128, Dhaka 1000), Bangladesh. Special Publication No. 87. February 1999. 5. Appleton, J. and Ali, M. (2000) Healthcare or Health Risks? Risks from Healthcare Waste to the Poor. Copyright 2000 WELL. (web: http://www.lboro.ac.uk/well/resources/well-studies/full-reports-htm/task0326- full%20report.htm). 6. Asian Development Bank. (1998) Dhaka City Management reform pilot project. Draft final report. Prepared by Bangladesh Center for Advanced Studies (BCAS) and BRAC. Dhaka Bangladesh. 7. BAN and HCWH. (1999) Medical Waste in Developing Countries. An analysis with a case study of India, and A critique of the Basel -TWG guidelines. Basel Action Network (BAN) secretariat, Asia Pacific Environmental Exchange, 1827 39th Ave. E., Seattle, WA. 98112 USA. 8. Halbwachs H. (1994) Solid waste disposal in district health facilities, World health forum, 85:583-9. 9. Hauri, A., Armstrong, G., and Hutin, Y. (2004) The global burden of disease attributable to contaminated injections given in health care settings, International Journal of STD & AIDS 2004; 15: 7 16. 10. Hutin, Y., Hauri, A., Chiarello, L., Catlin, M., Stilwell, B., Chebrehiwet, T., Garner, J., and the members of the injection safety best practices development group (2003) Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Bulletin of the World health Organization 2003, 81 (7). 11. Johnson B. (1999) Impact of hazardous waste on human health, Washington DC, Lewis Publishers. 114

12. World Health Organization. (1999) Safe Management of Wastes from Health-Care Activities, edited by A Prüss. E Giroult and P Rushbrook. 1999. XIV + 230 pages + 4 co/our plates (available in English; French and Spamh in preparation). ISBN 92 4 154525 9. CH-1 21 1 Geneva 27 þ Switzerland. WHO. (2000a), WASTES FROM HEALTH-CARE ACTIVITIES. WHO information, Fact Sheet N 253, October 2000. http://www.who.int/inf-fs/en/fact253.html (downloaded in March, 2002). 13. WHO. (2000) WASTES FROM HEALTH-CARE ACTIVITIES. WHO information, Fact Sheet N 253, October 2000. http://www.who.int/inffs/en/fact253.html (downloaded in March, 2002). 14. World Health Organization. (2000) Policy analysis Management of Health-care wastes, (Intended to provide a quick overview of the topic at policy-maker level, in particular at national level). Downloaded in April 2002. 15. Rahman AKMS (2002), Situation assessment and analysis of medical waste management (A pilot study), Ministry of Health & Family welfare, Bangladesh. 16. Worquestionnaireld Health Organization. (2003) Health Care Waste Management: At a glance. WHO publication 17. World Bank. (2000) Healthcare waste management guidance note, Urban Development Division, Infrastructure Group, Environment Department and Health, Nutrition and Population Team. The World Bank. 18. World health organization.(sept,2000) AIDE-MEMOIRE, Safe health care waste management. 19. MOH&FW (NOV, 2004), Draft version on Environmental assessment and action plan for the HNP sector program (2005-2010). 20. Basel convention (April 12-14, 1999), Technical group report of Basel convention, Eleven recommendations for improving medical waste management. 21. Rahman AKMS (2006), Risk assessment Financial analysis and correlates, DGHS, Ministry of Health & Family welfare, Bangladesh. 22. World Health organization.(1999),safe management of waste from health care activities. 115