hcwm guidelines ethiopia final
TRANSCRIPT
Health Care Waste Management for Ethiopia
Guidelines
Prepared by:Fikru Tessema (BSc, MSc), Senior Public Health Professional
M&E Specialist
May 2006
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
2
4.6 Waste storage guidelines 29
4.7 Waste handling guidelines
31
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
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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
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
5
6
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
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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.
National Guidelines for Health-Care Waste Management 9
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
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wastes, 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 11
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 12
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 substances physical agents, or biologic materials could
have serious consequences.
National Guidelines for Health-Care Waste Management 13
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 14
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 15
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 16
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 17
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 18
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 19
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 20
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 21
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 22
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
3.2.1Occupational 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 not been handled safely. In this respect, sharps are considered as
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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.
3.2.2Risks 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
National Guidelines for Health-Care Waste Management 24
required to 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
National Guidelines for Health-Care Waste Management 25
protect the health-care workers and the population and minimizes
indirect impacts from environmental exposures to HCW.
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 26
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:
27
1. Segregation of HCW should consist in separating the different
waste streams based on the type of treatment and disposal
required at economical cost.
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;
National Guidelines for Health-Care Waste Management 28
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;
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
National Guidelines for Health-Care Waste Management 29
coding system shall remain simple and be applied uniformly
throughout the country.
National Guidelines for Health-Care Waste Management 30
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.
4.3.1Guidelines 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 31
4.3.2Guidelines 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 1210C for at least 30 minutes to ensure complete
disinfection.
4.3.3Guidelines 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 32
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 33
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 34
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 35
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
4.8.1Transport 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 cleaned regularly, and especially before any
maintenance work is performed on it.
National Guidelines for Health-Care Waste Management 36
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.
4.8.2Transport 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 37
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 38
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 12000C.
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 39
Recommended techniques for treatment of infectious wastes
Type of
infectious
waste
Recommended treatment techniques
Steam
sterilizatio
n
Incineratio
n
Thermal
inactivatio
n
Chemical
disinfectio
n
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
partsX X
Bedding X
National Guidelines for Health-Care Waste Management 40
4.9.1Guidelines 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 41
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.
4.9.2Guidelines for Incineration
National Guidelines for Health-Care Waste Management 42
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 43
4.9.3Guidelines 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
4.9.4Guidelines for Gas/Vapor Sterilization
National Guidelines for Health-Care Waste Management 44
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
4.9.5Guidelines 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 45
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
4.9.6Guidelines 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 46
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 47
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
National Guidelines for Health-Care Waste Management 48
All workers who handle infectious waste should receive infectious
waste management training that includes:
(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 49
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 1'2000C shall be preferably used.
7. In minor HCFs, i.e. in health centers and Dispensaries, class 2
clinical HCW may be incinerated in a simple pit hole land
50
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.
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).
National Guidelines for Health-Care Waste Management 51
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 1'2000C.
3. Class 5 hazardous pharmaceutical wastes and cytotoxic waste
containing heavy metals shall not be incinerated.
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 52
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 53
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 54
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 55
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 56
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 57
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.
e) The DHEH shall be responsible give supportive supervision
on HCWM activities at all levels and Federal EPA at local
National Guidelines for Health-Care Waste Management 58
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.
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
National Guidelines for Health-Care Waste Management 59
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.
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.
National Guidelines for Health-Care Waste Management 60
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
vii) The Head of pharmacy
f) Include the following major functions:
i) Inspecting workplaces regularly to identify safety and
health hazards and infections
National Guidelines for Health-Care Waste Management 61
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.
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.
National Guidelines for Health-Care Waste Management 62
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.
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
National Guidelines for Health-Care Waste Management 63
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.
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.
National Guidelines for Health-Care Waste Management 64
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
6.3.1Guidelines for waste audits and needs estimate
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:
National Guidelines for Health-Care Waste Management 65
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.
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.
National Guidelines for Health-Care Waste Management 66
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.
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.
National Guidelines for Health-Care Waste Management 67
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:
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.
National Guidelines for Health-Care Waste Management 68
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 69
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National Guidelines for Health-Care Waste Management 71
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National Guidelines for Health-Care Waste Management 72