Health Care Waste Management for Ethiopia
Guidelines
Prepared by:
Fikru Tessema (BSc, MSc), Senior Public Health Professio...
Table of contents Page
Abbreviations 4
Preface 5
Section 1
1.1 Introduction 6
1.1.1 Overview of Health Facilities (HFs) Ha...
4.8 Waste transportation guidelines 31
4.9 Waste treatment guidelines 34
4.10 Guidelines for steam sterilization 36
4.11 G...
6.3 Guidelines for allocation of resources and equipment for
health-care waste handling 59
6.4 Guidelines for Awareness an...
Abbreviations
HCF : Health-Care Facility
HCW : Health-Care Waste
HCWM : Health-Care Waste Management
WHO : World Health Or...
PREFACE
The purpose of the health-care waste management guidelines is to
ensure safe and healthful working conditions for ...
Section 1 Introduction
1.1 Overview of Health Facilities (HFs) Hazards and Infections
Safe management of Health-Care Waste...
carry a higher potential for infection and injury than any other type of
wastes. An integrated effort is necessary in Ethi...
This document is prepared to provide guidelines for the persons involved
in health-care waste management at central, regio...
The HCFs safety and health committee should assist with this in
consultation with workers from each department. The most
i...
substances physical agents, or biologic materials could have
serious consequences.
1.3.5 Keep Records: No sufficient data ...
1.4 Objectives
1.4.1 The overall aim is at providing guidelines for HCWM methods that
can be applied in the HCFs of Ethiop...
1.4.2 It is also targeting the provision of both conceptual and practical
information on HCWM.
More specifically for:
o Th...
1.5 How to use these guide lines
These guidelines are divided into five sections and have bee structured to
be as practica...
Section 2 Definition
The definitions and the classification hereafter are adapted from the
international classification pr...
2.3 Pathological Waste
Pathological Waste groups all organs (including placentas), tissues as
well as blood and body fluid...
2.7 Sharps
Sharps are all objects and materials that pose a potential risk of injury
and infection due to their puncture o...
difference between these types of radiations is the X-rays are emitted
from X-ray tubes only when generating equipment is ...
2.13.1 Wastes from surgery and autopsies include soiled dressings,
sponges, drapes, lavage tubes, drainage sets, under pad...
Section 3 Public Health Importance, Risks and
Management of Health-Care Wastes
3.1 Public Health Importance
Nowadays, heal...
not been handled safely. In this respect, sharps are considered as one of
the most dangerous categories of waste. Many inj...
set up a proper management system discourage many medical
institutions to undertake the necessary steps to improve their c...
The instruction contained in theses guidelines for the handling and the
disposal of sharps, and more specifically used syr...
Section 4 Health-Care Waste Management Guidelines
The implementation of safe HCWM guidelines aims at containing
infections...
2. The segregation should identify waste according to source and
type of disposal or disinfections.
3. Segregation of HCW ...
Class 5: Hazardous pharmaceutical and cytotoxic waste include
pharmaceuticals (cytotoxic drugs and toxic chemicals), which...
All health- care facilities shall apply the following colour coding system:
1. Black: all bins or bags containing non-risk...
4.3.2 Guidelines for Recycling of glassware inside the
Diagnostic Laboratories
The following guidelines should be included...
equipment and other items which are designed for reuse and are
resistant to the sterilization, disinfection or disinfectio...
5.1 Selection of tear-resistant bags: use plastic bags that are
judged by their thickness or durability and the most
impor...
5. No waste shall be stored for more than two days before being
treated or disposed of.
6. The designated central storage ...
4.7 Waste Handling guidelines
The following guidelines should be included in Waste Handling:
1. All HCW or disposal of med...
cleaned regularly, and especially before any maintenance work
is performed on it.
4.8.1.2 Yellow bags of hazardous HCW and...
5. Outside the hospital and health centers or all HCFs,
infectious waste should be transported in closed, leak-proof
dumps...
4.9 Waste treatment guidelines
The following guidelines should be included in waste treatment:
1. Amongst all the current ...
Recommended techniques for treatment of infectious wastes
Type of
infectious
waste
Recommended treatment techniques
Steam
...
4.9.1 Guidelines for Steam Sterilization (Autoclaving)
Steam sterilization, autoclaving, involves the use of saturated ste...
4.2 To facilitate steam penetration, bags should be opened and
caps and stoppers should be loosened immediately before
the...
Incineration converts combustible materials into noncombustible residue
or ash. Gases are ventilated through the incinerat...
4.9.3 Guidelines for Thermal Inactivation
Thermal inactivation involves the treatment of waste with high
temperatures to e...
Gas/vapor sterilization uses gaseous or vaporized chemicals as the
sterilizing agents. Ethylene oxide is the most commonly...
1.4 Other relevant factors such as temperature, pH, mixing
requirements, and the biology of the microorganism
2. Ultimate ...
2.5 Accident shall be reported to the infection control
officer/staff;
2.6 All cases shall be registered by the management...
1. Workers should be instructed to use gloves during working in
contaminated areas and materials, and wash their hands
tho...
(1) Explanation of the infectious waste management plan.
(2) Assignment of roles and responsibilities for implementation o...
Section 5 Specific Guidelines Associated With HCW Categories
Class 1: non-risk health-care waste
1. Non-risk HCW of class ...
7. In minor HCFs, i.e. in health centers and Dispensaries, class 2
clinical HCW may be incinerated in a simple pit hole la...
9. Under exceptional circumstance, full safety boxes may be
incinerated in small numbers by open burning in a pit hole.
10...
3. Class 5 hazardous pharmaceutical wastes and cytotoxic waste
containing heavy metals shall not be incinerated.
4. For th...
7. Class 6 wastes from isolation wards or permanent treatment
centers (cholera) shall always be incinerated on-site.
Natio...
Class 7: radioactive waste
1. All radioactive waste of class 7 shall be stored to allow decay to
background level.
2. They...
Class 9: Effluents
1. All liquid infectious waste shall be discharged into the sewerage
system only after being treated ac...
Section 6. Guidelines for Implementation of HCWM Plan in HCFs
6.1 Guidelines for waste management plan
The following guide...
e) Information on procedures, display and location of HCF staffs,
receptacles, storage at strategic points.
f) Training co...
e) The DHEH shall be responsible give supportive supervision
on HCWM activities at all levels and Federal EPA at local
lan...
c) Enact regulations to refuse receiving mixed HCW with non
infectious wastes at local landfills; forbid uncontrolled HCW
...
b) Ensure that a HCWM plan is prepared and then watch to
ensure that procedures and regulations are respected.
c) Designat...
vii) The Head of pharmacy
f) Include the following major functions:
i) Inspecting workplaces regularly to identify safety ...
e) Ensure that cleaners and sweepers are not involved in waste
segregation and that they only handle waste bags and
contai...
b) Be responsible for the application of HCWM procedures by
the nursing and the cleaning staffs.
c) Be responsible for the...
c) Be responsible for the recording and the reporting of all cuts
or puncture wounds associated with sharps and needle sti...
a) A waste management baseline audit and needs estimate
should be conducted before developing a waste management
plan of t...
6.3.2 Guidelines for selection of the technology for HCW
treatment/disposal
The technology for HCW treatment /disposal sha...
6.4.2 To make sure that medical staff refresher training is given on
HCWM.
6.4.3 To make sure that the new staff member is...
6.5.1 Monitoring system shall be set up to track hazardous HCW and
sharps along the waste stream until final disposal.
6.5...
REFERENCES
1. Federal Democratic Republic of Ethiopia, Ministry of Health. Health
Related Indicators, 1996 EC.
2. EPA (198...
8. World Health Organization. Management of Solid Health care Waste
at Primary Health centers: a decision making guide. WH...
18. JOHN SNOW INCORPORATED – MAKING MEDICAL INJECTIONS
SAFER, Assessment of Health Care Waste Management Status in
Health ...
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Hcwm guidelines ethiopia final

  1. 1. Health Care Waste Management for Ethiopia Guidelines Prepared by: Fikru Tessema (BSc, MSc), Senior Public Health Professional M&E Specialist May 2006
  2. 2. Table of contents Page Abbreviations 4 Preface 5 Section 1 1.1 Introduction 6 1.1.1 Overview of Health Facilities (HFs) Hazards and Infections 6 1.1.2 Overview of HCWM Programmes for HCFs 7 1.1.3 Overview of the Need for Developing Comprehensive HCWM Programmes 8 1.2 Objectives 12 1.3 How to use these guide lines 13 Section 2. Definition 14 Section 3. Public Health Importance, Risks and Management of Health-Care Wastes 3.1 Public Health Importance 19 3.2 Risks of Health-Care Wastes 19 3.3 HCW Management 21 Section 4. Health-Care Waste Management Guidelines 4.1 Segregation of Health-Care Waste Guidelines 23 4.2 Guidelines for Colour coding system 25 4.3 Guidelines for HCW recycling and reusing 26 4.4 Guidelines for Recycling of non-contaminated plastic items 26 4.5 Guidelines for Packaging 28 4.6 Waste storage guidelines 29 4.7 Waste handling guidelines 31 2
  3. 3. 4.8 Waste transportation guidelines 31 4.9 Waste treatment guidelines 34 4.10 Guidelines for steam sterilization 36 4.11 Guidelines for incineration 37 4.12 Guidelines for thermal inactivation 38 4.13 Guidelines for gas/vapor sterilization 39 4.14 Guidelines for chemical disinfection 40 4.15 Guidelines for accidents and spillage 41 4.16 Guidelines for Ultimate Disposal 41 4.17 Guidelines for maintenance workers 42 4.18 Guidelines for occupational risks 42 4.19 Guidelines for Training 43 Section 5. Specific Guidelines Associated With HCW Categories 5.1 Class 1: non-risk health-care waste 44 5.2 Class 2: clinical waste 44 5.3 Class 3: sharps 45 5.4 Class 4: anatomical waste and placentas 46 5.5 Class 5: hazardous pharmaceutical waste and cytotoxic waste 46 5.6 Class 6: highly infectious waste 47 5.7 Class 7: radioactive waste 48 5.8 Class 9: Waste with high contents of heavy metals 48 5.9 Class 10: Effluents 50 Section 6. Guidelines for Implementation of HCWM Plan in HCFs 6.1 Guidelines for waste management plan 52 6.2 Guidelines for duties and responsibilities 53 3
  4. 4. 6.3 Guidelines for allocation of resources and equipment for health-care waste handling 59 6.4 Guidelines for Awareness and Training 61 6.5 Guidelines for monitoring system and reporting procedures for HCWM at all levels 62 6.6 Guidelines for private sector involvement 63 References 64 4
  5. 5. Abbreviations HCF : Health-Care Facility HCW : Health-Care Waste HCWM : Health-Care Waste Management WHO : World Health Organization EPA : Environment Protection Authority MoH : Ministry of Health DHEH : Department of Hygiene & Environmental Health RHB : Regional Health Bureau
  6. 6. PREFACE The purpose of the health-care waste management guidelines is to ensure safe and healthful working conditions for every working man and woman in the health-care facility by providing guidelines that will ensure, insofar as practicable, that no workers will suffer diminished health, functional capacity, or life expectancy as a result of their work experience. This document does present guidelines for reducing the incidence of injury and disease among health care workers of health care facilities and the population at large. Every effort was made to address all major health and safety hazards that might be encountered in hospitals or other health care centers. The document is not intended to affect patients directly, but implementing the guidelines will generally benefit patient care. 6
  7. 7. Section 1 Introduction 1.1 Overview of Health Facilities (HFs) Hazards and Infections Safe management of Health-Care Waste (HCW) is a key issue to control and reduce nosocomial infections inside a hospital, health centres, clinics and health posts and to ensure that the environment outside is well protected. Health-Care Waste Management (HCWM) should be part of the overall management system of a Health-Care Facility (HCF) and reflect the quality of the services provided by the facilities. Ethiopia has poor health status relative to other low-income countries, even within Sub-Saharan African countries. This is largely attributed to preventable infections and nutritional problems. Infectious and communicable diseases account for about 60-80% of the health problems in the country. Therefore, the recommendations that are contained in this document should be applied in all the HCFs of Ethiopia. In case these recommendations cannot be rapidly applied in certain HCFs, due to financial or institutional constraints, a minimum HCWM programme should always be set up. According to the Ministry of Health report, there are a total of 126 hospitals, 519 health centers, 1797 health stations, and 2899 health posts run by the government (over 90%), private institutions, and NGOs. 5627 public health service facilities that include hospitals, health centers, health stations, health posts, and clinics; and 2489 pharmaceutical retail outlets are owned by the government, private owners, OGA and NGOS. Health-care services inevitably generate wastes that may be hazardous and infectious to health as well as have harmful environment. Some of them, such as sharps and pathogenical wastes, 7
  8. 8. carry a higher potential for infection and injury than any other type of wastes. An integrated effort is necessary in Ethiopia to set-up safe health-care waste management practices. 1.2 Overview of HCWM Programmes for HCFs Health-care waste is a management issue (and not only a technical one) that should become and integral feature of health-care services. It is essential that clear individual and group responsibilities and monitoring procedures should be established at each level of the health-care establishments. Additionally, awareness and training programmes for medical and ancillary staff should be strengthened in health-care establishments. Specific administrative procedures should be defined and adequate resources allocated at all levels to ensure a proper management of health-care waste. Appropriate, environmental-friendly and affordable technologies should be selected for the treatment and the disposal of health-care waste, taking into consideration the resources of each health-care facility. A policy statement on hazardous waste exist at the national level, specifics that deal with hazardous waste management, in general, and health care waste, in particular, does not exist at the national level. Given the rapid expansion of health-related infrastructures, which implies a rapid growth of hazardous waste generation, the need for policies, directives, and a strategic plan as well as their implementation based on prioritized problems is a forthcoming challenge. Studies that are contributing to the appreciation of the depth and breadth of health care waste management problems currently become important. National Guidelines for Health-Care Waste Management 8
  9. 9. This document is prepared to provide guidelines for the persons involved in health-care waste management at central, regional, district and local levels. Some HCFs have started to establish safety and health care waste management committees. The committees have made important contributions by identifying safety and health problems and by educating the workforce about safety and health issues. Such committees can help to ensure safe work environments in HCFs. 1.3 Overview of the Need for Developing Comprehensive HCWM Programmes A comprehensive HCWM programmes are needed to: 1.3.1 Address Diverse Needs: The diverse HCWM concerns in HCFs are traditionally divided into HCW that pose an immediate threat and HCW that cause long-term health problems. These conditions may result in an immediate illness or in the long-term development of disease. Developing an appropriate and useful safety and health program for a health care facility requires the involvement of a safety and HCWM committee that represents workers and supervisors from all departments in the HCFs. To be effective, committee members should be knowledgeable in HCWM and have explicit responsibilities and appropriate authorities. 1.3.2 Identify Hazards and interventions: Hazard and infections identification involves not only recognizing the hazards and infections themselves but also learning their specific characteristics and identifying the population at risk so that control programs can be designed. National Guidelines for Health-Care Waste Management 9
  10. 10. The HCFs safety and health committee should assist with this in consultation with workers from each department. The most important step in identifying hazards is usually a physical inspection called a walk-through survey. Persons conducting the survey actually walk through the unit and note as many hazards as possible. 1.3.3 Conduct Medical Evaluations: Medical evaluation is usually on the extent of exposure to the agent, the severity of the adverse effects, the complexity of the work process, and protective measures. Complex work procedures (e.g. operating-room practices) should be analyzed carefully, noting products and byproducts formed during the procedures. The signs and symptoms that workers experience should be evaluated medically, taking care to avoid preconceptions about which ones are work related. An occupational history should also be maintained for each worker to help evaluate the long-term effects of exposures. This history should contain at least the worker’s prior occupations and job titles, the duration of employment at each job, and the name of any substance or agent to which the worker may have been exposed. 1.3.4 Provide Personal Protective Equipment: Personal protective equipment for health woprkers includes gloves, goggles, aprons, respirators (not surgical masks), and boots. Although the use of such equipment is generally the least and last desirable way to control workplace hazards and infections because it places the burden of protection on the worker, the equipment should be available for situations when an unexpected exposure to chemical National Guidelines for Health-Care Waste Management 10
  11. 11. substances physical agents, or biologic materials could have serious consequences. 1.3.5 Keep Records: No sufficient data is available on the amount of health care waste generated and how that waste is handled. Adequate recordkeeping is very important: (1) To track the safety and health of individual workers and work groups over time, (2) To provide documentation on quantity of waste generated and disposed off for future evaluations, planning for management, (3) To help the HCFs’ administrations and the safety and health committee identify problem areas, and (4) To measure the effectiveness of safety and health programs. The employer must maintain these records and provide access to concerned body. Workers and their representatives also have the right to access these records. National Guidelines for Health-Care Waste Management 11
  12. 12. 1.4 Objectives 1.4.1 The overall aim is at providing guidelines for HCWM methods that can be applied in the HCFs of Ethiopia. More specifically, it attempts to: o Provide a better knowledge of the fundamentals of HCWM planning and a better understanding of the hazards linked to HCW; o Develop HCWM plans and standards which are protective for both the human health and the environment, in compliance with the current environmental and public health legislations of Ethiopia taking into consideration the financial possibilities of each institution; o Set priority actions in order to tackle the most sensitive problems related to HCWM (e.g. disposal of sharps) and to present these actions as part of a more global framework; o Review appropriate and sustainable technologies to treat and dispose of HCW; o Facilitate the analysis of HCWM problems and develop strategies for the safe management of HCW at district level. National Guidelines for Health-Care Waste Management 12
  13. 13. 1.4.2 It is also targeting the provision of both conceptual and practical information on HCWM. More specifically for: o The medical staff members having a "duty of care" at all levels in public or private HCFs, namely: Medical Directors in Charge, Heads of all Hospital Departments, Administrators, Doctors, Matrons, Nurses, Medical attendants and all other staffs; o National policy makers, regional and district health management teams in charge of developing, implementing and devaluating HCWM plans at central, regional and district levels as well as health officers in charge of their implementation monitoring; o Members of the health training institutions; o International Organisations or NGOs involved in the backstopping of health care services delivered in Ethiopia. National Guidelines for Health-Care Waste Management 13
  14. 14. 1.5 How to use these guide lines These guidelines are divided into five sections and have bee structured to be as practical as possible. o The two first sections have been written for all people involved in health-care waste management at any level. They provide key information on HCW and the potential harmful effects that can result from its mismanagement; o The third section gives the procedures for health-care waste manipulation and disposal that should be applied and followed in all the HCFs of the country; o The instructions contained in the fourth section have been written for personnel involved in the organisation of HCWM plans in major hospitals and minor HCFs; o The fifth section has been written for personnel of central, regional and district Health Services that should deal with HCWM to ensure a smooth implementation of the instructions contained in this document; National Guidelines for Health-Care Waste Management 14
  15. 15. Section 2 Definition The definitions and the classification hereafter are adapted from the international classification provided by the World Health Organisation. 2.1 Health-Care Waste Health-Care Waste (HCW) includes all the waste, hazardous or not, generated during medical activities. It embraces activities of diagnosis as well as preventive, curative and palliative treatments in the field of human medicine. In other words, are considered as health-care waste, all the waste produced by a medical institution (public or private), a medical research facility or a laboratory. 2.2 Non-Risk Health-Care Waste Non-risk Health-Care Waste comprises all the waste that has not been infected. They are similar to normal household or municipal waste and can be managed by the municipal waste services. They represent the biggest part of the HCW generated by a medical institution. It includes paper, cardboard, non-contaminated plastic or metal, cans or glass, left over food, etc... and can also be included in this category of waste, all items that have been used for medical care but are visually not contaminated with blood or body fluids of the patient, this only being applicable if the patient is not confined in an isolation ward. National Guidelines for Health-Care Waste Management 15
  16. 16. 2.3 Pathological Waste Pathological Waste groups all organs (including placentas), tissues as well as blood and body fluids and follows the precautionary principle stipulated by WHO. 2.4 Anatomical Waste Anatomical waste comprises recognizable body parts. It is primarily for ethical reasons that special requirement must be placed on the management of human body parts. They can be considered as a subcategory of Pathological Waste. 2.5 Infectious Waste Infectious waste comprises of all biomedical and health-care waste known or clinically assessed by a medical practitioner to have the potential of transmitting infectious agents to humans or animals. Waste of this kind is typically generated in the following places: Isolation wards of hospitals; centres caring for patients infected with hepatitis viruses; pathology departments, operating theatres and laboratories. 2.6 Highly Infectious Waste Highly infectious waste includes all viable biological and pathological agents artificially cultivated in significant elevated numbers. Cultures and stocks, dishes and devices used to transfer, inoculate and mix cultures of infectious agents belong to this category of waste. They are generated mainly in Diagnostic Medical Laboratories. National Guidelines for Health-Care Waste Management 16
  17. 17. 2.7 Sharps Sharps are all objects and materials that pose a potential risk of injury and infection due to their puncture or cutting properties (e.g. syringes with needles, blades, broken glass...). For this reason, sharps are considered as one of the most hazardous categories of waste generated during medical activities. 2.8 Pharmaceutical Waste Pharmaceutical Waste embraces a multitude of active ingredients and types of preparations. This category of waste comprises expired pharmaceuticals or pharmaceuticals that ate unusable for other reasons 2.9 Cytotoxic Waste Cytotoxic Waste may be considered as a sub-group of hazardous Pharmaceutical Waste, due to its high degree of toxicity. The potential health risks for people who handle cytotoxic Pharmaceuticals results above all from the mutagenic, carcinogenic and teratogenic properties of these substances, which can be split into six main groups: alkylated substances, antimetabolites, antibiotics, plant alkaloids, hormones and others. 2.10 Radioactive Waste Radioactive Waste includes liquids, gas and solids contaminated with radio nuclides whose ionizing radiations have genotoxic effects. The ionizing radiations of interest in medicine include X-any. An important National Guidelines for Health-Care Waste Management 17
  18. 18. difference between these types of radiations is the X-rays are emitted from X-ray tubes only when generating equipment is switched on. 2.11 Special Hazardous Waste (Waste with high contents of heavy metals) Waste with high contents of heavy metals should normally be treated in specific recovering industries. Alternatively, as for chemical waste, it may be encapsulated. Waste with high contents of mercury or cadmium shall never be incinerated because of the risk of atmospheric pollution with toxic vapours. Special Hazardous Waste includes gaseous, liquid and solid chemicals, waste with a high contents of heavy metals such as batteries, pressurized containers, out of order thermometers, blood-pressure gauges, photographic fixing and developing solutions in X-ray departments, halogenated or non-halogenated solvents... this category of waste is not exclusive to the health-care sector. They can have toxic, corrosive, flammable, reactive, explosive, shock sensitive, genotoxic properties. 2.12 Effluents Effluents and more particularly, effluents from isolation wards and medical diagnostic laboratories should be considered as hazardous liquid waste that should receive specific treatment before being discharged into the sewerage/drainage system, if such a system exists. 2.13 Miscellaneous wastes These types of wastes are wastes include those from surgery and autopsies, contaminated laboratory wastes, dialysis unit wastes and contaminated equipment. National Guidelines for Health-Care Waste Management 18
  19. 19. 2.13.1 Wastes from surgery and autopsies include soiled dressings, sponges, drapes, lavage tubes, drainage sets, under pads, and surgical gloves. 2.13.2 Contaminated laboratory wastes include specimen containers, slides and cover slips, disposable gloves, laboratory coats, and aprons. 2.13.3 Dialysis unit wastes include contaminated disposable equipment and supplies such as tubing, filters, disposable sheets, towels, gloves, aprons, and laboratory coats. 2.13.4 Contaminated equipment refers to discarded equipment and parts that are used in patient care, medical research, and the production and testing of certain pharmaceuticals. National Guidelines for Health-Care Waste Management 19
  20. 20. Section 3 Public Health Importance, Risks and Management of Health-Care Wastes 3.1 Public Health Importance Nowadays, health care wastes generation is significantly large amounts by volume and diverse by types that require proper handling and disposal. Much of the waste is hazardous and must therefore be packaged, transferred, and disposed of properly to protect both the persons handling it and the environment All individuals exposed to hazardous HCW are potentially at risk of being injured or infected. They include: 1. Medical staff: doctors, nurses, sanitary staff and hospital maintenance personnel 2. In-and out-patients receiving treatment in HCFs as well as their visitors; 3. Workers in support services linked to HCFs such as laundries, waste handling and transportation services; 4. Workers in waste disposal facilities, including scavengers; 5. The general public and more specifically the children playing with the items they can find in the waste outside the HCFs when it is directly accessible to them. 3.2 Risks of Health-Care Wastes 3.2.1 Occupational Risks HCFs’ work environment, during handling of wastes, the medical and ancillary staff as well as the sanitary laborers can be injured if HCW has 20
  21. 21. not been handled safely. In this respect, sharps are considered as one of the most dangerous categories of waste. Many injuries occur because syringe and needles or other sharps have not been collected in safety boxes or because these have been overfilled. On dumpsites, scavengers during their reusing or recycling activities may also come in contact with infectious waste if it has not been properly treated or disposed of. Maintenance workers serve in all patient and non-patient areas and are thus potentially exposed to all of the health hazards found in drainage system, chemical stores, etc of the HCFs’ environment. Maintenance personnel are frequently exposed to pathogens. 3.2.2 Risks to the Population The general public can be infected by HCW either directly or indirectly through several routes of contamination. Dumping HCW in open areas is a practice that can have major adverse effects on the population. The ''recycling'' practices, the reuse of syringes are certainly the most serious problem in some of the developing countries. The WHO estimates that some millions infections of Hepatitis B, C and HIV occur yearly from the reuse of discarded syringes needles without prior disinfection. 3.3 HCW Management It is not often understood why HCW should be managed in a different way than the other categories of wastes, and particularly why HCW should be segregated on the spot, where it is generated. Furthermore, the constraints related to their management as well as the funds required to National Guidelines for Health-Care Waste Management 21
  22. 22. set up a proper management system discourage many medical institutions to undertake the necessary steps to improve their current HCWM practices. However, HCWM is an integral part of hygiene and infection control within a HCF and proper management should help control of nosocomial infections. HCWM is not only compliance with Federal and local regulations, but it should carefully consider the development of an infectious waste management plan to minimize the overall risks of HCWs. Each HCF should develop an infectious waste management plan that provides for: (1) Designation of the waste that should be managed as HCWs, (2) Segregation of infectious waste from the noninfectious waste, (3) Packaging of infectious waste to reduce contacts and exposure, (4) Storage of HCW for proper transport, (5) Treatment of infectious waste to avoid contaminations, (6) Disposal of infectious waste to eliminate risks, (7) Measures for emergency situations, and (8) Staff training on HCWM. Implementing adequate procedures to minimize the overall risks associated with HCWM remains the prior objective of these National Guidelines. Waste management and treatment options should first protect the health-care workers and the population and minimizes indirect impacts from environmental exposures to HCW. National Guidelines for Health-Care Waste Management 22
  23. 23. The instruction contained in theses guidelines for the handling and the disposal of sharps, and more specifically used syringes, attempt first to minimize the risks of cuts or needle stick injuries that may occur after an injection: Some treatment options - such as low-cost incinerators that emit pollutants - may be used in certain situations (e.g. low density populated areas) where the overall health benefits from preventing infections are likely to outweigh the risks from exposure to toxic pollutants in the air. Nevertheless, environmental-friendly practices, like the recycling of plastics are recommended when they are in accordance with the precautionary principle. National Guidelines for Health-Care Waste Management 23
  24. 24. Section 4 Health-Care Waste Management Guidelines The implementation of safe HCWM guidelines aims at containing infections and reducing public health risks both within and outside the HCF. The guidelines should always contain the following measures: 1. Segregation and identification of hazardous HCW from non-risk HCW; 2. Recyclingof HCW to minimize the quantity of HCW generated by the HCF; 3. Adequate packaging and safe storage of the different categories of HCW; 4. Proper treatment and disposal of hazardous and non-risk HCW. 4.1 Guidelines for Segregation of Health-Care Waste A proper segregation must follow rigorous and standardized procedures to enable and reduce the risks of infecting workers and control the economical incidence of hazardous HCW disposal by decreasing the treatment costs. It must be: 1. Simple to implement for medical and ancillary staff; 2. Safe and guaranty the absence of infectious HCW in the domestic waste flow; 3. Stable and homogeneously applied in all the HCFs; 4. Regularly monitored to ensure that the procedures are respected. The following guidelines should be included in HCW Segregation: 1. Segregation of HCW should consist in separating the different waste streams based on the type of treatment and disposal required at economical cost. 24
  25. 25. 2. The segregation should identify waste according to source and type of disposal or disinfections. 3. Segregation of HCW practices should provide coloured waste receptacles specifically suited for each category of waste. 4. Segregation shall take place at the source or at the site, that is at the ward bedside, Operation Theatre, Medical Diagnostic Laboratory, or any other room or ward in the hospital and health center where the waste is generated. 5. Seven categories of waste shall be considered in the segregation of HCW: HCW of classes 1, 2, 3, 4 and 9 are commonly generated in major and minor medical institutions. HCW of classes 5, 6, 7 and 8 are generated only in some institutions and in small quantities. Class1: non-risk waste comprises the non-hazardous waste generated within the medical institutions as defined in section 2, as well as the non-hazardous pharmaceutical waste; Class 2: clinical waste comprises pathological waste and infectious waste as defined in section 2. It includes also all items that are visually contaminated with blood or body fluids; Class 3: sharp waste includes all items that can case cuts or puncture wounds as defined in section 2 sharps shall be considered as highly hazardous waste and collected in rigid safety boxes; Class 4: anatomical waste and placenta comprises recognizable body parts as specified in section 2. Due to their physical characteristics, similar to anatomical waste, placentas are grouped in the same class; National Guidelines for Health-Care Waste Management 25
  26. 26. Class 5: Hazardous pharmaceutical and cytotoxic waste include pharmaceuticals (cytotoxic drugs and toxic chemicals), which pose a potential hazard when used improperly by unauthorized persons, and unidentifiable pharmaceuticals heavy-metal-containing disinfectants, which owing to their composition require special management and cytotoxic waste as defined in section 2. Class 6: highly infections waste comprises waste as defined in section 2. This category of waste is generated in medical Diagnostic laboratories or in isolation wards; Class 7: radioactive waste includes waste as defined in section 2. Class 8: Wastes with high contents of heavy metals include wastes as defined in section 2. This category of wastes is wastes with high contents of heavy metals such as mercury or cadmium. Class 9: Effluents comprises waste as defined in section 2. This category of waste is non-solid waste of all liquid infectious waste. 4.2 Guidelines for Colour coding system The colour coding system aims at ensuring an immediate and non- equivocal identification and segregation of the hazards associated with the type of HCW that is handled or treated. In this respect, the colour coding system shall remain simple and be applied uniformly throughout the country. National Guidelines for Health-Care Waste Management 26
  27. 27. All health- care facilities shall apply the following colour coding system: 1. Black: all bins or bags containing non-risk HCW of class 1; 2. Yellow: any kind of container filled with HCW from class 2 – 7; 3. Red: any kind of container filled with HCW from class 8 and 9. 4.3 Guidelines for HCW Recycling and Reusing The implementation of recycling procedures in HCFs to minimize the quantity of HCW generated is highly sensitive. Recycling procedures complicate the overall segregation scheme by increasing the segregation criteria and multiplying the number of waste streams in the HCF. It is a potential source of error. However, considering the specific recycling practices in Ethiopia, the necessity to implement an environmental-friendly process of HCW disposal and the financial resources of each HCF, a simple and safe recycling practice should be implemented whenever it is possible. In these situations the instructions hereafter should be followed. 4.3.1 Guidelines for Recycling of non-contaminated plastic items The following guidelines should be included in recycling of non- contaminated plastic items: 1. All non-contaminated plastic items (e.g. bags of sodium chlorine, etc) should be collected, packed in separate boxes. 2. They should be delivered to or picked-up local collectors capable of recycling them with environmental-friendly techniques. National Guidelines for Health-Care Waste Management 27
  28. 28. 4.3.2 Guidelines for Recycling of glassware inside the Diagnostic Laboratories The following guidelines should be included in glassware inside the Diagnostic Laboratories: 7 All non-contaminated and non-broken glassware (flasks of inject able penicillin for instance) should be collected separately. 8 They should be put in a disinfectant solution not less than 30 minutes, carefully washed, rinsed and dried before being reused. 9 The disinfected glassware should be reused only for specific medical Diagnostic (blood, urine) carried out inside the Diagnostic laboratory. 10 After having been used once, they shall be considered as contaminated and infectious. 11 Broken glassware shall always follow the stream of sharp waste (class 3) while non-broken glass flasks shall be reused only after disinfections in a disinfectant solution, carefully washed with a brush and soap, rinsed. 12 During the disinfection process, hands shall always be protected with gloves. It is further recommended to autoclave the glassware after washing at 1210 C for at least 30 minutes to ensure complete disinfection. 4.3.3 Guidelines for Reuse of specific equipment The following guidelines should be included in recycling of non- specific equipment: 1. In general, to encourage reuse, each hospital and health center shall collect separately, wash and sterilize, either thermally or chemically in accordance with approved procedures, surgical National Guidelines for Health-Care Waste Management 28
  29. 29. equipment and other items which are designed for reuse and are resistant to the sterilization, disinfection or disinfection process. 2. Pressurized materials as cylinders shall be returned to suppliers for refilling and reuse. 4.4 Guidelines for pharmaceuticals management The following guidelines should be included in pharmaceuticals management: 1. Drug stores in each HCF shall be rigorously managed on a base of first in first out to avoid wastage. 2. Stock positions should be recorded on a regular basis. 4.5 Guidelines for Packaging The following guidelines should be included in packaging: 1. Infectious wastes should be contained from the point of origin to the point at which they are not longer infectious. 2. The packaging should be appropriate for the type of waste involved 3. It should consider tear-resistant packaging materials in the process of handling, storage, transportation, and treatment. 4. Liquid infectious wastes should be placed in capped or tightly stopper bottles or flasks and large quantities may be placed in containment tanks. 5. Solid or semisolid wastes should be placed in plastic bags, but the following recommendations should be observed: National Guidelines for Health-Care Waste Management 29
  30. 30. 5.1 Selection of tear-resistant bags: use plastic bags that are judged by their thickness or durability and the most important considerations are tear-resistance. 5.2 Placement of sharps (sharp items, or items with sharp corners) in the bags: place sharps in impervious rigid, puncture-resistant containers made of glass, metal, rigid plastic, or wood. 5.3 Loading a bag beyond its weight or volume capacity: load bags up to its limit. 5.4 Keeping bags from coming into contact with sharp external objects: keep away bags from contacts with sharp objects. 5.5 Double bagging: Consider double bagging to ensure tear- resistance. 6. There should be special packaging characteristics for some treatment techniques: incineration required combustible containers, and steam sterilization requires packaging materials such as low-density plastics that allow steam penetration and evacuation of air. 4.6 Waste storage guidelines The following guidelines should be included in waste storage: 1. In each room where HCW is generated, an adequate place shall be dedicated for storing HCW bag-holders, bins or containers. 2. Waste storing places in each room of HCF should be easily accessible for the sanitary staff and instruction shall be displayed. 3. In all HCFs, separate central storage facilities shall be provided for hazardous HCW, except radioactive waste that shall be stored specifically. 4. It shall clearly be mentioned that the facility stores hazardous HCW and no materials other than yellow bag waste. National Guidelines for Health-Care Waste Management 30
  31. 31. 5. No waste shall be stored for more than two days before being treated or disposed of. 6. The designated central storage facility shall be located within the hospital premises close to the treatment unit but away from food storage or food preparation areas. 7. The designated central storage facility should be large enough to contain all the hazardous HCW produced by the hospital during one week, with spare capacity to cope with any maintenance or breakdown of the treatment unit. 8. The designated central storage facility shall be totally enclosed and secured from unauthorized access. 9. The designated central storage facility shall be inaccessible to animals, insects and birds. 10. The designated central storage facility shall be easy to clean and disinfect with an impermeable hard-standing base, good water supply, drainage and ventilation: The following procedures area recommended: 10.1 Infectious waste should be stored for a minimum amount of time and should be packaged securely enough to ensure containment of the waste and to prevent penetration by rodents and vermin. 10.2 Limited access to the storage area is recommended. 10.3 The universal biological hazard symbol should be posted on the storage area door, waste containers, freezers, or refrigerators. 10.4 Containers for bio-hazardous material should be a distinctive red or orange color. National Guidelines for Health-Care Waste Management 31
  32. 32. 4.7 Waste Handling guidelines The following guidelines should be included in Waste Handling: 1. All HCW or disposal of medical equipment shall be discarded at the point of use by the person who used the item to be disposed off in case any such used equipment or supplies are found or are handed over to another person, it should be discarded by that person. 2. All the specific procedures of HCW segregation, packaging and labeling shall be explained to the medical and ancillary staff and displayed in each department on charts located on the walls nearby the HCW containers. 3. When handling waste, sanitary staff and sweepers shall wear protective clothing at all times including face masks, aprons and boots, heavy duty gloves, as required. 4. Carts and recyclable containers that are used repeatedly for transport should be disinfected after each use. Single-use containers should be destroyed as part of the treatment process. 4.8 Waste Transportation guidelines 4.8.1 Transport to Central Storage 4.8.1.1 The waste collection trolley should be easy to load, unload and. The trolley shall not be used for any other purpose. It shall be National Guidelines for Health-Care Waste Management 32
  33. 33. cleaned regularly, and especially before any maintenance work is performed on it. 4.8.1.2 Yellow bags of hazardous HCW and black bags of non-risk HCW shall be collected on separate trolleys that shall be painted marked with the corresponding colours and washed regularly. 4.8.1.3 The collection route shall be the most direct one from the collection point to the central storage. 4.8.1.4 The collected waste shall not be left even temporarily anywhere other than at the designated central storage. 4.8.1.5 Containers should be covered with lids during storage. 4.8.1.6 Instead of chutes or dumbwaiters, carts should be used for transporting bags of infectious waste within the facility. 4.8.2 Transport to Final Disposal Site 4.8.2.1 When the waste is to be moved about for treatment or storage, special handling or packaging may be necessary to keep bags intact and to ensure containment of the waste. The following procedures are recommended: 1. Single-bagged waste and containers of sharps and liquids should be placed within a rigid or semi-rigid container such as a bucket, box, or carton lined with plastic bags. 2. Containers should be covered with lids during transportation. 3. When transporting plastic bags of infectious waste, care should be taken to prevent tearing the bags. 4. Infectious waste should not be compacted before treatment. This process could damage the packaging and disperse the contents, or it could interfere with the effectiveness of treatment. National Guidelines for Health-Care Waste Management 33
  34. 34. 5. Outside the hospital and health centers or all HCFs, infectious waste should be transported in closed, leak-proof dumpsters or trucks. 6. The waste should be placed in rigid or semi-rigid, leak-proof containers before being loaded onto trucks. 7. In case off-site transportation is required to treat hazardous HCW at treatment facilities, the local Government shall approve the off-site transportation plan before any transit occurs. 8. All yellow bags shall be collected and transported at least every second day. 9. The transportation shall be properly documented, and all vehicles shall carry a consignment note from the point of collection to the treatment facility. 10.Vehicles used for the carriage of yellow bags shall not be used for any other purpose. 11.The vehicles shall be free of sharp edges, easy, to load and unload by hand, easy to clean/disinfect, and fully enclosed to prevent any spillage in the HCF premises or on the road during transportation. 12.All vehicles shall be cleaned and disinfected after use. 13.The vehicles shall carry adequate supply of plastic bags, protective clothing, cleaning tools and disinfectants to clean and disinfect in case of any spillage. 14.All staffs handling yellow bags shall wear protective clothing. 15.Staffs shall be properly trained in the handling, loading and unloading, transportation and disposal of the yellow bags. 16.Staffs shall be fully aware of emergency procedures for dealing with accidents and spillage. National Guidelines for Health-Care Waste Management 34
  35. 35. 4.9 Waste treatment guidelines The following guidelines should be included in waste treatment: 1. Amongst all the current existing technologies for treating and disposing of HCW, the most appropriate technology shall be applied, that is: .1 The most reliable, affordable and sustainable technology in accordance with the technical, human and financial resources of each HCF; .2 The technology that minimizes the immediate public health risks associated with HCWM with the lowest impact on the environment. 2. Incineration may be considered as the technology that most reliable disposal of hazardous and properly buried in an appropriate pit. Nevertheless, in highly densely populated areas large quantities of hazardous HCW shall not be incinerated at temperatures lower than 12000 C. 3. Several methods are used for infectious waste treatment, depending on the type of waste material. These treatment methods shall include one of the following options or combination of options: steam sterilization, incineration, thermal inactivation, gas/vapor sterilization, chemical disinfection, or sterilization by irradiation. 4. After treatment, the wastes or their ashes should be disposed of by discharge into sanitary sewer systems (for liquid or ground-up waste) or burial in sanitary landfills. 5. Acceptable treatment methods for the various types of wastes are listed in Table 3-1. National Guidelines for Health-Care Waste Management 35
  36. 36. Recommended techniques for treatment of infectious wastes Type of infectious waste Recommended treatment techniques Steam sterilization Incineration Thermal inactivation Chemical disinfection Other Isolation wastes X X Cultures and stocks of infectious agents and associated biologicals X X X X Human blood and blood products X X X X Pathological wastes X X X Contaminated sharps X X Carcasses and parts X X Bedding X National Guidelines for Health-Care Waste Management 36
  37. 37. 4.9.1 Guidelines for Steam Sterilization (Autoclaving) Steam sterilization, autoclaving, involves the use of saturated steam within a pressure vessel at temperatures high enough to kill infectious agents in the waste. Sterilization is accomplished primarily by steam penetration. Steam sterilization is most effective with low-density material such as plastics. The following guidelines should be included in Steam Sterilization (Autoclaving): 1. An alternative treatment method, e.g. incineration, should be used on high-density wastes such as large body parts or large quantities of animal bedding or fluids because they inhibit direct steam penetration and require longer sterilization times. 2. Containers that should be used effectively in steam sterilization are plastic bags, metal pans, bottles, and flasks. High-density polyethylene and polypropylene plastic should not be used in this process because they do not facilitate steam penetration to the waste load. 3. Heat-labile plastic bags allow steam penetration of the waste, but they may crumble and melt. If heat-labile plastic bags are used, they should be placed in another heat-stable container that allows steam penetration, such as a strong paper bag, or they should be treated with gas/vapor sterilization. 4. The following precautions should be taken when using steam sterilization: 4.1 Plastic bags should be placed in a rigid container before steam treatment to prevent spillage and drain clogging. National Guidelines for Health-Care Waste Management 37
  38. 38. 4.2 To facilitate steam penetration, bags should be opened and caps and stoppers should be loosened immediately before they are place in the steam sterilizer. 4.3 Care should be taken to separate infectious wastes from other hazardous wastes. 4.4 Infectious waste that contains noninfectious hazards should not be steam-sterilized because of the possibility that the equipment operator will be exposed to toxic, radioactive, or other hazardous chemicals. 4.5 Waste that contains drugs, toxic chemicals, or chemicals that would be volatilized by steam should not be steam- sterilized. 4.6 Persons involved in steam sterilizing should be trained in handling techniques to minimize personal exposure to hazards from infectious wastes. Some of these techniques include: 4.6.1 Use of protective equipment 4.6.2 Minimization of aerosol formation 4.6.3 Prevention of waste spillage during autoclave loading and unloading 4.6.4 Prevention of burns from handling hot containers 4.6.5 Management of spills 4.7 The autoclave temperature should be checked with a recording thermometer to ensure that the proper temperature is being maintained for a long enough periods during the cycle. 4.8 Steam sterilizers should be routinely inspected and serviced, and the process should be routinely monitored to ensure that the equipment is functioning properly. 4.9.2 Guidelines for Incineration National Guidelines for Health-Care Waste Management 38
  39. 39. Incineration converts combustible materials into noncombustible residue or ash. Gases are ventilated through the incinerator stacks, and the residue or ash is disposed of in a sanitary landfill. If incinerators are properly designed, maintained, and operated, they are effective in killing organisms present in infectious waste. The following guidelines should be included in Incineration: 1. Incineration should be used for anesthetic disposal of pathological wastes such as tissues and body parts. 2. Incineration should be used to render contaminated sharps unusable. 3. The principal factors affecting incineration like variations in waste composition, the waste feed rate, and the combustion temperature should be considered to maintain efficiency of incinerating infectious wastes. 4. Infectious wastes containing drugs should be disposed of in an incinerator that provides high temperatures and enough time for the complete destruction of these compounds. 5. The incinerator’s effectiveness in disposing of chemical wastes should be documented before such use. 6. Persons involved in Incineration should be trained in handling techniques to minimize personal exposure to hazards from infectious wastes. Some of these techniques include: 6.1 Use of protective equipment 6.2 Prevention of waste spillage during incinerators loading 6.3 Management of spills National Guidelines for Health-Care Waste Management 39
  40. 40. 4.9.3 Guidelines for Thermal Inactivation Thermal inactivation involves the treatment of waste with high temperatures to eliminate the presence of infectious agents. This method is usually used for large volumes of infectious waste. Liquid waste is collected in a vessel and heated by heat exchangers or a steam jacket surrounds the vessel. The types of pathogens in the waste determine the temperature and duration of treatment. This method requires higher temperatures and longer treatment cycles than steam treatment. The following guidelines should be included in Thermal Inactivation: 1. After treatment, the contents should be discharged into the sewer or landfills in a manner that complies with Federal and local requirements. 2. Solid infectious waste should be treated with dry heat in an oven, which is usually electric. 3. Persons involved in Thermal Inactivation should be trained in handling techniques to minimize personal exposure to hazards from infectious wastes. Some of these techniques include: 3.1 Use of protective equipment 3.2 Prevention of waste spillage during Thermal Inactivation loading and unloading 3.3 Prevention of burns from handling hot containers 3.4 Management of spills 4.9.4 Guidelines for Gas/Vapor Sterilization National Guidelines for Health-Care Waste Management 40
  41. 41. Gas/vapor sterilization uses gaseous or vaporized chemicals as the sterilizing agents. Ethylene oxide is the most commonly used agent. The following guidelines should be included in Gas/Vapor Sterilization: 1. Gas/Vapor Sterilization should be used with caution since it is a suspected human carcinogen, because ethylene oxide may be adsorbed on the surface of treated materials, the potential exists for worker exposure when sterilized materials are handled. 2. Persons involved in Gas/Vapor Sterilization should be trained in handling techniques to minimize personal exposure to hazards from infectious wastes and handling of sterilized materials. Some of these techniques include: 2.1 Use of protective equipment 2.2 Prevention of waste spillage during Gas/Vapor Sterilization loading and unloading 2.3 Prevention of burns from handling hot containers 2.4 Management of spills 4.9.5 Guidelines for Chemical Disinfection Chemical disinfection is the preferred treatment for liquid infectious wastes, but it can also be used in treating solid infectious waste. The following guidelines should be included in Chemical Disinfection: 1. The following factors should be considered and labeled with wastes to be treated when using chemical disinfection: 1.1 Type of microorganism 1.2 Type of disinfectant 1.3 Contact time National Guidelines for Health-Care Waste Management 41
  42. 42. 1.4 Other relevant factors such as temperature, pH, mixing requirements, and the biology of the microorganism 2. Ultimate disposal of chemically treated waste should be in accordance with Federal and local requirements. 3. Persons involved in Chemical Disinfection should be trained in handling techniques to minimize personal exposure to hazards from infectious wastes and handling of sterilized materials. Some of these techniques include: 3.1 Use of protective equipment 3.2 Infections from exposure to pathogenic organism 3.3 Prevention of waste spillage during Chemical Disinfection loading and unloading 3.4 Prevention of burns from handling hot containers 3.5 Management of spills 4.9.6 Guidelines for Accidents (emergency) and spillage The following guidelines should be included in Accidents and spillage: 1. All HCF staff members shall be properly trained and prepared for emergency response, including procedures for treatment of injuries, cleanup of the contaminated area and prompt reporting of all incidents of accidents. 2. The following actions shall be taken: 2.1 Evacuation of the contaminated area if required; 2.2 Decontamination or disinfection, rinsing and wiping dry with absorbent cloth by personnel wearing adequate protective clothing; 2.3 Decontamination or disinfection of the protective clothing if necessary; 2.4 Cuts with sharps or needle stick injuries shall be immediately disinfected; National Guidelines for Health-Care Waste Management 42
  43. 43. 2.5 Accident shall be reported to the infection control officer/staff; 2.6 All cases shall be registered by the management Team of the HCF and annually reported to the District Health Authorities. 2.7 It is highly recommended to perform blood tests following such an injury to ensure that the injured staff has not been contaminated by any pathogen. 4.10 Guidelines for Ultimate Disposal The following guidelines should be included in Ultimate Disposal: 1. The recommended types of disposal options in accordance with the type of HCW are: 1.1 Conventional sewer system for discharge of treated liquids and grounded solids. 1.2 Landfill disposal of treated solids and incinerator ash. 2. EPA and MoH shall control that only treated infectious wastes are buried in landfills. 3. Facilities should secure the services of reputable waste handlers to ensure, to the extent possible, that ultimate disposal of hazardous wastes is performed according to applicable Federal and local regulations. 4.11 Guidelines for Maintenance Workers The following specific guidelines should be included in a HCWM for maintenance workers: National Guidelines for Health-Care Waste Management 43
  44. 44. 1. Workers should be instructed to use gloves during working in contaminated areas and materials, and wash their hands thoroughly after removing work gloves. 2. Workers should be aware that other persons may not have followed proper procedures for disposing of needles, knives, and glassware. 4.12 Guidelines for occupational risks The following guidelines should be included in HCWM for central store, food, laundry & other services and office workers: 1. Desks and countertops should be free of sharp. 2. Needles and other sharp instruments should be discarded in designated puncture-resistant containers and not in trash cans or plastic bags. 3. There should be no recapping of needles. 4. Rules for safe disposal and collection of sharp instruments or other hazardous materials should be reviewed regularly. 5. Workers should examine and handle soiled linens and similar items as if they contained hazardous items. 6. Workers should receive periodic instruction to keep them aware of the specific hazards of HCW of HCFs. 7. Worker should follow instructions issued by the infection control personnel for reporting infections. 8. Workers should take appropriate measures to limit further contagion from HCWs by practicing universal precautions of self- protection from exposure to infectious wastes. 4.13 Guidelines for Training All workers who handle infectious waste should receive infectious waste management training that includes: National Guidelines for Health-Care Waste Management 44
  45. 45. (1) Explanation of the infectious waste management plan. (2) Assignment of roles and responsibilities for implementation of the plan. (3) Refresher courses should also be given periodically. National Guidelines for Health-Care Waste Management 45
  46. 46. Section 5 Specific Guidelines Associated With HCW Categories Class 1: non-risk health-care waste 1. Non-risk HCW of class 1 shall be placed in black containers. 2. Non-contaminated items that are designated for recycling shall be packed in specific black containers marked ''Non-contaminated plastic, to be recycled'' or ''Non-contaminated glassware, to be recycled''. 3. All non-risk HCW not designated for recycling shall be collected with the other municipal waste. Class 2: clinical waste 1. All class 2 clinical waste shall be placed in yellow polyethylene bags of minimum 300 microns gauge marked ''Danger! Hazardous medical waste'' and indicated with the international Biohazard symbol. 2. Preferably, the bags shall be placed in bag-holders. 3. Bags shall be sealed with appropriate adhesive tape, removed and replaced immediately when they are no more than three-quarters full. 4. If not available, yellow bins or containers shall be used; they must nevertheless be systematically disinfected in a solution of 10% of sodium hypochlorite or Lysol once emptied. 5. All class 2 clinical HCW shall be incinerated in double chamber incinerators. 6. In highly densely populated areas centralized pyrolytic incinerator, reaching 1'2000 C shall be preferably used. 46
  47. 47. 7. In minor HCFs, i.e. in health centers and Dispensaries, class 2 clinical HCW may be incinerated in a simple pit hole land disposal is an alternative solution when there is no risk of contaminating underground water. Class 3: sharps 1. All class 3 sharps shall be placed in specific cardboard or plastic safety boxes, resistant to punctures and leak-proof, designed so that items can be dropped in using one hand and no item can be removed. 2. The safety box shall be coloured yellow, marked ''Denger! Contaminated sharps''. 3. It shall be closed when three-quarters full and then placed in a yellow plastic bag or containers with the other hazardous HCW of class 2. 4. In particular all disposable syringes and needles shall be discarded immediately following use. 5. The needle shall not be recapped or removed from the syringe; the whole combination shall be inserted in to the safety box. 6. Under no circumstances are used syringes or needles, or safety boxes, to be disposed of in normal garbage or dumped randomly without prior treatment. 7. Sharps are destroyed together with the hazardous HCW of class 2. The method of choice for destruction of full safety boxes is incineration, preferably in an appropriate double-chamber incinerator. 8. If such an incinerator is unavailable, alternative methods may be used like the use of sharp pits. National Guidelines for Health-Care Waste Management 47
  48. 48. 9. Under exceptional circumstance, full safety boxes may be incinerated in small numbers by open burning in a pit hole. 10. The residues of incineration shall be safety buried at sufficient depth (> 1m). Class 4: anatomical waste and placentas 13 In operation theatres, all class 4 anatomical waste and placentas shall be collected separately. 14 When a centralized incinerator is available they shall be incinerated. 15 Nevertheless, when low-cost incinerators are used, anatomical waste or large number of placentas can be difficult to incinerate and will reduce drastically the performance of the system. 16 If incineration cannot be performed, class 4 anatomical waste and placentas shall be dropped into a concrete lined pit or buried at a sufficient depth (> 1m) inside the HCF compound1 . 17 If transportation and disposal cannot be immediately ensured, anatomical waste should be stored in the mortuary. Class 5: hazardous pharmaceutical and cytotoxic waste 1. Hazardous pharmaceutical waste and cytotoxic waste shall be repacked in specific cardboard boxes marked ''Danger! Hazardous pharmaceutical and cytotoxic waste'' they shall be sent to the medical store Department that shall ensure their disposal at central level. 2. Class 5 wastes shall be incinerated in a pyrolytic incinerator at a minimum of 1'2000 C. 1 The area around the pit should be totally enclosed and secured from unauthorized access and at least 100 m away from any underground fresh water borehole or well. National Guidelines for Health-Care Waste Management 48
  49. 49. 3. Class 5 hazardous pharmaceutical wastes and cytotoxic waste containing heavy metals shall not be incinerated. 4. For this specific category of waste, inertization2 may be foreseen. Class 6: highly infectious waste 1. Highly infectious waste from the medical Diagnostic laboratory of the HCF, such as media and culture plates, shall be collected preferably in leak proof yellow bags suitable for autoclaving and properly sealed. 2. It shall be autoclaved at a temperature of 1210C at 1 bars for at least 20 minutes at source, i.e. in the medical Diagnostic laboratory itself. 3. Disinfected waste shall be collected and treated with the hazardous HCW of class 2. 4. If a distinct autoclave is not available at the medical Diagnostic laboratory to ensure a thermal treatment, highly infectious waste shall be disinfected in a solution of sodium hypochlorite in concentrated form and left overnight. 5. It shall than be discarded in a specific yellow bag properly sealed and itself discarded with the hazardous HCW of class 2. 6. If none of the above treatment options can be ensured, ensured, highly infectious waste should at least be packed in a specific yellow bag that shall be sealed and directly discarded with the hazardous HCW of class 2 and this option shall remain exceptional. 2 Inertization consists in mixing pharmaceutical waste with cement and lime before burying too minimize the risk that toxic substance migrate in to the surface water or groundwater. The packaging should previously be removed. National Guidelines for Health-Care Waste Management 49
  50. 50. 7. Class 6 wastes from isolation wards or permanent treatment centers (cholera) shall always be incinerated on-site. National Guidelines for Health-Care Waste Management 50
  51. 51. Class 7: radioactive waste 1. All radioactive waste of class 7 shall be stored to allow decay to background level. 2. They shall be placed in a large container or drum and labelled with the radiation symbol showing the radio-nuclide's activity on a given date, the period of storage required, and marked "Caution! Radioactive waste". 3. Containers or tanks with radioactive waste that has not decayed to background level shall be stored in a specific marked area, with concrete walls 25 cm thick. 4. Non-infectious radioactive waste, which has decayed to background level, shall follow the non-risk HCM stream (class 1) while infectious radioactive waste which has decayed to background level shall follow the clinical HCW stream (class 2). 5. Liquid radioactive waste shall be discharged into the sewerage system or into a septic tank only after it has decayed to background level in adequate tanks. Class 8: Waste with high contents of heavy metals 1. Wastes with high contents of heavy metals should normally be treated in specific recovering industries. 2. Alternatively, as for chemical waste, it should be encapsulated for handling and disposal. 3. Wastes with high contents of mercury or cadmium shall never be incinerated because of the risk of atmospheric pollution with toxic vapours. National Guidelines for Health-Care Waste Management 51
  52. 52. Class 9: Effluents 1. All liquid infectious waste shall be discharged into the sewerage system only after being treated according to WHO standards. 2. Wastewater from HCFs should not be released to the environment with out treatment because they may contain various potentially hazardous components such as microbiological pathogens, hazardous chemicals, pharmaceuticals and radioactive isotopes. 3. The proper treatment of wastewater from HCFs is very expensive and cannot be currently foreseen in every HCF of Ethiopia, however, basic steps described above (1 & 2) should be applied to contributes to the reduction of the public health risk associated with liquid waste and wastewater. National Guidelines for Health-Care Waste Management 52
  53. 53. Section 6. Guidelines for Implementation of HCWM Plan in HCFs 6.1 Guidelines for waste management plan The following guidelines should be included in HCWM plan: 6.1.1 Each HCW generating organizations should have a comprehensive waste plan as part of an overall health care strategy. 6.1.2 Implementation of HCWM plan shall be coordinated by the DHEH of the MoH, in concordance with other stakeholders who will participate in a range of activities - from implementation to supervision. 6.1.3 There should be a designated individual and/or waste management committee responsible for HCWM plan implementation. 6.1.4 The HCWM plan shall contain: a) Duties and responsibilities for each of management level and different categories of HCF staff members. b) An estimation of the quantities of HCW generated and the annual needs for the implementation of the HCWM procedures/plan. c) A manual describing all the procedures for the management of HCW in the premises with special explanation for those HCWs requiring specific management. d) Monitoring procedure to track and a day-to-day activities inside the HCF and ensure that HCWM rules are respected. National Guidelines for Health-Care Waste Management 53
  54. 54. e) Information on procedures, display and location of HCF staffs, receptacles, storage at strategic points. f) Training courses and programmes for all categories of HCF staff members. g) A plan for storage and disposal of hazardous HCW in cases of emergency in the events of a breakdown of the incinerators or autoclave, and emergency procedures. 6.2 Guidelines for duties and responsibilities: 6.2.1 HCWM in HFs shall involve clarifying who is responsible for what functions and identifying the fields of competencies of each actor involved in this process. 6.2.2 The following guidelines should be included in Duties and Responsibilities at National level: a) The Federal MoH, Department Hygiene and Environmental Health (DHEH), shall take the lead in coordinating implementation of the HCWM plan. b) The Federal government, DHEH, shall ensure that Regional Health Bureaus (RHB) prepare and implement a proper HCWM plan. c) The DHEH shall support the RHB in the definition and the implementation of the HCWM plan by providing technical advice. d) The DHEH shall set up periodic training programmes review in all the training institutions to ensure that adequate training on HCWM is given. National Guidelines for Health-Care Waste Management 54
  55. 55. e) The DHEH shall be responsible give supportive supervision on HCWM activities at all levels and Federal EPA at local landfills to ensure that treatment and disposal facilities comply with guidance and regulations. f) The DHEH and Federal EPA shall watch over the means of collection, transportation, destruction and disposal of the wastes. g) The Federal MoH, Health Extension and Education Department, shall play a role with activities of public information and awareness raising on HCWM. h) EPA shall watch over the respect of environmental norms and procedures, particularly as they are contained in the Environmental Impact Assessment guidelines for hazardous wastes and health-care wastes. i) EPA shall be responsible for developing norms and standards for soil, water and air protection, mainly as they relate to the use of landfill sites for HCW disposal. In these conditions, the EPA should develop norms and standards for landfills so that they could receive HCW in a safe manner. 6.2.3 The following guidelines should be included in Duties and Responsibilities at regional/district level: 6.2.3.1 The local (regional/district) governments shall: a) Design their landfills according to the norms and standards defined by Federal EPA, in order to avoid soil, water and air pollution in case of reception of HCW. b) Ensure that safe disposal of HCW accomplishment by reserving specific areas. National Guidelines for Health-Care Waste Management 55
  56. 56. c) Enact regulations to refuse receiving mixed HCW with non infectious wastes at local landfills; forbid uncontrolled HCW disposal; and set up strong waste management controls in their landfills (materials for covering, restriction for non authorized public access, equipment protection, etc.) 6.2.3.2 The Regional/District health and environmental bureaus/offices shall: a) Need to put in place arrangements to make sure that HCW are not mixed with general wastes in their public landfills. b) Give their opinion about the HCWM plan activities proposed for health facilities in their jurisdiction, in case some may have negative impacts on the local population's health. c) Ensure that coordination of the monitoring and reporting on implementation of the HCWM should be exercised by the HCWM Committee. d) Prepare and implement a proper HCWM plan. e) Support the HCFs in the definition and the implementation of the HCWM plan by providing technical advice. f) Set up periodic training programmes in all the HCfs to ensure that adequate training on HCWM is given to their staffs. 6.2.4 The following guidelines should be included in Duties and Responsibilities at health facility level: 1. The medical director of the health facility shall: a) Be responsible for HCWM plan in his/her HF. National Guidelines for Health-Care Waste Management 56
  57. 57. b) Ensure that a HCWM plan is prepared and then watch to ensure that procedures and regulations are respected. c) Designate a committee in charge with supervising HCW segregation, storage, collection, transportation, treatment and disposal. d) Assign duties and responsibilities to all medical and non- medical staff. e) Allocate sufficient financial and manpower resources for the implementation of HCWM plan. f) Ensure adequate training and refresher courses for the concerned hospital staff members. 2. The HCWM committees shall: a) Make important contributions by identifying safety and health problems and by educating the workforce about safety and health issues. b) Get a full support and commitment of the hospital administration to have a strong and effective HCWM in the HCFs. c) Be a committee with no informal tasks for the members but a regular part of their job responsibilities. d) Represent workers and supervisors from all departments in the HCFs. e) Comprise the following members: i) Medical director or Deputy, who shall be the chairperson. ii) The Head of administration iii) The Head of units/nurses iv) The Matron v) The HCWM officer/expert vi) The Head of operation and maintenance National Guidelines for Health-Care Waste Management 57
  58. 58. vii) The Head of pharmacy f) Include the following major functions: i) Inspecting workplaces regularly to identify safety and health hazards and infections ii) Regularly reviewing needle injury rates and results from prevention activities, and other relevant workplace data iii) Preparing information for workers on identified hazards and infections iv) Organizing educational classes v) Reviewing safety and health aspects when planning new construction or renovating facilities vi) Establishing motivational programs (e.g. recognition, awards, and dinners) to stimulate worker participation in HCWM activities. 3. The HCWM officer/expert shall: a) Be responsible for the daily implementation and monitoring of the HCWM plan. b) Ensure internal collection of bags and waste containers and their transport to the central storage facility of the HF on a daily basis. c) Liaise with the medical and supply units to ensure that an adequate supply of waste bags, containers, protective clothing and collection trolleys are available at all level. d) Ensure that cleaners and sweepers immediately replace used bags/containers with a new bag/ container of the same type and where a waste bin is removed from one container, that the container is properly cleaned before a new bag is fitted in. National Guidelines for Health-Care Waste Management 58
  59. 59. e) Ensure that cleaners and sweepers are not involved in waste segregation and that they only handle waste bags and containers, in the correct manners. f) Ensure correct use of the central storage facility and that it is kept secured from unauthorised access. He should also prevent unsupervised dumping of waste nags and waste containers on the hospital premises, even for short periods of time g) Coordinate and monitor all disposal operations, and for this purpose meet regularly with the concerned representative of the local council. h) Ensure that the correct methods of transportation and disposal of waste are used. i) Ensure the emergency procedures exist and can be taken. He shall investigate record and review all incidents reported regarding hospital waste management. 4. The Heads of administration shall: a) Ensure that all the logistics and human resources needs are adequately fulfilled to implement the HCWM plan. b) Ensure that a proper budget to the implementation of the HCWM plan. c) Liaise with the medical director and the HCWM officer/expert to estimate the specific costs and to request the proper budget to the waste storage, treatment and disposal facilities and health services. 5. The Matron shall: a) Liaise with the medical director and HCWM committee. National Guidelines for Health-Care Waste Management 59
  60. 60. b) Be responsible for the application of HCWM procedures by the nursing and the cleaning staffs. c) Be responsible for the recording and the reporting of all cuts or puncture wounds associated with sharps and manipulations such as needle stick injuries of medical and non-medical staff members. d) Ensure that the staff members know the immediate disinfection measures to be taken during spilling emergencies. 6. The Head of units/nurses shall: a) Be responsible for the proper management of the HCW generated in their respective units. b) Head of units/nurses shall: c) Ensure that al, the medical and ancillary staff working in their unit respect the HCWM procedures. d) Ensure that the HCWM procedures are clearly displayed at strategic locations. e) Liaise with the HCWM officer/ expert for effective monitoring reporting of mistakes and errors in the implementation of the HCWM plan. 7. The Head of operation and maintenance shall: a) Liaise with the head administration and HCWM officer/expert. b) Be responsible for the application of HCWM procedures by the maintenance staffs. National Guidelines for Health-Care Waste Management 60
  61. 61. c) Be responsible for the recording and the reporting of all cuts or puncture wounds associated with sharps and needle stick injuries of maintenance staffs. d) Ensure that the maintenance staff members know the immediate reporting of all cuts or puncture wounds associated with sharps and needle stick injuries. e) Ensure that the maintenance staff members know the immediate corrective maintenance measures to be taken during spilling emergencies wastes from drainage lines. f) Be responsible for the installation, maintenance and safe operation of waste storage facilities as well as the waste handling and treatment equipment. g) Ensure that the concerned HF staff members are properly trained for these purposes. 8. The Pharmacist shall: a) Ensure that all logistics and pharmaceutical commodities are stored properly to minimize wastage due mishandling. b) Ensure that a proper records for logistics and pharmaceutical commodities. c) Ensure that the application of first-in first-out dispensary for pharmaceutical commodities. d) Liaise with the medical director and the HCWM officer/expert to handle expired pharmaceutical commodities and to request the proper method of handling and disposing off. 6.3 Guidelines for allocation of resources and equipment for health-care waste handling 6.3.1 Guidelines for waste audits and needs estimate National Guidelines for Health-Care Waste Management 61
  62. 62. a) A waste management baseline audit and needs estimate should be conducted before developing a waste management plan of the HCF. b) The following information HCW for waste audit should be collected and assessed in accordance with the guidelines: i) Types, volume and/or weight, quantities and composition of waste generated; ii) Incidence and severity of waste handling injuries; iii) Incidence and nature of spills and leakages of hazardous wastes; iv) Sources of solid and liquid wastes; v) Points of generation, collection and storage sites; vi) Types and number of waste containers; vii)Loading, transport and disposal methods; viii) Transportation and disposal records; ix) Costs of waste handling, transport, treatment and disposal; c) The number of safety boxes, yellow, black and red bags as well as bag-holders, containers, collection trolleys and protective clothing annually required for HCW handling shall be estimated. d) A contingency margin of 5% shall always be applied for safety boxes, yellow, black and red bags. e) The quantities of disinfectants, necessary spare parts for HCW treatment and disposal shall be estimated. f) The number of staff members required for HCW collection and disposal. National Guidelines for Health-Care Waste Management 62
  63. 63. 6.3.2 Guidelines for selection of the technology for HCW treatment/disposal The technology for HCW treatment /disposal shall: a) Be selected according to the types of HCW generated in the HCF. b) Be sized according to the quantities of HCW generated in the HCF. c) The operation and maintenance procedures shall be carefully estimated and documented in the HCWM plan. d) A contingency plan shall be included in the HCWM plan in case of breakdown of the disposal/treatment facility. 6.3.3 Guidelines for allocation of resources and provision of equipment a) Equipment and materials (safety box, bags, disinfectant, protective clothing) should be supplied regularly with out any shortage in stock. b) Health facility heads should promote material recovery for reuse under supervision from national, regional and district health offices. c) Sufficient annual running costs shall be dedicated in the budget for the safe management of the HCW. 6.4 Guidelines for Awareness and Training Training and awareness efforts with regards to HCWM shall be made at all levels: 6.4.1 To raise awareness amongst the public about HCW health risks and safe practices. National Guidelines for Health-Care Waste Management 63
  64. 64. 6.4.2 To make sure that medical staff refresher training is given on HCWM. 6.4.3 To make sure that the new staff member is familiarized with HCWM of the HCF. 6.4.4 To ensure that of waste management is included in the curricula of health-care personnel in the National training package. 6.4.5 To ensure that waste management operators (transporters, treatment plant and landfill operators…) get appropriate training and support. 6.4.6 For public education on risks, waste segregation, or waste disposal practices by using the following methods: a) Displaying posters at strategic points in HCFs such as waste bin locations, giving instructions on waste segregation. Posters should be explicit, using diagrams and illustrations to convey the message to as broad an audience as possible, including illiterate people. b) Conveying simple messages outside HCFs through schools, radio or television programmes, raising awareness about the risks involved in scavenging discarded syringes and hypodermic needles, etc… c) Applying attractive manner for all information displayed or communicated to be at a maximum effectiveness in holding people’s attention. 6.5 Guidelines for monitoring system and reporting procedures for HCWM at all levels: National Guidelines for Health-Care Waste Management 64
  65. 65. 6.5.1 Monitoring system shall be set up to track hazardous HCW and sharps along the waste stream until final disposal. 6.5.2 Monitoring should include incident and accident reporting and recording. 6.5.3 Monitoring data should be analyzed and reviewed at regular intervals and compared with the host country regulatory limits so that any necessary corrective actions can be taken. 6.5.4 Records of monitoring results should be kept in an acceptable format. 6.5.5 Periodic survey shall be performed in waste generators, storages and transportation, treatment and disposal facilities. 6.5.6 All responsible bodies should submit annual HCWM performance monitoring reports to their respective bodies. 6.5.7 The annual reports shall contain quantitative data of the performance of the facility illustrating compliance with national guidelines. 6.6 Guidelines for private sector involvement 6.6.1 All contracts with private contractors for collection, on-site or off-site transportation, treatment or disposal of HCW shall be approved by regional health and environment bureaus. 6.6.2 A private contractor shall be licensed for HCWM operation by regional health bureaus for competency and regional environment bureaus for operation. 6.6.3 The MoU with private contractor shall include duties and responsibilities of ach party regarding HCWM procedures and handling, transportation and final disposal of HCW. 6.6.4 All workers of the private enterprise dealing with HCW shall be supplied adequate protection clothes and equipment. National Guidelines for Health-Care Waste Management 65
  66. 66. REFERENCES 1. Federal Democratic Republic of Ethiopia, Ministry of Health. Health Related Indicators, 1996 EC. 2. EPA (1986). EPA guide for infectious waste management. Washington, DC: U.S. Environmental Protection Agency, Office of Solid Waste. 3. Garner JS, Favero MS (1985). Guideline for handwashing and hospital environmental control, Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Infectious Diseases, Hospital Infections Program. 4. Federal Democratic republic of Ethiopia. Environmental Pollution control. Federal Negarit Gazeta, 9th year, Proclamation No 300/2002, Addis Ababa 3rd December 2002. 5. Hauri A, Armstrong G, Hutin Y. The Global burden of diseases from contaminated injections given in health care settings. Presentation at the 2001 meeting of the Infectious disease Society of America, San Francisco, October 2001. 6. World health organization. Safe management of wastes from health- care activities. Edited by Pruss A and Girout A, 1999. 7. Fikru Tesfaye. Assessment of injection safety at health facilities in four pilot Weredas of Oromia Region and SNNPR. A report submitted to JSI – Injection Safety Project. August 2004, Addis Ababa (Unpublished). National Guidelines for Health-Care Waste Management 66
  67. 67. 8. World Health Organization. Management of Solid Health care Waste at Primary Health centers: a decision making guide. WHO, Geneva, 2005. 9. WHO and the WB. Better health care waste management, an integral component of health investment. WHO/WB, Amman 2005. 10. Environmental Health department, Ministry of Health of Ethiopia. An assessment of the status of four Federal hospitals Infectious waste management system and hygiene practice. July 2004, Addis Ababa (Unpublished). 11. Federal Democratic Republic of Ethiopia, Ministry of Health.. Report on the assessment of situations of water supply and sanitation facilities in selected health centers and health stations. Hygiene and Environmental Health Department, December 1997 (Unpublished). 12. JSI-making Medical Injections Safer Project. Assessment of injection practices in Ethiopia: a case of six Woredas of Harari, Tigrai, Amhara Regions and Dire Dawa Administration. January 2006 (Unpublished). 13. Federal Ministry of Health. AIDS in Ethiopia: 5th report. Addis Ababa, June 2004. 14. Federal Democratic Republic of Ethiopia, Ministry of Health. Making medical injections safer, Ethiopia. Country strategic plans, 2005- 2009, Final draft. December 2004, Addis Ababa (Unpublished). 15. Yemane Berhane and Millogo, J. Report of injection safety survey in Ethiopia. Geneva, Switzerland, 2000 (unpublished). 16. WHO. Preparation of national health care waste management plans in Sub-Saharan Countries, Guidance manual. WHO, UNEP, Geneva 2005. 17. USAID. Treatment alternatives for medical waste disposal. Programme for appropriate technology in health (PATH), October 2005. National Guidelines for Health-Care Waste Management 67
  68. 68. 18. JOHN SNOW INCORPORATED – MAKING MEDICAL INJECTIONS SAFER, Assessment of Health Care Waste Management Status in Health Facilities of Ethiopia, February 2006 (unpublished). 19. The World Bank, Final Report - National Health-Care Waste Management Plan of the United Republic of Tanzania, March 2003. 20. Michael Reid, NSWHEALTH, Waste Management Guidelines for Health Care Facilities – August 1998. 21. California Polytechnic State University, MEDICAL WASTE MANAGEMENT PLAN, Risk Management, June, 1996 22. National Health and Medical Research Council, National Guidelines for Waste Management in Health Industry, March 1999. 23. REPUBLIC OF MALAWI MINISTRY OF HEALTH AND POPULATION In conjunction with UNICEF, WORLD BANK and WHO, HEALTH CARE WASTE MANAGEMENT PLAN OF ACTION, May 2003. 24. Board of Public Works HTM Office, City of Los Angeles Fact Sheet: Medical Waste Management, November 1995 25. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), Guidelines for Environmental Infection Control in Health-Care Facilities, May 2003 26. USEPA, Publication on Pollution Prevention for Selected Hospital Waste Streams, Environmental and Social Guidelines for Health Care Facilities, May, 2003 National Guidelines for Health-Care Waste Management 68

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