E609 June 2002 Enviromnental Management Plan Enhanced HIV/AIDS Prevention Project Background Biomedical and healthcare waste is produced by medical or other related practices. In reality, only a small proportion of this waste poses a higher risk than normal household or municipal waste. According to WHO, each hospital bed in developing countries produces about 0.5 KG potentially infectious and hazardous waste including from blood banks and pathological laboratories. Ministry of Health developed guidelines for Hospital Waste Management in 1998. As a consequence tertiary care hospitals have started implementing these guidelines. An important part of preventing HIV is to ensure proper handling and safe disposal of needles, other sharps, syringes, and blood bank waste. The proposed enhanced HIV/AIDS prevention project is not expected to generate any additional hazardous and infectious waste. The proposed environmental plan under the project would ensure safe handling and disposal of hazardous and infection waste already generated. Objectives The proposed Enhanced HIV/AIDS prevention program plans to reduce the risk to human health and diminish the burden on the environment by proper handling of hazardous and infection waste generated from blood banks and community based programs for injecting drug users. Scope of Work The environmental management plan (EMP) would cover: * Community-based programs for injecting drug users at cities of Karachi, Lahore, Rawalpindi, Peshawar and Quetta at drop-in centers * 25 large teaching/tertiary care hospitals at the federal capital, provincial metropolis, and large cities * 102 district level hospitals which run blood bank services Consultation Process EMP was developed using standard EMP development methodology with technical assistance of consultants. Stakeholders were identified and met with to identify challenges and concerns. This was followed by selective field visits to map out the practices in-vogue for handling and disposal of waste material. The environmental aspects of each of the practices were then listed. Annex I provides a list of stakeholders met and facilities visited. Mitigation measures for each of the significant aspects were then identified. The institutional requirements for successful implementation and continued operation and improvement of the EMP were then framed in consultation with stakeholders. The implementation schedule also addresses issues of capacity building and training needs of related staff. Implementation Plan 1. Plan for Safe Handllng and Disposal: The plan is for safe handling and disposal of blood bank based sharps, syringes, and other material at teaching and district hospitals, and community based programs for injecting drug users. The plan covers areas like; source of waste; quantity of waste generated; and method of segregation, dis-infection, transportation and disposal. For details, please see annex 2 and 3 respectively. FiLEF COPY 2. Training and Capacity Development Plan: Training requirements of health care workers cover teaching and district hospital, and drop-in centers for injecting drug users. The staff to be trained include: blood bank officers, blood bank technicians, related staff from hospital administration, sanitation staff, and service providers of drop-in centers. The expected staff to be trained would be around 800 persons. A curricular material would be developed using consulting services followed by consultative process for its finalization. This activity would be completed in first quarter of year one of the projecL Next nine months would be spent in training of provincial trainers and training of trainees. The detailed plan is enclosed as annex 4. 3. Pbysical Inputs for Collections, Segregation and Safe Disposal. This envisages provision of coded bags, collection containers, needle cutters, shredders, gloves, microwaves and autoclaves, liquid bleach for dis-infection, and inputs for deep land burial. The details are enclosed as annex 5. Institutional Arrangements Overall coordination would be carried out by the National coordination for blood Transfusion of services in close collaboration with national manager for HIV/AIDS. At provincial level, the Blood Transfusion Services Coordinator of the provincial program unit would monitor the implementation of EMP. Each hospital and drop-in center would nominate a focal person to ensure implementation of EMP as per agreed guidelines. The main responsibilities of the NACP Manager will be as follows: * Financing the EMP * Monitor the development of procedures and training materials * Overall monitoring and coordination The main functions at the provincial level would be as follows: * Ensure timely availability of inputs * Implement on a pilot basis before expansion * Evaluating pilot * Prepare provincial implementation plan * Schedule training * Identify and counter barriers * Monitor and report progress * Progress monitoring and evaluation The objective is to monitor implementation and evaluate its effectiveness. The ongoing supervision and monitoring would be done by a focal person at each blood bank and drop-in center, provincial Blood Transfusion Coordinator, and a consultant kept on retainer basis. A focal person at blood bank would generate monthly progress and share it with provincial Blood Transfusion Coordinator. The effectiveness of the EMP will be monitored through a measurement of the following parameters before and after the conduct of the trainings and equipment supply: * Non-decapitated syringes in blood bank wastes * Non-segregated sharps in blood bank wastes * Awareness interviews amongst healthcare and waste disposal workers * Evaluation of deep burial sites * Utilization of personal protective equipment Annex 1: Llst of Stakehokiers Met and Facilides Surveyed Orpanizations. NGOs. National AIDS Control Program (NACP). Fedal as well a Provincial Programs and Progms Health Savices Academy. Lsmabad Environmental Protection Agency United Nations Drug Control Progrm (UNDCP). Needle-Exchange Progrm Nai Zindagi (NGO working in Lahore on Needle-Exchange Pogram) People Related to Medical staff including doctors and nurses Health Care Blood bank staff Patients (people seeking health care) Blood donors Staff and patients of Expanded Immunization Program (EPI) People Involved in Waste Management Committee at Aga Khnn Medical College. Karachi Hospital Waste Hospital housekeeping and sanittion staff Management Hospital waste disposal staff Municipal corporation staff Waste scavengers Waste recyclers Health Cam Facilities Teaching Hospitals District Hospitals Stand Alone Blood Banks Annex 2 Handling and Disposal of Sharps, Syringes at Community-based NGO Programs Sources of Waste Amount of Waste Handling of Sharps. Synnges Handling of Used returned Storage/Dis- nfecuton of Waste FInal Disposal syringes Sharps and Syringes Community 14 kg syringes Field staff should: Field staff should: Field staff should: Field staff should: based IDUs per month Avoid accidental pricking Use needle cutter boxes to Wear non-pierceable gloves when Seal the coded bags conuaning Program Avoid leaving unpacked syringes decapitate syringes handling the sharps and needle syringes and send to deep burial site and sharps unguarded immediately containers for final disposal. In-Charge should: Collect the plastic body of the Transfer needles and sharps in Provide posters at needle exchange syringe in a coded bag puncture-resistant container for places indicating the methods of dis-infection vessel use and cleansing and disposal of Disinfect as per guidelines as syringes given in training with disinfectant Bleach Estimates based on Nai Zindagi Community-Based Intravenous drugs uscrs Program in Lahore - 45 syringes daily. 1350 per month approximately 14 kg per month Annex 3 Handling and Safe Disposal of Blood Bank Material at Teaching and District Hospitals Sources of Waste Amount of Waste Handling Blood Bank Materials Handling of Waste After Use Storage of Waste Fnal Disposal Prior to Use Blood Bap & Tmuon Tung Blood Banks I tonnchcaching Lab Tcchs and nurses should: Lab Techs and nurses should: Waste collection staff should: Buial staff should: hospitaVyear Avoid accidentally pricking Use needle cutter boxes to Not stre the waste for more than Carry out the burial as per themselves or their patients with remove needles from transfusion 24 hours instrucoons in guidelines imparted 0.03 tonne/District needles and sharps tubing Disinfect blood bags in the during training hospital/year Avoid leaving blood bags and Collect blood bags, transfusion provided microwave oven transfusion tubing unguarded tubing in coded bags Seal the coded bags containing disinfected blood bags and transfusion tubing and send for final disposal 5% infected blood bags 0 of 100 bags/day in teaching hospitals and 4 bags/day in District hospitals Annex 4: Training & Capacity Building Plan Activity Fo r quar ers year 1 Four qua ters year 2 Fours qua trs year 3 Foursqartersear 4 Consultancy 25d 20d 10d Sd 5d 15d 15d 5d 5d 5d 5d 5d 5d Sd 5d Services _ _ _ Develop x curriculum _ _ Consensus building on x curriculum Printing of x curriculum Training of x provincial master trainers Training of x x Trainees _ _ Implement Pilot __ x =_= = Assess x implementation of pilot Full scale implementation based on pilot results _ _ _ Six monthly x x x x monitoring visits by consultant _ Annex 5: Physical Inputs for CoDections, Segregation and Safe Disposal Items/Quantity year I year 2 year 3 year 4 Four quarters Four uarters Fours quarters Fours quarters coded bags x x x x x x x x x x x (16000) _ _ Cutters (200) _ x x x 1_T Microwaves (125) r T T r x I_______ Autoclaves (25) x T 1__1I 1__ Disinfectants*** x T _ I_ x I _T _I x 1_1_ Containers for x disinfecting (130) _ _ Sharps containers x x x (200) _ _ __ _ __ _ _ _ Latex Gloves (I x x x million pairs/yr) _ _ Gloves non pierce x x x able (500 pairs/year) _ Transportation trolleys* Inputs for deep land burials** * already available at the facilities ** cost are built in the cost estimates *** 1% Bleach solution @Rs 1 per liter. Requirement of 5 liters per day per station, amounting to 300,000 liters per year. Please note: All activities mentioned year four would be repeated in year five. Enhanced HIVIAIDS Control Program: NACP and Federal Areas Physical phasing and base cost: component 4 Capacity Building and Program Management. _ r I Physical phasing Unit Year wise cost (Rupees in Million) S.No Activities break down/ j Total cost Total S.No. sub activities Unit Yr 1 | Yr2 I Yr.3 I Yr4 I Yr5 I yQ I Rs.(00 Yr 1 | Yr2 I Yr3 I_Yr4 I Yr5 I cost Sub-component 4.6: Infection control - EMP Training & capacity 4.6.1 building plan-TA Mandays 55 45 20 20 0 140 15 0 825 0.675 0.300 0.300 0.000 2.100 4.6.2 Coded bags No: (000) 0 48 64 64 64 240 3 0.000 0.144 0.1921 0.192 0.192 0.720 4.6.3 Cutters No: 0 200 200 200 200 800 0.3 0.000 0.060 0 060 0.060 0.060 0.240 4.6.4 Microwaves No: 0 125 0 0 0 125 20 0.000 2.500 0.000a 0.000 0.000o 2.500 4.6.5 Autoclaves No: 0 25 0 0 0 25 30 0.000 0.750 0.000 0.000 0.000 0.750 4.6.6 Disinfectant chemical liters (000) 0 20 20 20 20 80 15 0.000 0.300 0.300 0.300 0.300 1.200 4.6.7 Dismnfecting containers No: 0 130 0 0 0 130 1.5 0.000 0.195 0.000 0.000 0.000 0. 1B5 4.6.8 Sharp storage bin No: 0 200 200 200 200 800 0.5 0.000 0 100 0.100 0.100 0.100 0.400 4.6.9 Latex Gloves (pairs) Pairs (000 0C 1000 1000 1000 1000 4000 1.5 0.000 1.500 1.500 1.500 1.500 6.000 4.6.10 Gloves non pierceable Pairs (000 0 500 500 500 500 2000 0 04 0.000 0.020 0.020 0.020 0.020 0.080 Sub-total sub- component 4.6 _ _ _ _ 0.825 6.244 2.472 2.472 2.172 14.185