FILE COPY. Health-care waste management. Democratic Socialist Republic of Sri Lanka. National Guidelines E600

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Democratic Socialist Republic of Sri Lanka Ministry of Health and Indigenous Medicine Health-care waste management National Guidelines E600 Vol. 1 FILE COPY Draft version 2 -October ZOO.i

2 Table of contents TABLE OF CONTENTS 1 List of figures 4 Abbreviations 4 FOREWORD 5 INTRODUCTION 6 Objectives 6 Audience 6 How to use these guidelines 7 We need your feedback 7 SECTION 1 - DEFINITIONS 8 1. Health-care waste 8 2. Non-risk health-care waste 8 3. Hazardous health-care waste Infectious waste Pathological waste Anatomical waste Pharmaceutical waste Chemical waste, waste with high contents of heavy metals and pressurised containers 9 4. Highly hazardous health-care waste Sharps Highly infectious waste Genotoxic waste Radioactive waste 10 SECTION 2 - PUBLIC HEALTH RISKS ASSOCIATED WITH HEALTH-CARE WASTE I 1 1. Occupational risks Risks to the population Indirect risks via the environment 12 last updated October 27th 2001 page 1

3 4. Managing health-care wastes to minimise the overall risks 12 SECTION 3 - HEALTH-CARE WASTE MANAGEMENT PROCEDURES Classification of health-care waste Segregation Colour coding system Consideration on HCW minimisation and recycling 14 Recycling of non-contaminated plastic items 14 * Recycling of glassware inside the Medical Analysis Laboratories 15 * Reuse of specific equipment General HCWM procedures Waste collection and on-site transportation Waste storage Off-site transportation Waste treatment and disposal Accidents and spillage Specific procedures associated with HCW categories Class 1: non-risk health-care waste Class 2: hazardous health-care waste 18 * Specific treatment of anatomical waste and placentas 18 * Specific treatment of blood 18 * Specific treatment of highly infectious waste Class 3: sharps Class 4: radioactive waste Class 5: specific hazardous health-care waste 20 * Large quantities of pharmaceutical waste 20 * Large quantities of chemical waste 21 * Waste with high contents of heavy metals 21 * Effluents 21 SECTION 4 - GUIDELINES FOR THE IMPLEMENTATION OF HEALTH-CARE WASTE MANAGEMENT PLANS IN THE HEALTH-CARE FACILITIES Assign duties and responsibilities Duties and responsibilities of the Director of the Hospital Duties and responsibilities of the health-care waste management team Duties and responsibilities of Head of administration Duties and responsibilities of the Heads of departments Duties and responsibilities of the Matron of the hospital Duties and responsibilities of the Head of infection control nurses Duties and responsibilities of the Head of overseers Duties and responsibilities of the health-care waste management Officer Allocate resources and provide equipment for health-care waste handling 33 last updated October 27th 2001 page 2

4 2 1 Estimation of needs Selection of the technology for HCW disposal Allocation of resources and provision of equipment Organise the HCW streams Outline the procedures and practices Ensure training of staff members Prepare the HCWM plan document Set-up a monitoring system and reporting procedures Focus on specific locations Consideration on the involvement of the private sector 35 SECTION 5 - GUIDELINES FOR CENTRAL AND PROVINCIAL HEALTH SERVICES Setting-up of annual provincial health-care waste management plans Backstopping of health-care facilities Inspection 38 CONCLUSION 40 last updated October 27th 2001 page 3

5 List of figures National Guidelines for Health-Care Waste Management in Sri Lanka Box 1: categories of health-care waste (examples) Box 2: hazards related to sharps Box 3: classification, packaging and treatment of health-care wastes Box 4: illustration of the protective clothing of HCW sanitary staff and sweepers Box 5: international symbols to be used for hazardous and radioactive HCW Box 6: treatment and disposing technologies for large quantities of health-care waste Box 7: example of low cost safety box made with cardboard recommended by the WHO Box 8: basic consideration for radioactive health-care waste disposal Box 9: health-care waste management inside the Medical Analysis Laboratories Box 10: synthesis of the health-care waste streams inside a hospital Box 11: sample sheet for the assessment of waste generation Box 12: Checklist for a minimum HCWM programme in HCFs Abbreviations HCF HCW HCWM : Health-Care Facility : Health-Care Waste Health-Care Waste Management last updated October 27th 2001 page 4

6 Foreword Health-care services inevitably generate wastes that may be hazardous to health or have harmful environmental effects. Some of them, such as sharps or infected blood, carry a higher potential for infection and injury than any other type of wastes. Their improper management can cause direct health impacts on the personnel working in the health-care facilities or on the communities. An integrated effort is necessary in Sri Lanka to set-up safe health-care waste management practices. To achieve this goal, the Democratic Socialist Republic of Sri Lanka set up a National Steering Committee on Clinical Waste Management chaired by the Ministry of Health. This Committee includes representatives of the Central Environmental Authority, The National Hospital of Sri Lanka, the Colombo Municipal Council, the World Bank and the World Health Organisation. The National Steering Committee on Clinical Waste Management underlines that the following issues are capital to define and implement a sustainable and effective health-care waste management programme: * Health-care waste is first of all a management issue (and not only a technical one) that should become an integral feature of health-care services; * It is essential that clear individual responsibilities are established and monitoring procedures set up at each level of the health-care waste management streams; * Additionally, awareness and training programmes for medical and ancillary staff should be strengthened in health-care establishments, Faculties of Medicine, Nursing Schools and at the National Institute of Public Health Science; * Specific administrative procedures should be defined and adequate resources allocated at all levels to ensure a proper management of the health-care wastes;. Appropriate, environmental-friendly and affordable technologies should be selected for the treatment and the disposal of health-care wastes, taking into consideration the resources of each health-care facility. The National Steering Committee on Clinical Waste Management prepared this document which provides guidelines for all the persons involved in health-care waste management at central and local levels. These guidelines have been reviewed and approved during a workshop held at the Ministry of Health in October They are part of a more global action undertaken by the Government of the Democratic Socialist Republic of Sri Lanka to improve the management of health-care waste throughout the country. last updated October 27th 2001 page 5

7 Introduction Safe management of Health-Care Waste (HCW) is a key issue to control and reduce nosocomial infections inside a hospital 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 hospital. The absence of management measures to prevent exposure to hazardous HCW results in a maximum health risk to the general public, in- and out- patients as well as the medical and ancillary staff. Therefore, the recommendations that are contained in this document should be applied to all the HCFs of Sri Lanka. This may not be possible in some of them due to financial constraints, etc... In this case, a minimum HCWM programme should be set up. Objectives This document aims at identifying appropriate HCWM methods that can be applied in the HCFs of Sri Lanka. More specifically, it attempts to: * Provide a better knowledge of the fundamentals of HCWM planning and a better understanding of the hazards linked to HWC; * Develop HCWM plans and standards which are protective for both the human health and the environment, in compliance with the current environmental legislation of Sri Lanka' taking into consideration the financial possibilities of each institution; * Set priority actions in order to tackle the most sensitive problems related to HCWM (e.g. disposal of sharps and blood) and to present these actions as part of a more global framework; Audience * Review appropriate and sustainable technologies to treat and dispose of HCW; * Facilitate the analysis of HCWM problems and develop strategies for the safe management of HCW at provincial level. This document provides both conceptual and practical information on HCWM for: * The medical staff members having a "duty of care" at all levels in public or private HCFs, namely: Directors, Heads of all Hospital Departments, Administrators, Doctors, Matrons, Infection Control Nurses and Overseers; National Environmental Act No 47 of 1980 and National Environmental (Amendment) Act, No 53 of last updated October 27th 2001 page 6

8 . National policy makers in charge of developing, implementing and evaluating HCWM plans at Central and Provincial levels as well as Public Health Officers in charge of their implementation and monitoring; * Members of the teaching boards in charge of training medical doctors, nurses and public health officers at National Faculties of Medicine, Nursing Schools as well as the National Institute of Public Health Science; * International Organisations or NGOs involved in the backstopping of the medical institutions of Sri Lanka. How to use these guidelines These guidelines are divided into five sections and have been structured to be as practical as possible. * The two first sections should be read by 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 of its mismanagement; * 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. * 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-*; * The fifth section has been written for personnel of Central and Provincial Health Services that should deal with HCWM to ensure a smooth implementation of the instructions contained in this document; * At the end of each section, practical tools are provided to help you to organise and manage the health-care waste streams at your level. We need your feedback This document will be periodically reviewed by the Steering Committee on Clinical Waste Management according to the inputs that will be sent back by each Medical Institution to the Ministry of Health. All the actors involved in this issue are therefore highly encouraged to send their comments to the Ministry of Health, Division of Health Services, 231 De Saram Place, Colombo 10. ' Are considered as Major Hospitals all the tertiary and secondary health-care institutions They include Teaching Hospitals, Special and Armed Hospitals, Provincial Hospitals and Base Hospitals - Are considered as Minor Health-Care Facilities all the pnmary health-care institutions. They include District Hospitals, Peripheral Units, Rural Hospitals, Maternity Homes, Central Dispensaries last updated October 27th 2001 page 7

9 Section 1 - Definitions (1) The definitions and the classification hereafter are adapted from the international classification provided by the World Health Organisation* and reproduced by The World Bank in its guidance note on health-care waste management'*. 1. Health-care waste (2) Health-Care Waste (HCW) includes all the wastes generated by medical activities. It embraces activities of diagnosis as well as preventive, curative and palliative treatments in the field of human and veterinary medicine. In other words, are considered as HCW all the wastes produced by a medical institution (public or private), a medical research facility or a laboratory. It can be divided into three groups: non-risk health-care waste; hazardous healthcare waste and highly hazardous health-care waste. (3) Although they represent the smallest part of the total amount of HCW generated by the HCFs, hazardous and highly hazardous HCW must be managed specifically due to their potential harmful effects both on health and the environment. 2. Non-risk health-care waste (4) Non-risk HCW includes all the waste that has not been infected like general office waste, packaging or left over food. They are considered as domestic waste and can be managed by the municipal waste services. They represent between 75% and 90% of the total quantity of HCW generated by medical institutions. 3. Hazardous health-care waste 3.1 Infectious waste (5) Are considered as infectious waste, all wastes that are susceptible to contain pathogens (or their toxins) in sufficient concentration to cause diseases to a potential host. This category includes for example tissues (swabs), material and equipment that have been used in surgery or been in contact with patients. 3.2 Pathological waste (6) Pathological waste consists in organs, tissues, body parts or fluids such as blood. Even if pathological waste may contain healthy body parts, it has to be considered as infectious waste for precautionary reasons. 'Safe management of waste from health-care activities, WHO, 1999 Edts Pruss, Giroult & Rushbrook. Health Care Waste Management, Guidance Note, HNP, The World Bank, 2000, Edts Johannssen and al. last updated October 27th 2001 page 8

10 3.3 A-natomical waste National Guidelines for Health-Care Waste Management in Sri Lanka (7) Anatomical waste consists in recognisable human body parts, whether they may be infected or not. Following the precautionary principal, anatomical waste is always considered as potential infectious waste. 3.4 Pharmaceutical waste (8) Pharmaceutical waste includes expired, unused, spilt and contaminated pharmaceutical products, drugs and vaccines. In this category are also included discarded items used in the handling of pharmaceuticals like bottles, vials, connecting tubing... Since the Ministry of Health has taken specific measures to reduce the wastage of drugs, HCFs should deal only with small quantities of pharmaceutical waste. 3.5 Chemical waste, waste with high contents of heavy metals and pressurised containers (9) Chemical waste consists of discarded chemicals (solid, liquid or gaseous) that are generated during disinfecting procedures or cleaning processes. They may be hazardous (toxic, corrosive, flammable...) and must be used and disposed of according to the specification formulated on each container. Nevertheless non-explosive residues or small quantities of outdated products may be treated together with infectious waste. (10) Waste with high contents of heavy metals and derivatives are potentially highly toxic (e.g. cadmium or mercury from thermometers or manometers). They are considered as a sub-group of chemical waste but should be treated specifically. (11) Pressurised containers consist of full or emptied containers or aerosol cans with pressurised liquids, gas or powdered materials. 4. Highlyhazardous health-care waste 4.1 Sharps (12) Sharps are items that can cause cuts or puncture wounds (needle stick injuries for instance). Whether they are infected or not, they are considered as highly dangerous and potentially infectious waste. They must be segregated, packed and handled specifically within the HCFs to ensure the safety of the medical and ancillary staff. 4.2 Highly infectious waste (13) Highly infectious waste consists in microbial cultures and stocks of highly infectious agents from Medical Analysis Laboratories. They also include body fluids of patients with highly infectious diseases. 4.3 Genotoxic waste (14) Genotoxic waste derives from drugs generally used in oncology or radiotherapy units that have a high hazardous mutagenic or cytotoxic effect. Faeces, vomit or urine from patients treated with cytotoxic drugs or chemicals should be considered as genotoxic. In specialised cancer hospitals, their proper treatment or disposal raises serious safety problems. last updated October 27th 2001 page 9

11 4.4 Radioactive waste (15) Radioactive waste includes liquids, gas and solids contaminated with radionuclides whose ionizing radiations have genotoxic effects. The ionizing radiations of interest in medicine include X- and y-rays as well as ax- and P- particles. An important difference between these types of radiations is that X-rays are emitted from X-ray tubes only when generating equipment is switched on whereas y-rays, ax- and j3- particles emit radiations continuously. (16) The type of radioactive material used in HCF results in low level radioactive waste. It concerns mainly therapeutic and imaging investigation activities where Cobalt 60 Co, Technetium 9 9mTc, iodine 1311 and iridium 192 1r are most commonly used. (17) With the noticeable exception of Cobalt 60 Co, their half-life is reasonably short (6 hours for 99 mtc, 8 days for 1311 and 74 days for 192 1r) and the concentrations used remain low. A proper storage with an appropriate retention time is sufficient to prevent radioactivity to spillage in the environment. Box 1: categories of health-care waste (examples) Health-care waste Non-risk health-care waste (75-909%) * Hazardous health-care waste (10-25%) - Infectious waste (laboratory cultures, waste from isolation wards, tissues, equipment that has been in contact with infected patients...) *Anatomical waste (body parts) -Pathological waste (blood, human fluids...) - Chemicals, heavy metals and pressurised containers (laboratory reagents, solvents, broken mercury thermometers...) - Pharmaceutical waste (expired drugs, bottles contaminated with drugs...) * Highly hazardous health-care waste (<5%) - Sharps (scalpel, needles, blades, infusion sets, broken glass...) - Highly infectious waste (microbial cultures...) - Genotoxic waste (mitotic inhibitors, alkylating agents...) - Radioactive waste (urine and excreta from inpatients treated with radionuclides, contaminated glassware...) last updated October 27th 2001 page 10

12 Section 2 - Public health risks associated with health-care waste (18) 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 at the generation point. Furthermore, the constraints related to their management as well as the funds required to set up a proper management discourage many medical institutions to undertake the necessary steps to improve their current HCWM practices. (19) Nevertheless, HCWM is an integral part of hygiene and infection control within a HCF and a proper management should help in controlling nosocomial infections. All individuals exposed to hazardous HCW are potentially at risk of being injured or infected. They include: Medical staff: doctors, nurses, sanitary staff and hospital maintenance personnel; * In- and out- patients receiving treatment in HCFs as well as their visitors; * Workers in support services linked to HCFs such as laundries, waste handling and transportation services; * Workers in waste disposal facilities, including scavengers; * 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. 1. Occupational risks (20) During handling of wastes, the medical and ancillary staff as well as the sanitary labourers can be injured if the waste has not been packed safely. In that respect, sharps are considered as one of the most dangerous waste. Many injuries occur because syringe needles or other sharps have not been collected in safety boxes or because these have been overfilled (see box 2). (21) On dumpsites, scavengers during their recycling activities may also come in contact with infectious waste if it has not been properly treated or disposed of. 2. Risks to the population (22) 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. (23) The "recycling" practices that have been reported, particularly, the reuse of syringes is certainly the most serious problem in some of the developing countries. the WHO estimates that some 10 million infections of Hepatitis B, C and HIV occur yearly from the reuse of discarded syringes needles without prior disinfection. last updated October 27th 2001 page 11

13 3 Indirect risks via the environment (24) Finally, the dumping of HCW in uncontrolled areas can have a direct environmental effect by contaminating soils and underground waters. During incineration, if no proper filtering is done, air can also be polluted causing illnesses to the nearby populations. This has to be taken into consideration when choosing a treatment or a disposal method by carrying out a rapid environmental impact assessment. 4. Managing health-care wastes to minimise the overall risks (25) Implementing adequate procedures to minimise 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 minimise indirect impacts from environmental exposures to HCW. (26) Currently environmental-friendly, safe and affordable options may not be available for every situation in Sri Lanka. The risk of health impact from environmental exposure should always be weighed against the risk of accidental infection from poor HCWM. This is why: * The instructions contained in theses guidelines for the handling and the disposal of sharps, and more specifically used syringes, attempt first to minimise the risks of cuts or needle stick injuries that may occur after an injection. * Some treatment options such as low-cost incinerators which emits pollutants may be used in certain situations (e.g. low densely 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*. Box 2: hazards related to sharps ~qjpetsrfiineaiozsiwtnagnsa,ripsh7rpsarve rconsrsiareaas one of the rrost ha2arizroiou at in orserous irw mnkttons Precautionary rienciple: when the magnitusdeofanpaerticular risk isluncerain,et should beasmed Infrenon RIsA of e-tiin thin71 Source. Safe management of waste from health-care activiyies, WHO, * Precauponary principle: when the magnitude of a partcular risk is uncertain, It should be assumed that this risk is significant, and measures to protect health and safety should be designed accordingly. last updated October 27lth 2001 page 12

14 Section 3 - Health-care waste management procedures (27) The implementation of safe HCWM procedures aims at containing infections and reducing public health risks both within and outside the HCF. The procedures should always contain the following measures: * Minimisation of the quantity of HCW generated by the HCF; * Segregation and identification of hazardous HCW from non-risk HCW; * Adequate packaging and safe storage of the different HCW; * Proper treatment and disposal of hazardous and non-risk HCW. 1. Classification of health-care waste (28) A proper segregation must follow rigorous and standardised procedures. It enables to reduce the risks of infecting workers and control the economical incidence of hazardous HCW disposal by decreasing the treatment costs. It must be: 1.1 Segregation * Simple to implement for the medical and ancillary staff; * Safe and guaranty the absence of infectious HCW in the domestic waste flow; * Stable and homogeneously applied in all the HCFs; * Regularly monitored to ensure that the procedures are respected. (29) The segregation consists in separating the different waste streams based on the type of treatment and disposal practices. A proper segregation should thus identify waste according to source and type of disposal or disinfection. It should provide receptacles specifically suited for each waste. (30) Segregation shall take place at the source, that is at the ward bedside, Operation Theatre, Medical Analysis Laboratory, or any other room or ward in the hospital where the waste is generated. It shall be applied uniformly throughout the country. * Class 1: non-risk HCW; * Class 2: hazardous HCW other than those classified under class 3, 4 and 5; * Class 3: all kind of sharps; * Class 4: radioactive HCW; * Class 5: specific hazardous HCW. (31) Non-risk HCW includes all the domestic waste as defined in 4. In the HCFs where a safe collection and recycling of plastic and glassware can be ensured, a more specific segregation may be set up (see 43 and 45). last updated October 27th 2001 page 13

15 (32) Hazardous HCW includes all infectious or highly infectious' waste, pathological waste (such as blood) and anatomical waste. Can be included in this category pharmaceutical, residues of genotoxic drugs and chemical waste as long as small quantities are concerned. Due to the specific treatment or disposal, all hazardous HCW shall not be identically treated or disposed of (see specific procedures). (33) Sharps include all items that can cause cuts or puncture wounds as indicated in 12. Sharps shall be considered as highly hazardous waste and collected in rigid safety boxes to avoid any wound. Once full, the safety boxes shall follow the hazardous HCW stream. (34) Radioactive HCWincludes all HCW as defined in 15, 16 and 17. They shall always be treated specifically and separately from the other categories of HCW. (35) Specific hazardous HCW includes large quantities of pharmaceutical or chemical waste, waste with high content of heavy metals and effluents. In Sri Lanka, large quantities of pharmaceutical and chemical waste are unlikely to arise from HCFs. 1.2 Colour coding system (36) The colour coding system aims at ensuring an immediate and non-equivocal identification of the hazards associated with the type HCW that is handled or treated. In that respect, the colour coding system shall remain simple and be applied uniformly throughout the country. (37) All health-care facilities shall apply the following colour coding system: * Black: all bins or bags containing non-risk HCW of class 1; * Yellow. any kind of containers filled with hazardous HCW, sharps, radioactive HCW or specific hazardous HCW (classes 2, 3, 4 and 5). 1.3 Consideration on HCWminimisation and recycling (38) The implementation of recycling procedures in HCFs to minimise 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 source of errors. (39) Nevertheless, considering the specific recycling practices in Sri Lanka, the necessity to implement an environmental-friendly process of HCW disposal and the financial resources of each HCF, a simple and safe recycling programme should be implemented whenever it is possible. In these situations the instructions hereafter should be followed. * Recycling of non-contaminated plastic items (40) All non-contaminated plastic items (e.g. bags of sodium chlorine) should be collected, packed in separate boxes and delivered to or picked-up by local contractors capable to Although highly infectious waste is defined as a highly hazardous HCW, it is disposed with the hazardous HCW in the HCFs after having been pre-treated ( 80) at the point where they are generated (i.e. in medical analysis laboratories most often). For this reason, they are considered with the hazardous HCW. last updated October 27th 2001 page 14

16 recycle them with environmental-friendly techniques. A non-contaminated item is an item that has never been in contact with any of the hazardous HCWs as defined in 5 and following. * Recycling of glassware inside the Medical Analysis Laboratories (41) All non-contaminated and non-broken glassware (flasks of injectable penicillin for instance) can be collected separately. They should be put in a solution of 10% sodium hypochlorite for 30 minutes, carefully washed, rinsed and dried before being reused. The disinfected glassware should be reused only for specific medical analysis (blood, urine) carried out inside the Medical Analysis Laboratory. (42) After having been used once, they shall be considered as contaminated and infectious. Broken glassware shall always follow the stream of sharp waste (class 3) while non-broken glass flasks shall be reused only after disinfection in a solution of 10% sodium hypochlorite for 12 hours, carefully washed with a brush and soap, rinsed and dried. It is recommended to autoclave the glassware after washing at 121 C for at least 30 minutes to ensure a complete disinfection. During the disinfection process, hands shall always be protected with gloves. * Reuse of specific equipment (43) In general, to encourage reuse, each hospital shall collect separately, wash and sterilise, either thermally or chemically in accordance with approved procedures, surgical equipment and other items which are designed for reuse and are resistant to the sterilisation process. Pressurised gas cylinders should be returned to suppliers for refilling and reuse. (44) Pharmacy department stores in each HCF should be rigorously managed to avoid wastage and stock positions should be recorded on a regular basis. 2. General HC WMprocedures (45) Are given hereafter all the general instructions that should be respected in a HCWM plan to ensure a safe manipulation of all the HCW generated in HCFs. The specific instructions associated with the manipulation and the treatment of each class of HCW are presented in 69 and following. 2.1 Waste collection and on-site transportation (46) 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 of. In case any such used equipment or supplies are found or are handed over to any person, it should be discarded by that person. (47) All the specific procedures of HCW segregation, packaging and labelling shall be explained to the medical and ancillary staff and displayed in each department on charts located on the walls nearby the HCW containers. (48) When handling waste, sanitary staff and sweepers shall wear protective clothing at all times including face masks, industrial aprons and boots, heavy duty gloves, as required and illustrated in box 4. last updated October 27th 2001 page 15

17 (49) The waste collection trolley should be easy to load, unload and clean. The trolley shall not be used for any other purpose. It shall be cleaned regularly, and especially before any maintenance work is performed on it. (50) Yellow bags of hazardous HCW and black bags of non-risk HCW shall be collected on separate trolleys that shall be painted or marked with the corresponding colours and washed regularly. (51) The collection route shall be the most direct one from the collection point to the central storage facility. The collected waste shall not be left even temporarily anywhere other than at the designated central storage facility. 2.2 Waste storage (52) In each room where HCW is generated, an adequate place shall be dedicated for storing HCW bag-holders, bins or containers. It should be easily accessible for the sanitary staff. Instruction shall be displayed as described in 47. (53) In all HCFs, separate central storage facilities shall be provided for hazardous HCW, except radioactive waste that shall be stored specifically (see 90). It shall clearly be mentioned that the facility stores hazardous HCW and no materials other than yellow bag waste. No waste shall be stored for more than two days before being treated or disposed of. (54) 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. It 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. (55) The designated central storage facility shall be totally enclosed and secured from unauthorised access. It shall be inaccessible to animals, insects and birds. It shall be easy to clean and disinfect, with an impermeable hard-standing base, good water supply, drainage and ventilation. 2.3 Off-site transportation (56) In case off-site transportation is required to treat hazardous HCW at a central treatment facility, the Provincial Council shall approve the off-site transportation plan before any transit occurs. (57) All yellow bags shall be collected at least every second day. The transportation shall be properly documented, and all vehicles shall carry a consignment note from the point of collection to the central treatment facility. (58) Vehicles used for the carriage of yellow bags shall not be used for any other purpose. They 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 hospital premises or on the road during transportation. (59) All vehicles shall be cleaned and disinfected after use. They shall carry adequate supply of plastic bags, protective clothing, cleaning tools and disinfectants to clean and disinfect in case of any spillage (see 65 and following). last updated October 27th 2001 page 16

18 (60) All vehicle staff handling yellow bags shall wear protective clothing. They shall be properly trained in the handling, loading and unloading, transportation and disposal of the yellow bags. They shall be fully aware of emergency procedures for dealing with accidents and spillage. 2.4 Waste treatment and disposal (61) After the proper implementation of segregation procedures, HCW shall be treated and disposed of in accordance with the National Environmental Act No 47 of 1980 and the National Environmental (Amendment) Act, No 53 of (62) Amongst all the current existing technologies for treating and disposing of HCW (see box 6), the most appropriate technology shall be applied, that is: * The most reliable, affordable and sustainable technology in accordance with the technical, human and financial resources of each HCF; * The technology that minimises the immediate public health risks associated with HCWM with the lowest impact on the environment. (63) Incineration may be considered as the technology that ensures the most reliable disposal of hazardous HCW. When incineration is used, ash and residues of incineration shall be safely removed and properly buried in an appropriate pit. Nevertheless, in highly densely populated areas, large quantities of hazardous HCW shall not be incinerated at low temperatures. Alternative technologies such as autoclaving and shredding shall be used or off-site transportation to a central treatment facility ensured. 2.5 Accidents and spillage (64) All hospital 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 or accidents. (65) In case of accidents or spillage, the staff involved in the decontamination or disinfection shall wear protective clothing as mentioned in 49. (66) The following actions shall be taken: * Evacuation of the contaminated area if required; * Decontamination or disinfection, rinsing and wiping dry with absorbent cloth by personnel wearing adequate protective clothing; * Decontamination or disinfection of the protective clothing if necessary. (67) Cuts with sharps or needle stick injuries shall be immediately disinfected, Accident shall be reported to the infection control nurse. All cases shall be registered by the Direction of the HCF and annually reported to the Provincial or Central Health Authorities. It is highly recommended to perform blood tests after such an injury to ensure that the injured staff has not been contaminated by any pathogen. last updated October 27th 2001 page 17

19 3. Specific procedures associated with HCW categories 3.1 Class 1: non-risk health-care waste (68) Non-risk HCW of classl shall be placed in black polyethylene bags of minimum 200 microns gauge. Non-contaminated items that are designated for recycling shall be packed in specific black containers marked "Non-contaminated plastic, to be recycled" or "Noncontaminated glassware, to be recycled". All non-risk HCW not designated for recycling shall be collected with the other municipal waste. 3.2 Class 2: hazardous health-care waste (69) All class 2 hazardous HCW shall be placed in yellow polyethylene bags of minimum 300 microns gauge marked "Danger! Hazardous medical waste" and indicated with the international Biohazard symbol (see box 5). Preferably, the bags shall be hanged in bagholders. If not available, yellow bins shall be used. Bags shall be sealed with appropriate adhesive tape, removed and replaced immediately when they are no more than threequarters full. (70) Class 2 hazardous HCW shall be preferably incinerated in double chamber incinerators. In densely populated areas, it shall be alternatively treated with a process ensuring a proper disinfection before being disposed of with the non-risk HCW by the municipal services. Autoclaving and shredding are the disinfecting and treating technologies currently recommended. (71) In minor HCFs, as long as small quantities are involved, hazardous HCW may be incinerated in a single chamber incinerator. A pit hole with a concrete lining is an alternative solution when underground waters do not risk being contaminated. * Specific treatment of anatomical waste and placentas (72) In Operation theatres, all anatomical waste shall be collected separately, packed as described in 70 but labelled "Danger! Anatomical waste" and transported to a crematorium for incineration. Alternatively it can be dropped into a concrete lined pit or buried at a sufficient depth (>1m) inside the HCF compound in a location totally enclosed and secured from unauthorised access and at least at 100 m away from any underground water well. If transportation and disposal cannot be immediately ensured, anatomical waste should be stored in the mortuary at temperature between 1 to 5 0C. (73) In maternity wards, all placentas shall be collected separately and preferably treated with the other hazardous HCW of class 2. Nevertheless, when incineration is used, large number of placentas can be difficult to incinerate and reduce drastically the performance of the incinerator. If incineration cannot be performed, placentas shall be dropped into a concrete lined pit. Alternatively they shall be buried as indicated for anatomical HCW. * Specific treatment of blood (74) Blood and any item contaminated with blood shall always be considered as infectious. They shall be discarded with the class 2 hazardous HCW and treated/disposed of consequently as mentioned in 71. last updated October 27th 2001 page 18

20 (75) In some specific locations such as Operation Theatres, Medical Analysis Laboratories or Transfusion Centres, large quantities of infected blood may be generated and found either spilled over or contained into recipients or bags. Their safe disposal may be problematic. (76) Ideally, Infected units/samples of donated blood should be autoclaved on a fluid cycle for an appropriate period and then incinerated. If there is no autoclave available, infected blood bags shall be directly incinerated with precaution to ensure that the bags do not explode while they are put inside the incinerator. If autoclaving or incineration is not possible, infected blood bags shall be securely packaged and transported to a suitable facility nearby for disposal. (77) Alternatively, infected units/samples of donated blood shall be opened with great care and blood poured into a plastic recipient with a strong disinfectant, such as sodium hypochlorite in concentrated form and left overnight before being discarded into the sink connected to a buffer (neutralisation) tank. The bags shall then be burned. Gloves shall always be put on. (78) Blood that has been spilled over shall always be washed with a solution of sodium hypochlorite 10% before being drained off with the effluents that shall be treated as mentioned in 100. (79) The sodium hypochlorite solution shall always be properly stored in hermetic and opaque plastic bottles, in ventilated areas. The expired date must be respected. Specific treatment of highly infectious waste (80) Highly infectious waste from the medical analysis 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. It shall be autoclaved at a temperature of 1210C at 2 bars for at least 20 minutes at source i. e. in the medical analysis laboratory itself. Disinfected waste shall be collected and treated with the hazardous HCW of class 2. (81) If a distinct autoclave is not available at the Medical Analysis Laboratory to ensure a thermal treatment, highly infectious waste shall be disinfected in a solution of sodium hypochlorite in concentrated form and left overnight. It shall then be discarded in a specific yellow bag properly sealed and itself discarded with the hazardous HCW of class 2. (82) If none of the above treatment options can be 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. This measure shall remain exceptional. 3.3 Class 3: sharps (83) Sharps shall be placed in specific cardboard or plastic safety boxes (see box 7), resistant to punctures and leakage proof, designed so that items can be dropped in using one hand, and no item can be removed. The safety box shall be coloured yellow, marked "Danger! Contaminated sharps)) and indicated with the Biohazard symbol. It shall be closed when three-quarters full and then placed in a yellow plastic bag with the other hazardous HCW of class 2 last updated October 27th 2001 page 19

21 (84) In particular, all disposable syringes and needles shall be discarded of immediately following use. The needle shall not be recapped or removed from the syringe, the whole combination shall be inserted into the safety box directly after use. (85) Under no circumstances are used syringes or needles, or safety boxes, to be disposed of in normal garbage or dumped randomly without prior treatment. (86) 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 doublechamber incinerator. (87) If such an incinerator is unavailable, alternative methods may be used like autoclaving and shredding or, in small HCFs, single chamber incineration as long as small quantities are concerned. Under exceptional circumstances, in rural areas, full safety boxes may be incinerated in small numbers by open burning. The residues of incineration shall be safely deeply buried at sufficient depth (<1m). 3.4 Class 4: radioactive waste (88) All radioactive waste of class 4 shall be stored to allow decay to background level. They shall be placed in a large container or drum and labelled with the radiation symbol showing the radionuclide's activity on a given date, the period of storage required, and marked 'Caution! Radioactive waste' (see box 5). (89) Containers or tanks with radioactive waste that has not decayed to background level, shall be stored in a specific marked area, preferably in a lead-shielded storage room or alternatively in a room with concrete walls 25 cm thick. (90) Non-infectious radioactive waste, which has decayed to background level, shall follow the non-risk HCW stream (class 1) while Infectious radioactive waste which has decayed to background level shall follow the hazardous HCW stream (class 2). 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. More detailed information is provided in box Class 5: specific hazardous health-care waste (91) Class 5 groups all the specific solid hazardous waste that is not often encountered in the HCFs of Sri Lanka. Are also grouped under this class, liquid waste and wastewater that should require specific treatment. * Large quantities of pharmaceutical waste (92) Large quantities of pharmaceutical waste shall be returned to the Regional Offices of the Medical Supply Division for a proper incineration. Alternatively and only if the return cannot be ensured, an inertization technique may be foreseen. Inertization consists in mixing pharmaceutical waste with cement and lime before burying to minimise the risk that toxic substances migrate into the surface water or groundwater. The packaging should previously be removed. last updated October 27th 2001 page 20

22 * Large quantities of chemical waste (93) Large quantities of chemicals shall be returned to the supplier. Nevertheless currently appropriate controlled and standardised methodology does not exist in Sri Lanka to dispose of chemicals: on-site disposal might be sometimes necessary. The disposal methodology shall depend on the type of chemicals. (94) In such circumstances, non-corrosive and non-flammable chemicals may be encapsulated- separately to avoid unwanted chemical reactions after neutralisation. In all circumstances, appropriate advises shall be requested at the regional representative of the Central Environmental Authority before any disposing of chemicals waste. * Waste with high contents of heavy metals (95) 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. * Emuents (96) No solid waste shall be discarded into the sewerage and all liquid infectious waste shall be discharged into the sewerage system only after being properly treated. (97) Wastewater from HCF may contain various potentially hazardous components such as microbiological pathogens, hazardous chemicals, pharmaceuticals and radioactive isotopes. The proper treatment of wastewater from HCFs is very expensive and cannot be currently foreseen in every HCF of Sri Lanka. Nevertheless basic steps can reduce the public health risk associated with liquid waste and wastewater. (98) Patients with enteric diseases shall be isolated in wards where their excreta can be collected separately for chemical disinfection. Whenever it is technically and environmentally possible, toilets shall be connected to septic tanks with soakaway pits or infiltration trenches. (99) Effluents of all medical analysis laboratories (see box 9) shall always be neutralised in a buffer tank before being drained off into the sewerage. (100) Radioactive effluents of isolation wards shall be discharged into the sewerage or into a septic tank only after it has decayed to background level in adequate retention tanks (see box 8). * Encapsulation consists in filling containers such as a drum with waste, adding an immobilising material and sealing the container. last updated October 27th 2001 page 21

23 Box 3: classification, packaging and treatment of health-care wastes Class Colour Coding Type of HCW Packaging Treatment system Non-Risk HCW 200p bags With municipal waste Black enon-contaminated plastics Adequate Disinfection or sterilisation Non-contaminated glassware container and recycling 2 Hazardous HCW - In Major Hospitals: Disinfection, Incineration,, Infectious and highly Autoclaving and shredding, infectious HCW - In Minor HCFs: Incineration or safe burying Yellow * Pathological HCW 300u bags *Incineration, or safe burying (placentas) Anatomical HCW. Incineration or safe burying * Small quantities of Pharma- *Incineration, encapsulation ceutical and chemical HCW or inertization 3 Yellow Sharps Safety boxes Safety boxes to be put together with hazardous HCW 4 Yellow Radioactive HCW Specific Storage and follow the containers streams of class 1 or class 2 5 Specific Hazardous HCW e Large quantities of Pharma- Specific To supplier or encapsulation / Yellow ceutical and chemical HCW cter' inertization * HCW with high content of To supplier or encapsulation heavy metals - Effluents To be treated specifically last updated October 27th 2001 page 22

24 Box 4: illustration of the protective clothing of HCW sanitary staff and sweepers H.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~t" '0 ~~~~~~~~~~~~~f '404.,{gS1,~~~~~~~''.,' " A,S.I 'IS., n t- - rgt; - Source. Safe management of waste from health-care activities. WHO, Box 5: international symbols to be used for hazardous and radioactive HCW Biohazard symbol Radioactive symbol t u e O- 20 pg 2 last updated October 27(h 2001 page 23

25 Box 6: treatment and disposing technologies for large quantities of health-care waste Option Description Advantage Disadvantages Rotary kiln Rotary oven with a post combustion Adequate for all infectious High investment and chamber ensuring an incineration waste and pharmaceutical operation costs. between 1200 and 1600 C waste. Pyrolytic Double chamber incineration at Very high disinfection Incomplete destruction of incineration medium-temperature combustion efficiency. cytotoxic waste. process ( QC), producing Drastic reduction in waste Relatively high investment solid ashes and gases Gases may be volume and operation costs. incinerated in the post-combustion chamber at high temperature Adequate for all infectious waste and most pharmaceutical and chemical waste. Chemical Adding of chemicals to waste to kill Highly efficiency Require highly qualified disinfection or inactivate the pathogens it disinfection under good technicians for operation contains with a shredding process operating conditions. and maintenance. before the treatment. Good reduction in waste Uses hazardous chemicals. volume. Inadequate for pharmaceutical, chemical and some type of infectious waste. Autoclave Wet thermal disinfection based on Environmentally sound. Shredders are subject to exposure of shredded infectious waste Reduction in waste volume. frequent breakdowns and to high-temperature (121 C Relatively low investment poor functioning. minimum), high-pressure steam (up and operation costs. Operation requires to 6 bars). qualified technicians. Inadequate for anatomic, pharmaceutical and chemical waste Microwave Application of microwave at a Environmentally sound. High investments and irradiation frequency of 2450 MHz rapidly Good disinfection efficiency operation costs. heating the water contained in the under appropriate Potential operation and waste and destroying infectious waste operating conditions, maintenance problems. by heat combustion. Good reduction in waste Shredders are subject to volume. frequent breakdowns and poor functioning. Source. Safe management of waste from health-care activities. WHO, last updated October 27th 2001 page 24