Sri Lanka - National HIV/AIDS Prevention Project : environmental assessment (Vol. 1 of 2) : National Guidelines

Democratic Socialist Republic of Sri Lanka Ministry of Health and Indigenous Medicine E600 Vol. 1 Health-care waste management National Guidelines FILE COPY Draft version 2 -October ZOO.i  National Guidelines for Health-Care Waste Management in Sri Lanka 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 8 3.1 Infectious waste 8 3.2 Pathological waste 8 3.3 Anatomical waste 9 3.4 Pharmaceutical waste 9 3.5 Chemical waste, waste with high contents of heavy metals and pressurised containers 9 4. Highly hazardous health-care waste 9 4.1 Sharps 9 4.2 Highly infectious waste 9 4 3 Genotoxic waste 9 4.4 Radioactive waste 10 SECTION 2 - PUBLIC HEALTH RISKS ASSOCIATED WITH HEALTH-CARE WASTE I 1 1. Occupational risks 11 2. Risks to the population 11 3. Indirect risks via the environment 12 last updated October 27th 2001 page 1  National Guidelines for Health-Care Waste Management in Sri Lanka 4. Managing health-care wastes to minimise the overall risks 12 SECTION 3 - HEALTH-CARE WASTE MANAGEMENT PROCEDURES 13 1. Classification of health-care waste 13 1.1 Segregation 1 3 1.2 Colour coding system 14 1.3 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 15 2. General HCWM procedures 15 2.1 Waste collection and on-site transportation 15 2.2 Waste storage 16 2.3 Off-site transportation 16 2.4 Waste treatment and disposal 17 2 5 Accidents and spillage 17 3. Specific procedures associated with HCW categories 18 3.1 Class 1: non-risk health-care waste 18 3.2 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 19 3.3 Class 3: sharps 19 3.4 Class 4: radioactive waste 20 3.5 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 30 1. Assign duties and responsibilities 30 1.1 Duties and responsibilities of the Director of the Hospital 31 1.2 Duties and responsibilities of the health-care waste management team 31 1.3 Duties and responsibilities of Head of administration 31 1.4 Duties and responsibilities of the Heads of departments 31 1.5 Duties and responsibilities of the Matron of the hospital 32 1.6 Duties and responsibilities of the Head of infection control nurses 32 1.7 Duties and responsibilities of the Head of overseers 32 1.8 Duties and responsibilities of the health-care waste management Officer 32 2. Allocate resources and provide equipment for health-care waste handling 33 last updated October 27th 2001 page 2  National Guidelines for Health-Care Waste Management in Sri Lanka 2 1 Estimation of needs 33 2.2 Selection of the technology for HCW disposal 33 2.3 Allocation of resources and provision of equipment 33 3. Organise the HCW streams 34 3.1 Outline the procedures and practices 34 3.2 Ensure training of staff members 34 3.3 Prepare the HCWM plan document 34 3.4 Set-up a monitoring system and reporting procedures 34 3.5 Focus on specific locations 35 4. Consideration on the involvement of the private sector 35 SECTION 5 - GUIDELINES FOR CENTRAL AND PROVINCIAL HEALTH SERVICES 38 1. Setting-up of annual provincial health-care waste management plans 38 2. Backstopping of health-care facilities 38 3. Inspection 38 CONCLUSION 40 last updated October 27th 2001 page 3  National Guidelines for Health-Care Waste Management in Sri Lanka List of figures Box 1: categories of health-care waste (examples) ................................................................ 10 Box 2: hazards related to sharps ................................................................... 12 Box 3: classification, packaging and treatment of health-care wastes ................................... 22 Box 4: illustration of the protective clothing of HCW sanitary staff and sweepers ......... ........ 23 Box 5: international symbols to be used for hazardous and radioactive HCW .......... ............ 23 Box 6: treatment and disposing technologies for large quantities of health-care waste ........ 24 Box 7: example of low cost safety box made with cardboard recommended by the WHO ... 26 Box 8: basic consideration for radioactive health-care waste disposal ............. ..................... 27 Box 9: health-care waste management inside the Medical Analysis Laboratories ......... ....... 28 Box 10: synthesis of the health-care waste streams inside a hospital .............. ..................... 29 Box 11: sample sheet for the assessment of waste generation .................... ......................... 36 Box 12: Checklist for a minimum HCWM programme in HCFs .................... .......................... 37 Abbreviations HCF : Health-Care Facility HCW : Health-Care Waste HCWM Health-Care Waste Management last updated October 27th 2001 page 4  National Guidelines for Health-Care Waste Management in Sri Lanka 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 2001. 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  National Guidelines for Health-Care Waste Management in Sri Lanka 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; * 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. Audience 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 2000. last updated October 27th 2001 page 6  National Guidelines for Health-Care Waste Management in Sri Lanka . 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  National Guidelines for Health-Care Waste Management in Sri Lanka 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 health- care 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  National Guidelines for Health-Care Waste Management in Sri Lanka 3.3 A-natomical waste (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  National Guidelines for Health-Care Waste Management in Sri Lanka 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 60Co, Technetium 99mTc, iodine 1311 and iridium 1921r are most commonly used. (17) With the noticeable exception of Cobalt 60Co, their half-life is reasonably short (6 hours for 99mTc, 8 days for 1311 and 74 days for 1921r) 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