The United Republic of Tanzania The World Bankf E734 March 2003 National Health-Care Waste Management Plan - Final Report - ,Aarch 2003 1 US = 980 TSL .ser\fices Emergence fol a sustail uable accoss to Vol, off,, I g3 I0, dt" /,I "- r . v I r o i, 1 0 L ox O t - 4,, 91 90 32 Orinrc; ruo~ d(js s 1bI,n2 2 CUI 200, N.',,cnJIl Ii - lei J1 1 32 ,24 53 0i water. sandtation and finance ,. , 2:: . ; 9 ,. , r /n'ln (egO14 ' l -t.ao 1 Ittp / U ww. eorgonro c twl¢fiFl h. Ize Rgtu/vb of Il ., he World Bank 1'.1r.no Acronyms AIDS Acquired Imunune Deficiency Syndrome ALAT Association of Local Authorities in Tanzania APHTA Association of Private Hospitals in Tanzania CEDHA Centre for Educational Development in Health CSSC Christian Social Service Councils DED Deutscher Entwicklungsdienst DHMT District Health Management Teams EHSS Environmental Health and Sanitation Services EPI Expanded Programmes of Immunization GNP Growth National Product GOT Government of Tanzania HCF Health-Care Facility HCW Health-Care Waste HCWM Health-Care Waste Management HCWMO Health-Care Waste Management Officer HDPE High Density Polyethylene HIV Human Immune Deficiency Virus HO Health Officer HSDP Health Sector Development Project IDA International Development Association MAP Multi-Country HIV/AIDS Programme MAT Medical Association of Tanzania MCH Maternal and Child Health MOC Medical Officer in Charge MOF Ministry of Finance MOH Ministry of Health MSD Medical Stores Department MSF Medecins Sans Frontieres MUCHS Muhimbili University College of Health Science NAP National Action Plan NEMC National Environmental Management Cotncil NGO Non Governmental Organisation NMC Nurses and Midwives Council RHOP: Regional Health Officer TACAIDS Tanzanian Commission for AIDS TARENA Tanzania Registered Nurse Association TUGHE Tanzania Union of Governmnent and Health Employees UNEP United Nation Environmental Programme UNICEF United Nation Children's Fund WHO World Health Organization PC Project Co-ordinator NSCHCWM National Steering Committee on Health-Care Waste Management NCHHIC National Commilttee for Hospital Hygiene and Infection Control WGRL : Working Group on Regulations and Laws WGP Working Group on Health-Care Waste Management Procedures WGE Working Group for the Equipment of the Medical Institutions WGT Working Group on Awareness and Training wa,laet/ I I.al,h-v',, ol 1I,;,;Z. 1 h 1 Or!,! l'I; / I :mrrhc,-,' The definitions contained in this report are in accordance with the ones proposed in the National Guidelines for Health-Care Waste Management that the mission drafted for Tanzania They take into consideration: 1) the necessity to provide a precise characterisation of the hazards associated with the type of HCW produced in Tanzanian medical institutions and, 2) the financial and institutional capacities of these institutions to set-up an overall HCWM scheme as well as to develop an environmentally sound, affordable and safe treatment/disposal system. In this report Health-Care Waste (HCW) includes all the waste, hazardous or not, generated during medical activities. It embraces activities of diagnosis as well as preventive, curative and palliative treatments in the field of human and veterinary medicine In other words, are considered as health-care waste all the waste produced by a medical institution (public or private), a medical research facility or a laboratory; Non-risk Health-Care Waste comprises all the waste that has not been infected. They are similar to normal household or municipal waste and can be managed by the municipal waste services They represent the biggest part of the HCW generated by a medical institution (between 75% and 90%). It includes paper, cardboard, non-contaminated plastic or metal, cans or glass, left over food. etc... Can also be included in this category of waste all items (such as gloves, gauze, dressings, swabs .) that have been used for medical care but are 'visually not contaminated with blood or body fluids of the patient, this only being applicable if the patient is not confined in an isolation ward. Sanitary napkins from maternity wards even if contaminated with blood, can be included in this category of waste as they are normally; Pathological WVaste groups all organs (including placentas), tissues as well as blood and body fluids. Following the precautionary principle stipulated by WHO9, this category of waste should be considered as infectious whether they may be infected or not. They should be disposed of consequently; Anatomical waste comprises recognizable body parts. It is primarily for ethical reasons that special requirement must be placed on the management of human body parts. They can be considered as a subcategory of Pathological Waste Infectious vaste comprises all biomedical and health-care waste known or clinically assessed by a medical practitioner to have the potential of transmitting infectious agents to humans or animals. Waste of this kind is typically generated in the following places: isolation wards of hospitals; dialysis wards or centres caring for patients infected with hepatitis viruses (yellow dialysis), pathology departments, operating theatres and laboratories Infectiousness is one of the hazard characteristic listed in annex II of the Basel Convention and defined under class H6.2; Highly infectiouts waste includes all viable biological and pathological agents artificially cultivated in significant elevated numbers. Cultures and stocks, dishes and devices used to transfer, inoculate and mix cultures of infectious agents belong to this category of waste They are generated mainly in hospital medical laboratories; Sharps are all objects and materials that pose a potential risk of injury and infection due to their puncture or cutting properties (e.g. syringes with needles, blades, broken glass ..) For this reason, sharps are considered as one of the most hazardous category of waste generated during medical activities and must be managed with the utmost care; Pharmaceutical WVaste embraces a multitude of active ingredients and types of preparations The spectrum ranges from teas through heavy metal containing disinfectants to highly specific medicines. This category of waste comprises expired pharmaceuticals or pharmaceuticals that are unusable for other reasons (e.g. call-back campaign) Not all the pharmaceutical wastes are 9 The precautionary principle stipulates that the magnitude of a particular risk, when it is uncertain, should be assumed significant and measures to protect healih and safety should be designed accordingly .,N~/i,,,,/ I Ilr,'l,h-( ..u......>,,'H a.'e I,',' ';.8'! tM -I.')'r03 200(3 PA:; II f o96 1 d hi p :ne.hJ c 7f'f ;,r,; 7he blfor/hl 13,m( / I:rs gc,;o hazardous. They can thus be classified into two categories: Non-Hazardous Pharmaceutical Waste and Hazardous Pharmaceutical Waste; Cytotoxic Pharmaceutical Waste may be considered as a sub-group of Hazardous Pharmaceutical Waste, but this category of waste must be managed and disposed of specifically due to its' high degree of toxicity. The potential health risks for people who handle cytotoxic pharmaceuticals results above all from the mutagenic, carcinogenic and teratogenic properties of these substances, which can be split into six main groups: alkylated substances, antimetabolites, antibiotics, plant alkaloids, hormones and others. Cytotoxic waste are still generated in a limited number of medical institutions in Tanzania; Radioactive Waste includes liquids, gas and solids contaminated with radionuclides whose ionizing radiations have genotoxic effects. The ionizing radiations of interest in medicine include X- and y-rays as well as a- and 3- particles. An important difference between these types of radiations is that X-rays are emitted from X-ray tubes only when generating equipment is switched on whereas y-rays, a- and 3- particles emit radiations continuously. The type of radioactive material used in HCFs results in low level radioactive waste and concerns mainly therapeutic and imaging investigation activities where Cobalt 60Co, Technetium 99'Tc, iodine 1311 and iridium 192Ir are most commonly used, Special Hazardous Waste includes gaseous, liquid and solid chemicals, waste With a high contents of heavy metals such as batteries, pressurized containers, out of order thermometers, blood-pressure gauges, photographic fixing and developing solutions in X-ray departments, halogenated or non-halogenated solvents... This category of waste is not exclusive to the health-care sector. They can have toxic, corrosive, flammable, reactive, explosive, shock sensitive, cyto- or genotoxic properties, Effluents, and more particularly, effluents from isolation wards and medical analysis laboratories should be considered as hazardous liquid waste that should receive specific treatment before being discharged into the sewerage / drainage system, if such a system exists. Na/./raid!t iarl// (I,tpa ll, , Ila,,'r/h'z; I,, / -ru 24I 03.2003 I'd-ct /2 of 96 7 e t :n,led Rcpabhc of Ian; ll.? 'Ih 7he lP or/,l B,k / L PART ONE Analysis of the situation Na.Z.ZzI'- I I'a F//-( aI./ ,' A II,t;wl//,/c/ | /lan 24 03 200(3 I/a"V / ; of 96 TI t ( ;,Ited v'i2/Jhc (if i I hk 1tt o :r / I e-,e This chapter presents the findings of the mission. Are successively analysed 1) the organisation of the Health Services; 2) the legal and regulatory frameworks; 3) the health-care waste production in the medical institutions, 4) the health-care waste management practices; 5) the risks associated with these practices; 5) the institutional and monitoring frameworks, and finally 6) the HCWM projects already carried out in Tanzania. All the findings are synthesised in the last section. Section 1. Organisation of the Health Services It is assumed that the reader already has a comprehensive knowledge of the organisation of the Tanzanian Health Sector. However, the information essential to understand the context in which the future National HCWM plan will be established and implemented is synthesised in this section. Although Tanzania is experiencing one of the highest rates of urbanisation among the Sub-Saharan countries with an urban population growth rate between 8 and 10%, more than 70% of the Tanzanian population still lives in rural communities where the Village Health Posts continue to play an important role providing preventive health through education. Hence, the Health Services and the distribution of the HCFs throughout the country still have a strong rural emphasis. 1. The Public Health Services Tanzania has created an extensive network of Health-Care Facilities that provides 90% of the population with at least one HCF in a radius of 10 km NGOs and private institutions play a major role in the sustainabilhty of the Tanzanian Health Sector. a) District-level. Primary Health Services At District level, basic clinical and public health services are provided through three layers of HCFs the Dispensaries, the Health Centres and the District Hospitals. The Dispensary is the smallest curative unit. Usually located at the ward level, it serves 3 to 5 villages and provides health services for 6'000 to 10'000 inhabitants It has an outpatient Department, a Mother and Child Health Unit (MCH) and a maternity room with at least two beds, latrines and rooms for the medical staff. It is administered by a Medical Assistant, a Nurse or a Midwife It provides health education, treatment of diseases, MCH and delivery services, treatment and immunization It can be located in urban or rural areas; The Health Centre is expected to cater for between 50'000 and 80'000 people, which is approximately the population of one administrative division. The services provided in Health Centres are similar to the ones provided in Dispensaries but short hospitalisations are possible and basic medical analysis can be carried out. A Health Centre groups health-workers trained in different professions such as a Medical Assistant, a rural Medical Aid, a Senior Nurse, a Midwife, a Public Health Nurse, an Assistant Health Officer, an Assistant Laboratory Technician and a Pharmaceutical Assistant. The Health Centre ensures both the supervision and serves as a referral centre for Dispensaries. However, in effect, it often fails to serve as a referral centre and operates like a dispensary but at a higher cost; The District Hospital is the referent health unit at District level. It normally has between 60 and 150 beds and provides OPD and MCH, a store for drugs and equipment, laboratory and blood banks, X-ray, OT, kitchen, laundry, technical carpenter and tailoring workshop, mortuary and dispensing room. The staff includes graduate and Assistant Medical Officers, Nurses of different qualifications, Pharmacists, Laboratory Technicians, Radiologists and a Health Officer The GOT attempts to get one District Hospital per District. ,\.a'i//ll.// 1-1.g1a/ti' C/;'lIt .S . 6. 41/ 03 20(' IPa lle1 N f96 7Ih l 'fl/f 1 I'AI Iep,'b/. I V he 81,'/,I la i', When there is no on-site disposal facility and when no special collection services are organised, clinical waste and domestic waste are stored in the same location, although segregation has been previously ensured. The "incinerators" are also regularly used as storage points before the waste is bumed. Access is rarely restricted and the waste is not protected from the effects of the weather (sun, rain...) and scavenging by animals (dogs, birds, flies, etc ) Only at Muhimbili hospital have lockable 31 storage rooms with a concrete floor for some of them, a roof and a wire netting stopping animals (including birds but not flies!) from entering been seen No adequate support facility like washing and disinfecting material has been observed close to the storage areas (photo 5). This situation associated with inadequate behaviours (no regular hand-washing practices, free access to wards.. ) results in insufficient standards of hygiene. Although a maximum storage time should not exceed 24 hours, the storage may last up to 4-5 days before the waste is disposed of, which leads to leakages of body fluids from the storage facilities and strong putrefaction odours. 3. Treatment and Disposal Hazardous / infectious HCW can be treated on-site (i e. in the HCF itself) or off-site (i.e. in an other HCF or in a dedicated treatment plant). On-site treatment is often the only one possible in rural HCFs but on-site treatment can be also carried out for HCW generated in large HCFs. On-site treatment systems are particularly appropriate in areas where hospitals are situated far from each other and the road system is poor. The advantages of providing each health-care establishment with an on-site treatment facility includes convenience and minimization of risks to public health and the environment by confinement of hazardous / infectious HCW to the health-care premises. However, extra technical staff may be required to operate and maintain the systems and it may be difficult for the relevant authorities to monitor the performance of many small facilities. This may result in poor compliance with operating standards, depending on the type of systems, and increased environmental pollution. The HCW generated in a HCF can also be treated off-site, when centralized facilities exist, in urban areas for instance. Greater cost-effectiveness may be achieved for larger units, through economies of scale 32, unless the running costs for waste collection and transportation remain too expensive. Although off-site treatment increases dependency of the HCF on an external actor and requires a fine- tuned transportation system, it provides the following advantages. Hospitals will not have to devote time and personnel to manage their own installations; Efficient operation can be more easily ensured in one centralized facility than in several plants where skilled workers may not be readily available, Future modifications or expansions (relating to flue-gas cleaning systems of incinerators, for example) are likely to be less expensive, Where privatization of facilities is seen as a desirable option, this can be achieved more easily on a regional basis than for numerous small units, Air pollution may be more easily kept to a minimum at a centralized plant, if specific flue-gas cleaning procedures and incineration temperatures are respected. Incineration is the only disposal technology known in the Tanzanian medical institutions. The GOT must be aware that altemative technologies exist to treat hazardous / infectious HCW and reach a level of hazard / infectiousness that is considered as acceptable, enabling the disposal of such categories of waste with the general solid waste. Detailed information on the advantages and disadvantages of each treatment / disposal technology are provided in Annexe 7. 31 But not locked' 32 This statement must be taken with precaution especially in developing countries where the Ficalth Authorities do not always have sufFicient technical and financial expertise to negotiate in good position with the private sector ,\';.'i,,,,,,/ I Aa;h-C ........... I 1,., s.\ iau,a' ,;/,, ,* 21(/ 03 ' I2'.0 3 241 f96 Th. { 'nj/ed l(1ps'/'b 0/ J ;t : i Ij,'/ l h? [EorA,1 6 -4 1:rneriJm-e a) In Large Health-Care Facilities Different ways of disposing of HCW have been observed by the mission, but none of them are fully satisfactory The current disposal of HCW in the absence of adequate financial means and specific budget iines is problematic and will certainly remain so in the coming years. In addition, the lack of specific and affordable transportation services in municipalities and towns as well as the low monitoring capacities of the Municipal Authorities reduces drastically the waste treatment and disposal options, which could be envisaged Due to the lack of protocols, there are disparities between the institutions visited in the way HCW is disposed of. The following practices have been observed: In some hospitals, clinical wastes and sharps are burnt in masonry single-chamber "incinerators" built by local private manufacturers (photo 6). The burning is carried out on a periodic basis (from daily to weekly depending on the resources of the HCF) The combustion is initiated by adding fuel, usually kerosene or charcoal The air inflow is based on natural ventilation. Most of these "incinerators" are in bad shape and temperatures of only 300°C to 400 °C are reached in these "incinerators". In many HCFs, more than one incinerator has been built, but they are usually all in a dismal state (photo 7). The conclusion is that these rudimentary single-chamber "incinerators" are not able to sustain combustion o,f waste in a reliable manner and do not demonstrate any significant advantage/improvement compared to open burning; General medical and domestic wastes, although they have been segregated at source can also be collected by the municipal services and disposed of together in dumpsites. In this kind of situation, sharps are burnt separately or dropped into pits without any -specific precautions. However, it has been observed that they may also be collected by mistake together with the municipal waste. In this kind of situation, the segregation benefice failed to be maintained all along the waste stream; Anatomical wastes generated in Operation Theatres are disposed of separately. When a "satisfactory" incinerator exists in the medical institution (such as Muhimbili Hospital), body parts are incinerated. Otherwise, anatomical wastes are buried inside the hospital compound Placentas and major human tissues are either burnt in a single-chamber incinerator or dropped inside a "placenta-pit" with concrete lining (photo 9). Finally, General medical waste but also sharps (photo 8) can be dumped, without any segregation, into an open pit. The pit can be lined or not and sometimes delimited by a fence (photo 10) The waste is then periodically burnt or covered with earth when it is full; a new pit is then built next to it. Effluents 3 of medical institutions are treated in general through separate septic tanks WHO (at central level, photo 1) and DFID (in Mbeya Region, photo 12) have supported the installation of low-cost, high-temperature incinerators that have been specifically developed and designed for the treatment of HCW in low-income countries by the De Montfort University . Mark II and III models of the De Montfort incinerator have been already installed in various Tanzanian HCFs and they are "recommended for district hospitals, health centres, dispensaries and regional and 33 It has not been possible to address thts point in a comprehensive way during the mission. Only some highlights are provided in the report showing ihat the currcnt situation may be considered as unsatisfactory The review of the current system for discharge of eftluents from hospitals should be addressed in a second phase after having first successfully ipiemcented a solid waste management system 34 The Mtfark III is designed for hospitals up to l'OO0 beds, and burns at about 4 times the rate of the Mark! I & 11 (50 kg/h approx ) The AMat V incinerator is thermodynamically the same as the Mark Ill, but modified to carry the weight of a much higher chimney for use where a high chimney is a legal rcquirement or wvhere the proximity of other buildings makes a high chimney necessary to dispcrse smoke and fumes ,\'e 'i, / / Cur I'[I'I?i'I .1,i c'w',.,/ Phi), * 21 03 2003 I P'c' 2 tlf 96 7 /St 1 ,wAerl 1c/)//h 1, ')h ei.\, 1;1 o,/1 B a;i'; consultancy hospitals respectively."35, If properly operated, a De Montfort incinerator has the following advantages It reaches temperatures above 900°C 36; The operating costs of the De Montfort incinerator remain extremely low (less than 5 USD/ton) as well as the capital cost (about 1'000 USD for a Mark II and 2'000 USD for a Mark III); Operation and maintenance are simple (coconut shells can be used for instance to initiate the combustion instead of kerosene); Products of Incomplete Combustion (PCI) are obviously generated during the whole process. Nevertheless in areas that are not densely populated, incineration enables to reduce the immediate hazards linked to medical waste and sharps. With respect to the financial resources available in the hospitals, this type of incinerator, if upgraded (for instance Mark V incinerators can be used), can constitute an acceptable intermediate solution to dispose of clinical wastes and sharps. The remaining ashes must be buried. In densely populated areas, incineration shouldn't be seen as a long term satisfactory solution but the reality of the current situation prevailing in Tanzania must be taken in consideration when alternative solutions are proposed. In any case, Operation and Maintenance of these incinerators must be well planned to ensure their sustainability and they should be replaced or repaired every 3 to 5 years when they are continuously operated. In that respect, the MOH should propose adequate financial, management and institutional mechanisms. b) In Small Health Facilities There is no significant difference in the way that clinical waste and sharps are disposed of. In the absence of adequate infrastructures and equipment, they are dropped into a pit, without segregation, and burnt periodically. Placentas are dropped directly in latrines or pits after delivery. DED and MSF have developed two different programmes to improve the situation in the Health Centres and in the Dispensaries located in remote rural areas 3. Following pilot projects that have been conducted in Tanzania by international and bilateral agencies (cf. section 6), the MOH has developed and is implementing a plan to install 63 Mark II De Mortfort incinerators in District Hospitals, Health Centres and Dispensaries. Low-cost De Montfort incinerators should actually become a standard disposal facility for the Dispensaries and the Rural Health Centres. The mission believes that it will be probably hard to implement such a policy for at least two reasons: Sustainable maintenance and adequate operation of such facilities cannot be guaranteed in rural HCFs due to their limited institutional capacities (cf. section 5); The implementation of such a solution remains relatively expensive 38; c) Specific cases The Mrunicipality ofDar-Es-Salaamn Disposal of HCW in the municipalities of Dar-Es-Salaam 39 or Mwanza remains problematic for the following reasons' 35 Source Waste Management GuLidelines, draft document Ministry of Flealth. September 2002 36 Results of a campaign of measures carried out at De Montfort University Personal communication of Professor D J Picken 37 See section 6 38 Considering the price of a Mark 11 De Montfort (1'000 USD), the number of Dispensaries (4'380), and the number of Ilcalth Centres (402) the total cost would approximately be 5'000'000 USD. Na/i;,:i,,I M/ healf (..,i' U1', w ' . 2 4liO C,//,;W I'/.n2* l.0 .2002 l Pi. 26 W/96 Ty,k ( :ued R[,,pib/h, - ; Ii': l.,e IJOr!'. 8w, ,/ I rergero The number of HCFs scattered in this municipality is important and the amount of HCW produced in such a densely populated area is significant. The utilisation of De Montfort incinerators, although some are already in use 40, cannot be seen as a sustainable long-term solution. On the other hand the use of on-site pyrolytic incinerators would be too expensive and would not significantly reduce the air pollution from that of a De Montfort, Although the introduction of alternative technologies such as autoclaving or hydroclaving)4t could be seen as valuable on-site treatment technologies, the success of their implementation is uncertain as long as pilot projects won't have been carried out and evaluated; The implementation of a centralised solution (off-site treatment), although interesting poses another set of problems relating amongst others to the verification of the transport of HCW. Currently the Municipal Council does not have the capacity to perform such controls. In addition, the public hospitals would have difficulties to pay for such a service and the public sector is, for the time being, not sufficiently developed to ensure that both transportation and treatment will be performed in the most cost effective, environmentally friendly way, There is no proper sanitary landfill where the general medical HCW could be safely buried. For the time being, there is only one 42 private company, Dispositek Africa Ltd 43 that would be able to propose a centralised incineration of the HCW. The City Council of Dar-Es-Salaam signed a Memorandum of Understanding with Dispositek Africa in 1997, reviewed in 2001. A double chamber pyrolytic incinerator 44 has been installed in a compound provided by the Ilala District Authorities 45 thanks to a loan of the American foundation PATH 46 According to the information provided to the mission by the MOH 47, Dispositek plans to provide a comprehensive service for the HCFs of DES including The delivery of preconditioned cardboard boxes lined with PE red bags and HDPE sharp boxes to the medical institutions of Dar-Es-Salaam; The collection of the clinical waste with three enclosed trucks to prevent any spillage in the hospital premises or on the road during transportation; The disposal of the clinical waste that includes: 1) a sterilisation '8 pre-treatment before; 2) a "separation of polymeric material from organic" with a magnetic removal of "steel components" so that it may "undergo a solid state shear pulverization (S3P) processing; 3) a pyrolytic incineration of the remaining waste 49, and finally, 4) land-filling of the residues 50. 39 According the MOH, this situation is also representative of the situation prevailing in the municipality Mwanza 40 For instance at Muhimbili Hopsital 41 The mission strongly recommends not introducing any other altemative technologies in Tanzania such as microwave or chemical disinfections the operation costs of such technologies remain extremely high while the maintenance requires very skilled personnel 42 The Tanzania Health Authorities should be aware that negotiations can be biased when there are monopolistic situations 43 Commercial company registcred in Tanzania, but whose main office is located in South Africa 44 Classic pyrolytic incinerator with two chambers designed to reached respectively 800°C and I '200°C 45 For the time being, the site is located in the futLre industrial zone of DES at Buyini Village (25 km) it Is not supplied with electricity or water, which will be problematic when the incineration will start 46 The mission visited the site where the HCW should be incinerated, met Dispositek Country Representative and contacted PATH However both interlocutors were reluctant to provide detailed information related to the financial sustainability of the overall HCWM system that Dispositek attempts to implement in Dar-Es-Salaam. 47 See "Proposal for the containment, removal and disposal of hazardous medical waste from medical institutions, City of Dar-Es-Salaam Dispositek Africa LTlD. 48 Apparently a nicrowave system is planned Surveys carried otit on autoclave and microwave systems show that, in practice, a disinfection of the clinical waste can only be guaranteed with thcse processes 49 Double-chamber incinerator (the first chamber should reach 800°C, the second 1'200°C) / I,//;I,; r ,, a.,', Al ,n'i,,w, l2 1),//I! '21 03 200(i3 Pt-2 - of 96 'I hei eel Rcpp/./,4 0/I ,,1 1 ; It' or/ : I' I : To date, only the incinerator is under construction (photo 13) The nominal costs of the overall process were initially estimated in the proposal at 2'500 USD/tonnes (1'500 USD/tonnes if the depreciation costs would not be taken into consideration). Compared to prices found in other countries5", the cost of the technology proposed would have remained expensive and not really affordable for Tanzanian HCFs. However, after having negotiated major points such as the donation of the land, Dispositek has reviewed the nominal costs down to 420 USD/tonnes52. If the Private Hospital might cope with these costs, they would remain problematic and high for the Public Sector, which will have difficulties to afford them The Disposal of Pharmaceutizcal Waste Drugs are state property. Therefore HCFs are not allowed to destroy expired drugs by themselves. These drugs are returned to the District or Regional Health Authorities that must get a clearance from the Government Auditors of the Ministry of Finance (MOF). Once the MOF certified that the drugs are effectively expired, District and Regional Authorities contact the pharmaceutical board to get the necessary recommendation for disposal (incineration or burming). MSD, which supplies nearly all the HCFs of the country through the Regional and the District MSD stores, disposes of its pharmaceutical waste at central level. Drugs are sent back to the Central MSD at Dar-Es-Salaam that must request the authorisation from the MOF to dispose off the drugs. This procedure prevents MSD from disposing the expired drugs regularly and stocks of pharmaceutical waste can increase significantly until they are destroyed. MSD incinerates the pharmaceutical waste in a pyrolitic incinerator 53 (photo 14). MSD has also developed in the past a co-operation with the Twiga Cement Factory to incinerate the pharmaceutical waste in the rotary kiln used to produce clinker. Actually the temperatures reached in this kiln as well as the current incineration capacity of the cement factory 54 would be sufficient to treat all the HCW generated in Dar-Es-Salaam. This option, as recommended by the WHO 55, would represent the best solution on both a technical and financial 56 point of view if the GOT could find an agreement with Twiga Cement Factory. Sharps The MOH, in agreement with UNICEF, has developed a new policy for disposable syringes and needles that is in accordance with WHO and UNICEF international recommendations- syringes and needles must be discarded of immediately following use. Needles shouldn't be recapped or removed from the syringe and the whole combination must be inserted into the safety box directly after use. UNICEF provides safety boxes specially designed for safe collections and open-air burning. The boxes provided are used only for EPI programmes 50 This treatment processing should aim at avoiding release of PCI in the atmosphere If implemented as such, this treatnient plant would be one of the most modem that the mission would have ever seen since it would combine two technologies that are generally, mainly due to their high cost, used separately St As an example, the Health-Care IVaste Managemtent Guidance NVote of the WVorld Bank (May 2000) gives indication of nominal costs that includes treatment (microwave or incineration with a flue gas control or autoclave) transport and disposal They range (in USD/ton) from 280 to 420 in USA, 410 to 750 in Mexico, 630 to I '670 (for a comprehensive treatment of thc stack emissions) in Argentina, 200 to 500 in UK, 186 to I '530 (for a mobile treatment unit) in Brazil, 500 to 1'500 in Germany, 150 to 500 in France, 150 in Egypt 52 Personal Communication from Allan Reynolds dunng the workshop held on March the 13th and 14tb, 2003 53 This incinerator has been installed by Balton CP Ltd, reaches I '200 °C for a capacity of 200 kg / hour 54 Three rotary kilns of 3,80 m diameter and 58 m long are capable to produce 3 x 220'000 tonnes of clinker a year The temperature reaches 1'400 to I'600°C in the rotary kiln 55 See Safe management of wastes from health-care activities, Pruss, Giroult, RLIshbrook, WHO, 1999 56 Needles can only be vaporized in rotary kilns In all the otlier categories of incinerators (low-cost or pyrolytic), they remain in the ashes that muist be safely buried Approximately 100 USD/ton are charged by Twiga Cement Factory. ^\(/w.'p,>/ I l,/aIJ-( .,i',' l,'le A I ,ra" rt , 1 21.03 2003 c 28 rf96 I Y, ( imwed R t p/,iX1 of 1 ';,/,.;,/ Ite11' or/,f Kto" 7 meqenre There are no provisions for the handling and disposal of syringes and needles used for curative care. In order to follow the new policy of the MOH, the medical and paramedical staff has to develop alternative solutions 57 and reuse recycled plastic bottles or cardboard boxes. In some health facilities, others practices exist, sometimes in parallel of the new MOH policy for EPI campaigns creating confusion among the medical and paramedical staff (cf. section 6). 4. Risks Associated with the Current Practices There is no standardized segregation procedure applied in the Tanzanian medical institutions - in this regard, the Guidelines 58 provided by the MOH are not adapted - the labelling system is deficient and there is no systematic colour coding system. The ancillary staff that is uncertain about the definition of medical wastes uses therefore identical and unmarked bins. Potential mistakes in segregation can easily occur and the risk of a person accidentally coming into contact with hazardous waste is important. In addition the incorporation of highly infectious waste to clinical waste without prior treatment should be prohibited. The WHO precautionary principle should be more rigorously respected. The nurses or the nursing-assistants fail to apply the aseptic measures when they handle and transport the bins within the wards or outside. The waste containers are not lined with adequate bags or even not regularly disinfected. The lids are manipulated with no specific precaution- fundamental hygienic measures are not applied. This obviously results in an increase of the risk of transmitting nosocomial infections The risk of spillage of medical waste and sharps during the transportation due to the use of inappropriate containers and the loss of syringes and needles from overfilled cardboard boxes (that are sometimes re-collected by the sanitary labourers without specific precautions), the failure in restricting access to the storage points, the lack of protection from scavenging animals or the disposal of HCW in dump sites without prior treatment increases the risks that HCW may be dispersed in the HCF compound and enter in contact with the general public. The inappropriate off-site transportation (at least for DES), the disposal of clinical waste with the domestic waste in dumpsites and the absence of control procedures increase the risk for scavengers to be contaminated The use of incineration, whatever temperatures may be reached, release air pollutants (PCI, heavy metals, etc...) that constitute an environmental health threat. Section 5. Appraisal of the Planning Capacities of the Health Services Most of the interlocutors met by the mission tend to develop a purely technical approach of the HCWM issue: numerous aspects that should be taken into consideration for the implementation of a sustainable HCWM programme - such as the capacity of the Administrative Authorities, the Health Services as well as the mobilisation of the civil society, etc - are rarely mentioned 1. Monitoring Capacities of the Health Authorities The capacities of the Health Authorities remain limited. There is no sufficient local or national expertise available in Tanzania for the management of HCW. Scientific knowledge on HCWM remains limited at central level and the Health Authorities have difficulties to provide adequate backstopping for the medical institutions under their jurisdiction. 57 The Annexe 6 provides more information on alternative solutions for the disposal of sharps 5R Waste Management Guidelines, draft document Milistry of FHealth September 2002 '\ar.), .h/ I-1,-a/1z (.,Ipi Wn at, -' i ,;'> t 11,/1,, * 2' [)J 20!) 3 a/le2. -if 96 a) At Central Level Despite the decentralisation management process that Tanzania has been experiencing since the mid 1980s, the MOH continues to play a major role in the day-to-day management of the Public Health Services but progressively shifts its role from a direct provider to a facilitator in order to centre most efficiently its tasks towards: 1) the policy formulation through appropriate legislation and regulations; 2) the development of guidelines and standards to facilitate the implementation of the National Health Policy; 3) the monitoring and evaluation of the Health Services to improve their quality; 4) the training, the deployment and transfers of all cadres of health workers The recent capacity building effort increased the number of staff trained in specialized areas and strengthened some sections of the MOH. However, the MOH's capacity remains limited and over- stretched, due to the shortage of staff with relevant skills and experience as well as the workloads from fragmented tasks 59. In addition, the past project approach and the implementation of vertical programmes (HIV/AIDS control, TB/Leprosy, EPI, etc.) have led to complex, fragmented planning and implementation arrangements with many parallel systems co-existing to serve multiple projects and programs 60 as well as a serious lack of co-ordination This has failed to strengthen the institutional capacity of the Tanzanian Health Administration. The MOH currently intends to move away from such fragmentation, and coordinate all activities in the sector under one common program and harmonize planning and implementation arrangements, using the Government systems as much as possible. b) At Local Level Authorities and budgets of the Public Health Services are more and more decentralised to the district level However, Local Authorities have so far not been able to exercise sufficiently their authority in the management of these services due to lack of critical decision making power and inadequate resources available Despite the decentralisation process, the present staffing level of the DHMTs and their capacities are severely limited, as the ones of the Regional Health Authorities that are in charge of the interpretation of the national policies and the supervision of their implementation by the DHMTs. It is however expected that each of the 113 districts develop a Health Plan using guldelines 61 provided by the MOH. These District Health Plans could be used to initiate monitoring and control procedures of the production of HCW in the medical institutions 2. Institutional Capacities of the Health Services The financial and institutional capacities remain extremely limited in the Tanzanian HCFs and the situation will not improve rapidly. The hospital administrations face drastic budget reductions while the medical needs are increasing continuously In this context, the safe management of the HCW is not - and cannot be - seen as a priority by the executive and managerial teams. a) Management and Administration Several sections of the referral system are not functioning as intended, largely because of consistent under-funding, weak management support systems and poor communications (roads and 59 This is particularly the case for the Environmental Health and Sanitation Services (EHSS), which will be in charge of co-ordinatng the National FICWM Plan 60 See for instance the dispersed and non co-ordinated approaches of the different co-operation agencies that have developed projects on HCWM throughout the country (section 6) 61 See for instance the National District Health Planning Guidelines Part I District Flealth Planning, Plan Preparation Part 11 Techniques and other Information for Planning Vcrsion I 0 Second Edition and Printing Ministry of l-lealth The United Republic of Tanzania April 1998 See also the Format of a prototype comprehensive council health plan issued by the Health Sector Reform secretariat of the MOI I in March 2001 Ya/icm.J/ I 1-a/,h-(mr, II' ale 1 L/}1 Pkn,;', * 1½ 03 '003 P'at, M) rf 96 Tlr, ( r,.Awd R,idl,ba O/ J h I hW I orld Kwkr , I :.'-rweas telecommunications). Consequently it is difficult to distinguish the level of care and services provided in one type of facility from those provided in a facility at a lower level. For instance most of the Regional (respectively Consultant) Hospitals perform like District (respectively. Regional) Hospitals but at a higher cost. They frequently lack essential medical equipment, drugs and supplies and suffer from deteriorating infrastructures and provide a substantial amount of primary health-care services, which could be dealt with by lower-level facilities. This often leads to overcrowding, as well as inefficient use of resources Hospital reforms are intended to change the current status by enabling the Regional and Consultant Hospitals to have devolved and decentralized management authority, broadened financing options, and strengthened management in resource utilization (financial, human, and infrastructure). Hospital Management Committees have been created to set up strategic and business planning. Commercial- style financial management and independent external auditing should be progressively introduced so that hospitals may know the real cost of their services to allow management decisions based on cost- effectiveness. b) Financial Resources and Planning Tanzania allocates a relatively high proportion of its budget to the Health Sector compared to the neighbouring countries 62, However, shortages of funds and weak management have meant that many public HCFs lack essential drugs and supplies and has also led to deteriorating infrastructures 63, The GOT budget for health is largely used to cover staff salaries (about 60% of the recurrent budget), leaving very little to cover day-to-day operation costs. If drugs and medical supplies are excluded, since managed directly by MSD, resources made available to Districts and HCFs are very limited 64. In addition, its release from the Treasury is unreliable and inadequate, and its use is highly restricted by itemized budget lines. Recently the Government with IDA has developed a cost-sharing program that aims at increasing the incomes of the HCFs and progressively changes the current unsustainable system 65, At HCF level, the move to cost-sharing practices in the Health System does not generate for the moment the resources, which would be necessary to allocate financial means specifically for HCWM. Therefore the HCWM plan will have to balance optimal but costly and unaffordable solutions with realistic but not always fully satisfactory technical options for the disposal of HCW. In order to cope with this constraint, a clear difference between short term and long term solutions will have to be provided in the plan. c) Monitoring and Control In practice, there is a lack of monitoring of the management of HCW due to: 1) scarce knowledge on HCWM in the country, 2) limited financial resources; 3) incomplete legal and regulatory provisions and 4) the understaffed Health Authorities 66 The finite resources of the Government strongly limit its 62 Approximately 1 5% of the GDP. 63 Tanzania Country Assistance Strategy The World Bank Group FY 2001-2003 64 The situation is worsened by the weak execution of the budget In 1996/97 for instance, only 60% of the MOH's non- salary recurrent budget was released as opposed to over 100% of personnel emolument (World Bank Report) 65 Approximately less than 4% of the budget of medical facilities is dedicated to the supply of goods necessary for cleaning and disinfecting 66 For instance, the Health Officer (110) plays a central role in the monitoring and control of the application of environmental health standards at HCF, district, regional and central level but his/her professional responsibilities include. I) the control of communicable diseases, 2) health education, 3) sanitary inspections, 4) food quality control, 5) enactment, revision and eiforcement of the relevant laws, 6) control of waste collection, transport and disposal, improvement of housing conditions, 9) improvcment of school health, IO) improvement of occupational health, 11) vector and vermin control, 12) contintiing education, 13) immunisation, 14) port health control The multiplicity of the N,;I/,gj/ I-; i/ I/I .(o, C.n ,i' .11, 4 /il i 1' () 20() 31 03 2003 of9 Ih.( 't. Re,p';h A. f J ke l orld 13an 1' / f:e"i c,,c, possibilities to set-up a monitoring system to control HCW streams inside and outside the public and private HCFs of the country. In addition, the general low salaries of health-care staff are not motivating and explain to a large extent the turnover observed by MSF in the Health Centres and Dispensaries. The monitoring of new HCWM practices and the control of new procedures in the medical institutions will thus be problematic. d) Training andAwareness of Staff Following the expansion of the HCF network in the 1970s, several training schools were established were a large number of health workers were instructed "However, performance of these health workers and quality of services offered are considered as generally poor. Weak management of health personnel has led to inadequate deployment of workforce, creating serious imbalances and mal- distribution of skilled staff with heavy bias toward urban areas and large referral hospitals. The levels of education of many health workers are low (e.g., the largest cadres such as Nurse B, Rural Medical Assistants, MCH Aides and Medical Attendants recruited at the standard seven level), and the inadequate curricula and the limited opportunities for skills development hinder development or upgrading of necessary skills for career development"67. What is your appraisal of the current situation regarding the HCWM within your institution? |Verybad Bad [ Fair | Good VeryGood MUHIMBILI HOSPITAL * direction x * hospital head nurse x * attendant x * mission x MBEYA REFERRAL HOSPITAL * direction x * chief nursing x * mission x IRINGA REGIONAL HOSPITAL * direction x * matron x * health officer x * mission x MTWARA REGIONAL HOSPITAL *regional health officer x *direction x * medical staff x e mission x Table 1: Opinions on the HCWM system in selected HCFs A vareness The level of awareness is a key element to change and improvement. To compare the needs identified by the mission with those expressed by the administrative and medical staff of the hospitals, a number tasks to be performed by the 1-lOs is such that it is obviously impossible to ensure that a proper monitoring is applied in all these fields of activities 67 Source Tanzania-Muilti-Sectoral AIDS Project, World Bank Report N°PID10683, Afnca Regional Office 2002 ,\,.'i/on-/ I 1haid (_r., IF h7','j hn'nr,/ ,';1/ //,, 2* 03 02003 I'>c v_' s2f 96 l, h. '/cI [Rt.V,,/'/h. uf Vwh,;,, 7ke [Vo-,41r ia-k / tU1r qence of qualitative questions were systematically asked during the field visits 68 This information is essential in helping to select the most appropriate strategy for the implementation of thc new policy. Table I illustrates both the differences in appreciation of a situation, which can prevail within a HCF depending on the actor's function/knowledge and how the situation is assessed by the mission. Actually, the discussions with the staff directly involved in the management of HCW (nurses, nursing assistants, attendants) reveal that most of them are quite aware that the current practices are unsafe and the minimum standards are not reached. It should be thus relatively easy to raise awareness in the "nurse community" and to get the support of the national nurse associations to implement the HCWM plan However, at executive level (nurses trainers, managers or some medical doctors), the situation is slightly different and the awareness less obvious. Training Several in-service trainings have been organised by different stakeholders, including WHO and DFID in Mbeya. Obviously, more regular in-service training should be developed but it will be necessary to review or complete the academic curricula of nurses and medical doctors with specific lectures dedicated to hospital hygiene and infection control as well as safe management of HCW. In addition motivation will be a major issue to implement adequate HCWVvM practices in the HCFs of the country. A participative approach could be developed for in-service training (see part two, recommendations). Section 6. External Support Capacities 1. Review of tle HCWMProjects Carried out in Tanzania Among the international co-operation agencies involved in the Tanzanian Health Sector, WHO, UNICEF, SDC, DFID, DED and MSF have developed HCWM projects in relation with their specific programmes unfortunately without coordination Each agency has therefore proposed several solutions for the management and the disposal of HCW, not all of them having the same standards, which are sometimes hardly compatible with each other. In addition, the management practices fail to be improved in a sustainable way since theses projects have not been integrated in a global and national strategy For instance: DFID, through it's Tanzania Family health Project 1994- 2001, installed several De Montfort incinerators in the region of Mbeya and produced a little brochure providing indications for the management of HCW that does not fully comply with the international recommendations of the WHO, Based on DFID experience, WHO has recently financed the installation of 12 De Montfort incinerators in large hospitals and the training of the nurses for the management of the HCW based on the recommendations developed in Geneva headquarters; DED (German cooperation) is currently working in Mtwara Region. For Health Centres and Dispensaries located in rural areas, DED has built "waste burning pits" (photo 15) and recommends throwing all the waste produced in the HCFs without segregation and burning them In the same region, MSF has developed its own specific guidelines for HCWM. The organisation recommends the segregation of the waste into three categories, the use of sharp pits (photo 16) as presented in annexe 6 and, "waste burning pits" but with a different design (photo 17). UNICEF recommends the use of safety boxes (in which the entire combination syringe plus needle are dropped) and then burning these containers The medical and paramedical staff may be confused with so many varying approaches. 6H Analysis of the needs identified by the mission vs the demand expressed by the ilterlocutors N\a/io,bu. I 1 Iyi//h-r .... Al. ' di,'h''n,\ 1, ") * 24 0 3 2"003 PA..ge 3 ; of 96 2. Mobilisation of the CivilSociety National NGOs and religious institutions play a major role in the provision of health-care services in Tanzania by managing half of the HCFs is the country. Their mobilisation capacity and the possibility to train medical and paramedical staff through their institutions are important They should be part of the national workshop that the MOH intends to organise. Some Tanzanian NGOs dealing with environmental protection have already stigmatised Twiga Cement Factory when the pharmaceutical waste was incinerated in the rotary kilns, arguing that atmospheric pollutants were emitted Such actions that do not take into consideration the necessary holistic approach that must be developed when dealing with the HCWW issue are regrettable69. Twiga is now reluctant to repeat the experience unless it could rely on a strong commitment of the COT. Another set of private actors are currently setting up plans and are clearly interested in taking part in the HCWM issue. However, the mechanisms to control transportation of solid waste in the municipalities as well as the negotiation capacities of the Local and National Authorities must be strengthened before hand The GOT could certainly stimulate the involvement of small and private enterprises in the construction and in the long-term maintenance of the De Montfort incinerators that are currently built in District and Regional Hospitals by proposing adequate subvention mechanisms. Section 7. Synthtesis of the Findings In the absence of disposal or treatment facilities within the hospitals, clinical and domestic wastes are disposed of together. All the efforts currently carried out in the wards/departments to segregate the wastes are consequently ruined When clinical wastes are disposed of separately, most often they are burnt in single-chamber incinerators or dumped into open-air pits. In general, treatment and disposal of clinical and highly infectious waste remains an urgent problem to be addressed. There is also an urgent need to develop an integrated and homogenous HCWM system for the country as well as to provide the hospitals with adequate equipment and to implement proper managerial procedures (colour coding system, collection procedures, etc...). Although the medical and paramedical staff has a relatively good perception of the degree of hazard associated with HCW, the current practices in the hospitals visited by the mission result in significant risks to public health. The hygiene conditions linked to HCW handling and disposal cannot giarantee a satisfactory control on the transmission of nosocommal infections throughout the HCFs. Although direct and indirect costs of this situation are difficult to establish, they remain certainly significantly high The backstopping and monitoring capacities of the Central, Regional and District Authorities to support the medical institutions remain limited Furthermore the legal framework is not sufficiently developed. Additional decrees, code of hygiene and internal rules for hospitals will have to be established and put at the disposition of the local authorities as well as the hospital administrations so as to clarify roles, duties and responsibilities of all the actors involved. Finally, the implementation of an efficient monitoring framework and the involvement of the executives remain key issues to improve the situation within the hospitals. The adminnistrations of the medical facilities have difficulties to estimate the costs related to the management of HCW The structure of their accounting system does not enable them to differentiate the expenses associated with the management of the HCW from the ones linked to other activities. 61 To avoid this kind of problem, these NGOs should not be left aside and should be inviled at the national workshop to be fully part of the decisional process '\'a'tfg / I al 1' C ri a .Y ,\ I, w!," " 1('lj l /) 3 _QO I Ia X of 96 IThe U nited Rp#hbic of f he lI or/l 13ank / I :mereqget-e Consequently it is extremely difficult for the medical institutions to estimate the financial costs for the development of an integrated HCWM plan. Some suggestions to improve the management of HCW within the medical institutions of Tanzania are proposed and their economical implications roughly analysed in the following part of this report. A strategy to upgrade the current HCWM practices is also developed taking into consideration that the improvement of the prevailing situation requires a long-term involvement from the MOH to monitor and implement adequate managerial procedures. A potential "National Action Plan" with measures that could be carried out by the MOH within the next five years to implement the recommendations is contained in the third part of this report. i\'\a/,gjjI I I eaIh-Ciart [I"a,'A \l au2q ,u/ I'laiiz 1 2'.03.2003 l 'aC: " of 96 96J~4 P 6 I 'OO Q9~ 0 f:j , W/!I,/(/ ~ UP~' /P I/VA SUOilWtPUMU1UOZO1 GAXI llIVd -.- _ / / jp/O .1 otq 1,'l i JO 10"qN j I/' ] . 7 'I l !//.-I /11h""/'" of I ';'; a/i, 7 I I or/,/ 13a'I?, ,wergeni The differentiation of the HCW streams within the medical institutions of Tanzania must be progressively improved taking into consideration the current situation prevailing in the country. The clear identification of the priority areas of improvement and the enunciation of adequate recommendations constitute the basis for the definition of the National HCWM Plan. The mission recommends targeting in priority the following objectives: Consolidating the legal and regulatory frameworks; Standardising HCWM practices, Strengthening the institutional capacities for HCWM; Encouraging the involvement of the Civil Society. Section 1. Consolidating the Legal and Regulatory Frameworks The legal and regulatory frameworks must be complete to provide the necessary basis for an efficient HCWM plan at national level. Legal procedures should aim at obliging the medical and non-medical staff in being responsible at their own level and securing the HCW disposal process70. central Regional Disctrict Health-Care Facility Add an addendum for Hazardous Edit a Decree for the Safe waste Management in the Local * Assign adequate responsibilities Management and Disposal of HCW Government Act, 1982 - l * Edit National Guidelines Review Job Descriptions * Edit a National Policy for HCWM Complete the Professionnal Code o Ethics for Nurses and Midwives in Tanzania Edit a National Policy for Injection Edit a Policy for Hospital Hygiene and Infection Control Consolidate the Public Health Act, 2002 Edit a separate Code of Hygiene for Hospitals Figure 3: Recomniiendations for the Consolidation of the Legal and Regulatory Frameworks 1. National Legislation and Regulations A number of legal documents should be reviewed or edited by the MOH to reinforce the duties and responsibilities of key staff / institutions. Any policy should outline the rationale for HCWM in Tanzania, the short-term and long-term objectives to improve HCWM and the key steps essential to achieve these objectives a) The Legislation The current legislation must be consolidated by completing the Puiblic Health Act, 2002 and by editing a specific decree related to the management and the disposal of HCW. The decree should contain general and specific provisions to determine the authorities of enforcement, the obligations of HCW Producers and Operators, the authorised management, Treatment and Disposal procedures as well as the range of penalties to be applied. Some details are provided in table 2. 70 In this respect, the inteinational "polluter pays" principle that implies that all producers of waste are legally and financially responsible for the safe and environmentally sound disposal of the waste they produce, should be applied However, the set-up and the application of this principle for Tanzania exceeds the scope of this report Xa,'up,,/ I ICa.' f, ',I a.' I, 'i,i"r't I'/as *-I ()3 2003 4d7L' '/0 ot 96 / hr ( n;,fr,I ze tj,,!!/, I2z v,.:;j,,,,,, J ke IE o'h/,l WO .,tt / I :o',-v" ne, An annexe specifying the different elements contained in the decree for the management of HCW should be added to the Local Government Act, 1982. Actually the GOT would have an advantage in elaborating an addendum that includes provisions for the safe management of hazardous waste in general b) The Regutlations In addition to the legislation, the mission recommends that the MOH urgently prepare for publication a paper presenting the National Policy on HCWM. It should be completed with practical, informative and incentive National Guidelines - jointly drafted with this report - to precise the national regulations for Tanzania. In absolute, the Professional Code of Ethics for Nurses and Midwives in Tanzania, 2002 should precise that "all nurses and midwives are personally responsible for the waste they may generate during their professional activities". It could be worthwhile that the GOT elaborate a specific Policy on injections safety - the current poster available at the MOH cannot be considered as National Guidelines. The MOH should also consider the development of an integrated Policy on Hospital Hygiene and Infection Control as a priority. 2. Code of Hygiene and Rules in Medical Institutions a) Code of Hygiene The Management of HCW must be considered as an integral part of hygiene and infection control in HCFs. The legal framework must therefore be reinforced with the application of strict internal rules that should be regularly monitored. Guidelines for the medical staff to ensure hygiene and control of nosocomial infections should be consigned in a comprehensive Code of Hygiene providing: Ongoing monitoring and managerial activities to be carried out in hospitals to reinforce hygiene and infection control; Rules setting duties and responsibilities of the medical and para-medical staff regarding the hygiene and infection control measures that should be applied in hospitals and during their medical practices, Recommended practices to maintain a high level of hygiene, particularly with regards to HCWM. b) Assignment of Responsibilities Personal responsibility is a key issue to ensure that the medical and paramedical staff actively participate in the general HCWM effort. The Medical Officers in Charge should formally appoint each category of staff, in writing, informing them of their duties and responsibilities concerning the management of HCW. A Health-Care Waste Management Officer (HCWMO) in major health-care facilities should be designated and left with the responsibility for the day- to-day operation and monitoring of the HCWM system (cf. section 4). Nurses and attendant job descriptions should be reviewed so as to reinforce the duties and responsibilities of this category of staff in the daily management of HCW. i\'.w.'t t I/l,I, (.rti,''.. ; .Iq.,;:i1'e';. - 'It )] W)( Pa.. 'II 1/1,f96 I-'h;, ( R,,t"ubb ofl / .;;;Z.,,u Ikeo',he lt' -3/,k tBewe,-k General Provisions of the Decree The rationale and the purpose of the Decree should be explained in the General Provisions of the Decree as well as basic but important definitions allowing to specify the appliance area of the Decree The main object is to regulate the generation, handling, segregation, collection, transportation, treatment and final disposal of all the HCW generated by health activities of preventive, curative and palliative treatments; activities of research as well as industrial production in relation with biomedical products; The objectives are that every producer and operator of HCW comply with the management, treatment and disposal procedures stipulated in the Decree and abide by the registration and tracking provisions contained in the Decree; As a minimum a glossary with the following information should be provided in the Decree definitions and a classification of HCW, generation, handling, segregation, collection, transportation, treatment and final disposal, HCW producers and operators. Authorities of Enforcement The Decree should: 1) specify which institution is responsible for the enforcement and the coordination of the policy on HCWM, 2) explain what should be the different competencies of the Central, Regional and District / Municipal Authorities regarding HCWM, 3) describe the enforcement power of each of these authorities. Provisions Related to HCW Producers and Operators Should be listed in the Decree. The type of institution that should be considered as a producer in the framework of the Decree 71, the type of institutions / societies that should be considered as operators; The obligations that each HCW producer and operator should comply with to be allowed to operate. registration procedures to enforcement authorities, list of environmental mitigation measures taken, The compulsory measures that should be taken by the HCW producers and HCW operators to reduce health risks for the staff and reduce the environmental impact of HCWM, The training courses on the risks and the safety measures that should be taken during the handling, transportation and treatment of HCW, medical check-up to be carried out in case of an accident, compulsory immunisation vaccines that staff being in contact with HCW should receive, equipment that the staff dealing with HCW should have, the security instructions and guidance manual that should be available for the staff in any establishment generating HCW. Provisions Related to Management, Treatment and Disposal Procedures The mission recommends to include the following provisions List all the management procedures that the producers should comply with: segregation, handling, on-site transportation, storage, off-site transportation, on/off-site treatment and final disposal, Describe the standard treatment and disposal norms that should be respected by HCW producers and operators to get an operating certificate issued by the Ministries to allow them to run their activities, Give the duration of validity of the certificate and provide specific provisions in case of an accident; Describe and inventory compulsory labelling and tracking measures and provide standardised labelling and registration forms in the annexe of the Decree. Penalties The major mismanagements that would lead the enforcement authority to withdraw the certificate and to apply penalties should be inventoried. Table 2: Fundamental provisions to be included in the Decree 71 Are considered as a producer of health-care waste all the physical or legal bodics, public or private, whose daily activities generate i-ICW in the sense of the definition given by the Decree .\Y';p:i/ I I,.'Ith-&rr Ii' ,-(,A' ..........ii. 2-1.0 3 2003 2/ f 96 Ihe l ;n1t ned I puil off' b. I h.e ll Knl3k / i:rn.i-yncr Section 2. Standardising HCWM Practices The recommendations that are presented hereafter should be implemented in all the medical institutions of the country The financial constraints that the medical institutions face are taken into consideration to propose pragmatic and affordable HCWM plans and disposal technologies. A step- by-step strategy has to be implemented to progressively improve the HCWM practices. 1. Mininising the Quantity of HCW Genierated in Medical Institutions The MOH should encourage the reduction of hazardous HCW generated in HCFs by coordinating, in co-operation with MSD, the establishment and the implementation of an adequate mznzmisation policy aiming at: Improving the purchasing practises to reduce the source of potentially hazardous HCW 72; Rationalising the stock management (use of the oldest batch of a product first, regular checking of expiry date ) Enforcing a rigorous and careful segregation of the HCW, at source (see below). * Improve purchasing practices * Rationalise stock management * Set-up a three-bins system and a colour coding systemr *Non-Risk HCW Clinical Waste . Sharps * e Consider special categories of waste:, * Highly Infectious Waste . * Cytotoxic and Hazardous'Pharmaceutical Waste * Placentas and other pathological waste Figure 4: The flrst steps for rationalising HCWivl 2. Segregation, Packaginig anid Labelling The recommendations provided in this chapter are mainly valid for major health-care facilities (i.e. District, Regional, Referral Hospitals) and in Health-Centres located in urban areas. a) Segregation The segregation ofHCW is of the utmost importance for three different reasons: 1) proper segregation is the basis for safe manipulation and appropriate disposal of medical waste; 2) the treatment and disposal procedures can be optimized for each category of waste; 3) it is the best way to reduce the costs linked to the treatment and the disposal of HCW 72 For instance, the replacement of mercury based thermomietrs Nvitih siiplc galLium (indium + stain) based thermometers would advaniagCously replace the mercury ones, avoiding that a hcavy, toxic and volatile metal be disposed of when thernometers arc broken or out of order. Nation,a/rllU//h-( ir,' i1,, I *, ,- ." r'',: *11 O Pn J'a(e '; 4of96 'l'Ar ~t ; IUvReibh/bc of I ,/;; 7h' Uo'-i, / " The mission recommends to set-up standardised segregation procedures in all the HCFs of Tanzania 73 by implementing a three bin system that should be systematically associated with a colour coding and labelling procedure. The following categories of HCW should be considered: Non-Risk HCW or domestic waste; Clinical Waste (hazardous HCW) that includes all the pathological and infectious wastes as described in the introduction of this report as well as some particular waste generated in isolation wards, Sharps that include all items that can cause cuts or puncture wounds They should always be collected in rigid safety boxes. In particular, all disposable syringes and needles should be discarded immediately after being used without recapping the needle or removing it from the syringe: the whole combination should be inserted into the safety box. In addition to this three bins system, in the different services where they are generated: Anatomical Waste, generated in Operation Theatres and Placentas should be collected separately to be specifically disposed of, Highly Infectious Wastes generated in Medical Laboratories have to be pre-treated before being disposed of with clinical waste (cf. Draft National Guidelines and annexe 8), Pharmaceutical Waste generated in Pharmacies should be separated into two categories. Non- Hazardous Pharmaceutical Waste could be disposed of with Non-Risk HCW while Hazardous Pharmaceutical Waste and Cytotoxic Waste should be specifically packed to be sent back to MSD (cf. chapter 4). The MOH, in co-ordination with MSD should thus establish a comprehensive list with adequate instructions of Hazardous Pharmaceutical Waste and Cytotoxic Waste and ensure a proper distribution within the country b) Packaging Packaging is a problem in Tanzania. The mission proposes to take into consideration the reality of the country by implementing different solutions for packaging: In all the HCFs outside cities, where on-site treatment is planned, 60 litre plastic bins can continue to be used if they are regularly disinfected. To enable the monitoring process, the use of other sizes should never be allowed by the MOH ! In the major HCFs located in cities, when off-site treatment is planned, bins for medical waste should be replaced with bag-holders using 80 litre yellow PE bags (200-300pm gauge). Black plastic bins could continue to be used for non-risk HCW; In all HCFs, cardboard safety boxes , similar to the one used for EPI programmes should be used for sharps. c) Cololr Coding A standardised colour coding system aims at ensuring an immediate and non-equivocal identification of the hazards associated with the type of HCW that is handled or treated. In that respect, the colour coding system should remain simple and be applied uniformly throughout the country The internationally recognised colours that should be applied in the medical institutions of Tanzania should be. Black. for all bins, bags containers filled with non-risk HCW; Yellow for all bags, sharp boxes and containers filled with hazardous HCW. 73 It is actually essential to Implement homogenous procedures throughout the country to reduce the risks of mistakes by the medical staff 74 Or at least to use recycled cardboard boxes in minor l-ICFs adequately conditioned, as shown in the poster edited for the EPI by the MOH N a ./i a/i I IllI/A-.arr 11 A In;a,;','e ;jf P/ *', 2- OY.2(' 3 J)rog 41 o,f P196 I /. l ;:gd.'ed 1Rtpflhh4 Of II.,;; I he lt ;,r/,d B,:"k / I :r_v ,weac d) Labelling In the major HCFs located in cities, when off-site treatment is planned, the mission would recommend to set-up an adequate tracking system of clinical waste and sharps. The labelling should be written in Swahili and English and mention: 1) the type of wvaste in the container with the formulation << Domestic waste »> or << Danger Hazardous biomedical waste >; 2) the name of the hospital; 3) the date of collection. | - - 2 Clinical Waste ; ,. Sharps - - Non-risk w Gloves, gowns, masks gauze, dressings, swabs, Needles, Needle and Gloves, gowns, masks, gauze, spatulas that are visually contaminated with blood Syringe assemblies, dressings, swabs, spatulas that are or body fluids Lancets, scalpels, blades, contaminated neither with blood Urine, blood bags, sump tubes, Suction canisters, Scissors nor body fluids disposable bowls and containers used for medical Broken glass, ampoules Sanitary napkins, Incontinence pads purposes, Haemodialysis tubing, Intravenous (IV) lines, Intravenous catheter (except in isolation wards) bags Foley catheters Packages, boxes, Wrappings Pre-treated highly infectious waste from medical Glass slides, cover slips Newspapers, Magazines Disposable laboratories, isolation wards plates, cups, food utensils, left over Are considered as potentially infectious waste but food and packaging, canisters are managed separately for technical reasons: Tissues, paper towels, intravenous Human tissue placentas, body parts bottles, packs. Table 3: Practical segregation examples 3. Collection, On-Site Transportation and Storage The recommendations provided in this chapter are mainly valid for major HCFs, i.e. District, Regional and Referral Hospitals For their formulation, the mission assumed that a medium-term objective that the MOH should target is the safe off-site transportation and disposal of the clinical waste generated by the major institutions located in the cities (i.e. Mwanza and Dar Es Salaam). a) Collection and On-site Transportation The mission would recommend: StDre temporarily filled up yellow bins or waste bags and black bins in separate locations so as to avoid mistakes, away from patient areas, preferably close to the nurses room, In the major HCFs located in cities, two-wheeled 240 litre bins (with a lid) should be used, for temporary storage of clinical wastes and sharps inside the HCFs and off-site transportation. Once again, to enable the monitoring process, the use of other sizes should never be allowed by the MOH! Precise the schedule for the collection of waste and containers from each Medical Department in order to ensure the regular removal of waste from each location and to avoid misunderstandings between medical and non medical staff, Remove the waste from the different units within the HCF at least once a day, Set-up separate schedules and separate collection times for black bins and yellow bags/bins; Ensure that the cleaners and waste collectors wear protective clothes when they handle waste, at least, heavy duty gloves, industrial boots and an overall. N ,,. Ic1,:.,I' (...,, tI - ;, A 1.l'/,i * I '/ ( 3 2 0(13 P1cw (I / of[9 IAl. let.t.9. ,,/r ................ loi,J,l,l"l)/, Er. .,X,()3 2003 of ........, ;,96 7lb d 1,rR'pli"'h1rc Of 7 i UllZnL ]'I be For/ld Bak f o3annkI - Members of Task ForceI Supervision Project Co -ordinator i|| TeamLLeader 1 jj ||| Team Leader3 Working Group 1 Working Group 3 Legislation & Regulations Equipment J1 Team Leader 2 ||| 1~~~~~~~~~~~~~~~~~~I Team Leader41 Working Group 2 Working Group 4 HCWM Procedures Capacity Building & Training l~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Regional Health Officer in Charge Regional Health Management Team a aI D000 e.eO*Oa.oe,...o.. - a***a****c 00 .. .F. .oo..e..e. .*.s.......e. District Health Officer in Charge District Health Management Team * 0 e a * 0 a 0 e * 0 o e * 00 e 1***-* e o * o o o a 0 e a * - a o o - a ----------------- - IMedical Officer in Charge] HCWMO Figure 7: Institutional Framework for the Implementation of the HCWM Plan Xt',"ona/I fbI-a/hC-ir, [I a 20 Al "', cirtI 'i;'I ( 'Y8)3 Parc 58 of 96 Section 2. The National Action Plan This section presents the National Action Plan in five tables The first table summarises the recommendations already formulated in the first section while the five other tables present in details, the actions to be launched to implement the objectives Preamble: Define a General Framtework for the Implententation of the NatiolnalAction Plan Actions C-riain Sprson Indicators of Cost (uSD) Actions Co-ordi nati on S upervIsIon achievement Initial Annual 0 1 Organisation of a national workshop to modify and validate the proposed NAP and MOH Chief Med Off Minutes of the Workshop 5 000 none set-up specific work groups Of Health 0 2 Establish a National Steering Committee on Health-Care Waste Management MOH Chief Med Off A list of the members is 20 000 Of Health established, the objechves are stipulated and regular E_ meehngs are scheduled i: 0 3 Designation of a project co-ordinator (PC) for the implementabon of the NAP NSCHCWM Chief Med Off Job descnpbon with clear 120 000 0 Of Health definition of tasks 0 4 Establishment of the cntena for the evaluabon of the NAP dunng its implementation PC NSCHCWM Indicators of evaluabon 0 5 Designation of the administrahve authorities in charge of the implementation of the MOH Chief MOH available NAP at Regional and District levels, selechon of the Regions to test the NAP Directive of the MOH 0 6 Set-up of 1) titernediary and 2) final evaluations of the implementabon of the NAP PC NSCHCWM Progress and final reports 10 000 Recommendation The involvement of bilateral or multilateral Agencies should be sought to obtain a financial support for the implementation of the NAP l.,.,'--.. ('rm If e i,' ;Sz. -Zi; j'/l - 2-4 ! 20f i3 Rl"r,9 *9 -`)G j J R . p-,h .f: /t-::.. T. PU 1i S xf } 'k 1. Develop tine Legal and Reglulatory Framtiework Actions Co-ordination Supervision Indicators of Cnit AUaD 1.1 Prepare National Guidelines for HCWM WGLR & PC NSCHCHM Guilelines are avaida6te at none all health service levels 12 Prepare Nalonal Policies for 1) Hospital Hygiene and Infecton Control 2) Safe MUCHS PC Two documents are 9000 Management or the Health-Care Waste available 1 3 Complete the Public Health Act ard edit a specific Decree NSCHCHM MOH Decree published in the 15,000 Tanzanian Gazette 1 4 Establish a Code of Hygiene for Hosptals NCHHIC MOH Code of Hygiene available 10 000 1 5 Elaborate a Specific Policy for Inlecton Safety 2 MOH Document available at tbe 1500 MOH . 1.6 Elaborate an Addendum to the Local Government Act AMOH GOT Addendum available 500 o 1.7 Complete the Professional Code of Ethics for Nurses and Midwives in Tanzania NMC MOH Code of Ethics available 500 and taught in the nursing schools Recommendations To implement these actions, the MOH should set-up a Working Group on Legislation and Regulations {WGLR) Should partcipate to this Group Lawyers, Environmental and Public Health Specialists from the MOH and MOE Ideally, the HNabonal Guidelines', the list of acceptable technologies and a catalogue of equipments should be annexed to the Decree The regulatory documents should cleady define roles, responsibilities, dubes and penalbes for the mismanagement of HCW (cf part 2 of this report) On-going controls carned out in the field by the MOH and the PHS should be reinforced to ensure an adequate implementation of the HCWM plans They should be accompanied with activites of advice and follow-up The cntena for enforcement and incitng measures to ensure that the medical staff complies with the management procedures defined in the lawldecree and descnbed in the *Nabonal Guidelines shoutd be set up together with the Trade Unions 2. Standardise the HCWMPractices and Improve Management and Monitoring Procedures Actions Co-ordinaton Supervision Indicators of Cost (USO) achievement Initial Annual 2.1 Set-up Committees for Hospital Hygiene and Infection Control at all levels of the MOH Chief MOH Member list is established, 0 2000 Health Services regular meebngs scheduled 2 2 Define acceptable procedures of HCWM and requirements for HCW disposal WGP & PC NSCHCHM Amended NaL Guidelines & 1500 0 E technologies list of accepted technologies 2.3 Designate 1) HCWMO in Referral, Regional and District Hospitals, 2) Officers in WGP & PC NSCHCHM Job descnpbons 0 5'000 charge in Health centres and Dispensaries 2.4 Define a plan to reduce hospital waste and pollubon WGP & PC NSCHCHM The plan is set-up 2000 0 2.5 Complete medical and paramedical lob descriptions WGP & PC NSCHCHM Job descripbons 500 0 2,6 Establish of the HCWM plans in the medical insbtubons MOC DHMT Hospitals HCWM Plans 7'500 15'400 2 7 Prepare official forms for the establishment of Regional, District and Hospital HCWM WGP & PC NSCHCHM Form available in medical 15'000 0 plans institubons E E 2.8 Establish Regional and Distnct HCWM plans DHMT DMOH District Council HCWM Plans 0 12'000 2 9 Prepare a Plan to reduce HCW and pollution RMMT RMOH The plan is available 2000 0 210 Elaborate a cost recovery system WGP MOH & MOF HCWM included in the 4'500 0 accountancy books Recommendations The action 2 2 should include 1) the inventory by MSD of Hazardous Pharmaceubcal Waste & Cytotoxics and the set-up of standardised procedures for their safe disposal The action 2 4 should include 1) the inventory by MSD of the matenals susceptible to generate pollubon when treated, 2) a feasibility study for the replacement of hazardous materials with less hazardous ones, 3) a feasibility study for the implementation of a national waste recyding programme, 4) the set-up of a waste minimisation programme The forms for the HCWM plans should provide the necessary indicabons to estmate the quanbbes of HCW generated in their institubons / Districts, report incidents, inventory the available equipment and matenals and assess the on-going needs for HCMW The Regional and Distnct HCWM plans should be gathered and analysed at central level to penodically adiust the 'Natonal Guidelines' and the 'National Policy' ,' p ,,, ( ,,i lL'-; r 1) tr 24 U3 21'fi3 M r I,096 3. Equip the Medical Institutions Actions Co-ordination Supervision ators of Cost Aual achievement Initial Annual 3.1 Elaborate of a National Catalogue of Equipment for segregation, packaging, collection WGE & PC NSCHCHM A catalogue of Equipment 4'500 0 and disposal of the HCW in the Medical Insbtubons matenals is available 3 2 Wnle Technical Specifications and Bids for the installation of centralised treatment City Councils, NSCHCHM Documents available 4'500 0 plants in Mwanza and Dar-Es-Salaam WGE & PC v 3.3 Impulse the creation of Mutual Benefit Groups in Mwanza and Dar-Es-Salaam City Councils NSCHCHM The Groups are constituted 18 000 0 o X 3 4 Negotiate with the Pnvate Sector for the construction of De Montfort incinerators in the Referral Authority MSD Agreement and Memorandum 1000 0 o Large HCFs outside Mwanza and Dar-Es-Salaam of understanding signed 3 5 Launch international bids for Dar-Es-Salaam and Mwanza Municipalities Evaluate the Referral Authority MOH Documents available 1000 0 possibility to use sanitary landfills 36 Equip all large HCFs with segregation, packaging, collection matenal (including City Councils NSCHCHM Offers, contracts 600600 359'300 protecbve clothes), transportabon (if necessary) and disposal equipments WGE & PC 3 7 Equip all small HCFs Referral Authority SCHCHM Delivery forms & field visits 150000 45000 WGE&PC Recommendations An Achon Plan for the equipment of the HCFs should be set-up The mission recommends to start in one or two regions first and always with large HCFs The Catalogue of Equipment should specify the technical charactensbcs of all the matenal (incuding protective clothes) that is accepted for segregating, handling, packaging, collecting and transporting HCW inside and outside Medical Insbtutions Ideally, the equipment should be listed The pnvate sector should be encouraged to participate and comply with the technical requirements issued by the MOH for HCWM handling and disposal Subventions could be foreseen for the private Tanzanian enterprises ready to commit themselves in producing disposal materialequipment at a reasonable pnce (e g WHO/UNICEF cardboard boxes or De Montfort incinerators) AQ 1. l,~ ' (r., r IL 2 ,~ It .7+ " .1Lwl,.ts,r '' 1'fr"i * 24/ iA S?iJ(iJ Pfln *~2 P,'. 6 4. Launch Training and A wareness Measures Actions Co-ordination Supervision Indicators of Cost (ual achievement IiilAna 4 1 Set-up an awareness campaign for the medical and paramedical staff in health-care WGT & PC NSCHCCWM Posters are displayed in 0 facilibes Hospitals 4 2 Review the Academic programmes in Faculbes of Medicine and Nursing Schools WGT & PC MOH New curricula available 1'000 0 E 4 3 Provide Technical Training for the Health Officers of the MOH, NESC, Health Officers of WGT & PC NSCHCWM Training packages available 50'000 0 Nabonal Insttubons (CEDHA, MUCHS), Regional and Distnct Authonbes (Train 'trainers and sessions organised 0 c of trainers') 4 4 Set-up a Group of Trainers and elaborate a specific and detailed iraining package in WGT &PC NSCHCWM Registration of the groups 11000 0 Swahili for them (train the trainers) 4.5 Set-up in-service training programmes in Regional Centres for medical, paramedical and WGT & PC NSCHCWM Reports of the different 15'000 6'000 technical staff groups of trainers n 4 6 Recruit new staff members at the MOH MOH GOT Job descripbons and new positions at the MON , 4 7 Organise systematic initial briefing in medical inshtutions WGT & PC NSCHCWM Briefing procedures available . Recommendations Academic curricula should be reviewed as soon as possible The mission recommends that the groups of trainers organise the on-going sessions directly in the hospitals Several steps implemented every sixth week for instance The sessions should be organised in a partcipative way and could be based on some elements already developed by the WHO and the WB through the PHAST programmes I,,,/ I" '16-, ..'.. ',n,,, 5. Develop a Plan to Reduce Hospital Waste and Pollution Actions C-riain Sprson Indicators of Cost 1USD) Actlon Co-ordination Supervision achievement Inibal Annual 5 1 Inventory the materials suscepbble to generate pollution when incinerated WGE & PC NSCHCWM List available 10'000 5 2 Contact suppliers to assess the feasibility to replace hazardous materials with less WGE & PC NSCHCWM List of matenal to be replaced 5'000 hazardous ones available 5.3 Inventory inadequate practces associated with incineration WGE & PC NSCHCWM Synthesis report 25000 vl 5.4 Assess the feasibility to implement a national waste recycling programme WGE & PC NSCHCWM Synthesis report 10'000 5.5 Set-up a of waste minimisation programme WGE & PC NSCHCWM Action Plan 40'000 Recommendations The waste minimisation programme should focus on the cleaning methods, stock management, etc but above all on the segregaton practices that are set-up in the medical insttutions and at nabonal level, Establish waste minimization and waste management objectves for each facility, propose and adopt modificabons in current practices and policies aimed at achieving obtectves, . Monitor and review progress, provide ongoing support and assistance to ensure objectives are being met, revise approaches as needed, Establish a countrywide or regtonal training program, with access to the facility, to train and certify experts who can then implement similar best practices at other health facilibes in the country and/or region Note special attention should be paid to the nsks linked to the Introduction of unsafe practices (for instance linked to the recycling programme) or to introduce at least more hazardous or costly material as the ones in use For instance the replacement of mercury-base thermometers by simple gallium (indium +stain) based thermometers would represent a huge improvement to reduce the release of hazardous pollutants in the atmosphere 6. Tinmeframne The mission proposes to develop a five-year action plan The MOH should establish an adequate timeframe according to its institutional and financial possibilities A regular monitoring of the implementation of the HCWM plan should be set-up - every quarter - and the strategy reviewed accordingly if necessary The Project Coordinator will play a major role in this matter Section 3. Cost Estimations Disposal of HCW remains costly The direct management costs should however always be weighted against the indirect costs associated with mismanagement practices The overall initial and annual costs for the implementation of the plan and the standardisation of the HCWM practices are presented in the table 4 and based on the calculation provided in the annexe 9 The initial costs cover the imiplenientation period of five years of the plan It has been assumed that The National Action Plan is imlplemented over a period of five years, Dar-Es-Salaam City Council will be able to negotiate an adequate price for the collection and the treatment of the HCW and will use the incinerator currently in construction, Not all the Dispensaries and the Health-Centres of the country will be Immediately equipped during the implementation of the HCWM Plan, Only the initial costs associated with the equipment of the Govemmental Hospitals have been taken into consideration, assuming that the other health- facilities will be equipped by themselves The total implementation costs of the plan ranges between I'300'000 USD and 1'400'000 USD while the annual costs associated with the new HCWM procedures would range between 450'000 and 500'000 USD, but could be crossed subsidised and significantly reduced through the development of Mutual Benefit Groups among Private and Public HCFs in Dar-Es-Salaam and Mwanza S..~d. .V,,t .Ie dl'#ChiAk Th.. a";'. '9 :g 61 ;.--t N. r1'f -- -; ' r ~~~ 5j- *-~~~~~~~~~~~4m 5w a a" * --~~~~~~~~~~~~~~~~~~~~~~~,f-. - dy D,E W _ OQipraipsalen oil no renol noinsOop 0 inoddy and vandals die piopoeid 49000Ct SOO a 0f1 7br,oosabrDoilo di Macen enfilrslp reqeres o e p-senano olficans _ _ NA? and nenono-Doof5Droint ootniopup, M fon. Iataiodays., OardsSlaan,a MsDs aos5ger9cmibro Hleith-Q, W.C.. 2 0 2 E'~nua Nacend ~ Cenoosan en HeAP-CWas, 150600030 20000 O 0 ReguDor merson9, ofdie NPC fouoa0eoffpeR3 NSCHCWWM d 10 p r 3 ininoh) 5 d Oestgnoon of.M pmefe 11o-on2nat (PC) bor die nennaoen oldie e000 e-ge ly ofd2M 000 USo I Ion th. piorenIl Odkaf,I -nl* ,g - N EAP and fIe eonhg pinups. gm__-WhN_ tups of 2 persns on 3 mgr pei yea, _ -Eslaimnnt fd onlb, foo hr eoatoaenn of die NAP durrg alh O o -v -rnssgnooen of ae ooneneooia. e udionemsne cai aoe of die _ 05 opeNaPsenpieINAPaiRegenal odOsunlvels, seleeon ofde O 0 | 0 O oin of Ij 9 1raneedeny ord 2) rAi erralaios of in anyomneDOq 9EaOOOOO inooo a C on. enatoabon psorqo'alen TOTAL - 15l900000 -- s155e00 . O . . - If Piepona Natial Gudednee to HCW4 0 0 0 0Qpieed r mamson - 2Pios M nel1 P1 oloe toil) ftaN Hfene- and lefufe Crlonrol 2) 8320000 9000 3 persons NAN mona, late lanaenee of 0* ffealu-Ca Waste .- 6-h 1 3Colplole te Pub Herdrh Al d ed dda lpe De-nie4 r 470W 1000 2 0 3 Pe-ns fb mIon-s - 4EslaoAolaCodeolHngeneteflepdal 96l000C0 1013.0 0 SgrDsieootoaiondis 1f Elabnae a Spekoid Poy fr, n1eon Sa-eyr 1f4700 lC) O 02 3 pe-nn WA I no - 10 Elaborrola antddenduinronelenoLDraGoveinmintAeo 90000 000 0 0P pfe Is -n moodi ~, Coineloc die Paofetsoional Cud. of Ed.etont ffr uisos an d Glodones nS9000io _ 0 _ persanfoolr mcndhe .. - - -- TOTAL . .. ........ . 22540000.- 2 n00, - -- 6fl 21 Pe la2 h Co-ooiiutsNAHYsp/-fhHyona[ and cIn-e Conrrol ola lo h 0 S-M w 2n3 d nf nine' easny seeospasoeenonndat w 2 2 dsposs ~tecnoe 10- SO 1 prIc b 3 -U.b 22 -1nW. 1) HCWMO o ROf- Rg- Ma Hospt. 2) 1 HCi ond rhrudre-e- Mi 2 b1C a pf od .o -bti 0 nre, on uta9e in Heofdi senSes and . 0Dtpe d *s o r oo 5wpese hm th CIM= L-1 (ph-pgsof d-1=in W 2 40ehe a pln oi oduoo nospual eas, and po.uien ldOP 2`C Z 02 persrisn N 2 monins 2 5CPinpifs medIal ed paiainedea job des .poone 490500 bOO 0 a I peenel- . orn -h 2 0 s Ia b h dhe H C W M plan ei i nh s nd ail s as non e 7 350 D0 D 500 25039 000 1540o = Cade les ru t b e pe ed arda d. etocod .the - p ,tH CFoC s and _~ 22 e7Oce ol *r dola HC 14 72000 ee 15 OOrn 2 P- sVb 3 iths rddl doof Wtt bm 2 f Ell.bl ahd Regsm-] kn D,l btHCWM pi.. EOC Z3btsOwgdHt9 bbrg -. 26El0ooRgooauilolodffkn 0 ff760500 l?CCDOaksoppngoH.ftha0Auenue, 20Pn2 e PI-P-'. ir dueHPi. dd HCW rd pobu-n 00 ZOOO 0 O2 p.---s t 2 -ons * 210 Elab-toa a mr os iy syeit 44100 4 S 2 02 Pe- 3 tmndhs . . - - .-:TOTAL - * 30'1700 000 z 337112000 - - ' i --i ! ;iiy I /0 1/4 ri./ til. L) f/JcplJ I~o, 6 _ _ .6 01W,r.w of A Nbuora Ca.aqgo of ESqp.el foe ooqeu00n 31 paognqM ollecU.oWr d.posaf of Ihe HCW,n he Medsal lmobne 4'410000 4050 0 0 3 pe-,os fo3 -U.nta WdUl. TeFd al S"oecabo,s 0 and ol, fo the -lblior of l 4410000 4300 0 0 3 pe n fe 3 -ot 2 -(ealenl pIanO In , me Mth ono al- Oil Es-Sala3 b 3 3 e IesI lne 0,0e410 of Mutua enehft G0oupo bWe,mn mhe HCF, n M -010 00 001 EssO.Soan fIT64010 IMO 0 01 p.-150 S 36 -eolh _ NegoUale 0h 01. Prolt Seoo fr tle C.6shl- of 0. M000p0 _ ,f rnrlnoMworHCFsu dM.W.a WW rDa-E'ZWbW. 3 Loneh rr-lematle M6ds J1I ts Dil Et S-bam and waM-E E-luaan ___6______TOGO_a_ _,_2 3eOl 0510n1a rlde fOe 010 trr 00Slao umbr 50.000 toIo. ' 90'd00 2 s 0 0 OC2 p es0ne foe 20000106 _Eqnu WI albg. HCF, w, h gqrqgr pazign w1.C ecrrnmai6 36 inLdudn pootecte M0Oe0) Iloranpeldon (1f rnassary) and dsposel b5226000 665l00 35211400 359'3 D oede.a- -0.IoboU , 3 7 1Equ1p small HCFs 14me0W0000 150'DO 4410000 4510 46 SegOrsee SyOletallo ~e50lElle.-;g =n.1 ,O6= ' neS HEO. R.- th. Adm. _rOTAL h F-rme,00 ofMdk00. rd N-n0g . 0 0 0 _P.nl T chnl T-mr q. brth HeaIUt Offa- of Uw MOH NESC h f4 2noealO CMne ofNnl Inssluborr (CEDHA0 MUCHS)0 R0 l ard 49TJn00sn0o'00W 5 52 _ nlsbd AuUp Uels 01ea ooed m fad Erly 01.10 ) alOSmll 3Sf4, rGe '1n SWdh3.111d. 0d d01211404000 0000 t0 5 P.- 0 2 mondnn 2' 61 emc UFt pog wrl RSg01 Cee h000, me al0 36000Ie000 a a 4e R .. A -eu WtIr bf membe,, .1 Uw MOH O 0 5 6B0vW g'00 r, I6,1 Orgam-s sysemU.1o bn,fiq n medal nsL uwor 0 0 0 _ _,r -~ 'Ff T 41 , TA8- 15680000 1, a160O A380'000 A 444700 5St Imr-ntwy thb m4 Estso oPUbliob hOe capital and anmnual ost of She SS00W0 H0 a ('511 2 mp- 0 -.# Ih. f,lb * y h'p'c- h-drofuf mso (ls 490lM 5 .trn0y narXroua praccr -ssoc 1 V, -.1-rHalr 24 sooooo 25'00 5*Ass-s the f.sbWlh to,.Mprrri naupr.1 tasl wydmrg pg.- m m 950W8001DO low.... 55SWlep . of wasle nr-mfilc pmqrWmm 39 200`WC MOO0 t ' _q-,>'-'T-"'- -' 9 ' '''2'w ''>.':l ,, TSH,'r,, " USD J5o ;SHI-^4>UD - 1 ii' ; ''7>'E XANoD TOTt> - ls ,, 1 t, 1, 278'0 18'000 ;1 305'6001-435'866 000 E ' 4"70 Table 4 .Estimation of the capital and annual cost of the National HCW,M, Plan .~~~~~~~~I 3 2.0 P..... 0. 1 T7, I R:ed itp!la/bbc of lI ;I. h, .ke W or'll Bz.ik 1_'Wrfen,'r Conclusion With a few exceptions, the current HCWM practices observed in Tanzania are not safe and have harmful environmental effects due to a lack of knowledge of management procedures and the disposal technologies available as well as the low financial resources of the Health Sector. Although they are difficult to estimate, the direct and indirect costs associated with this situation are certainly high. The development of appropriate financial means for the regular implementation of the National Health-Care Waste Management Plan will remain a key issue for its application with regards to the relatively high costs associated with such plans. The Government of Tanzania may therefore develop a specific strategy aiming at improving the health-care waste management practices in the large medical institutions of the country first or implementing measures for specific categories of health-care waste, such as sharps. However, the experiences carried out by several actors in the Tanzanian Health Sector have little chances to remain sustainable as long as a holistic approach is not developed. Actually, the sustainable implementation of safe procedures to manage health-care waste requires a lasting commitment starting at the government level and prolonged all the way down to the hospital staff The implementation of the five objectives targeted by the National Health-Care Waste Management Plan should contribute to durably improve the situation if they are progressively implemented. The legislative and regulatory provisions will need to be completed so as to define both which practices and technical solutions are admissible or not as well as who is competent/ responsible for what, The standardisation of the health-care waste management practices, though the establishment of clear protocols as well as managerial and monitoring measures will be a key issue so as to secure the whole health-care waste stream. The procedures will have to be in accordance with the prescriptions contained in the national legislation and in the internal hospital rules, The equipment of the health-care facilities will provide to the administration and medical staff the necessary tools to apply the standardised procedures in their establishments and medical services; In-service training programme and adequate curricula will have to be set up followed by the on- going training of all people involved so as to ensure that hospital staff know the importance and the best practices linked to the management of health-care waste. f"l,01' f ka/rLa' c , .! A ;, .wm , ,,,' . )I / 24; ?0) 2) 6 ol 96g s(, lo 8,9 ',Y,' ' (() ' J(J /P .1rI7( /1fa/ll,1 r)/"7J : d/')J 1 di' )-q/1/P2dil/l'l/(/l \: saxauuv .v.7u11.-- - / §Yuvfl ,qi0l a4L ,Il~IU lz,',,j qqlv1g7>] i `9/ 1." 7 I, ( f 'i{,] RQp,'hl/u '3/ 1,w/lU,11711 Ik e lLWoi B4.. "' I hr, l:re Annexe 1: Terms of Reference -- , '-'^S;]-HEALTH CARE ,WASTE MANAGEMENT PLAN n -, - -- GENERIC TERMS OF'REFERENCE . M uti sectnoriaI2RlV/AEDS-programs for the African'Region c ,(Senegal, central African Repubic, IBenin; Madagascar, Cape Verde,Lagos Abidjan CrridrTanzania) The introduction and project justification is taken from the CAR HIV/AIDS project and changes from project to project 1. Background and Introduction The proposed project is part of the World Bank's Multi Sectoral HIV/AIDS program for the Africa Region (MAP). In accordance with the main goal of the MAP, the development objectives of the project in the Central African Republic (CAR) will be (a) to contribute to reducing HIV/AIDS prevalence; (b) to reduce the impact of HIV/AIDS on persons infected with or affected by HIV/AIDS. The objectives will be attained through a multi-sectoral approach, facilitating effective activities undertaken in various sectors by public and private organizations , and by communities in the fight against HIV/AIDS . Project-supported activities will complement government, donor, and private sector initiatives. The activities will vary by community and sector but be consistent with the draft national strategy against HIV/AIDS, and proposed by the actors themselves. Nevertheless, the overall focus of these activities is likely to be massive behavioral changes, access to voluntary testing, counseling and treatment, and support to people infected or affected by HIV/AIDS. 2. Project Justification A social assessment and a series of consultative workshops held in early 2001 emphasized the lack of support to many public and private initiatives against HIV/AIDS, and requested that the proposed project focus on supporting and scaling -up of large numbers of such initiatives, in a massive, cost - efficient and coherent way, in order to facilitate a rapid nation-wide expansion of responses against HIV/AIDS. The project will support responses in agreement with (Comit6 National de Lutte contre le SIDA) CNLS strategic priorities, which are in line with the Government's overall policy to fight HIV/AIDS. Project supported activities will complement the activities of existing programs financed by various donors and NGOs which are already engaged in the fight against HIV/AIDS in CAR. The project will channel resources through large public and private organizations already providing basic health and other HIV/AIDS -related services at the national level. In addition, the project will develop Comites Prefectoraux de Lutte Contre le SIDA (CPLS) at the prefecture level to directly channel resources to local organizations and communities. 3. Detailed Project Description a. Objectives The proposed project will reach its objectives through activities financed under three components. These are: (a) strengthening of the public -sector responses , (b) strengthening of civil society responses, and (c) coordination, financial management, monitoring and evaluation. The project will invest in cost-effective activities with potential to reach large segments of the population To strengthen local capacities and ensure continuous and timely flow of information on HIV/AIDS and its prevention, all project components will include substantial emphasis on training and behavioral change communications activities. \`i:'w'I../ I 1],,/I, h ( 7i tI', I f! .¢>fl'; .' 1P/ *21 B2 2 ; 1'.4 G" ,/ R93 'I X,' ( Ac! lI pub. 0f 'I 7a' fiil,i 'JcSe Worlrd B,ak / 7:mrrgence The handling, collection, disposal and management of HIV/AIDS infected materials is the most significant environmental issue in this program. In light of its importance to contributing to the spread of the disease, the project will prepare a Medical Waste Management Plan, which will be appropriately costed with clear institutional arrangements for its execution. In many of our client countries, the inappropriate handling of HIV/AIDS infected materials constitute a risk not only for the staff in hospitals and in municipalities who are involved in waste handling, but also for families and street children who scavenge on dump sites. Some aspects of project implementation for example the establishment of testing' clinics, the purchasing of equipment by communities for home care of the sick etc... could constitute an increase in the environmental and health risk with regard to the handling of HIV/AIDS infected waste. b. Development Objective The objective of the study is to identify the level of Health Care Waste Management that will be relevant to help implement and enforce proper health and environmentally sound, technically feasible, economically viable, and socially acceptable systems for management of health care waste in CAR. The examination of the of the current practices with regard to the handling of hospital waste will verify both the management of waste within the hospitals, clinics and other health centers as well as the management by municipal authorities once the waste has left the source It will also look into the level of knowledge among staff (hospital orderlies, nurses, patients, municipal workers etc...) about the practices to be adopted, and into the availability of equipment such as incinerators to deal with this type of waste. 4. Scope of the Study Task I analysis of the current situation related to HCWM V Assess the Policy, Legal and Administrative Framework as well as the Regulatory Framework on health care waste management and treatment /destruction facility in the country including air emission standards which are currently required by law and which would likely be required in the next say ten years / Identify permit requirements, including environmental building, and other permits and procedures that health care waste treatment/destruction facilities would need to address V Outline any public participation or public hearing requirements and procedures. For each requirement, list the lead agency to be contacted. • Assess the typical time demands for proposed facilities to obtain permits and address environmental impact requirements and public participation requirements V Identify all healthcare facilities in the country and include basic information for each facility, such as number of beds, bed occupancy rate, specialists, divided into categories. university Hospitals (if any), Regional Hospitals, general hospitals, Municipal Hospitals, and other health care establishments. / Assess the health care waste generation at (i) one major hospital (ii) one major regional hospital (iii) one general hospital, and (iv) one private clinic. The details should include the minimum weigh of total generated at each health care facility per week. Composition of the waste should be determined through segregation at the waste end point, extrapolate the results to cover the entire country V Assess the level of scavenging, if any, or recycling taking place inside health care facilities; along transportation routes, and at final disposal sites. Determine social issues in relation to scavenging taking place. V Review and analyze existing health care waste storage, collection and disposal systems with due regard for level of separation, the frequency of collection; and environmental and health impacts for existing treatment Task 11: determination of technology and facilities for the treatment of HCWM V Assess alternative technologies and facility sizes for treatment and destruction. The assessment shall compare the alternatives on the basis of capital cost, operating cost, ease of operation , local availability of spare parts, local availability of operational skills, demonstrated reliability, durability and environmental impact. I\ S //{)}/, ./ 1 l { {//, I2 -( { .1 l t t ;/ {. l So, s l," & N z, _ 24 F 02 {)0) ; l ,, 70 t/ 93 , h. (f 'nied Rcp, , '/w , of I .'n..; I he 1l1 orAl Kwa . / I :m,n nCJ' / The technologies to be considered include. safe land-filling, incineration, sterilization (autoclave and microwave) and chemical disinfection. • On the basis of this assessment: recommend a process flow for economic and environmentally sound treatment and final disposal of health care waste leading to selection of appropriate technology The Government and/or facility should make the final decision on choice. Special provisions for the determination of disposal sites / If site for disposal exists, collect all existing plans of suitable sites to be considered for the locations of the treatment facility(ies) and review general transport and traffic systems relative to appropriate sites. Consider (a) accessibility to the site, (b) distance from health care facilities to the site, (c) distance to sensitive areas, (d) future development plans of the area, (e) possibility to acquire the area (f) cultural and historical sites, (g) public opinion, (h) noise and dust impact to nearby areas. Public consultation/hearing must be held as part of the final assessment for sitting of the treatment facility. V Analyze of the site: analyze the above information to determine whether there is sufficient appropriate material on site for daily and final cover, whether the site soil, hydrological and geo-hydrological conditions would ensure adequate protection of any ground and surface water used for drinking and/or irrigation. If the sites prove to be unsuitable, inform the client stating the reasons Financing The National/Local Governments, potentially in conjunction with other municipal solid waste treatment and disposal activities, may finance a regional facility. An alternative approach is for the private sector to provide the health-care waste treatment and disposal activities or waste transport for the entire region. / Assess private sector participation as service provider. / Assess public-private partnerships and cost recovery at the regional, municipal level, based on the polluter pays principle, where each health care facility pays according to the volume of waste generated. Task Ill: awareness and training / Review existing training and public awareness programs on health care waste management at hospitals and other health care establishments and prepare a training needs assessment. V Working in conjunction with the relevant government institutions and Municipal councils, prepare a costed training program and a well targeted Awareness Building Campaign Program including the general public, and more specifically health-care workers , municipal workers , dump site managers, incinerator operators (if that is the choice of technology), nurses , scavengers/pickers families and street children. The design of the material required for the awareness building programs should be discussed with the relevant authorities and the general public to ensure that their concerns that are deemed appropriate are incorporated in the design of the program, siting layouts, mitigation measures and community communication programs. V The Training and Awareness Building Program aw well as the Management Program shall be appropriately costed and the Plan shall be presented in a National Workshop. Task IV final report Output and Reporting Present and discuss a full draft report with the project authorities and the proponent, and focus on the significant environmental and human health issues in a format similar to the following V Executive Summary / Policy, Legal and Administrative Framework V Project Description V Baseline Data V Assessment of Healthcare waste V Healthcare waste Training Needs Assessment ,1\t,a')/o.// I-I '~I,/I,,-( , .. 1. IL2 , .fauaL 'no! 4 J)/, / 02 20(j1 71 7/ o/3 'ITh. ( lni!ed R ef/ul6/c of I;,wla 'I 7he ll'orl.d BUJ, n 1 ergee V Determination of Technology / Determination of Disposal Sites i Management and Training for Institutions and Agencies V Monitoring Plan / Appendices (list people consulted; references, record of Inter-agency I forum/ consultation meetings) Final reporl Revise the draft report in accordance with the comments of the World Bank, the Government and other interested parties and submit the Final Report incorporating all changes and modifications required to the Project Task Team. 5. Study supervision and time schedule The work of the consultant would be supervised by the relevant government institution(s) responsible for the project. The Agency will coordinate with all other governmental agencies, ministries and other donors working in the sector. The Consultant: $ shall begin work no later than one month after the date of the effectiveness of the contract. It is anticipated that the Consultant would complete the outputs of the work over a maximum duration of 6 weeks with four weeks in the field for data collection and two weeks for report writing and finalization of the document after the review has been carried out; / should propose a clear schedule with critical milestones, and makes all possible efforts to complete the work at the appointed time; / should have the technical competence in scientific, health, environmental and engineering fields in particular sanitary engineering He/She may also have competence in the private sector participation field and skills in training and institutional strengthening; $ is expected to provide 6-8 well binded reports with pictures and maps where necessary to the Government and the Bank N'\atl,m,/ I It,al/!1'-(, lle It dwI( A /i,, * 2/ (1_' 200; M,,P , -2 ol 93 I1 0 7 ' 0 l ie - , o , 1 IL . 0, .,1 Annexe 2: Agenda of the mission and contact list Agenda_* rnissions December 2002 and January 2003 Health-Care Waste Managemeiit-Tanzania a.) da ,'0 ." ..d. . . 0,_ _ ., .n. . 00r 0.1. 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WgTd Bftn S4.1-/ d1 LM AghHt hr Pf.--anw wof W- WK... 0830 1010 Th. wodd rbn MDobogt; M Osporl=k Re.c-.M,M,,MSDanMrO M M R.yno s(OrotMM,k)M, K-vod. . 13X~~~~Tf W.-I r,,v rpofr- a 21 X0 23 X IrRnoa IsSG Off5 0s 0T000Y br 160 M 30 1300 0 00000 M"0y0 00 0 0My '0300 000 M1000 0f Ohfc M M00010R0g.,M M0l Ofr M,60,,WM M,M1bb M- I 1 XW 12X r#L Wby.Rv2rawlrop IV., Mt,HoopIw M, WMWJPd Wre M.rI AW..t Th. .-1 hM4PW .uecnne MWM Mt OPO fY LwLrthVryrr - 0100 000 1.60901Sf fOfooeooo ('rl(i 'r'§Rrn' a it.lma:. 1 ar I t1Pz'd !}.liq'1 ....It W s l, ,,, Ag 3nda missions Deceimber 2002 a'nd January 2003 ' ,Health-Car6 Waste'.Mana,g3emerntltinzan.ia da, d.tla Dlrca .PUrpOS;rI lopl d.SCUBSaD - -ntocuios reark- 1200 0I MMe 4"r ,;t; r,i' *r ..aar. ;1. .A- 400 50 MxataRe.,endocOLtt Maletny V, ofa Materrory .ar.c iceyr M SMarmso Th.e a talr ryalrada.ulyl n al S Ir o M lb, l t lratibl *.: 1S50 15 2 rso On a Sra Macorg orlr ic Oan Mda tdDTr rof Hlltal DI Muga. 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SS+ R9*I ~ W), 1" 91,9WAye - - -<: - . .A*099*069*0.09199099 - .06996-61 1*1"*.1 *99191'4 96 .1, W.9,1 aly~- *.- IR *t m 2: ... 1 - o ....Js-* w. *uu *9i..eeze u -*'.w.:-./ 45e W . * 5 69*1.*H ______________ -. . .~~~~~~~~~~~~~~~~~~~~~~IS1 " IM 3 :F I O U UO -v(,JRiWI Jd., 9!U2ZU9j Z' ~UBWI JUJ'O~SUM'BJB3.LUIRG I h, 1 ,ied/ R'p.h,/h& of 1U11,,u.J J ke 11w-,/ 114u4 / I :Mergenre. Annexe 4: Data collection and analysis 1. Example of Hospital Assessment Min contact: Dr Ngwalle, Executive Director Dte of the survey: 18-19 Dec. 2002 General information Muhimbili Medical Centre was built in 1956. It includes the Muhimbili Health Faculty and the MLuhimbili National Hospital, which is the biggest Hospital in Tanzania and the main of the four referral Hospitals in the Country. A short walk through the hospital reveals a poor shape of the infrastructures (leakagc of boilers, water tanks or plumbing material, parts of ceiling falling down etc ..). Muhimbili National Hospital brings to mind Gericault's painting "Le Radeau de la MMdusC". * Number of wards: 40 * Number of beds: 1'200 * Average occupancy rate: 90% * Total staff: 2'800 workers HCW generation Type of wastes generated All the categories of health-care waste (HCW) are generated in this hospital corresponding to the numerous medical activities that are carried out in it. More details are provided hereafter. Quantities of HCWM produced The quantity of health-care waste produced at Muhimbili hospital has been roughly estimated through the discussions with the ancillary staff. The estimation of the daily quantity of HCW produced per occupied bed per day is actually important to estimate to: ' I) plan more adequately the resources necessary for the management of the HCW; v 2) size the disposal equipment. *-- ~ ~ ~ ~ ~ - ,,--.. . ,.= . ., -. --.'-.-*.. ~~~Daily - e category p 'Comments . - , - ~~~~~~~production I 3000 kg are daily collected by the munidpal services of Dae-Es-Salaam, Domestic waste 2800 including General Domestic waste that can roughly estimated to reDresent less than 10% of the total weight. General medical waste 200 considering that the capacity of the DeMontfort Incinerator (Mark 11) does Sharp production 150 not exceed 30 Kg/hour in the current conditions and that the incinerators is run 5 hours a day. Organic waste 214 considering that approximately 6 m3 are disposed weekly and that the waste has a ratio mass / volume of 0,6 kg/litre. Total 564 special and hazardous waste production 0,42 kg/occupied bed/day ratio (total hazardous HCW / total waste) 17%0/ The figures hereupon are similar to figures found in other African countries for a similar health facility. However, the production of hazardous and special HCW might have been overestimated since the hospital treats also the "organic waste" generated at the Medical Health Faculty. Natu, l / , I Jeal//-( l Ma I ; a11W<, "/l/ J/,,z- 2'4 02 2N); 200 ,. 93 The I h tw,irdI RL"Mb)/bILc of 1I'ii/z1I/1 7I ke Wt orl,Ild 13k /I ,' :mrgaei Segregation, packaging & labelling After having received a training organised by the WHO, the nurses attempt to segregate at source the HCW generated in the different wards, which is a positive aspect of the HCWM practices in Muhumbili Hospital that should be maintained and reinforced. A three bins system has been set-up in the different medical units: v The "organic waste" are collected in separate plastic bins of different size (mainly 60 litres) and colours They consist in anatomical andpathological waste as well as placentas. They are collected in plastic bags or buckets and disposed of separately. They are incinerated in an old air-excess incinerator. When the "organic waste" is too "bleeding", it is placed in an plastic bag (PE, black, no more than 0,35 trm of thickness). In general the bins are covered with a lid.. Typically, They are located in the ward/department, next to the nurse room. v Sharps are collected in separate containers, more often in recycled plastic bottles. The containers are not hermetically sealed and have no specific labelling that enable the medical staff or the general public to easily recognize them. Once full the containers are either disposed of or else emptied into the incinerator to be reused. Sharps have been found with general medical wastes indicating failure in the segregation practices; v The other categories of waste that consists in a mixture of domestic waste (papers, plastic bottles, left-over food, etc...) and general medical waste (gloves, bandages, swab) are collected into a v ariety of containers of different quality. The absence of adequate definitions does not enable to perform a correct segregation between 'these two categories of waste. Unfortunately, the absence of a systematic colour coding and labelling system is one of the numerous factors that lead to mistakes in the segregation. Segregation remains quite ineffective and sharps are founds in every category of waste due to the absence of a clear and systematic protocol that fails to be rigorously applied. The segregation and handling practices remain coarsely managed. The lack of equipment such as adequate bins or sharps containers worsens the situation. In final, the risks of 1) a person accidentally coming into contact with hazardous waste, 2) mistakes occurring during segregation are important. Waste collection system and on-site transportation The staff members of the Technical Services collect the HCW daily in the wards. The dustbins are transported through the corridors without any particular precautions before being emptied pell-mell directly on the floor of the storage sheds. During on-site transportation, there is a significant risk of spillage of the waste since the trailers does not have adequate edges to prevent the bins from falling down. Collection and on-site transportation are generally organised by the technical services. There are no specific schedule and collection routes within the hospital. However, sanitary labourers do not enter directly the wards/departments to collect the dustbins by themselves, but the nurses seems to leave the dustbins once they are full outside the department for collection. It is a positive aspect to limit the risks of nosocomial infections. Sanitary labourers carry heavy gloves and industrial boots. I A t ( :drwied R,vulul,c6b b f bm.Z,mg., I' o,-A/ Bnik / Han . ? z.r, Storage Different storage facilities and practices exist in the hospital: v' sharps are directly stored next to the incinerator before being incinerated; v four lockable storage facilities of 6 m2 without pavement are used to store the general medical waste. They are dispersed in the hospital compound and not locked. A roof and a wire net prevent animals (but not the flies) from entering but the doors remain permanently open (see annexe 5 photo 3). The waste are daily removed; v "organic wastes" are stored in a similar facility to the one hereupon but the facility has a concrete slab and is maintained locked. The facility is not kept clean and the wastes are not protected from the effects of the weather. The storage lasts too long (up to one week). An impressive number of flies (a noisy black cloud) fly in and around the facility The decomposing waste generates odours and leaks on the pavement that the mission refuses to describe or illustrate. No adequate support facility like washing and disinfecting material has been observed near the storage areas. This situation associated with inadequate practices (no regular hand- washing, decomposition of the "organic waste", flies...) results in absolute insufficient standards of hygiene. In addition the localisation of the storage facilities in the hospital compound remains inappropriate and too dispersed. Waste treatment and disposal Solid waste disposal General nmedical and domestic wastes are collected by the municipal services and disposed of together with the solid wastes of the municipality in the dump-site (located at Ilala district?). Sharps are incinerated in a masonry double chamber DeMontfort incinerator. The incineration is carried out on a periodic basis (daily, except on Sunday). Apparently, the incinerators used have some difficulties to reach a temperature of 900°C. Products of Incomplete Combustion (PCI) and Persistent Organic Pollutants (POPs) are generated during the whole process. Nevertheless incineration is performed in an area that is not densely populated and enables to reduce immediate hazards linked to the sharps. With respect to the financial resources available in the hospital, this type of incinerator can constitute an acceptable intermediate solution to dispose of the sharps. The ashes, full of needles, produced during the process are buried nearby. "Organic wastes" generated in Operation Theatres or in wards are disposed of separately. Twice a week, they are incinerated in an old incinerator, air excess type. Sanitation & Wastewater N/A. Management and administration Planning capacities The management of the HCW is not rigorously planned (no agenda scheduled for collection, the "organic waste" incinerator works when "we have fuel", etc...). The lack of planning is due to. 1) inadequate management procedures, 2) lack of equipment, 3) deficient resource and 4) a lack of know-how. N\/11 I,/I z I t UP,,; / -( ,4 12.20 ; lig'* . X0 ol 93 -17 r, ( J RP1,hihl/, of / ,; , ,,/ 1; J he Il or/li 13n / , ' I .,/w, rge What is yozur appraisal of the current situation regarding the HCWM within your institution 7 Very bad Bad Satisfactory Good Very Good * direction x * hospital head nurse x(.) *ward head nurse x * overseers x * mission x Specific issues Safety provisions in the Laboratories & Infectious Disease Units The mission was not able to analyse how highly infectious waste are managed in the Laboratories and if they receive at least a chemical pre-treatment before being discarded with the general medical waste. Hospital Hygiene & Infection Control Poor hygiene and infection control procedures in the different wards have been observed. Handling of syringes and needles - sharp management see Annexe 5 2. Results of the surveys ,~Nb," O j O- . .; . - A . . . General Medical Waste S sharps . .' HCf 4 ;<;:> [. C al4Ow N beds' rate ,~ Oecup l e d ' bloed k i9i| .glocbeidi RemarKs b.Caesor - -ratre dy, rati kg Id3ay. dy ' Amana Hospital Distnct 150 200% 300 537 0,30j 1611 0,54 Mbeya Consultant Hopsital Referral 477 95% 453 600 0,301 1800 0,40 Innga Regional Hospital Regional 36 85% 310 450 0,301 135; 0,44 Surveys carned out Mafinga Distnct Hospital Distnct 130 120% 156 150 0,30 45i 0,29 dunng the consultancy Mtwara Regional Hospital Regional 320 170%| 544 960, 0,301 288, 0.53 Muhibili Nabonal Hospital Referral O w 0,45 Dodoma Hospital Regional 395 71% 280 30 0.11 Surveys camed out Korogwe Hospital Distict 142 50% 71 50 0.70 previously and Bagamoyo Hospital District 88 44% 39 13c 0,33 consultancy Mwananyamala Hospital Distnct 115 1100/ 127 156 1,24 (1) |. Aerag_ - |'237..1 01%.? 24i \N! dCl.i/ru' lr,,//!I( .ur' lLKjr'e A Ia,tri/z¢o;:e,l/ P)eip. * 2f ()2 20P21 0221),g ol ')/3 7 s, ( ,' u / /1O'ss';u 1 . 1 7 Ls'I I[ fo~r/o l -''/ :" n Annexe 5: a/National Inventory of the Health Facilities REG5c0N 4-.'i a0.,-4s PI 0AS 1.4..C ~ ~ . ~ . ."E8LT.rCEN7RES,-. -4 -';qpj!y* MWN _0 202,, 0 01-251 0 IA_A00 0 - 63 0 0 0 - 0 ' U73 004.. 005 02 0 O I S,? 0 0 3 0 0 00.555530 0 0 I 500 0 0 o 1 T 5?000 0 0 0 0 0 0 0 0 0 Y t3~~~~~W 0 0 0 0 05 050 0 03 0 0~~~~~~~~~~~~ 0 _0 __ 0 0 UWANZA...s~o 50 _,~75 ~/ 0 1973 44oO .~0 '~s~ 2.o~92 ~2 4200 3222 ,i:ioo ..0oS .o99 C3530 53...j~/Oo,oo.3.~so70 .~oo.2 .2V20 5 5 5 0 5 0 0 0 0 0 0 00 050500500 0 OS 0 0 0 5 0 0 0,5~~~~~~~~~~~~A TABOftA, 0, .0 0 0 5 0 39 0 0i- 38 0 0 000GO 01 55 000 05 0 0 0 0 0 S 0 5 0 L o -14 - 503 ~MRA5 5'- 4 ~~43 ~ ~ 43 ,s2....o.O 0soO o7,O O5~.2 AlO ~ ...0 -'9. f.-. 4.-05-1 05 *05I00,,,.0,000 S 000 0 0 0~~- 05 - I0 _200 5 04 I 5 0 0 ______ 0 ~~~~~~~~~~~~~~~~~..j0 0 0 0 0 0 0~~~~~~~~~~~~~~2 0_,00. A 0 5 50 00 5 50 0 -,2 0- 1 110 0 0 0 0 5.s.,,. 5 505 5 500 0 0 0 0~~~~~~~~~~~.1 03 5`50 3 0 051 0 0-00 50---; 000' aEYA50 5 500 0 0 5 03 0 0G00s 0,005. 0 0 5 500 0 0 05 0 5 500-- 0 0 0 0 - 0 0 0 RUW'JOO/ -5 -31 ~ 0,4.0 ~ o ,49 ,3 ,401 ~ 0 .20 ~L4L7 .s4O..,.,O .4.~ ~49 4, __________________ 0 0 5 00 0 0 0 0 5 00 0 50 0 00 0 0 0 0 3 30~~~~~~~~~~~~~~~~~~~~~~~~~~2 Ssss,52.,.5100 00505 ..04. 0 0~31 0A 0 JL .0-0 0 0 0 F,sSRESNGAL5.AA. I 0O4s72024 oo4J_.9019 ŽL -..1 24o1- 219 0 ~27 4,45.539 22 .~ 4oij 1 4!T7 ,329 -192 03.03,. 2~~~~88 - I ~ 0O 0 0 80 07a53 310030 L53SINJDA44. ____3 345'~.- 4 997 450 -40 . - 4,5~0 ,,~. 7~0~192 4 2~,,,,O9 ,4442 ,~ ,.o,,o55. 55.550. 1~~~25 5 0 0 0 0 0 05 30 4 0 0 ' 50 055052.05I5.5 0 0 5 555-2. 0 0 0 5 5 5 5 .5L50 0 0 030M0R5I0. 0f- 0 0 A 0 0 " 05 -0 0 3 0 4 5 0 0035 ARU900bA 2.9:h19-.9 a.1121 -.,3,..O0 -0 92 2270-13 .4223 54,4.1,136 . . A505555 5 00 0 0 0 02, 7 0 0~~o 55 01 3,-85 020 5 01 0 0 5 05 0-~ 0_0 045 KIMNJR2, ~ ~ 5.O,.,Q lsk.o ,2,10- -.l .73,~. 9209.s. 2 ,3U ..2LO.o4 O.4O .o..- 0 s.. 4s..7 "I ,O4359 0.55. 5 500505 0 0 0 0 OLil07305 S 03~~~~~~~~~~~~~~~~~H---- LL 5,3504 -_TNG ~ ~ ~ L43'j -I3.1_I50032 135255 j 00.55005.5OS.t 05 00 5 503 0 00 00 L0505It LiiiiiZVIF F3sfl4T00 .TA0OA.,..~44 so~O.'04 4...s, .Ofs..O-S ,,, I'l 524 902.2,12 I 8 9 7 ;J.- ( r ,,£' ,! 1t. I,-,.s1, ,' h ..,..;,, * 1 ,5, Vi,/,/ Ri7'O I (,.- PbrMel b/NationalHCWProdiiction VentilatedperRegions The ratio of 0,41 kg/occupied bed/day has been used to estimate the National HCW production, using the National Inventory of HCFs provided in the Health Abstracts, 2001. The National production vary between 12 and 14 tonnes per day. The seven regions of, Kagera, Iringa, Kilimanjaro, Arusha, Pwani and Mwanza produce 50 % of the total HCW of the country They should considered are priority regions p;~~~~- sw -r , ' §NcLwse!9c!>BSBE .~A,-,,; > - , ';% . ,. Hositils',,, |eait sC,entr,ei`-- r Totai Jr prodcir 710326,361; 1 83- 6% 62% KILIMANJARO 82~~31,3. 92,8. 1, 7 5 ______________!,,_:-_34:4 72,6 1007,0 7% _ 82% i iii F -- 3~~75,66ir-'J 702 ill ! S 4 1~~~~~49 : ----42 -°Z PAI REGION 118476,4 3,45 17 8 91% ; ,\ , , lW ..' . 453,11 72,8. a 2 2 z z .,- ~~~446,9, - -=86,2- ________.___3___.__ 5102,5 74,6 1 % 100 *i = ! , ,j 617,5 - -114 - a B5> 5 - . i- ~~672,8 . 76,0---- E DAR E S SALAAM | 698,21 123,61 8218 6% | 56% KAGERA 710,1| 126,0| 836,1 6% | 62% IRiNGA | 737,61 158,6| 896,2 6% | 69% ,KiLIMANJARO | 823,3| 92,01 915,3 7°/, 75% ARUSHA 934,41 72,61 1007,0 7% 82% PWANI REGION T 1118,9| 38,4l 1 157,3 8 91% M AZA | 1045,51 272,61 1318,1 9% | 100% _1~~~~I a =jI"',,' 'l, o220( l1 I . th//et! I//// f J>' ;,l,1 J/ I Te Wor/l 8 ano /I ergern- Annexe 6: Fundamentals on the Management of Sharps Sharps represent one of the most problematic and hazardous types of waste generated within HCFs. Syringes and needles are of particular concern because they constitute an important part of the sharps and are very often contaminated with blood. The occupational risks are linked to: The great quantities that are manipulated daily by health-workers and generated throughout the world for both curative and preventive activities, The cuts and punctures they may cause followed by a potential infection of the wounds. The main diseases of concern are those which may be transmitted by subcutaneous introduction of the pathogens such as viral blood infections, The scavenging and re-use practices that occur in some countries, exposing the populations (and most particularly children) to risks of cross contamination All biomedical and health-care waste with sharps or pointed parts have a high potential to injure and inoculate potentially dangerous pathogens. They must therefore be categorized as infectious waste and have to be manipulated, discarded, transported and disposed of with maximum precautions by health workers. Due to the lack of reporting at HCF level, needle-stick injuries occurring worldwide are globally underestimated. However a recent study carried out by the WHO shows that, depending on the country, a nurse can get a needle-stick injury more that twice a year. Therefore, handling and disposing of safely needles and syringes, and more generally sharps, must be seen as an absolute priority by the Health Services of any country. The safe management of sharps requires to: Define a strict policy at national level with clear handling and disposal protocols to be respected in all HCFs, Provide each HCFwith adequate equipment for sharps discarding and disposal; Ensure that all HCF staff are aware of the protocols and properly trained (in-service trainmgs and review of the initial curricula are often necessary); Establish a system to report accidents that occur and monitor the application of the policy. It is internationally recognized that the safe management procedures of sharps should comprise the following practices: A health-worker performing an injection or the staff member transporting health-care waste should always wear appropriate gloves (a study carried out at the Geneva University Hospital - Switzerland - showed actually that more than 50% of the blood remaining in an infected needle is stopped by the gloves when a needle-stick injury occurs); All disposable syringes and needles should be discarded immediately following use. The needle should never be recapped or removed from the syringe since most of the accidents occur when the nurses attempt to recap the needles; Under no circumstances are syringes or needles (or the full containers) to be disposed of with normal garbage or dumped randomly without prior treatment; Sharps should be placed in specific cardboard, plastic, high-density polyethylene or metallic containers resistant to punctures and leak-proof, designed so that items can be dropped in using one hand, and no item can be removed. The container should be I) labelled with the international biohazard symbol; 2) be of a yellow colour (the international colour coding system for infectious waste strongly recommended by the UN Agencies), and 3) marked "Danger contaminated sharps, do not open)); allom /oIf //I I t<, M ,//.i,-( 24 02 20 RI, * o {11,93 T1/,, ( n,!edt R,yh.,bli Of 'Ihe Wor/,l /3a'L / f:re,,a,Y The containers should never be overfilled but systematically disposed of once they are three- quarters full. They should not be emptied for re-use, except when specifically designed for this option (see "the MSF practice" described hereafter). There are two ways to dispose of needles and syringes in a safe way. The first solution consists in discarding the needle and/or syringe in a puncture and leak-proof recipient which, once filled will then be treated/disposed of with other infectious waste or emptied in a sharp pit The second option consists in destroying the needle on the spot using a specific device. Option la The basic idea is to discard the whole combination "syringe plus needle" into a safety box immediately after use The box is then treated with other infectious waste. This option is recommended by the WHO and UNICEF and applied in all industrialised countries. This practice enables to reduce the risk of needle-stick injuries for the medical staff but generates important volumes of sharp waste that must be incinerated since alternative technologies such as autoclaving and shredding or microwave processing are difficult to apply in low income countries. In order to oxidise completely the needle, it is necessary to incinerate it at a temperature greater than 1'400°C. Modern pyrolytic incinerators or rotary kilns, which are expensive to install and operate, must therefore be used. Alternatively, air-excess incinerators or improved double-chamber auto- combustion incinerators such as the De Montfort incinerator can be used. These kinds of incinerators are able to burn the syringes and disinfect the needles at temperatures of 900°C. However the ash that is produced during the process still contains the needles. It must be carefully buried. Alternative incineration can hardly be applied in populated urban areas due to the potential e.mission of persistent organic pollutants (POPs) this technique may generate. Open-air burning of cardboard safety boxes is also seen as an alternative in rural areas when there is no other possibility. It is typically the case during mass immunisation campaigns The WHO and UNICEF recommend this practice in the rural areas of low-income countries '. ' ~ThelUNiCEMHO.safety box: .Xhdap .. otomrepnepsive n- I , L 41 .- it --- a -W J ' Optior, lb In this case one inserts the needle into a slot of a container specially designed to separate it from the syringe using one hand only The syringe is then discarded with the other categories of health-care waste while the needles remain in the container, which can be made of polyethylene (closed tube or empty drug-boxes, cans, etc .). Once full, the container is safety emptied into a sharp pit, using a system that prevents the user from being in contact with the needles it contains ("the MSF practice"). ^\z/Z/)Xz,,/1 ~ ~ ~ ~ ~ 2 02,//- ,2 l;. 0/l,y,^s/1z1X '1)) 1)) 1 .i 5 .Y ol pj I;h. ( I ,' / ,-, ,' / I *,,;,;,;I 7 he IVc'r/,/ Ba'ik / i The container can also be directly dropped into the sharp pit. The pit, once full, is encapsulated86 and a new one must be built This option requires greater care from the health-workers who must separate the needle from the syringe, using one hand only. - MSF PE sharp box. - -.- . - iPATH*removabl .can ("Po ;;;) Option 2 Oplo tion 2 In this case, the needle is destroyed at the poit of use with a needle destroyer. The user inserts the needle Into a hole or slot in the device, which positions the needle between two electrodes in the device's interior By contacting both electrodes simultaneously, the needle causes a electric current to run through it which heats the needle to temperatures reaching 1500°C to 3000°C. The result is a partial or total oxidation of the needle. 8,-,^, ', ,- A rne'edIesdestr6yer"-;a i, VI, . ,,,. 86 Encapsulation consists in adding an immobilising material in the pit and sealing it The immobilising material can be mortar, clay or bitunien \':1 Wi/ / I 1,1i//-C ' I I ./cI24 02.2fl(); I4 ,gc 6 ol () l il I ''zfed R/ywbh, of 'l f lid 7he It>,r/,ll orJ,1 k 1. CergC'f-e The table below provides a comparison of the advantages and the drawbacks of the different options. Oplionr - ; - . , Advanta6es,> X- ;' - .; - - - ' . It is possible to dispose of AD POPs may be produced depending syringes on the incineration system used The handling of the needle and If the incineration is not performed . - rr>b syringe is reduced at a maximum at sufficiently high temperatures, the enabling to diminish the risks of needles remain and ash must be ,-,r,*'@,4,2 needle-stick injury safely buried The volume reduction, once Incinerators require regular incinerated, is drastic (more than maintenance to be kept in optimal 90%) working conditions Except for open-air burning the capital and operational costs remain relatively high ~',f.2-, Once it has been constructed the pit The needle has to be separated from l ^ r'Js4t is simple to use and does not require the syringe which may increase the any maintenance risks of needle-stick injury for the There are no operational costs. The health-workers I * . -~ .~ ~ capital costs remain limited It is not possible to dismantle AD ! '- .: There is no emission of air pollutants syriges, which are used more and ,, ;, . . ~~~~~~~more frequently in low-income The volume reduction is similar to the one obtained with incineration countres ib A new pit has to be periodically built depending on its filling rate The pit may be filled with other material than sharps and become rapidly full, increasing the construction costs Requires space within the HCF compound to dig the successive sharp pits Provides a satisfactory solution to Requires electricity to run "' &9 S7:j-'. get ride of the needle at the point of Require a good maintenance of the use device that can "clog " easily if the Avoids the transport of sharps small amounts of ashes produced are Does not require an on-going supply not regularly removed 2 - - of sharp boxes or containers Expensive solution that will be May be an alternative technology in difficultly to include in a HCWM urban areas for some specialised policy in a low-income countries HCFs where a lot of sharps are manipulated (Mother and child centres, blood banks, sexual . - .: transriiitted disease clinics) ,;/'p;;/ J I,/ 8t. -( a}te l I 1ayc ',n:el: I/j1 *'I (1 2i')(i 1)221 A' , o/9 5j 7 ';h ( t.,!('/ l t/!bb/4 of I aa;,.1nI 7' Wo',',/ 8',- mr- e I -e Annexe 7: HCWDisposal Technologies The choice of a technology for HCW treatment and disposal should always be driven with the objective of minimizing negative impacts on health and the environment. Several technologies exist to treat or dispose of HCW. They include: I) Incineration in rotary kilns or double chamber incinerators; 2) Burning in single chamber incinerators; 3) Wet thermal treatment (autoclaving); 4) Chemical disinfection, 5) Microwave irradiation, 6) Sanitary landfill, including inertization and encapsulation. Not all these technologies can be used for the treatment or the disposal of all categories of HCW The suitable treatment and disposal technologies according to the different categories of HCW are presented in the table below. Two Waste cate y -.Rotary chambers Single Wet thermal Chemical Microwave Sanitary -kiln pyrolytic cabr temnt disinfection irradiation. landfill"-" * kin incineration incineration (autoclave) non-risk-HCWN N/A N/A N/A N/A N/A N/A N/A -Humant3--.!.t,' ' anatomical YES YES YES NO. NO NO waste. - -.'i.2 Waste,sharps ,$:;!1 Waste shars - YES YES YES YES YES YES -Hazardo'us ..- - g | -1.;- : Pharmaceutical - YES SAal amount NO .CI 'waste'ol ,f .,-. Cytotoxic - _- NO l,, . . 1a - pharmacutical YES YESfr < NO Infectious waste YES YES YES YES YES YES Highly infectious waste YES YES YES YES YES YES Other hazardous - , - waste - YES - NO' .:NO: -NO .NO NO DE Radioactive YEs health-care waste o-^ [ NO- NO; NO- NO Z. NO Specially designed Incineration is not the same as burning. Incineration is one of the only technologies that can treat all types of health-care waste properly and has the advantage of reducing significantly the volume and weight of the waste treated. Incinerators nevertheless re4uire skilled operators, extensive flue gas emission control systems and, frequently, imported spare parts. Incineration generates ash residues and air emissions can contain pollutants such as dioxins and heavy metals. Burning in small-capacity single chamber "incinerators" is a technique often used in HCFs in low income countries. These installations may nevertheless constitute a serious air pollution hazard to the surrounding area due to the relatively low operation temperatures and the lack of emission control systems. If biomedical and health-care waste are treated with single chamber "incinerators", waste fractions such as cytotoxic drugs, chemicals, halogenated materials or waste with a high content of heavy metals (batteries, broken mercury thermometers, etc.) should not be treated with this type of system (see table above) .; cincinrar tti n/>3 r* ' m"AdtanlageS, i--,% . ; .- . ' ' Drawbacks' -- In cinerto Q' V>vYtA Ynar+B¾,. Elimination of health nsks due to the complete High investment costs ;';-<^ " 'tJ@5i,'' k destruction of the waste * Requires skilled staff to operate Pyrolytic or double The waste IS non-recognizable Continuous monitoring required chamber :-, Fully destroys micro-organisms and sharps High maintenance, especially for rotary 'incinera~tors Reduces significantly volume and weight of the klins i ' (tncineration.at . waste Relatively high operation costs; costs 800:9000C) : jI Destroys a[l types of organic waste (liquids, rise with the level of sophistication of the K i~< A~ .~9jt-.; pharmaceuticals, and other solids) emission control systems Rotary kiln' * Important quantities of waste can be treated ' For batch inrn&ators. limited capacity (incineration al_', (j except for batch incinerators) * Emits toxic flue gases (including dioxins 1 200°C and higher) 9 and furans) Generates residues that need safe land- filling Good disinfection efficiency * Significant emission of atmospheric Sin'gle chamber i Reduces significantly volume and weight of the pollutants "lincinerators. waste * Need for periodic removal of slag and '(iricineration at low-.., No need for highly trained operators soot temperatures Inefficiency in destroying thermally 300400 C) resistant chemicals and drugs No destruction of sharps Auitoclaving is the exposure of waste to saturated steam under pressure in an enclosed container. Preparation of material for autoclaving requires segregation to remove unsuitable material and shredding to reduce the size of the individual pieces for greater treatment efficiency. Small autoclaves are common for sterilization of medical equipment but a waste management autoclaves can be a relatively complex and expensive systems requiring careful design, appropriate segregation of materials, and a high level of operation and maintenance support The output from an autoclave is non- hazardous material that can normally be land-filled with municipal waste. There is also a wastewater stream that needs to be disposed of with appropriate care and control. Furthermore, large autoclaves may require a boiler with stack emissions that will be subject to control. *N ., ,,',./ T I,,/we I it ;II A !an,,en/ ;r/u * 24 02 2 ('age ,Y o/ 93 7k (e ';"llien Repubibc oJf !,.oI , h It' "l1 'Vd 1Be"ew 'I et 1 A6ai. 7 Drawbacks -Steam Disirfection -: Advantages Relatively simple to operate (a known * Relatively expensive to install and technology at health-care facilities) operate Environmentally sound technology * Requires boiler with stack emissions controls * Relatively high maintenance costs * Cannot be used to treat some special wastes * Generates contaminated wastewater that needs special treatment Microwave irradiation is based on the use of a high energy electromagnetic field that heats up rapidly the liquids contained in the waste causing the destruction of the infectious components. The HCW passes through a preparative process which may include segregation to remove undesirable material before it is shredded and then eventually humidified prior to being treated in the irradiation chamber. At the end, the waste goes through a compactor before being disposed of. Similar to the autoclaving technique, the output from a microwave facility is considered non- hazardous and can be land-filled together with municipal waste. Since the technology does not involve the application of steam, there is a minimal generation of wastewater which can be recycled to the system. Since electricity is the main source of energy for operating this technology, gas emissions are also minimal compared to incineration or even autoclaving, which can require the combustion of fuel for the generation of steam. a Ad - K .,K. : .11Annunl Conts 1 ~~~~~~~~359 3001 352 1 14 000 \zZ//0Z / / 1t7//l (X i Vl,r', .s' kwi,-''e 2,'1'[)11*1e{ t1 _;{ Q3 o)Il(2 l 9)'/