health information infect on control

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR SOUTH-EAST ASIA

INFECTION CONTROL AND HEALTH CARE

WASTE MANAGEMENT

IN

THE KINGDOM OF BHUTAN

A MISSION REPORT

Prepared by

Dr Geeta Mehta, MD, MAMS,FIMSA, MPH

Director Professor and Head of Microbiology Lady Hardinge Medical College

New Delhi 110001, India

With support from

WORLD HEALTH ORGANISATION REGIONAL OFFICE for SOUTH EAST ASIA (SEARO)

May 2005

“INFECTION CONTROL AND HEALTH CARE WASTE MANAGEMENT IN THE KINGDOM OF BHUTAN”, WHO SEARO, 2005

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Contents

1. PURPOSE OF THE ASSIGNMENT 2. BACKGROUND

2.1 The Health Care System in Bhutan 2.2 Infection Control in Bhutan 2.3 Infection Control and Health care Waste Management Plan

2.3.1. The National Infection Control Committee 2.3.2. Infection Control Team 2.3.3. Waste Segregation Policy 2.3.4. Training 2.3.5. Awareness and IEC 2.3.6. Monitoring and Evaluation 2.3.7. Procurement 2.3.8. Implementation Plan

2.4 Current HCWM Situation in Bhutan 2.4.1 Quantum of Health Care Waste in Bhutan 2.4.2 Legal Aspects and NEC Guidelines 2.4.3 Options Available for HCWM 2.4.4 Occupational Safety Issues and Training

3. ACTIVITIES AND FINDINGS

3.1 Visits to Health Care Facilities in Bhutan 3.1.1 Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), Thimphu 3.1.2 District Hospital at Paro 3.1.3 Basic Health Unit at Dawakha

3.2 Review of existing materials from Bhutan.

3.2.1 Health Care Waste Management Plan Bhutan 2004-2006 June 2004 3.2.2 Environmental Codes of Practice for Hazardous Waste NEC June 2002 3.2.3 Operational Manual of World Bank Funded National HIV/AIDS project 3.2.4 Guideline for Infection Control in Health Care Settings Bhutan

4. CONCLUSIONS AND RECOMMENDATIONS 5. ACKNOWLEDGEMENTS


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ANNEXES ANNEX 1 List of persons met

ANNEX 2: Report on visits carried out in India ANNEX 3 Outline of HCWM System suggested for Bhutan ANNEX 4 IC & HWM Plan Bhutan: Terms of Reference ANNEX 5 IC & HWM Plan Bhutan: Training Needs ANNEX 6 IC & HWM Plan Bhutan: Implementation Plan ANNEX 7 Estimated Generation of HCW in Hospitals and BHU’s Bhutan ANNEX 8 Draft Specifications for equipment required for HCWM

8.1 High Pressure Steam treatments 8.1.1 Autoclave 8.1.2 Shredder 8.1.3 Hydroclave 8.2. Accessories 8.2.1 Specifications for Heat Resistant Protective Gloves 8.2.2 Specifications for Containers for Health Care Waste 8.3. Specifications for Needle and Syringe Destroyers 8.4. Specifications for Deep Pits for Hospital Waste

8.4.1 Clay Lined Pit for Sharps 8.4.2 Concrete Lined Pit for Sharps 8.4.3 Concrete Safety Vault for Hospital Waste 8.4.4 Deep Burial Pit for Hospital Waste

8.5. Options for Disposal of Sharps 8.6. Standards for Land fill. 8.7. Waste water treatment ANNEX 9 Check list for Needs Assessment of Health Care Facility in HCWM ANNEX 10 Guidelines for implementers of IC & HWM Pl 10.1 Definitions, Epidemiology and Types of HAI 10.2 Surveillance of HAI 10.3 Waste Survey 10.4 Employee Health Programme 10.5 Investigation of Outbreak of HAI 10.6 Microbiology Laboratory in the Control of HAI 10.7 Monitoring and Evaluation: Indicator Checklist ANNEX 11Draft Revised Infection Control Guidelines (Incorporating HCWM) SELECTED REFERENCES and WEB SITES


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ABBREVIATIONS USED

ACO Assistant Clinical Officer ANM Auxiliary Nurse Midwife BHU Basic Health Unit BHW Basic Health Worker DANIDA Danish International Development Agency. DMS Department of Medical Services ECOP Environment Code of Practice EHO Employee Health Officer HAI Hospital/ Health Care Associated Infections HCWM Health Care Waste Management HCWMPB: Health Care Waste Management Plan Bhutan (DANIDA) HWM Hospital Waste Management (synonymous with HCWM) IC Infection Control IC&HWMC: Infection Control and Hospital Waste Management Committee. (National) ICN Infection Control Nurse ICO Infection Control Officer ICT : Infection Control Team IEC Information Education and Communication IGNOU Indira Gandhi National Open University- (India) JDWNRH Jigme Dorji Wangchuk National Referral Hospital MOH Ministry of Health MSDS Material Safety Data Sheet NEC National Environment Commission NICC National Infection Control Committee (redesign Ted as IC&HWMC) OHS Occupational Health and Safety ORC Out Reach Clinic PEP Post Exposure Prophylaxis POP Persistent Organic Pollutants RGOB Royal Government of Bhutan RIHS Royal Institute of Health Sciences SEAR South East Asia Region SSN Senior Staff Nurse STD Sexually Transmitted Diseases (synonymous with STI) STI Sexually Transmitted Infections TOR Terms of Reference UNICEF United Nations International Children’s Educational Fund WB World Bank WHO World Health Organisation WMO Waste Management Officer


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1. PURPOSE OF THE ASSIGNMENT

Support the national authorities in developing a national sound infection control and health care waste management system, sustainable and with minimal adverse human and environmental impacts. TERMS OF REFERENCE FOR THE CONSULTANT Together with he Department of Health Services, Ministry of Health (MOH), Bhutan and relevant personnel to undertake the following actions:

1. Assess current infection control practices, in particular the current Health Care Waste Management (HCWM) practices in Bhutan (1 week)

2. Review and revise the existing national infection control guidelines, incorporating

the dimension of waste management (1 week)

3. Develop a comprehensive draft of a national infection control programme together with a draft action plan (1 week)

4. To assess the needs (training, infrastructural, financial needs and resources) to

implement the draft action plan (1 week)

5. On the basis of the documents provided , develop specifications for the procurement of an autoclave to treat health care waste and provide the guidelines for the construction of sharp pits, for the Jigme Dorji Wangchuk National Referral Hospital( JDWNRH) (1 week)

Time Frame: 5 weeks (8th March to 10th April 2005) Products to be submitted at the end of the mission:

1. Specifications for the procurement of an autoclave and guidelines for the construction of sharp pits

2. Revised national infection control guideline incorporating HCWM

3. Draft National HCWM system and draft Action Plan

4. Mission Report Annex 1 reports on the persons met during the mission. Annex 2 reports on results from pre-mission visits to facilities in Indi Annex 3 gives an overview of a HCWM system for Bhutan


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2. BACKGROUND

Bhutan is located between India and China and is a landlocked country having few communications with the rest of the world. The country has a rugged topography and harsh climate. It still has limitations in availability of qualified and skilled manpower, which cuts across all sectors.

2.1 THE HEALTH CARE SYSTEM IN BHUTAN

Bhutan has an integrated health service and has adopted the primary health care system. The present health care system in the country provides access to primary health care to 90% of the population.

The development of modern health systems and health infrastructure in Bhutan commenced during the early 1960s. Presently, the country has a four-tiered network of 29 hospitals at national, regional and district levels. The number of hospital beds was 1093 in 2003. The number of surgical procedures performed in 2003 was 11043 (Annual Health Bulletin 2003). Traditional medicine also forms an integral part of the health system. There is one hospital for indigenous medicine and 19 traditional health units. Training in Health Sciences is provided by the Royal Institute of Health Sciences (RIHS). The training is limited to paramedical workers and nurses. There are no training possibilities for medical doctors in the country. Basic Health Units

Primary Health care is provided by a network of 172 Basic Health Units (BHU’s), 19 indigenous units and 440 outreach clinics. The BHU is a primary level institution in the health care system and caters to a population of about 2,500- 5,000. The staff of a BHU comprises a health assistant (HA), an auxiliary nurse midwife (ANM), and a basic health worker (BHW). Each BHU has an average of 3-6 outreach clinics (ORC’s) through which services to the most distant villages are delivered, at present on a once-a-month basis. The village volunteer health worker (elected by the communities based on criteria prescribed by the health services) is the first point of contact between the health care system and the community. He/she is also trained in improving the environmental sanitation. He/she is supported by basic health care units. The Government has consolidated and strengthened its health infrastructure during the Eighth Plan with additional BHUs constructed in 2002. District Hospitals District hospitals are the first-level referral institutions and are equipped to provide curative, promotive, preventive, and emergency services. There are currently 29 district hospitals (including the three regional referral hospitals), 14 of which have indigenous units. Regional referral hospitals There are 3 regional hospitals, one each in the eastern, central and western regions. Regional referral hospitals are the second-level referral hospitals and provide specialist services. The largest hospital in Thimphu has 200 beds. The hospital’s OPD attendance is approximately 500 to 1,500 patients per day.


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Health expenditure as percentage of total government expenditure was 12.2 % in the year 2000. External assistance in health sector is to the tune of 27.5 % of public expenditure on health. Health & education are free in the country. 2.2. INFECTION CONTROL IN BHUTAN (TOR: to assess current infection control practices, in particular the current HCWM practices in Bhutan) An initiative was taken by the Department of Health in 1994 to prevent health care associated infections (HAI). The threats posed by the HIV/AIDS pandemic and the recognition of increasing Hepatitis B infections gave impetus to this initiative. Infection control was implemented under the national STD/AIDS programme. Guidelines for infection control in health care settings were developed in 1996 and revised in 1998 (see review in 3.4) currently these guidelines give the standards to be followed in the country and forms the basis for training. The situation of infection control as reported in Health Care Waste Management Plan Bhutan (HCWMB) drawn with assistance from DANIDA 2002-2004 (reviewed in detail in section 3.2.1) is the following

• At the end of 2003, 690 health care workers had been trained in infection control practices.

• Although the Department of Public Health as well as Department of Medical

services are concerned about HAI, no formal system has been implemented on IC in Bhutan, so far.

• Regarding practices in IC, visiting teams for the HCWMPB found autoclaves

being used for the sterilization of medical equipment. Boiling of instruments has been discontinued.

• Disposable needles and syringes are used in all places. Reusable injection

equipments are used only in those situations where disposables were not available.

• A cause for concern was the inadequate management and poor practices of

handling sharps. Disposable needles are routinely recapped before disposal. No initial and regular health screening, recording of immunity and immunizations of health care workers was there. There was no systematic recording of needle-stick injuries among health care workers. However, there was a policy to offer all members of the staff immunization against Hepatitis B.

• The HCWMPB project team found the knowledge of IC among health care staff

to be acceptable; staff was familiar with the guidelines and had attended workshops on IC. Health care staff seemed to carry out the disposal of waste in the correct way but sweepers and caretakers were not sufficiently instructed in proper disposal principles and methods.


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2.3. THE INFECTION CONTROL AND HEALTH CARE WASTE MANANAGEMENT PLAN The Ministry of Health, RGOB drafted a comprehensive Health Care Infection Control and Waste Management Plan in April 2004. Its implementation is only starting. The World Bank is supporting the IC and HCWM programme under the HIV/AIDS and STI prevention programme. (Details are given in the Operation Manual, reviewed in Section 3.2.3) 2.3.1. The National Committee for Infection Control and Hospital Waste Management According to the Plan, there are two committees at the National Level: a) Infection Control and HWM Committee (IC&HWMC) established in the Ministry of Health, Department of Medical Services with the purpose to

• Provides the framework for overall policy development and strategies within infection control and hospital waste management.

• Facilitates the resource allocation for implementation of the plans and activities agreed for IC and HWM

Composition: The Committee is chaired by Secretary, Ministry of Health and members will be Director, Department of Medical Services, Director Department of Public Health, Medical Director JDWNRH, Thrompon City Corporation Thimphu, Representative NEC Thimphu, and Director RIHS. b) Technical Committee for IC and HWM This committee was formed to assist the IC&HWMC and composed of members with a special interest and knowledge on infection control and waste management. The technical committee will guide, coordinate and monitor all relevant strategies and activities within IC and HWM programme. The terms of reference of the technical committee are given in the Annex 4. The technical committee will be chaired by the Medical Director JDWNRH and includes senior medical and nursing staff, Pathologist and also senior officers from the Public Health, Health Care, Drugs Vaccines and Equipment, Quality assurance and Standards Division, Health Engineering Institute of Traditional Medicine Service, Royal Institute of Health Services, National Environment Commission and City Corporation Comment: The absence of a clinical microbiologist member in this committee is significant. Currently no clinical microbiologist is available in the country. 2.3.2. Infection Control Team At each of the referral hospitals there will be Infection Control Teams (ICT). The ICT’s will comprise of two link nurses and a doctor. The ICT’s will be responsible for programme implementation and reporting to the District Medical Officer and the IC &HWMC. At the BHU level, the Health Assistant will be responsible for infection control and waste management activities and reporting to the district ICT. Comment: The absence of a clinical microbiologist here is again significant. A doctor specializing in clinical microbiology should be the leader of the ICT (at least at the national referral level) because such a specialist is the key to effective implementation.


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In terms of training and expertise, he/she is most suited to guide and monitor IC activities, and conduct IC training. 2.3.3. Waste Segregation policy The infectious waste will be segregated into sharp waste and non sharp infectious waste streams. The colour coding for infectious waste will be red and colour coding for sharps waste will be yellow. Waste will be further segregated into biodegradable and non biodegradable waste. Autoclaving will be the preferred method of treatment of infectious waste. Disposal of health care waste will be in municipal landfills wherever available or in specially constructed deep burial pits. Comment: It was noted that Incineration or combustion in pits or primitive incinerators will not be an option for the treatment of waste according to the plan due to potential adverse environmental and public health impact from combustion... 2.3.4. Training Training on IC and HCWM will be initial as well as ongoing. The responsibility of planning the training programme will be the Department of Medical Services. Training will be imparted initially by a contracted technical expert and ongoing refresher training will be undertaken by members of the ICT’s. Training is planned for members of Infection Control Committee, Infection Control Teams and all levels of health care staff. The training needs for the IC&HWMC, ICT, link nurses and other health care staff is given in the Annex 5. Comment: A medical doctor specializing in clinical microbiology would be the ideal person to conduct the training. Continuous and ongoing training in IC and day to day advice on infection control problems can be the mandate of such a specialist. 2.3.5. Awareness and IEC IEC material on the correct handling and disposal of health care waste will be developed building on resources available regionally and internationally. Awareness of correct disposal of health care waste will be promoted amongst health care workers and general population by displaying IEC materials. 2.3.6. Monitoring and Evaluation. The ICC and ICT’s at the respective health care facilities will undertake monitoring of infection control and waste management. Standardized reporting formats will be developed centrally and staff at district and central level will be trained in monitoring and reporting. The reports would cover:

• Implementation of the programme: IC and HCWM check lists • Trainings held in the facility • Nosocomial infections (wound infections, intravenous cannula site infections,

UTI’s and other suspected infections. • Occupational exposures (needle-stick injuries, blood and body fluid splash) • Stock adequacy and needs ( IC and waste management equipment)

Reporting will be on a three monthly basis, frequency will be reviewed at mid term evaluation.


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2.3.7. Procurement The two main areas of procurement will be (a)Protective attire (gloves, masks, aprons, boots) (b)Equipment for waste management including Autoclaves, needle destroyers, colour coded bags, bins, buckets etc. 2.3.8. The Action Plan The MOH has developed an Action Plan, the implementation and procurement details with the time frame are given in the Annex 6. 2.4. CURRENT HCWM SITUATION IN BHUTAN With the exception of Thimphu, municipal waste form urban areas is disposed off either in rivers/streams, valleys or in low lying areas. In Thimphu, the solid waste is disposed off Memelakha, which is currently the only landfill site in Bhutan, about 12 km away from the city. The landfill site is now being extended to accommodate more waste. The Municipal Corporation collects the general category of waste from the National Referral Hospital in Thimphu to the Memelakha landfill. The hospital disposes its sharps in a concrete pit within the premises. The organic waste and human placenta are also disposed in the same pit. Other infectious waste is burnt in a drum like incineration device. In a few hospitals of the kingdom, having locally constructed incinerators, the hazardous waste is collected in disposal bags and incinerated. 2.4.1. Quantum of Health Care Waste generated in Bhutan

The quantum of waste produced in the health care facilities is difficult to measure because different categories of waste are usually collected together in the same container. According to the Health Care Waste Management Plan Bhutan prepared by DANIDA, it is estimated that the amount of municipal waste produced in Bhutan is 100,000 tons per year of which approximately 75 tons is hazardous health care waste. Basis of the HCWMPB estimates: The waste quantities generated by hospitals and BHU’s was based on observation during the visits of the team from DANIDA to hospitals and BHU’s in 2001. According to HCWMPB , 29 hospitals and 160 BHU’s were present in Bhutan (Annual Health Bulletin for 2000) This number combined with estimated and preliminary key figures provided the basis of the figures presented in the document as follows:

Hospitals

Ist Grade BHU’s Other BHU’s

Infectious waste 0.25 kg/patient day 6 kg/week 2 kg/week Sharps 0.02 kg/patient day 0.1 kg/week 0.05 kg/week

The magnitude of waste generated was based on the above key figures which was estimated to be approx 73 tons per year for the whole country , with 54 tons per year generated at hospitals and approx 19 tons per year generated at BHU’s. The district wise details of the estimates are given in Annex 7.


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Health Care Waste generated in Thimphu In Thimphu there are three hospitals including the National Referral Hospital (JDWNRH) , with a total of 242 beds and bed occupancy of 78.4% , the number of patient days were 69,244, one grade 1 BHU and 3 other BHU’s. The infectious waste was estimated to be 17,311 kg/year; sharps were estimated to be 1,385 kg/year. The BHU’s generated 624 kg/year of infectious waste and 13 kg per year of sharps (Annex 7). Most of the waste (80%) produced by the health sector is similar to domestic waste and comes from administrative and housekeeping functions. Approximately 20% is hazardous or potentially hazardous mainly due to the infection risk and due to the presence of other hazardous materials. However, since the waste is not segregated from general domestic waste the entire waste produced by the health sector becomes potentially hazardous. Comment: It is not clear as to how the preliminary key figures have been obtained. There is no mention about a waste survey in the HCWMB document. The total number of hospital beds is approximately 1000; the average waste produced by day per bed is estimated to be of 1 kg. Therefore, the total annual health care waste volume, if not segregated, would be approximately 365 tons. 2.4.2. National legislation At present there is no specific legislation on the management of health care waste in Bhutan. The Environmental Assessment Act was passed by Parliament in July 2000 and the National Environment Commission issued guidelines to support the Act. A series of guidelines exist and provide directions for the management of solid waste, hazardous waste including health care waste. These guidelines were prepared with Technical assistance and funding provided by DANIDA under the Environment Sector Programme Support, and by ADB. These guidelines area: (a) Environmental Codes of Practice for Solid Waste Management in Urban Areas October 2000. This guideline states the following issues related to HCWM:

• Involvement and education of the public • Training, education and awareness building among those being responsible for

waste management at all levels. • Knowledge of waste generators and waste types, amounts and composition. • Secure hygienic storage and collection of waste in order to avoid scavenging by

dogs and subsequent spillage and spread of waste to the surroundings. • Special identifiable containers and bins (colour-coded) should be provided in

hospitals and BHU’s for infectious waste and other waste. • Hospitals and health units should be able to pre-treat their infectious waste in

future as waste production increase, before final disposal takes place. • Infectious waste from hospitals and health units shall be excluded from the main

disposal area at landfills and special precautions taken (e.g. deep-buried). • Incineration of infectious waste at hospitals and health units in locally produced

incinerators can be an option, but must be regarded as a temporary solution. (b). Environment Code of Practice for Hazardous Waste Management, June 2002


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According to this draft guideline infectious waste from hospitals and BHU’s is to be considered as hazardous waste. With regard to infectious waste the guideline states:

• Infectious waste shall be segregated at point of generation • If infectious waste is transported off site a Chain of Custody system must be

established in order to make it possible to track infectious waste back to point of generation.

• Appropriate containers and dustbins must be used for collection, storage and transportation of infectious waste, equipped with proper lids and clearly labelled in both English and Dzongkha.

• Adequate treatment of infectious waste prior to final disposal is important, because this will render the waste non-infective and reduce its volume, thereby saving landfill capacity.

• Training, education and awareness building among those being responsible for infectious waste management at all levels are important. All staff should be aware of their responsibilities and adequately trained in their day-to-day duties.

• If incineration is chosen as the final solution for treatment of infectious waste, the incinerator shall be properly designed, sited, operated, maintained and monitored. Also the incinerator shall be equipped with emission control devices, which meet the standards set by NEC.

A detailed review of this guideline can be seen in Section 3.2.2

2.4.3. OPTIONS AVAILABLE FOR TREATMENT AND DISPOSAL OF HCW IN BHUTAN 1. Incinerators In Thimpu, there are two incinerators, relatively small and of low technology with no pollution control equipment. Operation and maintenance require availability of expertise to ensure effic ient incineration and avoidance of toxic gas emissions. Inadequate incineration of health care waste, particularly plastics, leads to the release of dioxin and furans which are persistent organic pollutants. These substances are bio-accumulative and released during combustion of waste, including municipal solid waste and health care waste, wood burning, burning of household waste, particularly when chlorine containing materials including plastics are burnt. The potential ill effects from exposure to dioxins and furans, which are recognized as human carcinogens, include:

• Alteration of foetal development • Reduction of the reproductive capacity • Effects on the endocrine system • Immunosuppressant effects • Development of skin diseases such as chloracne • Alteration of liver enzymes

2. Primitive incineration in drums/containers/ locally built incinerators: This option was suggested as an interim solution by a team from DANIDA. This has serious problems similar to the relatively advanced incinerators mentioned above. It is again extremely unlikely that temperatures achieved/ emission standards will comply with environmental norms. The possible release of dioxins and furans is a major concern.


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3. Open Pit Burning In some BHU’s, disposal of waste including health care waste is often done through burning in open pits on the ground or in concrete pits. The pits are filled with waste over a period of time (few days to a week) and then burnt. There is no fencing around these pits. The following problems are posed with this option:

• Burning in open pits causes serious smoke emission problems. • Due to lack of sufficient oxygen in deeper layers incomplete combustion occurs

and waste is not rendered harmless • Due to a lack of securing by fencing, children and animals may have access to

the pits which subjects them to risk of infection and burns. • The waste is left to accumulate in these pits before burning and filled sharps

boxes have been found lying in these pits exposed to the public(M McLean –personal communication)

Comment: Main hazard of treating waste by burning or incineration are the products of combustion particularly dioxins and furans which have serious effects on human health and the environment. To control emissions, technically advanced incinerators retrofitted with advanced pollution control equipment are required. Maintenance, constant monitoring of emissions, and trained manpower to operate this sophisticated equipment are essential. High level of segregation is required to exclude chlorinated material including PVC plastics from the waste going for incineration. The ash from incinerators is also toxic as it contains concentrated heavy metals and other non combustible residues. The two incinerators examined by this consultant in Thimphu and Paro hospitals did not have the requisite standards (provision of two chambers, adequate stack height, monitoring facility and pollution control equipment.) Technical specifications, operation manual were not available to the consultant so the basic design cannot be commented upon. It was informed that the one at Thimphu had worked only for one month after installation and is now out of order and cannot be repaired. 4. Waste Pits Some BHU’s use waste pits without burning. The problem with this option is:

• These pits are not secured and children, unauthorized persons and animals may have access to them.

• The pits are not covered • The leachate may contaminate water sources

Comment: Burial of waste should be done according to standards to prevent hazard to humans and environment. These standards for deep burial are given in section 4 of this report 5. Landfills Hazardous waste from hospitals is currently being deposited in landfills meant for general waste. There is no appropriate fencing and poor supervision of landfills, allowing easy access to scavengers and animals. Comment: For health care waste secure landfills with concrete lining, leachate and emission control are required. At present there is only one sanitary landfill in Bhutan and


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there is no secure landfill. The .Environment Codes of Practice for Hazardous Waste Management give the design and operating requirements for hazardous waste landfills 6. Facilities for the disposal of other, non medical, hazardous wastes: Solvents, disinfectants, used batteries are disposed along with general household waste i.e. in landfills or by burning. No facilities for treatment and disposal of hazardous waste such as waste chemicals exist in Bhutan Some types of hazardous waste such as waste oil, lead accumulators, dental mercury, X-ray films and Developers are collected and transported for treatment or reuse to India. Comment: There are no specific guidelines or facilities for chemical waste and heavy metals such as mercury. A plan for the treatment and disposal of chemical waste needs to be formulated in collaboration with the concerned stakeholders. 7. Handling of Sharps Waste Within the hospital wards and departments the sharp waste is collected in either plastic boxes or in cardboard sharps boxes provided by UNICEF for immunization programmes. The plastic boxes are emptied into buckets which are then emptied into pits. The plastic boxes and buckets are not cleaned adequately before reuse. The cardboard boxes are disposed along with the sharps into the open pit, and burnt. Comment: Sometimes there is a delay in burning the waste, so the sharps boxes lie in the pit exposed to the public. Children and animals have easy access to them. Sharps were often encountered in municipal waste by municipal workers which are most likely due to inadequate segregation and mixing of waste. The survey team from DANIDA found that there was insufficient equipment for handling, storage and disposal of waste. There was also inadequate supervision of waste handling and disposal There was an attempt to establish a colour code and segregate the infectious waste; however this was not uniformly practiced probably due to limited availability of locally produced containers and bags. A centralized purchase of standardized colour coded bins and bags would help fill these shortcomes. 8. Waste water and liquid waste No special attention is paid to the discharge of waste water and effluents from health care establishments. Waste water flows into the common sewerage system, when available. Comment: No mention is made in the document HCWMPB of any special treatment for liquid waste including secretions, excretions, blood or disinfectants. The report mentions that these are probably disposed in drains and then into water courses. Waste Water treatment plants need to be constructed. An outline of waste water treatment in health care facilities is given in ANNEX 8.7. 2.4.4. OCCUPATIONAL SAFETY ISSUES AND TRAINING There is no system of health screening or recording of accidents and injuries including needle-stick injuries. No training on occupational safety is offered on entry to the health system. Comment: During a visit to the National Referral Hospital, it was informed that registers and forms have been made for reporting the injuries but these were not available: Occupation Safety aspects have not been developed. This needs attention on PRIORITY basis.


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3. ACTIVITIES AND FINDINGS 3.1 Visits to Health Care Facilities and Meetings Bhutan

Hospitals: 1. Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), Thimphu 2. Paro Hospital 3. Punakha Hospital 4. Tshimalakha Hospital 5. Gedu Hospital Basic Health Units: 1. Bajo BHU 1 2. Chapcha BHU 3. BHU Dawakha 4. Thinleygang BHU

Objective : To gain first hand information and assess the needs for implementation of the Infection Control and waste Management Plan, 5 hospitals including the national referral hospital and 4 BHU were visited. (The districts visited are shown in the map). At each health care facility, an interview questionnaire and observational checklist were used to record information. Details of the findings in 3 health care facilities: the National Referral Hospital, Paro District Hospital and Dawakha BHU are presented below:

Districts Visited


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3.1.1 Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), Thimphu Persons contacted: Dr Tobgyal Wangchuk, Deputy Medical Superintendent and MsTandin Pemo Nursing Superintendent. Hospital details: JDWNRH is a National Referral Hospital having 200 beds and will have 235 beds after a planned expansion. Along with General Medicine and Surgical services the hospital provides Dialysis, ICU, Gynae and Obstetric service, EENT, Paediatric, Reproductive Health Unit, Psychiatry, Skin and Orthopaedic and Laboratory services including radiology, pathology, microbiology and biochemistry. It provides training to students from the Royal Institute of Health Sciences The hospital employs 57 doctors, 143 nurses, 30 ward boys and 30 sweepers/ caretakers. The patient turnover per year is approx 9000 in patients and OPD attendance is 225,000 out patients per year. Situation of infection control and waste management There is no committee on Infection Control and waste Management nor is there any person identified as a nodal person for these activities. The nursing superintendent oversees the waste management along with her other duties. Type and quantity of waste generated: No quantification or survey of waste generated has ever been done Waste Segregation status:

• Red coloured containers are provided in the hospital for infectious waste. • Waste sharps (needles, scalpels, broken glass, ampoules) are collected in

yellow coloured puncture proof reusable containers. • Red coloured polythene bags are used to line all types of containers including

those for infectious waste as well as non infectious waste. These bags are not labelled and did not have the biohazard sign.

• Blue colour had been suggested for dry non-infectious waste (paper, wrappers etc) and green suggested for food waste however this segregation is not practiced.

• Although plastic IV bottles are seen to be collected separately, it was informed that hospital workers are taking these away probably for sale to plastic recyclers.

Options for waste treatment and disposal: The options in place for management of waste are; (a) Pit Burial: sharps as well as placentas and human organs and body parts are

disposed in this pit the pit is approximately 12’X 12’ and 1 foot high from the ground level. It has a sloping hatch for feeding the waste. Although the surface is made of concrete, it is not certain if the bottom under ground level was lined with concrete.


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Pit for burial of sharps and anatomical waste, Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), Thimphu

(b) Burning in a drum like improvised incinerator: • Infectious waste including dressings, gauze, syringes, catheters, blood bags

collected in a drum shaped burning device. • The burning produces offensive smoke and there are complaints about it from

the school in the vicinity. • An incinerator fired by light diesel oil is not working and has been out of order for

6 months, the room housing the incinerator is used for storage of waste... • Waste is brought to the incinerator site by waste handlers or caretakers who are

either illiterate of have a minimal primary level education. They have been supplied masks and gloves and boots and a uniform, but do not wear aprons.

• 50-60 bags containing wastes from different parts of the hospital are bought to the site either manually or by a trolley, on a daily basis. The bags are not secured or labelled with the site of generation. There is no system of recording or weighing the waste bags.

Storage of red bags before incineration, JDWNR Hospital, Thimphu


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Primitive drum-like incinerator for infectious waste. The red bags are burned here. Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), Thimphu

Training:

• No HCWM training had been received by nurses, doctors or caretakers. • Nurses received training in infection control about 2 years ago and some of the

staff involved in waste collection, about 2-3 months ago. • Doctors never received any training neither in infection control nor HCWM.

Disinfectants • The chemical disinfectants used are bleaching powder which is dissolved in

water to make bleach solution. Savlon and Cidex (2% gluteraldehyde) are the other disinfectants used.

• Cheatle forceps are not stored in disinfectant but stored dry in plastic bottles due to concern about possibility of contamination and growth of bacteria in the solution. The forceps are autoclaved every day.

Sterilization

• Patient care items are sterilized by autoclaving in Pre-vacuum sterilizers in a sterile supply unit.

• Chemical indicator strips (SignalogR) are used for monitoring. • Biological indicators and Bowie Dick test are not done. • Items to be sterilized are wrapped in linen and filled in steel drums.


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3.1.2. District Hospital at Paro Person contacted: Dr Pandup Tshering, District Medical officer The day of the visit was a holiday due to annual festival Hospital details This is a 40 bedded facility providing general medical and surgical services , gynaecology and obstetrics, and paediatric service. There are 9 nurses and 3 doctors employed and ACO (assistant clinical officer) to help with clinical and emergency duties. Situation of Infection control and waste management. No infection control committee as yet but in the process of forming. Infection control aspects are looked after by the chief nurse Waste Segregation status

• Sharps (needles, ampoules, broken glass), are collected in a puncture proof cardboard sharps box. Sharps boxes are not labelled.

• All other wastes, including infectious and non-infectious except glass bottles and vials are collected altogether in a foot operated steel bin lined with a red polythene bag.

• Glass bottles and vials are collected separately. No other segregation of waste is done.

Waste Disposal (a)Burning in an incinerator:

• Sharps boxes as well as other red bag waste are burnt in an incinerator. • The incinerator was installed in the hospital premises. It was of German

make, technical details are not available. • There are no pollution control devices and the stack height is low. No

monitoring or record keeping of the waste is done. • Disposable plastics including plastic bottles, syringes, catheters and

specimen containers are also burnt in the incinerator. Sharps boxes collected from the hospital and from the BHU’s are stored next to the incinerator and incinerated twice a week. Needles are sifted out from the ash with gloved hands and a stick and placed into the adjoining pit.


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Incinerator, District Hospital at Paro (b)Burial Pit

• The pit has a concrete surface and a hatch to introduce the waste but it was not clear whether the pit was lined with concrete or not.

• Glass bottles and vials are also placed in this pit.

Pit for disposal of glass waste adjacent to incinerator, District Hospital at Paro


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Disinfectants • The main disinfectant used is bleaching powder measured and made into

hypochlorite solution. The staff is aware of the quantities required to make the solution.

• Used instruments are first disinfected by immersing bleach solution and then washed.

• Gloves are first washed with water to remove blood, followed by soaking in bleach and are then burnt.

Comment: Serious emission problems are anticipated particularly due to burning of the following materials:

• All types of plastics waste (Dioxin and Furans), • Material treated with hypochlorite is being burnt (Dioxin and Furans), • Red coloured polythene bags (Cadmium)

Sterilization:

• Done in a sterile supply unit having two horizontal (Pre-vacuum ) and one vertical sterilizer.

• Monitoring is done by chemical strips. • No biological indicators are used.

Protective equipment: • Gloves, mask, boots are available. • A waste handler was observed to wear uniform, gloves and boots while

cleaning. Training

• HCWM training not received by any category of staff. • Infection control training given some time ago. • Doctors have not received any training in IC or HCWM

Hepatitis B vaccine:

• Not uniformly received. • Persons trained at the RIHS received 3 doses of the vaccine during their

training


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Open dumping of domestic wastes, District Hospital at Paro 3.2.3 Basic Health Unit at Dawakha Person contacted: Mr Pema Wangchuk, Basic Health Worker. Services provided by the facility: This facility provides primary health care to a population of 3500. Cases which cannot be handled are referred to the district hospital at Paro. Staff of the unit consists of Basic Health Worker (BHW), Auxiliary Nurse Midwife, Health Assistant and a Caretaker The unit carries out outreach and house surveys. Patient turnover per day in winter is 15-20 per day and summer 30-40 per day. Water supply: the unit receives piped water through a tap. Waste management: Off Site Incineration: Waste sharps are collected in cardboard sharps boxes which when filled (once a month) are transported to District Hospital at Paro for incineration. Burning in improvised incinerator All waste excluding sharps and including drip sets, dressing’s gauze, syringes etc are burnt in an improvised incinerator.


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Improvised incinerator at BHU, Dawakha Sterilization

• Three pressure cooker type autoclaves are used for sterilization of delivery packs and dressing packs.

• Sterilized reusable glass syringes are used for drawing water for injection; all other injection procedures are done using disposable syringes.

• Auto-disable syringes are used for immunization.

Disinfection: • There was a boiler for disinfecting instruments. • Chemical disinfectants used are mainly bleaching powder and Chlorhexidine

+ Cetrimide in Alcohol (“Savlon”) The BHW was aware of the concentration used. “Savlon” was used as it is in the cheatle forceps solution. Used Instruments are first dipped in 1% Savlon and then washed.

• Wounds are cleaned with hydrogen peroxide. • 70% ethyl alcohol (“Spirit”) was used for emergency disinfection of hands

and disinfection of sutures Protective gear:

• Both sterile and unsterile gloves are available. • The sterile gloves are used for delivery and handling injuries. • The un-sterile gloves are worn while washing and cleaning procedures. • Plastic gowns are available and worn while conducting deliveries. • Masks not available • Comprehensive delivery kits (from UNICEF) are available. • The BHW had received hepatitis B vaccine during training.

Training: The BHW informed that he had never received specific training in infection control and waste management. However, careful questioning revealed that basics of infection were taught during his course at the RIHS.


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3.2: Review of existing HCWM materials in Bhutan The following materials were reviewed:

1. Health Care Waste Management Plan for Bhutan 2004-2006 June 2004,

DANIDA

2. Environmental Codes of Practice for Hazardous Waste Management : National Environment Commission, Thimphu Bhutan, June 2002

3. Operation Manual of World Bank Aided Bhutan National HIV/AIDS and STI

Prevention and Control Project. (Review given in 3.1.1)

4. Guideline for Infection Control in Health Care settings STD/AIDS Programme Health division Ministry of Health and Education Second Edition, 1998.

3.2.1. Health Care Waste Management Plan for Bhutan 2004-2006 June 2004 DANIDA (HCWMPB)

The plan was based on the findings and proposals made by teams visiting Bhutan from 8 February to 5th March 2002 and 8th Dec-18th Dec 2003. A summary of the information in the document HCWMPB is given below

• The HCWM plan gives priority to safe handling of waste, working environment as well as external environment.

• It describes the current practice and data on waste quantity providing the

background material for the future planning and new initiatives which could be adapted to existing structures and procedures.

. • The document states that staff of the institutions visited are familiar with the

guidelines for handling infectious waste and had attended workshops on infection control. It was the general impression that the health care staff carried out the disposal of hazardous waste correctly, however in some cases the waste handlers and care takers are not aware of proper disposal principles and methods.

• An evaluation of the current situation has been presented and the areas in which

improvements are required have been identified.

• The document identifies the disposal methods used at present which are burial or incineration mainly in primitive incinerators.

• The plan advocates the establishment of destruction facilities with a low

environmental impact but with well documented destruction efficiency.


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• The plan proposes to establish 4 treatment centres for health care waste starting with a facility in Thimpu, and then 3 in the rest of the country.

• As an interim solution before the treatment facilities are established, the plan

advocates the disposal of waste in simple drum incinerators. Comment: This is contrary to international opinion, and to WHO’s policy on HCW management, where combustion of waste is considered harmful for the environment; in particular. The Signatories and Parties to the POP Convention have recently stressed this issue once more (Denmark is also Party to the Stockholm Convention). An alternative needs to be sought urgently. The 2004 WHO Policy on health care waste management and the publication on solutions for primary health centres, may be of use in this context.

• Other proposed activities under the plan are establishment of a nationwide

collection system, cooperation between various sectors and ministries on safe collection and disposal system of hazardous waste, training courses and workshops on health care waste management, preparation of local guidelines.

• The plan advocates integrating waste management aspects to other activities

within the health sector operation. Efforts should be made to reduce the waste amounts. Waste management aspects should also guide procurement so that materials and products which are less harmful to the environment are purchased.

• The plan advocates that the task of coordinating the HCWM activities under the

plan should be given to the National Infection Control Organisation proposed in 2002 to coordinate infection control activities.

• The implementation strategy proposed under the plan is to implement the

policies in line with the availability of resources. To start with improvements within areas and at locations where the effects are expected to be significant so that in the course of time, the health care waste management will be raised significantly.

Comment: Despite suggesting simple drum incinerators as an interim measure, the plan emphasizes that significant investment in waste treatment facilities must only be made in facilities that are considered environmentally safe and fully comply with requirements of a safe working environment.


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3.2.2. Environmental Codes of Practice for Hazardous Waste Management: National Environment Commission, Thimphu Bhutan, June 2002

• The Environmental Code of Practice (ECOP) for hazardous wastes management was prepared in consultation with a number of resource persons in Bhutan, together with the use of documents and website references.

• This Code forms a part of several Environmental Codes of Best Practice

prepared by the National Environment Commission (NEC), Royal Government of Bhutan (RGOB), and provides support to the RGOB’s “Water and Sanitation Rules”.

• The Environment Code of Best Practice describes environmental terms and

conditions to be considered in the management of hazardous wastes and should be considered as a guideline. However, where the competent authority issuing an environmental clearance deems it necessary, quotes from the relevant sections of this Code may be extracted and included in the environmental clearance issued for a project under Chapter 3 of the Environmental Assessment Act, 2000. Furthermore, the language of the extracted sections may be altered in order to make the relevant activity, procedure or practice mandatory.

• The ECOP for hazardous waste management defines the role of the regulatory

authority and the responsibilities of the occupier/generator of the waste. Role of National Environment Commission (NEC): In order to establish proper management of hazardous wastes, NEC, the regulatory authority, shall require producers/users/occupiers of hazardous wastes to;

• Maintain complete records of the types, quantities and characteristics of hazardous wastes produced, handled, stored and treated.

• Ensure that adequate Occupational Health and Safety (OHS) standards are established and maintained at facilities handling hazardous wastes.

• Ensure that hazardous wastes are segregated at source from the non-hazardous wastes to facilitate transportation, storage and disposal options.

• Ensure that transportation of hazardous wastes is done through certified carriers that have demonstrated practical capabilities.

• Ensure that hazardous wastes are disposed at approved disposal sites. • Ensure that hazardous wastes are stored on-site in approved containers’ storage

facilities and the maximum storage and loading capacities are not exceeded. • Ensure that they have all the necessary safety equipment, such as for fire

control, decontamination, and alarm systems for emergency situations. • Ensure that hazardous wastes containers are appropriately labelled and colour

coded for differentiation (e.g. medical wastes). • Ensure that there is at least one qualified employee always onsite or on-call to

co-ordinate emergency response efforts. • Ensure that a Chain of Custody system is established to track hazardous wastes

from the source of generation to final disposal/storage locations.


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• Ensure that they provide a Material Safety Data Sheet (MSDS) for all the hazardous wastes produced.

Responsibilities of Producers/Users/Occupiers of Hazardous Wastes

• Identify the quantity, composition, and proper disposal facilities for any hazardous wastes generated or used on site.

• Provide adequately detailed information regarding the hazardous nature of waste material to persons responsible for its transport, treatment, storage or disposal. Personnel dealing with hazardous wastes, including contractors, must be properly trained in the handling of wastes, and the risks involved.

• Use an appropriate Chain of Custody system to ensure the proper disposal of hazardous wastes.

• Bear the costs associated with the treatment, storage, transport, and disposal of hazardous wastes.

• Hazardous wastes are provided with appropriate safety devices such as safety masks, goggles, hand gloves, and boots.

• Assume responsibility for any damage to property or health during the storage and transportation of wastes produced at their facility.

• Ensure that MSDS are attached to appropriate containers and/or prominently displayed.

This guideline gives details about the standards for Landfills (given in Annex 8.6)

3.2.3. Operational Manual of the World Bank funded National HIV/AIDS and STI Prevention and Control project

• The World Bank has started to fund an HIV/AIDS project of the RGOB in July

2004. The goal of the project is to reduce the risk of HIV and STI transmission among the general population.

• The project consists of 4 main components(i) Prevention of HIV/AIDS and STI’s

(ii) Institutional strengthening and Capacity Building (iii) Care, support and treatment of HIV/AIDS and STI’s and (iv) Strategic information for HIV/AIDS and STI’s

• The operational manual describes the various components of the project and

how and by who it ill be implemented. It also details the implementation strategies, activities and methods of monitoring and evaluation.

• Under the Component 3: Care, support and treatment of HIV/AIDS and STI’s;

the subcomponent 3.4 aims to institute Universal Precautions and Waste Management through training, monitoring, and procurement of equipment and supplies. The activity complementing this aim is Infection Control and Hospital Waste Management (Activity 34010) with the Department of Medical Services being the responsible agency.

Task description and objectives


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a) Infectious and hazardous health care waste will need to be properly treated and disposed to ensure minimum negative impact on health care workers, the general public and on the environment as a whole. An infection control and waste management plan has been developed and will be implemented in all health care facilities.

b) Equipment for treatment and disposal of infectious medical waste and sharps (needle cutters, bags bins and protective gear, autoclaves) at health care facilities will be procured and needle disposal pits will be dug at key facilities.

c) Training will be imparted to health care workers on proper management of

hospital waste.

d) A strategy for post exposure prophylaxis (PEP) will be considered at midterm

review once the national HIV/AIDS treatment policy and guidelines have been developed

e) A National Infection Control Committee (NICC) will be established in the Ministry of Health (MOH), Department of Medical Services for implementation and monitoring ad evaluation of the National Infection Control and Waste Management programme.

f) The NICC will have the director of Department of Medical Services as the

chairman and will include senior officers from the MOH (Public Health, Health Care, Drugs Vaccines and Equipment Division, Quality assurance and Standards Division, Health Engineering, Institute of Traditional Medicine Service. Royal Institute of Health Services, senior medical and nursing staff). National Environment Commission and City Corporation.

g) The NICC will set up working groups to work on specific tasks as needed. At each of the Dzongkhag hospitals there will be infection control teams (ICT) which will be responsible for programme implementation and reporting to the Dzongkhag medical officer and the NICC. At the BHU level, the Health Assistant will be responsible for infection control and waste management activities and reporting to the Dzongkhag ICT.

Implementation Strategy

a) Establishment of National Infection Control Committee and Infection Control teams at the Dzongkhag hospitals

b) Development and distribution of IEC materials c) Training of health care workers on Health Care Waste Management and Infection

Control: universal precautions d) Procurement of equipment and civil works for environmentally sound treatment,

disposal and management of hospital waste.


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e) Regular reporting, monitoring and evaluation of the implementation of Infection Control and Waste Management Plan.

Comment: The activities and products provided by the present mission will complement the objectives and implementation strategy outlined above as follows:. 1..The MOH, RGOB has already developed an infection control and waste management plan which needs to be updated and requires technical inputs.. Most of the required technical inputs including the updated infection control manual, additional guidelines on surveillance, waste survey, sterilization procedures and validation, occupational safety, role of microbiology laboratory, as well as the terms of reference of the various key persons (Infection Control Officer, Infection Control Nurse, Waste Management Officer) and the allocation of duties and responsibilities are being provided through the present report (Annex 4) to assist in implementation. 2. Specifications for waste treatment autoclave, needle destroyers and syringe cutters, protective wear as well as the design of various disposals pits form part of this mission and have been provided in Annex 8 3. The existing infection control guidelines that were developed in 1996,1998 have been updated through the present mission and the detailed HCWM guidelines have been incorporate ( Annex 9) The modifications, additions have been made in keeping with current knowledge and concepts, paying attention to human and environmental health and safety. Specifically, the earlier document laid emphasis on burning in pits or incinerators as the mode/option for waste treatment. This has been eliminated and replaced with environmental friendly options for waste treatment such as autoclaving. The updated manual and guidelines will form the source material for the development of training modules and training courses. 4. An outline for post exposure prophylaxis has been included in the guideline for employee health which can be seen in Annex 10. This can provide the background for developing guidelines and a strategy for post exposure prophylaxis

5. The MOH, RGOB has initiated the establishment of two NICC’s, one for policy and the other for technical matters, the members and terms of reference of these committees are given in Annex 4. 6. At the time of this report, working groups and ICT’s had yet to be formed. Thus implementation of the infection control and HCWM Plan has yet to be initiated 3.2.4. Guideline for Infection Control in Health Care Settings STD/ AIDS Programme, Health Division, Ministry of Health and Education, Bhutan, 2nd Edition 1998 The document was produced by the Health Division to facilitate and standardize the concepts of Universal Precautions in all health care facilities in the country. The document as revised in 1998.


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The broad principles of infection control advocated in this guideline are:

• Infection Control Measures: Each institution should establish an appropriate infection control (IC) policy and programme mechanism should be set up for planning, implementing, monitoring and evaluation of the IC programme.

• A patient should not be admitted in hospital unless it is absolutely necessary and

should be discharged as soon as possible to reduce the risk of infection Patients with low immunity should be given special care. Patients with communicable diseases should be isolated.

• Environment cleanliness is stressed. Cleaning with disinfectant is not necessary

unless there is a spillage with infectious material. Proper waste disposal water treatment disinfection and sterilization of equipment can reduce the risk of infection among patients, health care workers and community.

• Micro -organisms responsible for infections in health care settings may originate

from patients, the environment or health care workers. The sources of infection are to be identified and specific measures must be taken appropriately to prevent their spread.

Review of the chapters in the guideline: Chapter 1: Universal Precautions: This chapter deals with hand washing indications and techniques, and protective barriers such as glove use, masks, gowns aprons and overshoes. COMMENT: The chapter needs revision due the recent concept of standard precautions instead of universal precautions wherein appropriate precautions are required to be taken against all body substances (secretions and excretions) as well as blood and body fluids from all patients regardless of the diagnosis or presumed infectious status of the patient. The other concept is transmission based precautions or additional precautions which are needed for diseases that are transmitted by air, droplets and contact. Incorporation of recent evidence pertaining to hand-washing is also required.


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Chapter 2: Disinfection and Sterilization The document gives guidelines on the cleaning of used and soiled equipment. A listing of disinfectants, their effect on micro-organisms and recommendations for use is given for guidance in selection of a particular disinfectant for a particular use. Sterilization by steam is outlined which includes the cycle parameters, pre-sterilization cleaning and packaging, post sterilization storage. Guidelines have been provided. Comment: The recommendations need revision and updating based on existing evidence in world literature and their potential to effect the environment. Record keeping and validation processes for sterilization need to be added to the section on sterilization. Stepwise detailing of the use of sterilizers is also required. The guidelines for sterilization and reuse of sterilizable syringes need some modification in terms of occupational safety considerations. Chapter 3: Precautions in selected settings The special settings listed are Tuberculosis, HIV/AIDS and Hepatitis B, Diarrhoea, Meningitis, Dentistry and Laboratory settings. Comment: This section needs updating and precautions observed for specific infectious diseases can be based on the principle of transmission based precautions. Other settings need to be added such as neonatal units, multi-drug resistant organisms etc. Chapter 4: Specific measures for preventing common infections This chapter relates to the prevention of common hospital associated infections (HAI) namely: (a) nosocomial urinary tract infection (b) blood stream infections (prevention of infection during intravenous infusion) (c) surgical wound infection (d) skin infection and pressure sores. Comment: Some guidelines and criteria for diagnosis of these infections are required to be added. A basic surveillance and recording process for the different types of nosocomial infections should be included to generate standardized data to estimate the magnitude of the problem of HAI. A policy and guidelines on antibiotic use should be added as a separate chapter. Chapter 5: Waste Disposal (Management) This section suggests the handling, collection and disposal of hospital waste. It also gives the methods of waste disposal which are (a) Incineration in large capacity incinerators (b) simple oil drum incinerator, (c) simple stone or mud incinerator. Comment: This section needs major revision and elaboration in the light of the Health Care Infection Control and Waste Management Plan. . Due to environmental safety, incineration is precluded as an option and the waste management section needs to be modified accordingly, particularly to complement the establishment of the Waste Management Autoclave which is being considered as the preferred, environmentally safe option for Bhutan. The existing guideline is suitable for the Basic Health Worker Level but does not cater to the training needs of the IC&HWM committee and the Infection Control Teams. In addition to revising the information contained in the existing document, it is felt that additional chapters are needed.


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3.3. Activity. Revise Existing Guidelines on Infection Control In the light of the review of Guideline for Infection Control in Health Care Settings Bhutan (3.2.4) and discussions with National Counterpart Ms Sonam Wangmo, it was decided to a) Revise the existing basic document -While retaining its suitability for Basic Health worker level. The revised guideline is given in Annex 9 The style and order of chapters was retained for continuity and familiarity. The original contents are in black whereas the additions and revisions are in re, indicating changes brought by... b) Draft new sections Considering the needs of other Health Care staff including the IC&HWMC and ICT (see Annex 4) It was decided to formulate guidelines on the following issues which may be presented as new chapters or as a separate document.

• Employee Health Programme • Guidelines for setting up HAI surveillance and case finding • Guidelines for conducting waste surveys • Revise and elaborate hospital waste management guideline to include the

options under the infection control and waste management plan • Validation, record keeping and monitoring of sterilization and disinfection

processes • Guideline on Investigating an outbreak of HAI • Microbiology Laboratory in the investigation and control of HAI • Monitoring and evaluation of infection control and waste management.

The new sections are given in the Annex 10

3.4. Activity: Develop a comprehensive draft of a national infection control and HCWM program :

The MOH has already drafted a detailed Infection Control and Hospital Waste Management Plan for Bhutan in April 2004, including allocation of responsibilities, terms of reference of the committees, revision of the existing guidelines, training requirements. Monitoring and Evaluation, Procurement of materials as well as a detailed implementation plan with time frame. See section 2.3 and Annex 3-5 The consultant reviewed this Plan along with the minutes and recommendations of the meetings held between April and December 2004. The consultant then added her inputs which can be seen in the recommendations section It was noticed that that there was no mention of a legislation on HCWM in the Plan. The RGOB could decide when HCWM needs to be regulated by a specific legislation.


33

3.5: Activity: Prepare Draft Specifications for Equipment and Material for the Treatment and Disposal of hospital waste A comparison of the major technologies available for the treatment and disposal of waste are given in the table Annex 8.1 The Infection Control and Hospital Waste Management Plan for Bhutan recommends that the infectious waste from Health Care Facilities will be treated by autoclaving and end products will be disposed off into the municipal waste , Needle destroyers are recommended for needles to reduce occupational hazards. Health Centres with in the districts with no municipality will have deep pits for the final disposal of waste. In addition to the Autoclave and deep pits, the consultant was requested to draft the specifications for Hydroclave, Waste Containers, Heat Resistant Protective Gear, Needle and Syringe Destroyers. Useful inputs about the autoclave were gained from the visit to autoclave facility in Delhi prior to travelling to Bhutan ( see report of visits in India in Annex 2 ) The detailed specification of the autoclave and other equipment for waste management are given in the Annex 8. A variety of deep pits have been described to allow a choice according to availability of resources, amount and type of waste. An outline of waste water treatment plant is also provided.


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4. Conclusions and Recommendations 4.1 CONCLUSIONS:

• The 2004 Infection Control and Hospital Waste Management Plan developed by the RGOB is a major achievement. To ensure proper implementation, it now needs to be reviewed and updated according to recent scientific evidence with regard to occupational safety and environmental safety considerations.

• The detailed Action Plan needs implementation in terms of procurement of

material, human resource development and initiation of a training programme for all categories of health care staff in infection control incorporating HCWM.

• At start, the implementation of the plan requires RGOB’s firm commitment to

allocate specific budgets so as to ensure sustainability.

• Inter ministerial, inter agency and inter programme coordination between health department and various stakeholders such as urban and rural development ministries, National Environmental Commission, civic agencies, and other health programmes is required for an integrated approach and sustainable effects, at national and district levels.

4.2 RECOMMENDATIONS Recommendations for implementation of the Infection Control and Waste management Plan The MOH of RGOB has drafted an Infection Control and Waste Management Plan .A National Infection Control and Hospital Waste Management committee has been formed and also Infection Control Teams planned to implement the plan. On the basis of observations and review of current situation in Bhutan through the present mission, the following are recommended for immediate action (Phase 1): Institutional Development • A meeting cum workshop on “Integrated Infection Prevention and Control” should

be organized in Bhutan before end 2005. The gathering will allow obtaining inputs from the concerned health officials at national and district level as well as from HCWM expert in the SEA region. Further the meeting will allow identifying training needs.

• Besides the National Infection Control and HWM Committees for policy and a technical committee, A local Hospital Infection Control Committee and ICT for JDWNRH needs to be established with terms of reference as detailed in the Annex 3.3

• An Orientation Session should be organized for the committee members.


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Manpower development • Awareness / orientation programmes for senior medical staff to be initiated • Training programmes for all categories of staff including doctors, nurses,

cleaning staff in infection control. Curriculum for the training for Doctors, Nurses and Cleaning Staff can be seen in ANNEX 4.

• Health Care workers have not had any training in Hospital Waste Management which needs to be initiated

• An infection prevention drive to be initiated with focus on patient safety Development of Training Modules It is recommended that that two training modules should be developed one for Infection Control and the other for Hospital Waste Management. Both modules should be developed at two levels one for the training needs of Doctors and Nurses and another for cleaners and caretakers... It is estimated that this will take about 3 months. A WHO supported training module is currently been finalized to be used for distance learning purposes by the Indira Gandhi National open University in new Delhi. Part of this module could be used for national training. Special attention must be paid to the modules developed for the cleaning staff and caretakers. User friendly modules should be developed with pictures, group exercises and participatory activities.

Baseline Survey • A waste survey should be carried out as the first step to find out the quantum and

types of waste generated in each unit of the hospital. Guidelines for conducting a waste survey are included in Annex 10.3.

• A surveillance programme for HAI needs to be established. Guidelines for conducting surveillance for HAI are enclosed (Annex 10.2) Surveillance of infections should be initiated by the ICT.

Allocation of responsibility • Infection Control Officer, Waste Management officer and Occupational Health

Officer needs to be designated in each hospital and responsibility allocated. The most suited person for ICO is a clinical microbiologist who is also the key person of the ICT. Initiatives should be taken to train a doctor in Clinical Microbiology who can take the lead in implementation and be the nodal officer... In the absence of a Clinical Microbiologist, a pathologist who is also looking after microbiology will be the most suitable person in terms of training and duties. The terms of reference are given in Annex 3.4

• It is suggested that a medical officer with administrative experience could be

given the responsibility of the WMO, The terms of reference can be seen in Annex 3.6


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• Infection Control Nurse needs to be designated and trained. This should be a senior nurse with an interest in infection control. The terms of reference of ICN are in the Annex 3.5

• Training of ICO, ICN and WMO to be arranged at the Health Care Waste

Management reference centre at Bangalore, India.

Procurement of materials and equipment • As a prerequisite the equipments required for implementation of the plan need to

be procured immediately e.g.: bags, containers, protective gear, and needle destroyers. Specification of containers, needle destroyers and special protective gear can be seen in Annex 8.2-8.4.

• Since incineration is not the acceptable option for waste treatment due to adverse environmental and public health impact, arrangements for procurement of waste autoclave should be initiated. It is suggested that a major waste autoclave be acquired for JDWNRH and smaller autoclaves for district hospitals. One of the autoclaves being used for sterilization of patient care equipment can be dedicated to waste treatment. In BHU’s a surplus pressure cooker type autoclave can be used. Detailed Specifications of a waste treatment autoclave and shredder / Hydroclave for JDWNRH can be seen in Annex 8.1.

• Sharps pits can be constructed in the District hospitals and sharps can be disposed into these pits. Specifications for various types of pits are in Annex 8.4.

Phase 2 Need for specific HCWM legislation • No specific legislation on Hospital Waste Management exists so far in Bhutan. The

NEC document ECOP for Hazardous Waste Management does include guidelines for the management of HCW as a component of Hazardous Waste. However, more detailed guidelines focusing on HCW are required. Another document on similar lines for Health Care Waste Management should be developed in collaboration with the MOH.

• This can form the basis of legislation and come under the Environment Assessment Act 2000.

• The components and an outline of rules for Health Care Waste Management and Handling are suggested in Annex 11.

Construction of Sanitary Landfills with Liner system, leachate management, security and fencing. Secure cells can be constructed in a section for hazardous waste. Details are given in the Annex 8.6 Construction of Waste Water Treatment Plant For treatment of waste water from hospitals. An outline is given in Annex 8.7. Development of Centralized Waste Treatment Facility A CWTF and a collection system with designated vehicles for transportation should be developed in each region.


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Based on the recommendations an Action Plan with time frame is given below:

2005 2006 Recommendations

3rdQtr 4th Qtr 1st Qtr 2nd

Qtr 3rd Qtr 4th Qtr

National workshop with regional inputs

X*

Establishment of IC HWM Committee for JDWNRH

X

Appt of ICO, WMO, ICN X Orientation of Committee members

XX

Training at HWM training centre at Bangalore

XX

Waste Surveys XXX XXX XXX Surveillance for HAI X XXX XXX Procurement of material, equipment

XXX XXX XXX XXX XXX XXX

Review and printing of Revised Guideline

XXX

Development of training modules

XXX XXX

Testing of training modules

XXX

Training for doctors X X X X X Training for nurses X X X X X Training for waste handlers

X

X

X

X X

Construction of waste water treatment plant

XXX

Construction of Sanitary Landfill,

XXX

Centralized Waste Treatment Facility

XXX

National HCWNM Legislation

XXX XXX XXX XXX XXX XXX

*Each month is represented by ‘X’


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WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR SOUTH-EAST ASIA

INFECTION CONTROL AND HEALTH CARE

WASTE MANAGEMENT

IN

THE KINGDOM OF BHUTAN

A MISSION REPORT

ANNEXES

Prepared by

Dr Geeta Mehta, MD, MAMS,FIMSA, MPH

Director Professor and Head of Microbiology Lady Hardinge Medical College

New Delhi 110001, India

With support from

WORLD HEALTH ORGANISATION REGIONAL OFFICE for SOUTH EAST ASIA (SEARO)

May 2005


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ANNEX 1 List of persons met

ANNEX 2: Report on visits carried out in India ANNEX 3 Outline of HCWM System suggested for Bhutan ANNEX 4 IC & HWM Plan Bhutan: Terms of Reference ANNEX 5 IC & HWM Plan Bhutan: Training Needs ANNEX 6 IC & HWM Plan Bhutan: Implementation Plan ANNEX 7 Estimated Generation of HCW in Hospitals and BHU’s Bhutan ANNEX 8 Draft Specifications for equipment required for HCWM

8.1 High Pressure Steam treatments 8.1.1 Autoclave 8.1.2 Shredder 8.1.3 Hydroclave 8.2. Accessories 8.2.1 Specifications for Heat Resistant Protective Gloves 8.2.2 Specifications for Containers for Health Care Waste 8.3. Specifications for Needle and Syringe Destroyers 8.4. Specifications for Deep Pits for Hospital Waste

8.4.1 Clay Lined Pit for Sharps 8.4.2 Concrete Lined Pit for Sharps 8.4.3 Concrete Safety Vault for Hospital Waste 8.4.4 Deep Burial Pit for Hospital Waste

8.5. Options for Disposal of Sharps 8.6. Standards for Land fill. 8.7. Waste water treatment ANNEX 9 Check list for Needs Assessment of Health Care Facility in HCWM ANNEX 10 Guidelines for implementers of IC & HWM Pl 10.1 Definitions, Epidemiology and Types of HAI 10.2 Surveillance of HAI 10.3 Waste Survey 10.4 Employee Health Programme 10.5 Investigation of Outbreak of HAI 10.6 Microbiology Laboratory in the Control of HAI 10.7 Monitoring and Evaluation: Indicator Checklist ANNEX 11Draft Revised Infection Control Guidelines (Incorporating HCWM) REFERENCES and WEB SITES


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ANNEX 1: List of persons met Place Bhutan Dates 17th March- !0th April 2005

• Dr Ei Kubota WHO Representative Bhutan, Thimphu • Ms Sonam Wangmo, Programme Officer, Infection Control and Hospital Waste

Management Programme, Dept of Medical Services, Ministry of Health.

• Mr Rinchen Yoezer Project Coordinator HIV/AIDS and STI Prevention and Control Project, Thimphu

• Dr Hnin Hnin Pyne Senior Public Health Specialist, Human Development Unit

South East Asia Region, Thimphu

• Dr Tandin Dorj, Lab Technician, Thimphu

• Dr Tobgyal Wangchuk, Deputy Medical Superintendent, Jigme Dorji Wangchuck National Referral Hospital,Thimphu

• Ms Tandin Pemo, Nursing Superintendent, JDWRNH, Thimphu.

• Dr Pandup Tshering, District Medical Officer, Paro

• Mr Pema Wangchuk, Basic Health Worker, Dawakha.

• Dr Dorji Wangchuk Director Department of Medical Services, Ministry of Health, Thimphu

• Dr Ugyen Dophu, Medical Director, JDWNRH, Thimphu.

• Mr Budhamani, Senior Staff Nurse, JDWNRH, Thimphu

• Mr Kencho Tenzin Central Procurement Division, Ministry of Health, Thimphu

• Mr Dorji Wangchuk Assistant District Medical Officer, Punakha

• Ms Lhamo, Assistant Clinical Officer, Punakha

• Mr Wangchuk Dukpa, Sr Compounder, Punakha

• Ms Eka Devi Auxiliary Nurse Midwife, Punakha

• Ms Tandin Pema, Pharmacy Technician, Punakha.

• Ms Sonam Wangmo, Eye Technician, Punakha.


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• Dr K.M. Sharma, District Medical Officer Tshinalakha,Chukha • Ms Prem Choki, Assistant Nurse, Gedu Hospital,Chukha

• Dr Marc McLean, Public Health Consultant, Injection Safety Assessment Project

Place New Delhi Dates 8th March - 16th March 2005

• Mr Alexander von Hildebrand: Regional Environmental Health Advisor, WHO SEARO, New Delhi, India

• Mr Sean Doolan: Environmental Advisor, DFID India

• Dr Bharat Sagar Incharge Waste Treatment Facility LNJP Hospital, New Delhi,

India

• Dr Anita Arora Incharge Waste Treatment Facility Escorts Hospital and research Centre, New Delhi, India

• Ms Ruma Tavorath (over the phone discussions) Environmental Advisor, World

Bank, New Delhi, India


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ANNEX 2: Report on visits carried out in India Visit to Waste Treatment Facility to examine Waste Treatment Autoclave at LNJP Hospital at New Delhi Date of visit 15.3.05 Activity details 1. Discussion with Dr Bharat Sagar , Environment Officer, in-charge of Waste Management Lok Nayak Jai Prakash Hospital in New Delhi is a 1500 bed teaching hospital having general as well as specialized medical and surgical facilities. There is a medical college attached to it ; The Maulana Azad Medical College. The Hospital and Medical College are under the administrative control of the Delhi Government. The institution generates 170-200 Kg of biomedical waste per day 2. Examination of Medical Waste Treatment Autoclave Facility (Tuttanhauer supplied by OMRON) 1700 litre capacity handling 100 kg per cycle 3. Study of the infrastructure required for installation and operation

• Supply of steam: Boiler specifications are complementary to the autoclave unit. • Civil Works: structural requirements • Electrical requirements: 3 phase electric current • Colour coding and segregation policy

• Red colour coded polythene bags for infectious non sharp waste • Cardboard single use containers for sharps • Black polythene bags for general waste

• Non sharp waste as well as sharps waste in red bags are carried to the autoclave facility in trolleys where the waste is autoclaved and then shredded.

• Storage areas for bags before autoclaving. The construction and design of the storage areas were studied. The area was secured to prevent unauthorized access. The flooring had a wire mesh to allow for drainage and washing if there was any spillage.

• Waste Transport trolleys (fabricated by SintexR India) . Bags are loaded onto trolleys and carried to the autoclave facility through a centralized collection. There was a separate area with water connection to wash the trolleys before reuse.

• Record keeping: Method of record keeping was examined. • Validation of autoclaving process: Physical parameters for each cycle are

recorded and biological indicators using B. stearothermophilus spore strips are placed in the load once a week.

• Manpower: 4 waste handlers, trained in loading and unloading the autoclave and shredder. One supervisor of the facility also trained in waste management. .

• The workers are provided with personal protective equipment which are : (1) Gloves: Two types of gloves are being used by the workers: (a) Kelver gloves of heat resistant material and (b) Zeetex Alumino Borosilicate heat resistant


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gloves. (2) Cloth apron (3) Rubber knee length boots (Duckback gum boots) (4) Masks are also provided, these are ordinary surgical masks.

• Recycling of sterilized and shredded plastic waste: Plastics are autoclaved separately and shred and the shredded sterilized material was sold to a contractor which fetched some revenue for the hospital.

3.1.2. Meeting with World Bank representative Ms Hnin Hnin Pyne, Senior Public Health Specialist Discussions with Ms Ruma Tavorath, Senior Public Health Specialist World Bank (Delhi) were also referred to. Main Points

• World Bank will be funding the infection control and HCWM initiative under the USD 6 million grant for HIV/ AIDS prevention for Bhutan

• Incinerator is not a recommended option both from the environmental as well as public health perspective

• Autoclaves, and other treatment technologies should be explored which are environment friendly

• On principle WB will be able to support environment friendly initiatives only. ( will not be able to support the procurement of incinerators or combustion options which are considered to be hazardous to human health and environment)

This consultant was referred to Operational Manual of the National HIV/AIDS and STI prevention and control project for further details. This document is reviewed in chapter 3.2.3


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ANNEX 3: Outline of a HCWM system for Bhutan General Principles The management of health care waste will be based on the following principles:

• Minimization of waste generation and reduction in the dangerous characteristics of waste

• Treatment of hazardous waste to render it non hazardous as far as possible and

to reduce the volume.

• Promote the reuse , recycling and material recovery of non hazardous waste

• Selection of safe final disposal with minimal adverse effects on health and environment

Segregation policy for infectious waste

• Infectious non sharp waste : red bag and container • Sharp waste : yellow, white puncture proof container

Segregation policy for general (non hazardous) waste

• Kitchen waste (compostible): green • Recyclable (paper, cardboard, non-infectious plastic) blue • General waste for disposal : black

Equipment, Facilities for waste treatment and disposal: 1. Needle and syringe destroyers for destruction of needles at point of use in every ward. Specifications are given in the Annex 8.3 2. Autoclave: For the sterilization of infectious waste including: waste sharps, syringes, needles, scalpels, ampoules, broken glass, infected plastic, disposable catheters, soiled waste including swabs, dressings, gloves, infected glassware., cultures, specimens, blood bags. Sterilization to be followed by selective shredding. The detailed specifications for autoclave and shredder are given in Annex 8.1. Alternatively a Hydroclave can be installed for the treatment of waste instead of autoclave and shredder. Shredded parts are to be recycled. 3. Deep Burial: for human organs, placenta, body parts, animal parts, carcasses Details are given in Annex 8.4. 4. Sharps pits for needles, scalpels, lancets, broken ampoules, glass slides. (Infectious plastics may also be disposed in these pits by BHU’s that do not yet have access to an autoclave) These pits may be clay lined or concrete lined or in the form of concrete lined septic vault design depending upon amount of waste and resources. (See Annex 8.4)


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5. Sanitary Landfill: for disposal of general waste and treated health care waste. (Details in Annex 8.6). Should have a secure section for disposal of hazardous waste such as chemical and toxic waste 6. Waste Water Treatment: Hospitals not connected to municipal sewage treatment plant, should construct their own waste water treatment plant. The waste water or sewage from hospitals can be treated in the following ways:

• Treat used waters at point of use by neutralizing or diluting used chemical solutions

• Lagooning system: This is the minimal requirement for the treatment of waste water. The system consists of two successive lagoons after which the liquid is allowed to infiltrate into the soil where it gets filtered as it passes through the soil to achieve an acceptable level of purification.

• Onsite Waste water Treatment plant as given in Annex 8.7 Hospitals that cannot afford the treatment plants should minimize health risks from waste water by the following:

• Excreta from patients with enteric diseases should be treated with disinfectant. • No chemicals or pharmaceuticals to be discharged into sewer, they should be

returned to the manufacturer as far as possible. • Pharmaceutical waste and cytotoxic waste can be disposed in concreted lined pit similar to the disposal of sharps. • Small amounts of chemicals such as formalin can be diluted with plenty of water. • The sludge from hospital sewage can be left to dry naturally in a secured place

and can also be disinfected with bleaching powder.


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ANNEX 4: INFECTION CONTROL AND HEALTH CARE WASTE MANAGEMENT PLAN BHUTAN: TERMS OF REFERENCE OF COMITTEES AND RESPONSIBLE OFFICERS 3.1 National Infection Control and HWM Committee (Policy)

• Approve and facilitate the implementation of new guidelines covering infection control and health care waste management

• Review and endorse the national health care waste management plan • Review and endorse any new policies, modified policies and strategies formed by

the technical committee • Approve annual plans and budgets and review quarterly • Frame a policy for health workers and safe health care delivery • Receive information on current problems regarding infection control and specific

reports on the incidence of infection • Receive information on current problems regarding waste management • Establish and monitor a recording system for waste performance at all

establishments 3.2. Technical Committee IC and HWM (National)

• General technical support to the policy committee and the IC & HWM programme on all issues of infection control and hospital waste management

• Develop standards and policy guidelines together w ith inputs from the JDWNRH committee, the infection control teams and link nurses and submit to the committee.

• Facilitate the implementation of the guidelines covering IC and HWM in all health care institutions.

• Establish and monitor a recording system for all nosocomial infections at National level. Review the prevalence surveys and audits.

• Review, revise and ensure existing guidelines are implemented in the various health care institutions.

• Introduce, maintain and when necessary modify policies on disinfectants, antibiotics and other issues related to infection control and put up for approval.

• Advise on the selection of the equipment for the prevention of infection, including disposal methods of sharps and infectious wastes

• Take action in case of nosocomial infection outbreak. • Monitoring the recording system for initial and regular health screening and

immunization of all the staff in the health care institutions 3.3. IC and HWM Committee for Referral Hospital.

) • Develop standards and policy guidelines for Referral Hospital. • Facilitate the implementation of the guidelines covering IC and HWM at the

Referral Hospital. • Together with the committee and ICT’s, prepare and make prevalence surveys

and audits, twice a year in selected wards. • Review, revise and ensure that guidelines are implemented on basis of available

equipments and provide the budget, personnel and administrative support.


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• Introduce, maintain and when necessary modify policies on disinfectants, antibiotics and other issues related to infection control.

• Advise on the selection of the equipment for the prevention of infection, including disposal methods of sharps and infectious wastes

• Establish and monitor a recording system for all nosocomial infections. • Take action in case of nosocomial infection outbreak. • Monitoring the recording system for initial and regular health screening and

immunization of all the staff in the Referral Hospital 3.4 Infection Control Officer (ICO)

• Consultant member of Infection Control Committee and leader of ICT • Responsible for identification and reporting of pathogens and their antimicrobial

sensitivity • Analysis and dissemination of antibiotic resistance data, emerging pathogens on

a regular basis. • Initiating surveillance of HAI detection and investigation of outbreaks. • Liaise with WMO on IC and maintaining standards of Waste Management. • Plan and conduct Training on IC and HCWM.

3.5 Infection Control Nurse (ICN)

• Works under the management of ICO • Liaison between microbiology dept and clinical departments for detection and

control of HAI • Surveillance of infection and detection of outbreaks • Preparing statistics and reports under supervision of ICO • Training and education in IC and HWM under supervision of ICO • Awareness among patients and visitors about infection control • Monitoring and evaluation of IC and HWM practices .

3.6 Waste Management Officer (WMO)

• Responsible for day to day control of internal collection of waste containers and transport to central hospital storage, treatment and disposal

• Supervisors, caretakers and other workers assigned to collect and transport hospital waste will be directly under his line of management

• Shall ensure that waste bags and other material for waste management are ordered on a continuous basis and there is regular supply

• Shall liaise with Nursing superintendent, Medical Superintendent and Heads of Departments to ensure all staff are familiar with their responsibilities for segregation and treatment.

• Shall prepare statistics on waste generated and maintain records • Shall liaise with ICO and ICN regarding IC and HWM training.


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ANNEX 5: INFECTION CONTROL AND HWM PLAN, BHUTAN: TRAINING NEEDS 4.1. National Infection Control Committee Members

• General Introduction to HAI and the routes of transmission. • Occupational Health Hazards • Universal Precautions (standard precautions) as a mean to reduce nosocomial

infections and risk of occupational exposure. • Segregation, treatment and disposal methods for waste management. • Monitoring and evaluation of IC and HWCM. • Protective equipment and importance of adequate supply. • Monitoring of facility stock reporting

4.2. Infection Control Teams and Link Nurses (Train the Trainers)

• General introduction to HAI and routes of transmission • Participatory Training methodology • Surveillance methodology • Occupational health hazards • Disinfection and Sterilization • Universal Precautions (standard precautions) as a means to reduce nosocomial

infections and risk of occupational exposure. Transmission Based Precautions. • Personal Protective Equipment, what, when and how to use. • Segregation, treatment and disposal methods for waste management. • Operation of equipments used for the treatment and disposal of waste. • Reporting. • Evaluation : of IC and HCWM and of training

The trained ICT’s and Link Nurses will serve as Trainers for training other Health Care Staff (doctors, nurses, laboratory staff, and blood bank staff, cleaning staff) 4.3 Health Care Staff

• General introduction to HAI and routes of transmission • Occupational Health Hazards • Disinfection and sterilization • Universal (Standard Precautions) as a means to reduce nosocomial infections

and risk of occupational exposure. • Segregation, treatment and disposal methods for waste management. • The use of Personal Protective Equipment.

4.5 Additional Focus Areas for cleaning staff and caretakers

• Basic Health Education • Cleaning and disinfection methods • Detailed Waste Handling methods • Occupational Safety • Operation of waste management equipment

ANNEX 6: IMPLEMENTATION PLAN

Infection Control and Health Care Waste Management Program

HCD, Department of Medical Service Indicators: 80% of facilities in compliance with national policy on Infection and waste management

RGOB code Activities not funded

Budget Mil.Nu 2004-2005

2005-2006 2006-2007 Remarks

I II III IV I II III

IV I II III IV

11.02 Meeting/Conference/Seminar/ Workshop 0.100 Whenever available 17.07 Monitoring /Supervision 0.100 24.01 Membership subscription to IFIC 0.020 54.02 Office stationery 0.030

Current 0.250

41.00 Construction of pits for sharps and infectious waste ( 16 hospitals ) 0.700

45.00 Study tour for committee members / health workers /program 0.400 Whenever available

45.02 Refresher course for HWs on infection control in district hospitals 0.500

45.01 Training - Human Resource Dev

Infection Control & HCWM and patient management course-3 health workers

Masters in IC &HCWM- 1nos

To be included in the HRD master plan. It is very important to strengthen the Dzongkhags by training the health workers and specializing in infection control and health care waste management to prevent many probable infections in the hospitals

Capital 1.600 Current + Capital 1.850


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Project subcomponent (World Bank): 34010-Improve Universal precaution and health Care Waste Management

Item code Activity Budget( $)

2004-2005

2005-2006 2006-2007 Remarks

I II III IV I II

III IV I II III IV

34011 Consultation meeting for updating national guideline 5000 34012 consultant to de velop training program 15000

34013 printing of manuals and IEC materials 30000

Total budget of $267000.00 is allocated from World Bank project for 5 years (2004-2009)

34014 training of health workers /support staffs on revised manual 50000

34015 procurement of needle cutters 20,000 34016 procurement of autoclaves 75000 34017 procurement of protective attires 40000 34018 Civil works digging of needle pits 12000 34019 Establishment of IC committee and meetings 20000

Total budget for 5 years from World Bank project for HIV /AIDS (04-09) US$ 267000

ANNEX 7: Estimated Generation of Health Care waste

Source: Health Care Waste Management Plan Bhutan


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ANNEX 8: DRAFT SPECIFICATIONS FOR EQUIPMENT FOR HCWM CONTENTS: 8.1 Comparison of Waste Treatment Technologies 8.2 Specifications High Pressure Steam Treatment

8.2.1 Waste Autoclave

8.2.2 Shredder

8.2.3 Hydroclave 8.3 Accessories

8.3.1 Heat Resistant Protective Gloves 8.3.2 Containers for Health Care Waste

8.4 Needle and Syringe Destroyers 8.5 Deep Pits

8.5.1 Clay Lined Pit for Sharps

8.5.2 Concrete Lined Pit for Sharps

8.5.3 Concrete Safety Vault for Hospital Waste

8.5.4 Deep Burial Pit for Hospital Waste

8.6. Guide for Selection of Options for Disposal of Sharps 8.7 Standards for Landfill


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8.1. Comparison of Waste Treatment Technologies

Incinerator Pre-vacuum Autoclave Microwave Capital Cost Depends upon the quality of

steel used, stack height, process control, fire brick lining , air pollution control devices Approx Cost (with air pollution control equipment): Rs 60-80 lacs

Depending upon the quality of steel, capacity and level of automation Approx Rs 2-40 lacs With shredder 7-60 lacs

Depends upon capacity, model and make Approx Rs 10-40 lacs With shredder 15- 60 lacs

Running (Treatment Cost)

Approx cost Rs 3/Kg of waste

Approx Rs 2.25/Kg of waste Approx cost Rs 2.50/ Kg of waste

By products Ash, super heated steam Toxic emissions such as dioxins and furans

Steam and sterilized waste Disinfected waste and some steam

Personnel requirement

Highly skilled operator and maintenance required

Comparatively low skill level of operator and maintenance required

High level maintenance skills

Disadvantages • Highly toxic emissions possible particularly if chlorinated items are burnt

• Expensive pollution control devices required.

• Having incinerators on site indirectly favours poor segregation.

• Puts economic burden on institutes

• Volume reduction low, hence strain on land filling capacity,

• Not recommended for body parts or anatomical waste

• Steam penetration depends upon density of waste

• Bad Odour • Needs shredding

/compacting after sterilization to reduce the volume

• Barriers to steam exposure such as air pockets may compromise the effectiveness of the system.

• Volume reduction low, hence strain on land filling capacity

• Bad odour • Not recommended for

anatomical waste • Needs shredding

before or after disinfection

• Capital cost relatively high

• If hazardous chemicals are in the waste, these toxic contaminants are released into the air

Advantages • Can deal with all anatomical and cytotoxic waste

• Reduces volume of waste substantially

• Non polluting and environment friendly

• Minimum realignment of personnel

• Recommended for plastic waste

• Is a proven technology, with various installations to its credit. The technology is easily understood and readily accepted

• Non polluting and environment friendly

• Recommended for plastic waste

• Automated and easy to use technology


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8.2 High Pressure Steam Treatment or Autoclaving as an option for HCWM Autoclaving or high pressure steam treatment is a tried and tested method of sterilization used widely in the health care sector. It is a recommended and environmentally safe option for the treatment of infectious waste to render it non infectious. A component of the HCWMPB is the establishment of a Waste Management Autoclave along with a grinder /shredder in JDWNRH in Thimphu To this end the TOR for the present mission includes the development of specifications for the procurement of a Waste Treatment Autoclave and Shredder. As a preliminary to this exercise the consultant visited installations of waste treatment autoclave in New Delhi and had discussions with the managers of waste treatment facilities Another system based on the autoclaving principle is the Hydroclave (which is considered to be a modified autoclave with an inbuilt waste fragmenter) was also examined as an option. Requirements The autoclave and shredder/ Hydroclave will be installed in JDWNRH and will handle the waste generated in the hospital and also other health care facilities in Thimphu. The HCWMPB suggests that it should also handle sharps from the entire country. The transportation modalities will have to be worked out. The HCWMPB suggests an autoclave with a batch capacity of 35 kg giving a capacity of 50 kg /hour, 2-3 hours of operation are required per day for 200 days in the year. Quantity of waste required to be treated in the autoclave: Estimated quantity of sharps: 5 tons a year. Other infectious waste: 25 tons per year COMMENT: HCWPB mentions placenta, human tissue, organs etc to be treated in the autoclave, however, these are not recommended to be treated by autoclaving and shredding due to aesthetic reasons. Burial is an option for this type of waste. (Quantity of Waste: According to Table 5-2 HCWMPB, 17311+624 kg of infectious waste is generated in Thimphu and 4072 Kg sharps for whole of Bhutan. Thus amount of waste to be treated per day =17311+624+4072=22007/ 200 days =110 kg per day or 35 kg per hour)


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EQUIPMENT SPECIFICATIONS. 1. HIGH SPEED STEAM STERILIZER (AUTOCLAVE) FOR STERILIZATION OF REGULATED HEALTH CARE WASTE, AND 2. SHREDDER FOR STERILISED WASTE GENERATED BY (1)

3. HYDROCLAVE

Either (1) and (2) can be installed or (3)

Objective: The equipments are required for sterilizing and reducing the volume of regulated biomedical waste generated from health care establishments in Bhutan and is to be installed in Thimphu. . Preferably A and B should be integrated in one unit, if not then should be supplied by the same supplier/manufacturer and should be complimentary to each other. 8. 1.1. AUTOCLAVE Capacity: Should be able to handle approximately 35 kg of medical waste per hour. The equipment should be able to handle the entire load of 110 kg in 3 cycles of one hour each. It should be a Pre-vacuum type of autoclave with advanced design; the medical waste should be subjected to a minimum of one Pre-vacuum pulse to purge the autoclave of all air and the following parameters:

a) Temperature not less than 1350 C, pressure not less than 31 PSI, autoclave residence time not less than 30 minutes.

b) Should have provision to sterilize ( secondary sterilization) the condensate and

drainage from waste produced during the Pre-vacuum pulse Type of Medical waste to be sterilized: Infectious waste including: waste sharps, syringes, needles, scalpels, ampoules, broken glass, infected plastic, disposable catheters, soiled waste including swabs, dressings, gloves, infected glassware Design features

a) The sterilizer shall consist of a chamber with a steam jacket

b) The sterilizer shall be of robust design with adequate thickness of sheets and reinforcement so as to withstand the hydrostatic test without sign of leakage sweating or deformation.


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c) The equipment shall be designed with low chamber/ floor height for easy loading and unloading

d) The chamber shall be provided with one single door properly hinged. The door

shall be provided with automatic safety door locking/unlocking mechanisms. Sterilization cycle shall not begin until door is closed and fully locked.

e) The biomedical waste in packages shall be loaded in a carriage, which shall roll

in and out easily on a trolley mounted on rails. The trolley shall have the provision for locking the carriage and arrangement to lock itself.

f) Valves should be provided for operation, safety, steam inlet, drainage.

g) The door gasket material should be durable enough to withstand working

pressure and temperature.

h) The chamber should be properly insulated to minimize heat loss and to restrict the surface temperature within reasonable limits not to cause burn due to accidental touch.

i) Chamber/ jacket/ outer walls door valves piping fittings carriage trolley rails trays

etc should be made of stainless steel of non corrosive quality ( 0.4 18 Ni. 10 or equivalent ) Sterilization vessel should be constructed of quality as per ASME or equivalent.

j) Should have a system to dry the wet waste after sterilization Accessories: (as part of the equipment) a) Steam generator with demineralizer plant and having capacity adequate for

requirements of the sterilizer and provided with necessary connections for efficient functioning.

b) Air compressor c) Secondary sterilizing device and cooling system d) Other accessories required to operate the equipment for satisfactory performance

like bags, containers etc. Control and Monitoring System Microprocessor based computer system and printer shall be provided for controlling and monitoring the sterilizing cycle with the following features:

a) microprocessor unit with non volatile memory and with different programme combinations

b) The operation of the sterilizer should be fully automatic c) Self diagnostic system able to give fault messages to the operator d) Manual operation facility for stand by programming in case of control failure e) Printer shall record data, time, day load identification number as well as

operating parameters such as temperature of steam in the chamber, steam pressure, vacuum, time and temperature of steam condensate after cooling throughout the entire length of the autoclave cycle. It will also record cycle progress and error messages.

Validation tests


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The equipment shall be able to successfully pass the following validation tests:

a) Hydrostatic test: The sterilization chamber shall be able to withstand 1.5 times the working pressure and sterilization jacket twice the working pressure for 20 minutes.

b) Biological test: The autoclave should be able to completely and consistently kill

the approved biological indicator 1X106 B stearothermophilus spores at the maximum design capacity.

Installation Commissioning and Inspection The manufacturer/ supplier shall arrange for installation, commissioning and satisfactory trial for one month at the consignee’s premises. Power supply and environment:

a) Voltage : 440V 3 phase supply b) Frequency 50+3% Hz c) Environment: Temperature -100 C to 300C

Other considerations

a) Continuous monitoring of temperature during the exposure time and at various points in the chamber is important in detecting heating problem

b) Thermocouples should be tested to ascertain their accuracy Note

a) Tenderer shall provide details of the infrastructure requirements such as space, electrical, water connections etc and coordinate with the hospital regarding the same.(Turnkey arrangements can also be considered)

b) Tenderer shall submit catalogue and technical literature of the models quoted indicating detailed technical specifications

c) Tenderer should provide a trained operator for 3 months (one year?) and provide training to two hospital staff to operate the machine.

d) Guarantee period should be for a period of two years and firm should also submit an annual maintenance contract for 5 years after the expiry of the guarantee period year wise.


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8.1.2 SHREDDER FOR STERILIZED WASTE GENERATED BY AUTOCLAVE Shedder is required for shredding of sterilized/ autoclaved waste before disposal to landfill. Its aim is to reduce the volume of the sterilized waste and as far as possible make the waste unrecognizable. Capacity: Should be able to handle approximately minimum of 35 kg and maximum of 110 kg of sterilized waste per hour. The volume of the packages of sterilized waste depends upon the type composition as specified below; Type of Waste to be shredded: Waste sharps, needles, broken ampoules, small pieces of metal blood bags, , laboratory waste, cultures, biotechnology waste, discarded glassware, latex rubber gloves, bandages, dressings, disposable PVC/plastic/ cardboard/ catheters, thermocol.

a) Design: a) The feeding hopper should have adequate capacity to handle volume and weight

of waste sterilized from the autoclave. Volume and weight of each bag depends upon the nature and composition of waste.

b) The hopper should be easily accessible for ergonomic loading. c) Chamber shall be able to accommodate two hexagonal counter rotating shafts

mounted with knives. The number of teeth, its profile and configuration shall be designed to suit the material to be shredded as specified (type and quantity of waste). The shred size should be up to 5 mm approx (depending on the type of material).

d) Reverse rotation should take place on overloading/ the material getting stuck for any reason

e) The tenderer shall declare the material of shaft/ knife/tooth; the number of knives /spacer/ contour cleaning fingers and spacing of knives, maximum tooth cutting force.

f) The hopper and chamber shall be made from stainless steel of non corrosive quality (composition 040 Cri8Ni10 or equivalent)

g) The framework and stand should be of adequate thickness to take care of the shredder load and vibration

h) Tenderer shall declare type of electric motor, HP speed for the drive system. i) The shredder should be so designed as to avoid spillage and dust generation.

Should require minimum manual handling. j) In case of shock loading there should be a mechanism to automatically stop the

shredder to avoid any accident. k) The minimum capacity of the motor to be attached to the shredder should be 3

kW for 50 kg/hr, 5 kW for 100 kg/hr & 7.5 k W for 200 kg/hr. This would ensure effective cutting of the medical waste.

Control and safety

a) Control panel shall be provided with function buttons , keyed power switch, timer, reversal on overload, safety switch


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b) Chamber shall not open during operation c) Minimum vibration and noise (<90 decibels)

d) Must be covered and have maximum safety provisions to protect operator

against dust and aerosols. Power supply and environmental conditions V: 440V, 3 phase supply F: 50 Hz+3% Temp: -100C to 300 C Installation Commissioning and Inspection Tenderer shall be responsible for installation, commissioning and satisfactory trial of the equipment at the consignees place Note

a) Tenderer shall provide details of the infrastructure requirements such as space, electrical connections etc and coordinate with the hospital regarding the same (Turnkey arrangements can also be considered)


c) Tenderer should provide a trained operator for 3 months (one year?) and provide training to two hospital staff to operate the machine.

d) Guarantee period should be for a period of two years and firm should also submit an annual maintenance contract for 5 years after the expiry of the guarantee period year wise

8.1.3 SPECIFICATIONS OF HYDROCLAVE

Description: STEAM STERILIZER WITH INBUILT WASTE FRAGMENTER

Capacity: Should be able to handle approximately 35 kg of medical waste per hour. The equipment should be able to handle the entire load of 110 kg in 3 cycles of one hour each. Type of Medical waste to be sterilised: Infectious waste including: waste sharps, syringes, needles, scalpels, ampoules, broken glass, infected plastic, disposable catheters, soiled waste including swabs, dressings, gloves, infected glassware

Design Specifications

a) Steam jacketed Double walled cylindrical vessel horizontally mounted. Built to

ASME standards

b) The sterilizer shall be of robust design with adequate thickness of sheets and reinforcement so as to withstand the hydrostatic test without sign of leakage sweating or deformation.


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c) The equipment shall be designed with low chamber/ floor height for easy loading and unloading

d) The vessel should have a top or side loading door and another smaller unloading

door at the bottom.

e) The vessel should be fitted with a motor driven shaft to which are attached

powerful fragmenting arms that slowly rotate within the vessel

f) Should sterilize the waste by high temperature and pressure steam.

g) Should be able to fragment and dehydrate the waste

h) It should reduce the volume and weight by 70%

i) After treatment the equipment should allow self unloading through the unloading

door.

j) The waste load should attain 1210C temperature and 15 Psi which should be

maintained for at least 30 minutes.

k) Valves should be provided for operation, safety, steam inlet, drainage.

l) The door gasket material should be durable enough to withstand working pressure and temperature.

m) The chamber should be properly insulated to minimize heat loss and to restrict

the surface temperature within reasonable limits not to cause burn due to

accidental touch

n) Negligible air emissions within exposure limits laid down by USEPA.

Accessories: (as part of the equipment)

a) Steam generator with demineralizer plant and having capacity adequate for requirements of the sterilizer and provided with necessary connections for efficient functioning.

b) Air compressor c) Other accessories required to operate the equipment for satisfactory

performance like bags, containers etc. Control and Monitoring System Microprocessor based computer system and printer shall be provided for controlling and monitoring the sterilizing cycle with the following features:

a) microprocessor unit with different programme combinations b) The operation of the sterilizer should be fully automatic c) Self diagnostic system able to give fault messages to the operator d) Manual operation facility for stand by programming in case of control failure e) Printer shall record data, time, day, load identification number as well as

operating parameters such as temperature of steam in the chamber, steam pressure, time and temperature of steam condensate after cooling throughout the


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entire length of the autoclave cycle. It will also record cycle progress and error messages.

Validation tests The equipment shall be able to successfully pass the following validation tests:

c) Hydrostatic test: The sterilization chamber shall be able to withstand 1.5 times the working pressure and sterilization jacket twice the working pressure for 20 minutes.

d) Biological test: The autoclave should be able to completely and consistently kill the approved biological indicator 1X106 B stearothermophilus spores at the maximum design capacity.

e) After the sterilization period, the vented steam from the internal vessel should pass though a condenser, the water effluent so produced should be sterile and be able to be disposed into a sanitary sewer.

Installation Commissioning and Inspection The manufacturer/ supplier shall arrange for installation, commissioning and satisfactory trial for one month at the consignee’s premises. Power supply and environment:

d) Voltage : 440V 3 phase supply e) Frequency 50+3% Hz f) Environment: Temperature -100 C to 300C

Note

a) Tenderer shall provide details of the infrastructure requirements such as space, electrical, water connections etc and coordinate with the hospital regarding the same.(Turnkey arrangements can also be considered)


c) Tenderer should provide a trained operator for 3 months (one year) and provide training to two hospital staff to operate the machine.

d) Guarantee period should be for a period of two years and firm should also submit an annual maintenance contract for 5 years after the expiry of the guarantee period year wise.


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8.2 ACCESSORIES

8.2.1 HEAT RESISTANT PROTECTIVE GLOVES (for operators of autoclave) (a) The Gloves should be up to the elbow (b) The material of the gloves should be either: o Zetex aluminoborosilicate. o Kelver aramid fibre.

8.2.2 CONTAINERS FOR BIOMEDICAL WASTE A. For non-sharp infectious waste for autoclaving Colour code: red

(a)Inner: red bags made from polyethylene/Polypropylene • Have a minimum of 225 gauge (55 micron) if of low density, and 100 gauge (25

micron) if of high-density material. • Red bags must be “BMW for autoclave only” for all BMW destined for autoclaving

and with Biohazard symbol and name of the hospital i.e. JDWNRH. • The polypropylene bags (Autoclave bags) should be made of material specifically

design for this purpose and should be heat resistant up to 1350C and should carry an indicator (e.g. heat sensitive tape) to show whether autoclaving has occurred.

(b) Outer container: Red plastic bin or metal with handles and foot operated lid • Various sizes: suggested are three sizes- one large for transportation e.g. 50l

capacity and two smaller sizes according to amount of waste generated • The inner plastic bag should fit into the container with 1/4th of the plastic bag

turned over the rim B. Sharps containers (a) Reusable containers for storage and transportation of sharps to the sharps pit. Colour code: yellow. Specifications: • Sharp container (British Standard, or UN standard approved, certification letter to

be enclosed if any) • Material should be puncture proof , made of polypropylene/polyethylene; should

be able to close securely , with pocket handle. • Clearly marked with biohazard label and words “sharps only”. (b)Disposable containers for storage and transportation for autoclaving and shredding. Colour code: yellow Specifications: • Cardboard or fibreboard with plasticised lining • Should have handles • Should be leak proof and puncture proof • Should be capable of being securely closed • Made of material that is cheap as it cannot be reused. • Clearly marked with biohazard label and words “sharps only”


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8.3. SPECIFICATIONS FOR NEEDLE AND SYRINGE DESTROYERS

These are instruments that destroy the disposable needle as well as the syringe. The aim is to prevent hazard to the health care worker and also to prevent the reuse of the needle and syringe.. These can be electrically or manually operated. It is preferable to wear a mask and eye protection while using these instruments to protect from aerosols.

Specifications

Electrical:

• Should destroy the needle using low voltage electrical current reaching temperatures of 1600-1700 C.

• It should turn the needle into ash.

• The process should be rapid and taking 1-2 seconds.

• There should be no visible arcing or sparking.

• Users should be specified for certain processes like regular cleaning of the electrodes, which increases the life of the equipment.

• After incineration, the needle debris should be contained in a built in receptacle/ container which may be disposable or reusable.

• Should have a cutter to cut the nozzle of the syringe with minimal agitation.

Mechanical:

• Should destroy or deform the needle and syringe by mechanical means.

• The cutting blades should be of the best quality.

• The equipment should be completely shock proof


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8.4. SPECIFICATIONS FOR DEEP PITS 8.4.1 CLAY LINED PIT FOR SHARPS

8.4.2


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8.4.3 CONCRETE LINED PIT FOR SHARPS


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8.4.3. CONCRETE SEPTIC VAULT FOR DISPOSAL OF WASTE

Source: “Disposal of mass immunization waste without incineration”: Health Care Without Harm and Dept of Health NCDPC Philippines.


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8.4.4 DEEP BURIAL PIT

Deep burial is the recommended disposal option for human anatomical waste (including human tissues, placenta, organs body parts) and animal waste (animal tissues, organs, body parts, carcasses, experimental animals, wastes from animal houses.

Specifications for Deep Burial (Source: Standards for deep burial: Biomedical Waste Management and Handling Rules 1998, India)

a) A pit or trench should be dug about 2 metres deep. It should be half filled with waste then covered with lime within 50 cm of the surface, before filling the rest of the pit with soil

b) It must be ensured that animals do not have any access to burial sites. Covers of galvanized iron / wire meshes may be used.

c) On each occasion, when wastes are added to the pit, a layer of 10 cm of soil shall be added to cover the wastes.

d) Burial must be performed under close and dedicated supervision

e) The deep burial site must be relatively impermeable and no water source must be close to the site

f) The pits should be distant from habitation, and sited to ensure that no contamination occurs of any surface or ground water. The area should not be prone to flooding or erosion.


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g) The location of the deep burial site should be authorized by the prescribed authority

h) The health care facility should maintain a record of all pits for deep burial.

8. 5 OPTIONS FOR DISPOSAL OF SHARPS BASED ON AMOUNT OF WASTE, LOCATION AND RESOURCES

Source: “Disposal of mass immunization waste without incineration”: Health Care Without Harm and Dept of Health NCDPC Philippines

Note: The small scale options for sharps (II, or IV) outlined above can be applied at district level as well as BHU level


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8.6 STANDARDS FOR LANDFILL

(Source: Environmental Codes for Practice for Hazardous Waste Management)

The country has low population density of 45.5 persons per sq km with abundance of forest area. Hence, landfills are preferred mode of option for treatment and disposal of many categories of wastes. Standards of design of solid waste landfills are provided in the ECOP (Environmental Codes of Practice) for solid waste management entitled “Design and Development of the Landfill Site” and also in the ECOP for hazardous waste management, published by NEC, Bhutan, which advises following standards for the liner system and leachate management system in the landfills.

Liner System

• Each landfill shall have a liner to prevent any contamination of ground water, surface water and subsurface soil during the active life of the facility (including closing and decommissioning).

• Liner should be constructed of a material, which has appropriate chemical resistance, sufficient strength and thickness to prevent failure due to physical contact with waste material or leachate, pressure gradient, climatic conditions, and stress of installation and daily operation.

• Liner should be placed on a substrate that will provide adequate support.

• Leak detection, leachate/ leak collection and removal system should be designed and constructed as an integral part of the liner system.

Leachate Management System

A leachate collection and removal system should be constructed, maintained and operated to collect all leachate generated by the landfill. The system should have following features.

• It should be constructed of materials that are chemically resistant and of sufficient strength and thickness to prevent collapse by the weight of waste material and the equipment used at the landfill.

• It should be designed and operated to function without clogging throughout the life of landfill.

• Toxic constituents of leachate should be removed before discharge. The drain design for leachate flow should be accessible for cleaning and inspection.

Comment: Leachate has to be treated before it is disposed. The quality of treated leachate has to be as per standards which need to be defined under the Water Act


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Regular Monitoring and Inspection

At the time of construction and installation of liners and cover systems, proper care should be taken to check the uniformity and integrity of all systems. Once the landfill is operational, a person should be designated to monitor the facility and ensure:

• Leachate collection and treatment systems are functioning correctly • Run-on and run-off control are maintained • Drainage systems are maintained • Cover material is properly deployed • Security , fencing and signposting of the facility is maintained • Scavenger populations are controlled • Proper records are maintained regarding the location, dimensions, and

contents of each cell and • Content of the leachate collected.

Closure and Post-closure Care The operator has a responsibility to design, develop and maintain final cover of a landfill upon closure of the facility. Final decommissioning plan should be approved by NECS and take the following into consideration:

• Minimise infiltration by precipitation • Minimise wind dispersion of hazardous wastes and • Minimise direct contact by humans and animals with hazardous wastes.

Proper drainage systems should be built to minimize erosion, avoid build up of gas

pressure and accommodate settling and subsidence so that cover integrity is

maintained. Natural vegetation, like grasses and weeds should be grown to prevent wind

and surface erosion.


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ANNEX 8.7: Standards and Treatment of Waste Water from Health Care Facilities

Wastewater from health-care establishments is of a similar quality to urban wastewater, but may also contain various potentially hazardous components, discussed in the following paragraphs. Microbiological pathogens The principal area of concern is wastewater with a high content of enteric pathogens, including bacteria, viruses, and helminths, which are easily transmitted through water. Contaminated wastewater is produced by wards treating patients with enteric diseases and is a particular problem during outbreaks of diarrhoeal disease. Hazardous chemicals Small amounts of chemicals from cleaning and disinfection operations are regularly discharged into sewers. If the recommendations of section 9.4 are not followed, larger quantities of chemicals may be present in wastewater. Pharmaceuticals Small quantities of pharmaceuticals are usually discharged to the sewers from hospital pharmacies and from the various wards. If the recommendations of section 9.2 are not followed, more important quantities of pharmaceuticals—including antibiotics and genotoxic drugs—may also be discharged. Radioactive isotopes Small amounts of radioactive isotopes will be discharged into sewers by oncology departments but should not pose any risk to health if the proper recommendations are followed. Related hazards In some developing and industrializing countries, outbreaks of cholera are periodically reported. Sewers of the health-care establishments where cholera patients are treated are not always connected to efficient sewage treatment plants, and sometimes municipal sewer networks may not even exist. Although links between the spread of cholera and unsafe wastewater disposal have not been sufficiently studied or documented, they have been strongly suspected, for instance during recent African outbreaks (Democratic Republic of the Congo, Rwanda), and during the 1991–92 cholera epidemic in southern America, the Asian SARS epidemics in 2003/4. Little information is available on the transmission of other diseases through the sewage of health-care establishments. . The toxic effects of any chemical pollutants contained in wastewater on the active

bacteria of the sewage purification process may give rise to additional hazards. Wastewater management Connection to a municipal sewage treatment plant In countries that do not experience epidemics of enteric disease and that are not endemic for intestinal helminthiasis, it is acceptable to discharge the sewage of health-care establishments to municipal sewers without pretreatment, provided that the following requirements are met: Ø • the municipal sewers are connected to efficiently operated sewage treatment

plants that ensure at least 95% removal of bacteria;


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Ø • the sludge resulting from sewage treatment is subjected to anaerobic digestion, leaving no more than one helminth egg per litre in the digested sludge;

Ø • the waste management system of the health-care establishment maintains high standards, ensuring the absence of significant quantities of toxic chemicals, pharmaceuticals, radionuclides, cytotoxic drugs, and antibiotics in the discharged sewage;

Ø • excreta from patients being treated with cytotoxic drugs may be collected separately and adequately treated (as for other cytotoxic waste).

If these requirements cannot be met, the wastewater should be managed and treated as recommended in section below. In normal circumstances, the usual secondary bacteriological treatment of sewage, properly applied, complemented by anaerob ic digestion of sludge, can be considered as sufficient. During outbreaks of enteric disease, however, or during critical periods (usually in summertime because of warm weather, and in autumn because of reduced river water flow), effluent disinfection by chlorine dioxide (ClO2) or by any other efficient process is recommended. If the final effluent is discharged into coastal waters close to shellfish habitats, disinfection of the effluent will be required throughout the year. When the final effluents or the sludges from sewage treatment plants are reused for agricultural or aquacultural purposes, the safety recommendations of the relevant WHO guidelines should be respected. On-site treatment or pretreatment of wastewater Many hospitals, in particular those that are not connected to any municipal treatment plant, have their own sewage treatment plants. Efficient on-site treatment of hospital sewage should include the following operations: Ø • Primary treatment Ø • Secondary biological purification. Most helminths will settle in the sludge

resulting from secondary purification, together with 90–95% of bacteria and a significant percentage of viruses; the secondary effluent will thus be almost free of helminths, but will still include infective concentrations of bacteria and viruses.

Ø • Tertiary treatment. The secondary effluent will probably contain at least 20 mg/litre suspended organic matter, which is too high for efficient chlorine disinfection. It should therefore be subjected to a tertiary treatment, such as lagooning; if no space is available for creating a lagoon, rapid sand filtration may be substituted to produce a tertiary effluent with a much reduced content of suspended organic matter (<10mg/litre).

Ø • Chlorine disinfection. To achieve pathogen concentrations comparable to those found in natural waters, the tertiary effluent will be subjected to chlorine disinfection to the breakpoint. This may be done with chlorine dioxide (which is the most efficient), sodium hypochlorite, or chlorine gas. Another option is ultraviolet light disinfection.

Disinfection of the effluents is particularly important if they are discharged into coastal waters close to shellfish habitats, especially if local people are in the habit of eating raw shellfish.


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Sludge treatment The sludge from the sewage treatment plant requires anaerobic digestion to ensure thermal elimination of most pathogens. Alternatively, it may be dried in natural drying beds and then incinerated together with solid infectious health-care waste. On-site treatment of hospital sewage will produce a sludge that contains high concentrations of helminths and other pathogens. Reuse of wastewater and sludges in agriculture and aquaculture According to the relevant WHO guidelines (Mara & Cairncross, 1989), the treated wastewater should contain no more than one helminth egg per litre and no more than 1000 faecal coliforms per 100 ml if it is to be used for unrestricted irrigation. It is essential that the treated sludge contains no more than one helminth egg per kilogram and no more than 1000 faecal coliforms per 100 g. The sludge should be applied to fields in trenches and then covered with soil. Options for establishments that apply minimal waste management programmes Ø Lagooning

In a region or an individual health-care establishment that cannot afford sewage treatment plants, a lagooning system is the minimal requirement for treatment of wastewater. The system should comprise two successive lagoons to achieve an acceptable level of purification of hospital sewage. Lagooning may be followed by infiltration of the effluent into the land, benefiting from the filtering capacity of the soil. There is no safe solution for the disposal of sewage from a hospital that cannot afford a compact sewage treatment plant and that has no space available to build a lagooning system. Ø Minimal safety requirements

For health-care establishments that apply minimal programmes and are unable to afford any sewage treatment, the following measures should be implemented to minimize health risks:

1. Patients with enteric diseases should be isolated in wards where their excreta can be collected in buckets for chemical disinfection; this is of utmost importance in case of cholera outbreaks, for example, and strong disinfectants will be needed

2. No chemicals or pharmaceuticals should be discharged into the sewer. 3. Sludges from hospital cesspools should be dehydrated on natural drying

eds and disinfected chemically (e.g. with sodium hypochlorite, chlorine gas, or preferably chlorine dioxide).

4. Sewage from health-care establishments should never be used for agricultural or aquacultural purposes.

5. Hospital sewage should not be discharged into natural water bodies that are used to irrigate fruit or vegetable crops, to produce drinking water, or for recreational purposes.

6. Small-scale rural health-care establishments that apply minimal waste management programmes may discharge their wastewater to the environment. An acceptable solution would be natural filtration of the sewage through porous soils, but this must take place outside the catchment area of aquifers used to produce drinking-water or to supply water to the health-care establishment.

Sanitation


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In many health-care establishments in developing countries, patients have no access to sanitation facilities. Excreta are usually disposed of in the environment, creating a high direct or indirect risk of infection to other people. Human excreta are the principal vehicle for the transmission and spread of a wide range of communicable diseases, and excreta from hospital patients may be expected to contain far higher concentrations of pathogens, and therefore to be far more infectious, than excreta from households. This underlines the prime importance of providing access to adequate sanitation in every health-care establishment, and of handling this issue with special care. The faecal–oral transmission route and other routes such as penetration of the skin—must be interrupted to prevent continuous infection and re-infection of the population. The health-care establishment should ideally be connected to a sewerage system. Where there are no sewerage systems, technically sound on-site sanitation should be provided. Guidance on this is available in a number of publications (Franceys, Pickford & Reed, 1992; WHO, 1996; Mara, 1996) which cover both simple techniques, such as the simple pit latrine, ventilated pit latrine, and pour-flush latrine, and the more advanced septic tank with soakaway or the aqua-privy. In temporary field hospitals during outbreaks of communicable diseases, other options such as chemical toilets may also be considered (Dunsmore, 1986). In addition, convenient washing facilities (with warm water and soap available) should be available for patients, personnel, and visitors in order to limit the spread of infectious diseases within the health-care establishment. The waste water generated from the hospital not connected to sewers should conform to the limits given below. In case the permissible limits are exceeded, the water should be treated by waste water (effluent) treatment plants the outline is given below: Standards of waste water Parameters Permissible limit Ph 6.5-9.0 Suspended soil 100 mg/l Oil 10 mg/l BOD 30 mg/l COD 50 mg/l Bio-assay tests 90% survival of fish after 96 hrs in 100% effluent.


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ANNEX 9: Check list for needs assessment of health care facility for HCWM 1. Hospital Details

• Total Number of Beds: • Specialities and bed distribution • Patient turnover per year • Facilities provided

2. Types and quantities of Infectious Waste generated:

Categories Quantity • Human Anatomical • Animal • Microbiology/Biotechnology • Waste Sharps • Dressings Plastic Disposables • Discarded Medicines • Liquid Wastes • Incineration ash • Chemical waste

3. Technologies available/in place for the management of waste:

• Incinerator: Make/ capacity/ satisfactory working / cycles per day • Burning in a pit • Burial • Landfill Secure/Sanitary Describe • Syringe Cutter and needle destroyer: make/where placed/satisfactory working • Chemical Disinfectants used: Name / Quantity / application

4. Infrastructure:

• Colour coding practices • Material of colour coded bags • Cost and Availability of coloured bags • Transportation method • Storage • Labelling and Recording

5. Manpower • Qualification • Personal Protective Gears available/used

6. Training received: By whom/ who were the trainers/ frequency, content/ modules

available or not


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ANNEX 10: Guidelines for implementers of IC and HWM Plan

10.1 Definitions, Epidemiology and Types of Hospital Associated Infections 10.2 Surveillance of Hospital Associated Infections. 10.3 Survey of Hospital Waste. 10.4 Employee Health programme 10.5 Investigation of Outbreak of Hospital Associated Infections. 10.6 Role of Microbiology Lab. in Detection, Investigation and Control of HAI. 10.7 Monitoring of Sterilization 10.8 Monitoring and Evaluation of Infection Control


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ANNEX 10.1: Definitions, Epidemiology and Types of Hospital Associated

Infection

Definition

Hospital associated Infections or nosocomial infections are those infections that were neither present nor incubating at the time the patient was admitted to the health care facility. The majority of nosocomial infections become evident 48 hours or more following admission • Classification of infection as nosocomial is based on a combination of clinical as well

as laboratory data. • The presence of organisms on a body site but not causing signs or symptoms of

infection is known as colonisation and is not infection • Inflammation resulting as response to injury or reaction to a non infectious agent is

not considered as infection • Infection acquired in the hospital but not evident until after discharge is also

considered as nosocomial • Infection in hospital born new born infant may also be considered as nosocomial

EPIDEMIOLOGY OF HOSPITAL ASSOCIATED INFECTIONS

The successful invasion, establishment and multiplication of microorganisms in the living tissue of a host and producing signs and symptoms of disease are dependant on the following factors: The Agent: Infective agents include bacteria, viruses fungi, protozoa, helminths and prions The ability of a micro-organism to cause infection depends upon its invasiveness, pathogenicity, virulence, infectious dose, whether it can survive in the environment, and its resistance to anti-microbial agents The Reservoir: A reservoir is the source of the infectious agent where it lives and multiplies. These can be humans, animals or the environment. • Human reservoirs can be symptomatic (exhibiting signs and symptoms of the

disease) or asymptomatic (without signs and symptoms) or they can be carriers (presence of organisms for varying periods without signs or symptoms).

• Asymptomatic cases and carriers are more likely to transmit the disease as precautions may not be taken since it is not known that the person is harbouring the organisms. This is why standard precautions are necessary which are based on the concept that precautions are taken in all cases regardless of the diagnosis.


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Portal of Exit: The portals of exit are necessary for the organism to exit the body and be transmitted to another person. The portal of exit can be the excretions/secretions of respiratory tract, gastrointestinal tract, genital tract, blood or any body fluid.

Modes of transmission

This is the way an agent is transmitted from reservoir to a susceptible host. The mode of transmission can be by: • Contact direct contact through hands or indirectly through an inanimate object. • Large sized droplets by sneezing, coughing or even talking. • Airborne route through very small particles which can travel from room to room via

air currents. • Common vehicle where a contaminated vehicle serves as the means of spread of

the infection to several persons such as food in a salmonella epidemic or blood in a blood borne epidemic (hepatitis B)

Portal of entry

Similar to portal of exit, it is the site of entry of the organism into the body such as the mucous membrane of the respiratory, genital, gastrointestinal, urinary tract, conjuctiva and skin . Susceptible Host A person susceptible to the infection or lacking in resistance to the infective organism. Host factors that influence susceptibility to infection are: • Age: extremes of age. Neonates are susceptible to a variety of organisms as they

have little resistance. In the same way, old people are also more susceptible to infection.

• Socio-economic status: nutritional status is also dependant upon this • Underlying disease such as cancer, diabetes. • Immunisation status • Medications: immunosuppressive agents , chemotherapeutic agents • Pregnancy • Interventions such as surgery, intubation, urinary catheterisation, vascular

catheterisation etc. Host factors on the part of the host that prevent the entry and establishment of infective agents are: • Non specific defences: • Endogenous flora, organisms residing at the various body sites such as skin,

respiratory tract, genital tract, gastrointestinal tract. • Natural antibodies • Natural barriers: intact skin, mucous membranes, facial planes, cilia and cough reflex

protecting against respiratory infections, mechanical flushing of eyes with tears, gastric acid secretion.


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Colonization and infection

• Colonization: means presence of organisms in the body without causing any cellular damage or any response on the part of the host. Infection occurs when the organism causes cellular damage and also a host response

• Colonization with one organism may prevent the establishment of another more virulent organism at that body site.

• Colonizing organisms can be a part of normal flora for that body site but cause infection at another body site. Example: E. coli is a normal flora of the intestinal tract but it can cause infection in the urinary tract.

• Removal of the normal flora can cause abnormal organisms to colonize the body site Example: antibiotics will kill the organisms such as drug sensitive E. coli and allow drug resistant organisms to colonize.

• Colonization can precede infection if the host defences are altered or impaired in some way which can happen if the patient is on immunosuppressive drugs, has undergone surgery or any intervention such as catheterization, intubation etc.

TYPES OF HOSPITAL ASSOCIATED INFECTIONS The common types of Hospital Associated Infections are • Blood Stream Infection • Urinary Tract Infection • Nosocomial pneumonia • Post operative wound infection • Gastrointestinal infection BLOOD STREAM INFECTIONS (BACTERAEMIA/SEPTICAEMIA)

Definition • Recognized pathogen isolated from blood culture and pathogen not related to

infection at another site. • Fever >38C, chills ,or hypotension and one of the following • Common skin contaminant (coagulase negative staphylococci, diphtheroids )

isolated from 2 blood cultures drawn on separate occasions • Common skin contaminant isolated from patient with intravascular access

device • Positive antigen test on blood for N meningitidis, pneumococci, H influenzae,

group B streptococci.

Common causes of blood stream infections: S epidermidis, S aureus, Klebsiella spp, Salmonella, Serratia, Candida spp. Pseudomonas spp,corynebacteria, Enterobacter spp, Acinetobacter spp. Diagnosis: Blood culture, Semi-quantitative culture of the catheter tip, catheter lumen.

GASTROINTESTINAL INFECTIONS Definition:


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• A change in the persons bowel habits with at least two consecutive days of at least three loose or watery stools with onset more than 48 hours after admission to the hospital

• Infectious diarrhoea is confirmed when a bacterial or viral aetiology is demonstrated.

Diarrhoea may occur due to non infectious causes such as medications, antibiotics etc. In many cases the cause of diarrhoea cannot be diagnosed.

• Infections related to the gastrointestinal tract also include intra abdominal abscesses

which can occur due to leakage of gastro intestinal contents into the peritoneum Infectious diarrhoea: Mode of transmission Organisms are transmitted via the faecal-oral route. Infection may be acquired from contaminated food or water, from infected patients or staff from contact with environment contaminated with organisms or from instruments entering the alimentary tract such as endoscopes. Index case or asymptomatic carrier introduces the infection in the ward which then leads to person to person spread. Nosocomial diarrhoeas often present as outbreaks. Some documented sources of salmonella outbreaks arte given in the table. Causes of infectious diarrhoea: Salmonella spp, Shigella spp, Campylobacter sp, Clostridium difficile, E coli, aeromonas and plesiomonas, Vibrio spp, Cryptosporidium, Giardia lamblia, Entamoeba histolytica Rotavirus, Norwalk and similar viruses, Adenoviruses, hepatitis A, enteroviruses. Risk factors: Extremes of age, achlorhydia, antibiotic therapy oral or systemic, decrease in normal flora, overgrowth of resistant or sensitive pathogens, gastrointestinal procedures such as nasogastric tubes, endoscopy, Factors conducive to person to person spread such as overcrowding of unit, understaffing, lack of adequate hand washing facilities.

NOSOCOMIAL PNEUMONIAS

Definition

Nosocomial pneumonia is one of the most serious of nosocomial infections. It is defined as a lower respiratory tract infection that appears during or after hospitalisation of the patient who was not incubating the infection on admission. The diagnostic criteria are: • Fever, cough, development of purulent sputum, • Radiological changes showing progressive infiltration, • Sputum Gram stain showing many WBC’s and bacteria, • Positive culture Specimen for culture: sputum, preferably transtracheal aspirate or protected brush specimen


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Mode of transmission Nosocomial pneumonia is acquired by: • respiratory droplets through inhalation of aerosols, • from oropharynx through the hands of staff while performing suction procedures • aspiration of colonised oropharyngial and gastric secretions. This is particularly

important in patients with low gastric pH. Microbial Causes of Nosocomial pneumonia Ø Gram negative bacilli: Klebsiella pneumoniae, E coli, .P aeruginosa, S

marcescens, Enterobacter spp, Acinetobacter spp, L. pneumophila Ø S. aureus Ø Haemophilus influenzae, S. pneumoniae (in post operative patients with existing

pulmonary disease) Ø Respiratory viruses Ø Fungi such as C albicans and A fumigatus Ø Pneumocystis carinii (in HIV positive patients)

Risk factors: Ø Extremes of age Ø Surgical operation Ø Severe illness Ø Major injuries Ø Coronary bypass surgery Ø Existing pulmonary disease Ø Coma Ø Heavy smoker Ø Sedation, general anaesthesia Ø Tracheal intubations, tracheostomy, artificial ventilation, enteral feeding Ø Antibiotic therapy antacids immunosuppressive and cytotoxic drugs.

URINARY TRACT INFECTIONS

Definition

Clinical symptoms of fever, suprapubic tenderness frequency dysuria accompanied by the presence of bacteria in the urine in significant quantity. For non catheterised patient 105 organisms per ml are significant whereas in catheterised patients 103 per ml are significant. Nosocomial Urinary tract infections are nearly always associated with an indwelling catheter or instrumentation of the urinary tract The presence of an indwelling catheter in the urinary tract may give rise to bacteruria or mild infection or may even result in severe infections such as pyelonephritis, septicaemia. The source of organisms can be endogenous by the patients own flora or exogenous through the hands of staff or contaminated instrument Specimen for culture: • Urine should be removed aseptically from catheter for culture. • For non catheterised patients, clean voided specimen is acceptable.


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• Catheter tips and specimen from urine bag should not be cultured. Organisms responsible for nosocomial UTI • Esch coli, Klebsiella sps, Proteus sps, enterococci • Pseudomonas auruginosa , Serratia marcescens • Candida sps • Staph aureus, coagulase negative staphylococci Risk factors: • Indwelling urinary catheter • Instrumentation of the urinary tract • Advanced age • Female gender • Severe underlying illness POST OPERATIVE (SURGICAL) WOUND INFECTIONS Definition Infection in the surgical wound that occurs within 30 days of the surgical procedure Can be superficial or deep: Superficial

• Drainage of pus from the superficial incision • Pain, tenderness, localised swelling, redness or heat. • Positive culture from aseptically collected specimen

Deep

• Infection appears within 30 days of the procedure or within one year if there is an implant or foreign body such as prosthetic heart valve, joint prosthesis

• Pus discharge from the deep incision • Spontaneous dehiscence or “gaping” of wound • Fever >38 C , localised pain or tenderness • Positive culture from aseptically collected specimen.

Specimens for culture: wound swabs, drainage fluid, exudates Organisms causing Surgical wound Infections: Staphylococcus aureus, coagulase negative staphylococci, Esch. coli, Enterobacter sps, Klebsiella sps, Pseudomonas sps, Anaerobic bacteria such as Bacteroides sps.


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Risk factors • Host • Extremes of age • Concurrent disease malnutrition • Underlying clinical condition • Skin infections

Surgical procedure

• Surgical category : clean, clean contaminated or dirty • Implant or prosthesis • Poor surgical technique • Excessive use of diathermy • Duration of surgical procedure • Haemorrhage, necrosis, haematoma • Presence of drains

Pre operative preparation • Inadequate skin preparation • Shaving the day before surgery • Inappropriate antibiotic prophylaxis Operation theatre design, discipline, staff

• Increased traffic and movement of staff • Inappropriate theatre clothing • Inadequate theatre ventilation • Inadequate sterilisation and disinfection • Open containers of sterile solutions. • Inadequate cleaning and “breathing time”


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ANNEX: 10.2: GUIDELINES FOR SURVEILLANCE OF HOSPITAL ASSOCIATED INFECTIONS

Objectives of Surveillance: • To detect cases of hospital associated infection (HAI) and provide baseline data on

HAI • Observe practices and procedures related to infection control • Identify the spread of infection and sources of infection • Detect any unusual changes and trends in the level of infection • Implement control measures • Monitor antibiotic use and resistance Monitor use of disinfectants The detection of cases of HAI and their recording is an important component of surveillance of hospital infection and gives the base line information about the types and level of endemic infections in the hospital.

Case definition In order to identify a case of HAI it is necessary to lay down criteria for definition (see details in types of HAI section XX) of the various types on HAI such as wound infection, pneumonia, blood stream infection, urinary tract infection etc. Methods of surveillance:

Detection of HAI Identification of the case can begin in the wards or laboratory, that is, either: • Detection of cases by regular visits to the ward to obtain information on infection

from the staff and case sheets daily, with follow up in the laboratory, or: • Daily review of laboratory reports to detect the cases of HAI with follow up in the

ward The cases are identified as per the case definition which will include both clinical as well as microbiological criteria

Data collection The following data are collected for each suspected case of HAI Patient details: Name, age, gender, registration number, unit/ward, date of admission, date of discharge, underlying disease. Procedure details: Type of procedure, duration of procedure such as surgical operation, location of procedure (where it was performed) e.g. emergency, OPD, ward, operation theatre) Staff doing the procedure, type of device used, prophylaxis if any Treatment details:


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Type of treatment (e.g. antibiotics, cytotoxic drugs, enteral nutrition, blood transfusion etc), date and duration of treatment.

Details of infection:

Site of infection, date of onset, specimens processed with date, pathogens isolated, antibiograms, antibiotics given, outcome. Infection Rates Two kinds of rates are calculated to give the baseline status of HAI in the hospital: Incidence rate It involves the identification of every case of HAI in the unit over a time period e.g. a year. • Define the clinical as well as microbiological criteria for each type of infection : UTI,

respiratory tract, septicaemia, wound infection etc • Identify and enumerate all cases during a particular time period , these will form the

numerator • The denominator is the total number of discharges or patient days. Calculated per

100 discharges or patient days. It is very labour intensive and not practical to carry out through out the hospital. It should be carried out in high risk units such as ICU, NICU, Burns units.

Incidence density This is calculated in relation to a particular procedure or group of patients For example to calculate the incidence density of catheter related urinary tract infection , the number of patients with urinary catheter that develop infection forms the numerator and denominator is the total number of catheterization days for all patients during the specified time period. It is a useful means of comparing data between hospitals and different groups of patients. Prevalence rate: This is more practical than incidence rate and gives the prevalence of HAI in the hospital at a particular point in time • All cases of HAI throughout the hospital are identified on the particular day. This

forms the numerator. • The number of patients present in the hospital on that particular day forms the

denominator.


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ANNEX 10.3: GUIDELINES FOR SURVEY OF HOSPITAL WASTE A waste survey performs a qualitative and quantitative estimate of the waste generated in a hospital. The information is essential to determine

• The consumption patterns of consumables like bags, containers ties, disinfectant, protective equipment

• Capacity of waste treatment methodologies, e.g. capacity of autoclave, disposal pits, sharps containers, size of containers

• It estimates the cost required to manage waste, both one time expenditure and recurring expenses.

It helps in identifying the material that can be recycled e.g. plastics, paper etc Before conducting a survey do the following:

• Make an inventory of the type and quantity of material particularly disposables that come into the facility, this will give a fair idea about the type and quantities of waste that will be generated.

• It is easier to conduct a waste survey if segregation of waste is established, hence establish segregation as far as possible.

• Should be conducted in all waste generating locations like wards, OT’s, ICU’s etc.

• The procedure is hazardous hence all precautions should be taken to protect the person conducting the survey

If segregation is not properly established, the waste survey is done in the following way: Equipment required:

• Protective clothing including elbow length gloves, mask, apron, boots and gloves. • Tongs, long handled forceps for handling the waste • Large plastic sheets • Appropriately coloured bags fixed in containers to collect the waste. • Weighing machine

Method:

• Empty Waste bags or containers onto the plastic sheet • Visualise the waste and with a pair of tongs pick up the different types of waste

and place it in the appropriate container • Weigh the different containers as per segregation code and note the quantity. • Divide the weight of each type of waste by the number of beds and the average

waste generated per bed is obtained. After segregation at the point of generation is established, the waste containers with their segregated categories of waste can be weighed without having to empty the contents. This is appropriately done at the storage facility and recorded.


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Waste Survey Sheet

Date of beginning the survey Person doing the survey Name of the Waste Management officer Segregation policy: Colour coding: Treatment and Disposal Methods: Sno Date Generating

source Type of waste

No of bags Weight

More detailed information on assessing health care waste using the WHO Health care waste management: rapid assessment tool for country level”, available online at: http://www.who.int/water_sanitation_health/medicalwaste/ratupd05.xls


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ANNEX 10.6: Role of Microbiology laboratory in the detection, investigation and control of HAI The microbiology laboratory has an important role in the control of HAI. The Clinical Microbiologist is an important member of the Hospital Infection Control Committee (HICC), in most situations is the Infection Control Officer (ICO) The role of the Microbiology Laboratory in the HAI control programme is 1. To identify the pathogenic organism and to guide antibiotic therapy by: • Culture of appropriate specimen from the infected cases and accurate identification

of the etiological agent up to species level. Standard microbiological techniques of specimen collection, transport, handling, microscopy, culture and identification and reporting as for the identification of pathogenic organisms from other infections Principles:

• Accurate and rapid diagnosis is of primary importance • Identification should be up to the species level Specimen collection and transport General • Specimen should be collected before antibiotic therapy is instituted • Sufficient quantity of specimen should be collected. • Appropriate collection technique should be applied • Should be collected in leak proof container • Transported upright to the laboratory • Transport media should be used where ever required • Transported promptly to the laboratory (within 2 hours) Processing specimen from specific culture site Wounds and abscesses Collection • Remove debris by cleaning with sterile saline • Collect tissue fluid where ever possible rather than swabs • Aspirate abscess material with needle and syringe, transport syringe containing the

material to the laboratory. • In the case of swabs, two swabs must be collected, one for gram stain and one for

culture. Culture Inoculate Blood agar, Mac conkey and glucose broth. If anaerobes are suspected then include thioglycollate broth. Inoculate additional media for fungi and or AFB if clinical situation suggests. Incubate at 37C for 48 hours, identify significant organisms For details of methods consult Microbiology SOP


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Blood Culture Collection: • Prepare site with tincture iodine followed by 70% alcohol. Disinfect the stopper of the

collection bottle with 70% alcohol. • Collect blood specimen during paroxysm of fever • Inoculate 10 cc of blood into 50 ml of glucose broth. (Collection of more than one

specimen increases the chances of recovery ) Add thioglycollate broth for anaerobic organisms.

• After Incubation overnight at 37C, prepare and examine a gram stain and subculture on Blood Agar and Mac Conkey Agar. Process thiogycollate broth for anaerobic organisms

• Continue incubation for at least 7 days, sub culture as required. • Identify organisms. For details consult microbiology SOP. Vascular Catheters (Includes central or peripheral venous or arterial catheters, urinary catheters should not be cultured as they are contaminated with urethral flora.) Procedure (Maki 1981): • The skin around the insertion site is cleaned with alcohol to prevent contamination of

the cannula by skin flora. • The cannula is withdrawn and 5 cm from the distal end is cut. • The cut segment is transported in a sterile tube to the laboratory and cultured within

2 hours of removal. • In the laboratory using flamed forceps, the segment is transferred to the surface of

blood agar plate and rolled over the agar surface several times. • Plates are incubated aerobically at 370 C and colonies counted after overnight

incubation. Over 15 colonies are significant and indicate cannula related infection Culture of catheter lumens: • The catheter segment is transferred to a sterile test tube • A predetermined amount of broth or peptone water is flushed through the catheter

segment. This is done to dislodge any adherent organisms. The process is facilitated by a vortex or shaking the tube vigorously.

• Ten fold dilutions of the broth are made and an aliquot of 100 ul of each dilution is cultured on an agar plate.

• Plates are incubated at 24-48 C at 37C and quantitative estimation is done by the formula:

Number of colony forming units /ml = No of colonies on the plate x dilution factor Volume of the broth Faeces • Instruct patient to pass directly into a dry receptacle • Avoid contamination by urine • Transport within an hour of collection to prevent overgrowth of commensals... If delay

in culture then refrigerate • Inoculate on Selenite broth , MacConkeys agar and DCA Inoculate special media

as required


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• Proceed further for microscopic examination and culture according to the organisms suspected.

• Rectal swabs should be collected from patients unable to pass stool Sputum • After rinsing and gargling with water, the patient should cough deeply and

expectorate sputum directly into sterile container. • Broncho alveolar lavage and tracheal aspirate is collected in a sterile container • Transport within 2 hours or store at 40 C if delay is anticipated. Process within 24

hours. • Make a Gram stain and examine for the presence of inflammatory cells which

indicate that the specimen has been collected properly. • Culture on blood agar, Mac Conkeys agar, chocolate agar and other media as

appropriate e.g. for suspected tuberculosis stain sputum for AFB and inoculate into Lowenstein Jensen’s medium.

• Culture from protected brush for diagnosis of ventilator associated pneumonia: The

specimen brush is vortexed in saline. 0.1 ml is inoculated on Blood agar, Mac Conkeys agar and chocolate agar.

Urine: • After cleaning the area with soap and water the midstream urine is collected in a

sterile container. • Transport immediately to laboratory for culture or if delay then keep at 4 C. process

within 24 hours. • Examine microscopically for pus cells • Culture by semi quantitative technique by plating 0.001 ml on blood agar and Mac

Conkeys agar. Greater than 105 CFU/ml of a single isolate indicate infection. In a catheterised or symptomatic patient lesser number may indicate infection.

Collection of urine specimen from an indwelling catheter: • Disinfect the collection port with 70% alcohol. • Collect 5-10 ml urine with needle and syringe and transfer to sterile container. • Transport immediately for culture or keep at 40 C if delay is anticipated. Antimicrobial susceptibility testing • Should be carried out as given in the SOP on antibiotic susceptibility testing. Panel of

antibiotics selected should include antibiotics that have clinical efficacy against the particular organism.

• Antibiotics not recommended for clinical therapy can also be included in the panel in order to characterize or type the isolate for epidemiological purposes.

• Periodic reporting of the anti-microbial resistance:

The periodic reporting of anti-microbial resistance patterns of hospital pathogens is an important service provided by the microbiology laboratory. The frequency of this should be as determined by the Infection Hospital Infection Control Committee.

2. To search and identify sources and mode of transmission of the infection by:


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• Culture of carriers, environment for isolation of the similar organism as that causing

infection (outbreak organism). Selection of sites for culture will depend upon the known epidemiology and, survival characteristics of the organism.

• Studies to establish similarity between organisms by epidemiological typing of the

isolates from cases, carriers and environment by one or more phenotypic (biotyping, resistotyping, phage typing, serotyping) and genotypic characterisation methods (plasmid profile, RFLP, pulse field gel electrophoresis, ribotyping) depending upon the facilities available. These are advanced techniques requiring special expertise the description of these procedures is beyond the scope of this guideline.

• If facilities for further characterisation are not available then send the stocked

isolates with the relevant epidemiological data to a reference laboratory for typing. Transport of isolates to reference laboratory will depend on local postal regulations. For standard procedure of packing of isolate for transport refer to microbiology SOP. The details required by reference laboratory usually include the following: date of isolation, patient details, site of isolation, geographical location and results of preliminary procedures performed. The specific epidemiological question that needs to be answered such as confirmation of common source or mode of transmission should be intimated.

Studies to establish similarity between organisms (clonal relatedness). These tests are done when there is suspicion that a group of nosocomial infections with organisms of the same species have a common origin • To determine whether two isolates are similar, examine the results of biochemical

tests and pattern of susceptibility to anti microbial agents. For commonly encountered organisms such as Staph. aureus and Esch coli similarity on basis of routine antimicrobial testing and biochemicals may be on basis of chance alone, additional tests will be required...

• Test for susceptibility to additional antimicrobials not included in the routine testing of

the organism, or to other antibacterial substances such as heavy metals. (resistotyping)

• Characterise the isolates by special typing methods such as bacteriophage typing,

biotyping, serotyping genetic typing and typing by molecular markers. A number of typing systems based on phenotypic as well as genotypic characteristics have been employed for the identifying clonal similarity between epidemiologically related organisms.

• Hospital laboratories may not have the facilities for special typing procedures; they should send the epidemiologically important isolates to reference laboratories in their countries.


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Typing Systems which have been used for organisms causing nosocomial infection: • Phenotypic.

• Susceptibility to Antimicrobials and Heavy Metals • Biotyping • Serotyping • Phage typing • Bacteriocine production or susceptibility • Colony morphology • Analysis of enzyme production • Analysis of marker proteins • Serum opacity • Lipopolysaccharide immunotyping

• Genotypic methods • Plasmid profile • Ribotyping • Analysis of PCR product • Restriction Fragment Length Polymorphism • Pulse Field Gel Electrophoresis. Storage of strains For further study of strains as given above, the strains must be stored or “stocked” for revival later on or sending to a reference laboratory. The important isolates should be sub cultured and retained. Important isolates which should be stored are: • Strains isolated from an outbreak or cluster of infections • Unusual isolates or isolates from potentially epidemic diseases. Microbiological testing of hospital personnel or environment: As a part of the infection control programme, the microbiology laboratory at times needs to culture potential environmental and personnel sources of nosocomial infections. This should be limited to outbreak situation when the source and method of transmission needs to be identified... Indiscriminate routine microbiologic sampling and testing is not recommended. Search for potential carriers of epidemiologically significant organisms Sites to be sampled: Staphylococcal carriage: Axillae, anus, hands, fingers, anterior nares. Since 30% of adults are carriers of S aureus, establishing relatedness between strains is necessary before implicating the carrier as a source of infection. Group A streptococcus: Throat. May also be carried in anus and vagina Group B streptococcus: Vagina Enteric gram negative bacilli and enterococci: rectal swab Procedure for the culture of hands:


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• Moisten sterile swabs with saline or Brain Heart Infusion Broth and swab the palmer surface of both hands

• Broth rinse Pour 50 ml of BHI into a sterile plastic bag large enough to accommodate the hand... Rub hands in the broth. Collect 1 ml of the broth and quantify the organisms by culturing 0.01ml of 10 fold dilutions on BHI agar

• Press palmer surface of fingers on agar surface. Selective media can be used for the isolation of specific organisms. E.g.: Salt milk agar for staphylococci, MacConkey’s agar for enteric gram negative organisms.

Surveillance of high risk groups • Depending upon the health care facility and If the HICC decides, microbiological

surveillance of high risk groups can be undertaken in the absence of outbreak situation.

• The high risk groups can include the immunocompromised patients in intensive care, neonatal units. A procedure for elimination of asymptomatic carrier state, isolation and cohorting of patients should be defined by the HICC.

• Surveillance should target the detection of colonisation and asymptomatic infection with problematic organisms such as MRSA and resistant gram negative organisms.

• The sites sampled depend upon the colonising site for the organism, for example the anterior nares for MRSA, rectal swabs for enteric organisms. Standard microbiology procedures should be carried out. Selective media can be used as appropriate.

Routine environmental testing The following are recommended for routine testing: 1. Biological Monitoring of sterilization : • Resistant spore preparations are used for the biological monitoring of sterilizers. The

spore preparations recommended are: spores of Bacillus stearothermophilus for steam sterilization, Bacillus subtilis for ethylene oxide sterilization and dry heat sterilization...

• Sterilizers should be checked once a week or at any other suitable interval as

determined by the HICC with the appropriate spore preparation. Biological methods should be done in addition to physical and chemical methods as given in the chapter on disinfection and sterilization.

Procedure: • Spore preparations consist of filter paper strips or carriers having !06 spores /ml

which are either prepared in the laboratory or obtained commercially . • The spore strips are placed in the sterilizer and subjected to the sterilization cycle • The test strip and a control strip is then cultured in tryptic digest caesin soy broth and

incubated at 56 C for Bacillus stearothermophilus and 370 C for Bacillus subtilis for 72 hrs.


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• Non viability of spores in the test strip indicates that the sterilizer has passed the test. 2. Sampling of infant feeds and other products prepared in the hospital such as oral

rehydration fluid, hyperalimentation fluid • Frequency of culture should be determined by the HICC. • Quantitative cultures should be done and the fluid should have less than 25

organisms/ml and no virulent organisms such as Shigella and Salmonella 3. Monitoring of blood products • Blood products prepared in open systems should be monitored. An open system is

one in which the transfer container is not an integral part of the blood container... • Samples should be cultured aerobically and anaerobically, for 10 days at 200 C as

well as 370 C. 4. Monitoring of dialysis fluids • Water used in preparation of dialysis fluid should be cultured quantitatively and

should not have more than 200 organisms per ml. • Frequency of sampling should be once a month or as recommended by the HICC 5. Spot sampling of disinfected equipment. • Some equipment that are sterilized or high level disinfected by liquid chemicals (such

as Cidex) can occasionally be cultured to spot check for sterility since process controls for chemical sterilization are not available.

• Spot checking of steam sterilized or ethylene oxide sterilized equipment is not recommended since process controls are available for these sterilization processes.

• Sterility testing of commercially sterilized equipment is not recommended 6. Testing of disinfectants There is evidence that contaminated diluted disinfectant can be a source of outbreak of HAI. Thus in-use testing of disinfectants is recommended on a routine basis in every hospital where chemical disinfectants are used. The frequency is determined by HICC. Procedure (Kelsey Maurer, 1972) Ø Sample for testing is collected from the diluted disinfectant in use in a sterile

container. Ø The sample is diluted one in ten with a diluent to inactivate the disinfectant in the

sample. The diluent used is Nutrient Broth with Tween 80 (3%, W/V) Ø Two nutrient agar plates are inoculated. Each at 10 different sites with 200 ul of

the diluted sample. Ø The plates are incubated for 72 hrs, one at 370 C and the other at room

temperature. Ø Growth on more than 5 out of 10 sites on either of the two plates indicates a

failure of the disinfectant. Environmental testing in special situations: • Only in special situations such as outbreaks or to answer an epidemiological

question is it useful for identifying sources and routes of transmission of the infection.


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• Should be limited to sites and items that have been implicated as possible sources and reservoirs on the preliminary epidemiological investigation of outbreak or infection problem.

• Environmental testing can also be done for educational purposes • Standard bacteriological culture techniques should be employed. Air Sampling: Air may be a source of infection in high risk areas such as operation theatres. Airborne contamination is best controlled by proper design and ventilation. The ventilation standard for operation theatres is that the theatre should have mechanical ventilation of the plenum type which should provide approximately 20 air changes per hour. When these standards are being met, routine air sampling is not recommended. Air should be sampled at: • Commissioning and refurbishing the theatre. • As an educational exercise to show the influence of staff activity, protective clothing

and theatre discipline on air bacterial contamination Procedure: • Sampling of air can be done by settle plates or using volumetric air samplers. • Volumetric air sampling is the more accurate method. Settle plate counts can be

converted into air counts by using the formula that the number of bacteria carrying particles settling on one m2 of medium per min is approx equal to number of such particles per 0.3 m3 (ft3). A simple calculation to obtain the number of cfu /ft3/ min is

No of colonies on 4” diameter petri dish exposed for one hour

Standards for air borne contamination: • Empty operation theatre: less than 35 colony forming units of bacteria per mm3 and

/less than one cfu of Clostridium perfringens or Staph aureus in 30 m3 • During operation there should be less than 180 cfu/m3 Sampling of surfaces: • The routine sampling of surfaces is not recommended since surfaces rarely serve as

a source of infection • The environmental surfaces can be brought into contact with the patients vulnerable

areas is through hands , inadequately disinfected and sterilised equipment and gloves.

• It has been seen that routine sampling of surfaces does not contribute to the prevention of HAI or predict when post operative infections are most likely to occur.

• Sampling flat surfaces is best done by RODAC plate method using special plates that when filled with agar medium will form a convex meniscus on the surface. Plates are pressed firmly against a dry surface and colonies are counted after incubation.

• Uneven surfaces can be sampled by swab rinse method: sterile moistened swabs are rubbed over the area to be sampled then placed in rinse fluid to elute the organisms. The rinse fluid is then subcultured to isolate and identify the organisms.

• Selective media to isolate specific organism which is implicated in the outbreak is recommended.

ANNEX 10.7: MONITORING OF STERILIZATION


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Steam Sterilization One of the most efficient and economical of sterilizing patient care items is sterilization by steam under pressure. It should be the preferred method for all critical items unless they cannot be processed by steam or are sensitive to heat in which case other methods should be considered There are basically two types of sterilizers • Gravity displacement type: air is displaced from the chamber by gravity Cycle parameters are: 121 C for 15 min • Pre-vacuum type: air is removed by means of a vacuum pump: the speed and

efficiency of the removal of air is better in Pre-vacuum sterilizer and processing time is faster as compared to the gravity displacement sterilizer. Cycle parameters are 1350 C for 4 minutes.

The efficiency of steam sterilization to deliver sterile products for patient care will depend upon: • Reducing the bioburden ( i.e. reducing biological material like blood, secretions etc

and contaminating organisms) by thorough cleaning of the instrument • Effective quality control and monitoring of the sterilisation process • Maintenance of sterility during transport and storage. Pre-cleaning procedure Mechanical cleaning of instruments is preferred, e.g. by ultrasonic cleaner. If mechanical methods not feasible manual cleaning may be done Manual cleaning: • Cleaners must wear protective gear such as gloves, mask, gown eye protection • Should be done underwater to prevent aerosols • Cleaned with non abrasive brushes. Lumens must be cleaned of debris by help of

brushes of appropriate diameter (brushes should be disinfected daily) • Rinsed with abundant water at 55C-65C to remove detergents • Last rinse with deionized or distilled water is preferable • Dried after cleaning and rinsing. Assembled and lubricated before sterilization Packaging

Requirements of packaging material • Should allow the penetration of steam into the pack contents • To maintain the sterility of the contents of the pack after removal from sterilizer and

during transportation and storage • To protect the contents of the pack • To allow aseptic opening and removal of the contents

Packaging materials • Linen is the traditional material used for wrapping it is reusable, economical strong

and offers good protection. However it is not water repellent and does not offer a good bacteriological barrier

• Linen wrapper should have 140 thread count and should be used in two thicknesses


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• Medical grade kraft paper or crepe paper can be used instead of linen • Chemical indicators (SignalogR strips) should be placed inside and outside the pack. Loading of sterilizer, • wrapped packs are placed on edge leaving 3”of space between the top and walls of

the chamber and between the items • Metal objects should be placed on the bottom and fabric items on the top. • After the cycle is over, open the door partially , to avoid burns from steam and allow

to cool, wait for 30 minutes before unloading • The packs must be dry, if packs are wet they have to be resterilised after repacking • Liquids should be sterilised separately and pressure must be released slowly over 15

minutes. Door opened very slightly wait for another 30 minutes before unloading.

Monitoring of steam sterilization process 1. Gravity displacement sterilizer Should be monitored by

• thermographs and temperature recorders • chemical indicators demonstrating temperature and holding time, placed inside

and outside individual packs and show the required colour change • Biological indicators (Bacillus stearothermophilus spores) should be used once a

week 2. Pre-vacuum sterilizer Should be monitored by all the above and also by • Air removal indicator test (Bowie Dick test) which should be done daily at the start of

the day in an empty sterilizer. Bowie Dick test: This is a method of demonstrating that even and rapid penetration of steam has occurred within the load. Procedure: • An adhesive tape which is printed with a chemical indicator is fixed in the shape of a

cross to a suitable sheet of paper. This test sheet is placed in the centre of a stack of towels. This forms the test pack.

• The test pack is placed horizontally in an empty sterilizer and subjected to the sterilizing cycle (134-138C for 3-4 min).

• After the cycle the test sheet is withdrawn and the chemical indicator is examined for a change in colour. A uniform change in colour throughout the length of the adhesive tape indicates a successful test. It indicates that there is even penetration of steam into the load.


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ANNEX 10.8: MONITORING AND EVALUATION OF INFECTION CONTROL

Evaluation and monitoring on an on going basis is essential to ensure that infection control policies are being implemented and work practices are according to the guidelines. The monitoring is carried out by: (a)Hospital Infection Control Committee (HICC) meetings when the infections are reviewed, emerging infections and trends are identified. The HICC should ensure that supplies and equipment for infection control procedures; standard/universal precautions are maintained and available in the clinical areas. (b)The Infection Control Team (ICT) monitors the day to day compliance with guidelines on infection control. The team visits the clinical areas with a checklist to see that certain practices are being carried out in the appropriate manner. The level of awareness can also be evaluated. The various areas to be checked are: Infection Control Indicator Check list Indicator 1: Sharps are handled safely to minimize the risks of sharps injury

• Appropriate puncture proof sharps container • Container less than 3/4th full. • No sharps protruding from container • No recapping or one handed capping • Where needle destroyers are used, needles are burnt completely • No sharps are strewn around.

Indicator 2: Instruments are decontaminated fully.

• Sterilizer available and in good working order, cycle parameters and load records maintained

• Instruments are thoroughly cleaned after use • Sterile instruments are correctly stored

Indicator 3: Hands are washed appropriately to prevent cross infection

• Soap and clean water available/ hand rubs available • Clean towels available • Staff observed to wash and dry hands after contact with body fluid, removal of

gloves and contact with patients. Indicator 4: A protective barrier is worn to prevent exposure to blood Depending on clinical area and risk of exposure, protective barriers for the staff

• Gloves • Mask • Aprons • Protective eye wear

Indicator 5: Waste is disposed safely

• Waste is segregated into appropriate containers • Evidence of regular autoclaving or deep burial • Burial site fenced and properly maintained.

Indicator 6: Disinfectants are changed regularly and the date of change is recorded


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ANNEX 11: OUTLINE OF DRAFT LEGISLATION ON HEALTH CARE WASTE MANAGEMENT Suggested Title: Health Care Waste Management and Handling Rules Application: To apply to all persons who generate, collect, receive, store, transport, treat, dispose off or handle health care waste. Definitions: to include all terms used in the document such as health care waste, authorization, authorized person, biologicals, health care waste treatment facility, occupier, operator of a health care waste treatment facility etc Duty of occupier :The duties of the occupiers of any institution that generates health care waste to be defined i.e. it shall be the duty of the occupier to take all steps to ensure that the health care waste is handled without adverse effects on the human health and environment. Treatment and Disposal: Schedules should be drawn out giving the types and classification of waste included under health care waste and various treatment and disposal options for different types of waste. Standards for the various treatment options such as autoclaving, incineration, deep burial etc should be elaborated... The time frame in which the facilities and systems are to be established should be defined. Segregation, Packaging Transport and Storage Schedules regarding the segregation of waste at site of generation, prior to its transportation, treatment and disposal need to be laid out. This will include the rules for colour coding, labeling, packaging, record keeping and the requirements of the vehicle used for transportation of waste. The maximum time for which the waste can be stored before treatment and disposal should also be defined. The labeling should be such that waste can be tracked at any stage back to the generator of the waste. Prescribed Authority: The RGOB should establish a prescribed regulatory authority (NEC) for authorization and implementing the rules. The responsibility of NEC has already been elaborated under the ECOP for hazardous waste. Can apply to HCW as a part of hazardous waste. Authorization: An authorization form should be developed for every occupier of an institution generating, collecting, receiving, storing, transporting, treating, disposing and/or handling health care waste to apply to the authority for authorization. Advisory Committee: An advisory committee should be instituted by the RGOB which could include experts in medical and health fields, environmental management, municipal administration and NEC. The committee can advise the Govt ad prescribed authority on matters related to the implementation of the rules. Annual Report: Every occupier should submit to the authority an annual report regarding information about the categories and quantities of health care waste handled during the preceding year. The information should be on a prescribed form.


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Maintenance of records: Every authorized person shall maintain records related to the generation, collection, reception, storage, transportation, treatment, disposal or any form of handling in accordance of the rules. Accident reporting: Whenever any accident occurs at any institution or facility where the health care waste is handled or during the transportation of the waste, the authorized person should report the incident. A format for reporting has to be drawn out. Appeal Provision should be made for an appeal by a person on whom legal action has been initiated according to the rules. The role of Municipal Authority: The Municipal’s Authorities role in picking up and transporting the segregated treated waste should be defined in those areas where such an authority exists.


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SELECTED REFERENCES

• Manual for Control of Hospital Associated Infections standard Operating

Procedures National AIDS Control Organization, India, 1999.

• Infection Control: Basic Concepts and Training. International Federation of

Infection Control, 2003.

• Safe Management of Wastes from Health Care Activities Pruss A, Giroult E. and

Rushbrook P., WHO Geneva, 1999

• Hospital Waste Management Guidelines for implementation GOI/ WHO Project

on Hospital waste Management IND EHH 001., WHO Regional Office for South

east Asia, 2000

• Guidelines for preventing HIV, HBV and other infections in the health care

setting. WHO Regional Office for South east Asia, 1999.

• Non Incineration Medical Waste Treatment Technologies, Health Care Without

Harm, Washington, USA, 2001.

• Disposal of mass immunization waste without incineration (executive summary of

report : Waste Management and Disposal during the Phillipine Follow up

Measles Campaign). Health Care Without Harm and Dept of Health,

Philippines, 2004.

• Biomedical Waste Management and Handling Rules 1998. The Gazette of India

Part II-Section 3-Subsection (ii), New Delhi, India

• Operation Manual of the World Bank funded National HIV/AIDS and STI

Prevention and Control Project Bhutan, MOH, Thimphu, Bhutan, 2004.

• Environmental Codes of Practice for Hazardous Waste Management : National

Environment Commission, Thimphu , Bhutan 2002

• Health Care waste Management Plan for Bhutan 2004-2006, Danida, June 2004.

• Guideline for Infection Control in Health Care Settings STD/AIDS Programme,

Health Division Ministry of Health and Education, Thimphu , Bhutan, 2nd Edition

1998.

• Practical Guidelines for Infection Control in Health Care Facilities. WHO Regional

Office for Western Pacific, Manila, Regional Office for South East Asia Region,

2004.


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WEB SITES

• World Health Organization http://www.who.int

• WHO Water and Sanitation http://www.who.ind/water_sanitation-health

• United Nations Environmental Programme http://www.unep.ch/index.html

• UN Basel Convention http://www.basel.int/

• US Environmental Protection Agency, USA http://www.epa.gov

• Joint Commission on Accreditation of Health Care organizations http://www.jcaho.org

• Center for Disease Control, USA http://www.cdc.gov

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