national agency for the control of aids second hiv/aids ......table 6.3: advantages and...

Federal Republic of Nigeria

National Agency for the Control of AIDS

Second HIV/AIDS Program Development Project (HPDP 2)

HIV/AIDS Medical Waste Management Plan

FINAL REPORT

Submitted to: The Director General

National Agency for the Control of AIDS (NACA) Plot 823 Ralph Sodeinde Street Central Business District, Abuja Nigeria

December 2008

Maximizing Resources and Sustaining Development

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HIV/AIDS Programme Development Project Medical Waste Management Plan

Table of Contents

Table of Contents ....................................................................................................................... i

List of Figures .......................................................................................................................... iii

List of Tables............................................................................................................................ iv

Executive Summary................................................................................................................. vii

Chapter 1: Introduction...............................................................................................................1

Chapter 2: Baseline Situation .....................................................................................................4

2.1 General Description and Location ............................................................................4

2.2 Socio –Economy of Nigeria .............................................................................................4

2.3 Status of Health Care Institutions and Facilities .......................................................5

2.4 HIV Prevalence in Nigeria ........................................................................................7

Chapter 3: Medical (or Health Care) Wastes and Legal Provisions...........................................9

3.1 Definition...................................................................................................................9

3.2 Health Impacts ...........................................................................................................9

3.2 Sources of HIV/AIDS Medical Waste ......................................................................9

3.3 Health Care Waste Management.............................................................................11

3.4 Legal and Regulatory Framework...........................................................................11

3.5 National Health Care Waste Management Plan ........................................................14

Chapter 4: Analysis of Medical Waste Management ...............................................................16

4.1 Medical Waste Composition ...................................................................................16

4.2 Medical Waste Handling Practices .........................................................................16

4.3 Responsibility for Medical Waste Management ..........................................................18

Chapter 5: Medical Waste Generation and Management Practices..........................................19

5.1 Waste Generation....................................................................................................19

5.2 Waste Management Practices .................................................................................21

5.3 Potential Impacts of Existing Medical Waste Management Practices ....................23

5.4 Existing Disposal Facilities.....................................................................................23

Chapter 6: Technologies for Medical Wastes Disposal in HPDP2 ..........................................25

6.1 Medical Waste Treatment and Disposal Technologies ...........................................25

Chapter 7: Institutional Arrangements and Implementation Responsibilities ..........................31

7.1 Training Needs Assessment .....................................................................................32

7.2 Training Strategy.....................................................................................................33

7.3 HIV/AIDS Medical Waste Management Plan ........................................................34

7.4 Cost Estimate for of HIV/AIDS Medical Waste Management Plan .......................39


Chapter 8: Monitoring and Evaluation .....................................................................................46

8.1 Monitoring and Evaluation Objectives ...................................................................46

8.2 Monitoring Indicators ..........................................................................................46

8.3 Monitoring Plan ......................................................................................................47

8.4 Monitoring of HIV/AIDS Waste Management Plan Implementation.....................48

Chapter 9: Public Awareness and Consultation .......................................................................49

9.1 Objectives...............................................................................................................49

9.2 Potential Stakeholders.............................................................................................49

9.3 Consultation Strategies.................................................................................................49

References ................................................................................................................................51

Annex A – Disposable HCW Containers .................................................................................52

A.1 Specification for Disposable Containers .......................................................................52

A.1.2 Specification of Reusable Containers .................................................................53

B Specification for HCW Brackets and Baskets..................................................................55

Annex C: Data Collection Instruments.....................................................................................58

C.1 Data entry form..............................................................................................................58

C.2 Survey Questionnaire for HCWM.................................................................................60

C.3 Short Questionnaire for Health Care Facilities Officers................................................74

Annex D: List of People Met....................................................................................................76

Annex E: HCWM Procedures to be Applied in Health-Care Facilities ...................................77

Annex F: Health Care Waste Management Procedures to be Applied in Medical Laboratories

..................................................................................................................................................82

Annex G: HIV/AIDS Medical Waste Management Plan (2009 - 2014) .................................84


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List of Figures

Figure 4.1: Administrative Map of Nigeria ................................................................................4

Figure 5.1: Synopsis of the HIV/AIDS Waste Stream .............................................................19

Figure 5.2: Boxes for Sharps Disposal .....................................................................................22

Figure 6.1: Flow diagram of a Typical Autoclave/Steam Sterilisation Plant ...........................26

Figure 6.2: Flow Diagram of a Typical Microwave Plant........................................................26

Figure 6.3: Flow Diagram of a Modern Incineration Plant. .....................................................28


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List of Tables

Table 2.1: Demographic Data.....................................................................................................5

Table 2.2 Health Care Facilities by State in Nigeria ..................................................................6

Table 2.3: State Level figures for HIV Prevalence in Nigeria ...................................................7

Table 3.1: Major Categories of Medical Waste........................................................................10

Table 4.1: Findings from Field Assessment .............................................................................18

Table 5.1: Typical Waste Generated in Hospitals ....................................................................20

Table 5.2: Recommended Colour-Coding for Health Care Waste (WHO/FMOH) .................21

Table 6.1: Advantages and Disadvantages of Autoclaving and Microwaving.........................27

Table 6.2: Characteristics of Waste Suitable/Unsuitable for Incineration................................28

Table 6.3: Advantages and Disadvantages of Incineration ......................................................30

Table 6.4: Recommended Treatment and Disposal Technology for Health Care Facilities ....30

Table 7.1 HIV/AIDS Medical Waste Management Plan..........................................................35

Table 7.2 HIV/AIDS Medical Waste Management Plan..........................................................35

Table 7.3: Break down of Total Indicative Budget for HIV WMP..........................................40

Table 7.4: Break down of HIV/AIDS Medical Waste Management Implementation Budget

across all HCF levels ................................................................................................................41

Table 7.5: HIV/AIDS Tertiary Health Care Facility Medical Waste Management Plan

Expenditure ..............................................................................................................................42

Table 7.6: HIV/AIDS Secondary Health Care Facility Medical Waste Management Plan

Expenditure ..............................................................................................................................43

Table 7.7: HIV/AIDS Primary Health Care Facility MWM Plan Expenditure (Urban) ..........44

Table 7.8: HIV/AIDS Primary Health Care Facility MWM Plan Expenditure (Rural) ...........45


Acronyms AI Avian Influenza

AIDS Acquired Immune Deficiency Syndrome

ART Anti-Retroviral Treatment

ARV Anti-Retroviral

BCC Behaviour change Communication

CBOs Community Based Organizations

CSO Civil Society Organisation

DfID Department for International Development

EIA Environmental Impact Assessment

ESM Environmental Sound Management

ESMF Environmental and Social Management Framework

FEPA Federal Environmental Protection Agency

FMEH & UD Federal Ministry of Environment, Housing and Urban

Development

FMENV Federal Ministry of Environment

FMOH Federal Ministry of Health

GDP Gross Domestic Product

HAF HIV/AIDS Fund

HCF Health Centre Facility

HCT HIV Consultancy and Testing

HCW Health Care Waste

HCRW Health Care Risk Waste

HIV Human Immuno-deficiency Virus

HSDP II Second Health Systems Project Development

HPDP HIV/AIDS Program Development Project

ISDS Integrated Safeguards Sheet

ITCZ Inter-Tropical Convergence Zone

LACA Local Action Committee on Aids

LAWMA Lagos State Waste Management Agency

LGA Local Government Area

MAP Multi-Country AIDS Program for Africa

M&E Monitoring and Evaluating

MWMP Medical Waste Management Plan

NAAQS National Ambient Air Quality Standards

NACA National Agency for the Control of AIDS


NHP National Health Policy

NSF National Strategy Framework (2005 – 2009)

NSF 2 Second National Strategic Framework 2 (2010 – 2014)

OPS Organized Private Sector

OVC Orphans and Vulnerable Children

PAD Project Appraisal Document

PCN Project Concept Note

PHC Primary Health Care

PIU Project Implementation Unit

PLWHA People Living With HIV/AIDS

PLWA People Living With AIDS

PMTCT Prevention of Mother to Child Transmission

POP Persistent Organic Pollutant

PPT Project Preparation Team

ROP Resident Organic Pollutants

RRF Rapid Respond Fund

SACA State Action Committee on AIDS/State Agencies

SEPA State Environmental Protection Agency

SMOH State Ministry of Health

TA Technical Assistance

TB Tuberculosis

TDS Total Dissolved Solids

TOR Terms of Reference

TOT Training of Trainers

UNAIDS Joint United Nations Program on AIDS

UNDP United Nations Development Program

WHO World Health Organization


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Executive Summary

Introduction

The World Bank launched the HIV/AIDS Program Development Project (Project 1: $90 million) as part of its Multi-Country AIDS Program for Africa (MAP). The Project became effective in April 2002 and was extended to June 2009, with $50 million of additional financing approved in May 2007. A joint review assessment of the project by DfID and the World Bank in 2006 concluded that that the Project has been successful in achieving a vibrant multi-sectoral response in Nigeria, through the engagement of a multitude of partners in the response. A joint World Bank /DfID scoping mission conducted in September 2007 revealed that the project was also successful in establishing the institutional framework necessary for a successful HIV/AIDS Program. The reviews and the evaluation reports, encourage ongoing support by the World Bank, recognizing the Bank as a lead organization in moving the response forward to the next stage. The proposed Second HIV/AIDS Program Development Project (HPDP2) will be tailored to build on the success of Project 1.

The HPDP2 will build on the substantial success of Project 1 and to utilize the existing institutional structures in the national AIDS response.

In fulfilling the requirements of the World Bank’s procedures, the proposed project is expected to prepare a HIV/AIDS Medical Waste Management Plan (MWMP) for the implementation of the project.

The objective of the plan is to provide processes that the implementing agencies (NACA and SACAs) will follow to maximize project compliance with international and national environmental regulation and ensure that the disposal of medical wastes is conducted in an environmentally safe and sustainable manner.

Medical Wastes (MW) are a reservoir of potentially harmful micro-organisms which can infect patients, health-care workers and the general public. Other risks include the spread of micro-organisms into the environment. These wastes can also cause injuries, e.g. radiation burns or sharps-inflicted injuries; poisoning and pollution, through the release of pharmaceutical products e.g. antibiotics or toxic elements such as mercury.

There are over 20,000 Health Care Facilities (HCFs) with an estimated 243,000 beds in Nigeria and activities from these institutions generate about 5,000 kg of medical wastes daily, most of which are not handled or disposed off properly. These existing practices constitute a major risk to human health due to the hazardous, toxic and infectious characteristics of this waste stream. Careless and indiscriminate disposal of medical waste would contribute to the spread of HIV/AIDS. HIV/AIDS Medical Waste Management Plan

This HIV/AIDS MWMP describes the existing practice and proposes actions for a standardized approach to management of HIV/AIDS wastes. The study examined the current medical wastes handling practices within HCFs. The study shows that infectious and non-infectious wastes are dumped together in most hospitals, resulting in a mixing of the two, which are then disposed of with municipal waste at the dumping sites. It also assessed the level of knowledge among health-care staffs about the practices to be adopted, and the availability of treatment equipment such as incinerators, autoclaving and chemical treatment. Details of the first year of implementation of the HIV/AIDS MWMP can be seen in Annex G. Results

The results of the study demonstrate the need for strict enforcement of existing provisions, capacity building and a better environmental management system for the disposal of medical wastes.


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The findings reveal that:

• Medical Waste is usually not classified at source according to its type for easy of treatment and final disposal.

• Most HCFs do not take due responsibilities for the waste they generate to the environment and the public to ensure safe, efficient, sustainable and culturally acceptable methods for the collection, storage, transportation, treatment and final disposal both within and outside their premises.

• Local authorities do not have sound managerial approaches for dumpsites and the use of appropriate technologies, which would minimize health risks that result from inadequate management of hazardous and infectious medical waste.

The level of knowledge among those involved in handling hazardous and infectious medical waste is low especially among those outside the HCF who are exposed to such waste due to poor management practices. The over arching National Health Care Waste Management Plan (NHCWMP) findings in the field and specifics derived from the HPDP2 formed the basis for the development of this HIV/AIDS MWMP.

This is a practical MWMP that would ensure that wastes generated by the project are handled in accordance with universally upheld best practices. Specifically, some of the steps in this plan include waste minimization/generation, segregation, evacuation treatment and final disposal. Adequate provision is made for awareness creation, capacity building, incineration of sharps, septic tanks to handle the liquid stream of medical wastes and monitoring of the implementation of the MWMP. Budget:

In order to adequately implement the HPDP2 HIV/AIDS MWMP in the 36 states and FCT Abuja, three scenarios for implementation of the HIV/AIDS MWMP were derived as seen in the table below.

SCENARIO 1 SCENARIO 2 SCENARIO 3

Health Care Facility (HCF) Category

Total Cost

Per HCF Category

($)

No of Facilities

intervened in 37 States

Total Estimated Amount

for 37 states ($)

No of Facilities

intervened in 37states

Total Estimated

Amount for 37 states

($)

No of Facilities


Total Estimated


($)

Tertiary HCFs 128,576 37 4,757,312 0 0 0 0

Secondary HCFs 126,825 37 4,692,535 37 4,692,535 0 0

Primary HCFs (Urban) 10,571 37 391,127 222 1,955,635 518 5,084,651

Primary HCFs (Rural) 9,130.68 37 337,835 333 2,364,846 518 4,729,692

Total Indicative Budget 148 10,178,809 555 10,079,813 1,036 10,205,470

Scenario 3 is assumed to be the most cost effectiveness and has widespread impact amongst the three Scenarios.

The break down of Scenario 3 is as follows:

• 518 Urban Primary Health Care Facilities * $10,571 = $ 5,084,651

• 518 Rural Primary Health Care Facilities *$ 9,130 = $ 4,729,692

• Total Indicative Budget: = $ 10,205,470

The Total Indicative Budget to implement the HIV/AIDS Medical Waste Management Plan (MWMP) in Nigeria in the first year is: Ten Million, Two Hundred and Five Thousand, Four Hundred and Seventy Thousand US Dollars ($10,205,470).


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Chapter 1: Introduction

Nigeria is one of the world’s largest oil exporters, but poverty is pervasive with more than 70% of the population living on less than $1 per day. Nigeria has a population of over 144.7 million people and GDP growth of 5.2%. The Human Development Report (UNDP) rates Nigeria 158 out of 177 countries. Life expectancy has dropped from 52 years in 1995 to 46.5 years in 2005 partly as a result of HIV/AIDS. Nigeria’s HIV and AIDS epidemic is complex and comprises a ‘generalized’ epidemic, affecting both urban and rural, population, but also pervasive sub-epidemics with high prevalence among geographic and social groupings. There were about 2,600,000 people living with HIV in 2007 out of which 370,000 were new infections with 170,000 AIDS deaths recorded for the year. Cumulative deaths from AIDS stand at 1.48 million. The situation is getting worse, according to UNAIDS figures in 2007; Nigeria now has the second highest burden of the disease. The main factors contributing to HIV/AIDS vulnerability include poverty, lack of awareness, dense commercial sex networks, early age of sexual debut, and poor gender empowerment, with religious and cultural factors obstructing open debate on sexuality. The World Bank launched the HIV/AIDS Program Development Project (Project 1: $90 million) as part of its Multi-Country AIDS Program for Africa (MAP). The Project became effective in April 2002 and was extended to July 2009, with $50 million of additional financing approved in May 2007.A joint review assessment of the project by DfID and the Bank in 2006 concluded that the Project has been successful in achieving a vibrant multi-sectoral response in Nigeria, through the engagement of a multitude of partners in the response. A joint World Bank/DfID scoping mission conducted in September 2007 revealed that the project was also successful in establishing the institutional framework necessary for a successful HIV/AIDS Program. The reviews and the evaluation reports encourage ongoing support by the World Bank, recognizing the Bank as a lead organization in moving the response forward to the next stage. The proposed Second HIV/AIDS Program Development Project (HPDP2) will be tailored to build on the success of Project 1. The HPDP2 will build on the substantial success of Project 1 and to utilize the existing institutional structures in the national AIDS response. It will directly address key emerging sector issues that have been identified by Government in partnership with a range of stakeholders, through epidemiological and behavioral surveys and the National Strategic Framework Mid Term Review (2007). These include:

• Radically scaling up access to prevention, treatment, care and support interventions in an informed and prioritized approach. There is also a need for better balance between prevention, treatment care and support, with treatment currently receiving substantial additional resources compared to other services.

• Strengthening the institutional capacity of the Federal Ministry of Health (FMOH) to plan and deliver sustainable integrated HIV and AIDS services within the primary and secondary health system, and to utilize existing resources from all partners.

• Continuing political commitment at the highest level of all tiers of Government. Sustaining and increasing the level of support at the Federal, State and Local Government Area (LGA) levels is essential for enabling country and local ownership of the response. Political support at the State and LGA levels has been particularly mixed.


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• Strengthening gender mainstreaming. The NSF (2005-2009) provided for gender mainstreaming but the effect is yet to be seen. There is increasing feminization of the HIV/AIDS epidemics in Nigeria, as in other African countries. Evidence from treatment centers shows more women are infected, more women are affected as caregivers and more women are likely to be involved in sex work for economic reasons.

• Targeting. The recent Integrated Biological and Behavioural Surveillance Survey (IBBSS) among selected high-risk groups in Nigeria showed HIV prevalence among brothel and non-brothel based female sex workers at 37.4% and 30.2% respectively. The other two groups with high prevalence rates were men having sex with men and intravenous drug users at 13.5% and 5.5%.

• Strengthening the ‘multisectoral’ response. At Federal and State levels, the response within line ministries should now follow the model set by Ministries of Education, Health and Information to become more strategic with a move from work place policies to planning activities targeted at the clients of those ministries.

• Strengthening the involvement of civil society. The role of Civil Society Organizations (CSOs) in prevention education is critical but the process of funding the CSOs needs to be improved, activities need to be better targeted, and the capacity of CSOs needs to be built and supervised through a more systematic approach that ensures sustainability.

• Strengthening the national M&E system, especially with regards to data quality and reporting. Although the existing system, NNRIMS, did benefit immensely from Project 1 and capacity building efforts from other partners, data dissemination, demand and use of information are relatively nascent activities that require considerable technical and human resource investments, going forward. The national M&E systems needs renewed focus to identify and scale up effective interventions targeting key sectors, high transmission populations and situations

The project, although designed to strengthen institutional capacity to deal with HIV/AIDS will generate medical wastes as well as small site-specific negative environmental and social impacts related to construction and rehabilitation of health infrastructures. In fulfilling the requirements of the World Bank safeguard policies and existing national regulations, the proposed project is expected to produce a Medical Waste Management Plan (MWMP) to address current medical waste management problems and an Environmental and Social Management Framework (ESMF) to address environmental and social impacts associated with the refurbishment, rehabilitation and construction of health related infrastructures.

This report address the MWMP, the ESMF is prepared as a separate report. The MWMP and the ESMF will provide a framework for measures to mitigate adverse impacts during project implementation. In particular, the MWMP will provide a framework to ensure safe medical waste management at HCFs and waste dump sites to prevent further spread of HIV/AIDS due to unsafe medical waste management. The examination of the existing medical waste handling practices will:

� verify waste management practice in health-care institutions and management by municipal authorities after collection;

� appraise the level of knowledge among health-care staff (doctors, nurses etc.) about the practices to be adopted;

� assess the availability of equipment such as incinerators, autoclaves etc to deal with medical waste; and


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� verify and assess capacity building needs in medical waste management practices.

The MWMP will be prepared according to national policies, regulations and guidelines as well as regulations of the World Bank.

The objective of the plan is to provide processes that the implementing agencies (NACA, SACAs) will follow to maximize project compliance with international and national environmental regulation and ensure that management of HIV/AIDS medical waste is carried out in an environmentally sound and sustainable manner.


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Chapter 2: Baseline Situation

2.1 General Description and Location

Nigeria is situated in the western portion of Africa, and lies between latitudes 40 00’ N and 140

00’ N, and longitudes 20 50’ E and 140 45’ E. Nigeria is bordered by Chad to the northeast, Cameroon to the east , Benin Republic to the west, Niger to the northwest and the Atlantic Ocean to the south. The country’s total area is 923,768 sq km, of which 910,768 sq km is land and 13,000 sq km is water. Nigeria was created by the merging of the northern and southern protectorate by the British Colonial Government in 1914. The country gained independence on October 1st, 1960 and was declared a republic in 1963. The country is divided into 36 states and a federal territory.

Figure 4.1: Administrative Map of Nigeria

2.2 Socio –Economy of Nigeria

The main characteristics of the biological, physical and socio-economic environment of the project area are summarized below.

2.2.1. Demographics

Nigeria is the most populous country in Africa and ninth most populous country in the world. According to the 1991 census, the country’s population was 88.5 million; with an average population density of 96 persons per sq km.

Rivers

EkitiOsun

Lagos

Ogun

Oyo

Delta

Bayelsa

OndoEdo

Kogi

Niger

Kwara

Kebbi

Kaduna

Sokoto

Zamfara

Adamawa

AbiaImo

Anambra

Enugu

CrossRiver

AkwaIbom

Benue

Ebonyi

Taraba

Plateau

FCT

Nassarawa

Katsina

Kano

Jigawa

GombeBauchi

Yobe

Borno

Kilometres

250200150100500

Geopolitical Zones

North West

North Central

North East

South West

South South

South East


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Table 2.1: Demographic Data

1990 1995 2000 2005 2010 2015

Total population (000s) 96,154 111,721 128,786 147,610 168,369 190,922

Urbanization level (%) 35.0 39.6 44.0 48.2 52.0 55.4

Urban population (000s) 33,664 44,184 56,651 71,121 87,557 105,699

Urban population growth rate (%) 5.53 5.44 4.97 4.55 4.16 3.77

Rural population growth rate (%) 1.65 1.55 1.32 1.17 1.1 1.06

Source: UN Habitat 2004

The United Nations estimated the population of Nigeria in 2003 to be 124 million and the 2006 national census report puts the population at 144.7 million, which placed it among the ten most populous nations in the world. Regional differences are significant; population is densest in the south and sparsest in the north. According to the UN, the annual population growth rate for 2000–2005 is 2.53%, with the projected population for the year 2015 at 190 million (Table 2.1).

2.2.2 Economy

Nigeria’s economy depends heavily on the oil sector, which contributes 95 percent of export revenues, 76 percent of government revenues, and about a third of gross domestic product (GDP). Despite the country's relative oil wealth, poverty is widespread - about 37% of the population lives in extreme poverty (World Bank, 2006).

Nigeria’s major industries are located in Lagos, Sango Otta, Port Harcourt, Ibadan, Aba, Onitsha, Calabar, Kano, Jos and Kaduna.

2.2.3 Infrastructural Facilities

The main transportation means in Nigeria is the road. Water transportation is fairly developed in some coastal areas. Air transportation is considered fair with major airports in Lagos, Abuja, Port Harcourt, Kano and Kaduna. The railway sector has experienced a major decline in the last decades but efforts are being made to revive it. Electricity is supplied through the national grid. The power supply is erratic; and government is promoting the development of independent power supply to augment the current inadequate supply. With regard to educational facilities, Nigeria is reasonably served. There are over 65 universities consisting of federal, state and private owned. High schools in most states are insufficient and are in dilapidated state.

Presently the Federal Government is refurbishing all existing tertiary health institutions nationwide. There is at least One (1) primary health care institution in each of the 744 LGAs.

2.3 Status of Health Care Institutions and Facilities

In Nigeria, there are more than 22,000 public and private health care institutions distributed among the 36 states and the federal capital. These institutions are categorized according to their administrative structure as follows:

Tertiary Health Care Institutions

These are funded by the federal government to provide highly specialized services. They include:

- University Teaching Hospitals/Federal Medical Centres - State Specialist Hospitals - Medical Research Institutes/ Veterinary Research Institutes - Pharmaceutical Research Institutes


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Secondary Health Care Institutions

These are funded by the states and provide specialized services to patients referred from the primary health care centres. They include:

- General Hospitals - Missionary Hospitals - Large Private Hospitals

Primary Health Care Institutions

These are funded by Local Governments to provide general medical services. They include:

- Health Centres - Veterinary Clinics - Smaller private hospitals and clinics - Health Stations/Traditional Health Clinics

Table 2.2 Health Care Facilities by State in Nigeria

s/n State Tertiary Secondary Primary Private Public Total Beds Doctors Nurse

1 Abia 2 80 656 473 265 4,420 790 5,530

2 Abuja 2 17 243 225 37 3,540 298 2,280

3 Adamawa 1 12 650 51 612 4,680 268 3,976

4 AkwaIbom 2 188 345 151 384 4,980 482 2,422

5 Anambra 1 576 282 661 198 5,896 1021 7,147

6 Bauchi 1 21 1063 120 965 5,059 328 3,982

7 Bayelsa 1 15 151 6 161 3,210 372 2,548

8 Benue 2 102 1228 534 798 4,185 586 4,488

9 Borno 2 38 440 44 436 6,655 368 3,738

10 CrossRiver 2 51 488 117 424 6,908 640 4,480

11 Delta 1 57 480 244 294 8,520 624 4,368

12 Ebonyi 2 127 560 276 413 6,440 580 4,980

13 Edo 3 282 385 375 295 9,880 1,420 8,484

14 Ekiti 1 31 247 114 165 4,980 822 5,516

15 Enugu 3 178 539 520 200 6,400 866 6,420

16 Gombe 1 16 297 52 262 6,845 268 2,420

17 Imo 3 179 712 667 226 6,840 860 6,020

18 Jigawa 1 58 440 72 427 5,826 438 3,828

19 Kaduna 2 15 1137 333 821 10,280 1,680 7,680

20 Kano 2 42 604 27 621 12,860 1,420 8,400

21 Katsina 1 7 754 5 757 4,400 488 3,820

22 Kebbi 1 23 488 22 490 5,870 680 5,760

23 Kogi 1 62 839 97 805 7,650 1380 8,400

24 Kwara 1 491 73 195 370 8,640 1,340 9,380

25 Lagos 4 1,002 1680 2,220 466 19,892 3,541 23,820

26 Nasarawa 1 26 683 372 338 5,680 438 3,820

27 Niger 1 54 848 180 723 3,580 786 6,320

28 Ogun 3 842 437 790 492 6,850 1,684 11,760

29 Ondo 1 164 611 290 486 4,845 1,453 10,156

30 Osun 164 611 290 487 6,580 832 5,460

31 Oyo 2 43 1240 765 520 9,580 1,620 11,340

32 Plateau 2 38 906 459 486 5,820 1,760 10,846

33 Rivers 1 40 631 381 291 9,860 1,842 11,242

34 Sokoto 1 15 385 29 372 5,480 368 3,980

35 Taraba 1 3 586 189 401 4,320 540 3,890

36 Yobe 1 10 253 0 264 2,680 368 3,182

37 Zamfara 1 28 300 10 319 3,310 302 2,980

Total 58 5,097 22,272 11,356 16,071 243,463 33,853 234,765

Table 2.2 clearly shows the distribution of HCFs in the 36 states and the F.C.T Abuja. In analyzing the distribution regionally, the South West (26%) has the largest proportion of beds in Nigeria, followed by the North Central (20%), North West (16%), South East (14%) ;


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North East (12%) and the least number in the South South with 11%. The south West with the largest number f beds is mainly due the large population in Lagos and Ibadan. An evaluation of the bed capacity data of health care institutions shows the distribution as follows: South West (22%); North West. In terms of the hospital type, the southern part of the country has 73% of private and 36% of public HCFs compared to 27% private and 64% of public HCFs in the Northern part of Nigeria.

2.4 HIV Prevalence in Nigeria

Table 4.4 gives us a break down of HIV prevalence in 36 states and FCT Abuja. Table 2.3: State Level figures for HIV Prevalence in Nigeria

STATE HIV PREVALENCE 95% CONFIDENCE INTERVAL Benue 8.8 5.5-12.1

Kogi 4.5 1.8-7.2

Kwara 3.2 0.9-5.5

Nasarawa 6.8 3.5-10.1

Niger 5.4 2.6-8.2

Plateau 4.6 1.7-7.5

FCT Abuja 5.3 2.3-8.7

North Central Region 5.7 4.6-6.8

Adamawa 5.6 2.5-8.7

Bauchi 3.1 0.8-5.4

Borno 3 0.8-5.4

Gombe 2.5 0.3-4.7

Taraba 3.6 1.1-6.1

Yobe 2.8 0.6-5.0

North East Region 3.4 2.4-4.4

Jigawa 2.5 0.7-4.3

Kaduna 6.3 3.5-9.1

Kano 2.8 1.3-4.2

Katsina 2.3 0.5-4.1

Kebbi 1 0.4-2.4

Sokoto 3.2 1.0-5.4

Zamfara 1.8 0.1-3.5

North West Region 2.9 2.2-3.6

Abia 1.6 0.2-3.4

Anambra 1.8 0.0-3.6

Ebonyi 6.3 3.0-9.6

Enugu 1.3 -1-2.8

Imo 4.1 1.1-7.1

South East Region 2.9 1.9-3.9

Akwa Ibom 8.8 5.1-12.5

Bayelsa 1.1 -4-2.6

Cross River 4.2 1.8-6.6

Delta 1.4 0.2-2.6

Edo 1.1 -4-2.6

Rivers 3.2 1.0-5.4

South South 3.3 2.4-4.2

Ekiti 4.5 1.9-7.1

Lagos 3.1 1.5-4.7

Ogun 8.5 4.8-12.2

Ondo 0.9 -4-2.2

Osun 1.3 .-.2-2.8

Oyo 3 1.1-4.9

South West 3.5 2.6-4.4

Nigeria 3.6 3.2-4.0

Source: NACA – National AIDS Reproductive Health Survey 2007


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At 95% confidence interval, all the regions were statistically valid or fall within the

acceptable/specified region. North Central is highest with prevalence rate of 5.7% followed

by South West (3.5%) and North East (3.4%).

As regards state level, Benue and Akwa Ibom have the highest prevalence rate (8.8%), Ogun

with 8.5%, Nasarawa with 6.8% and Kaduna and Ebonyi with 6.3%. However, the result

shows that the prevalence national average for Nigeria is still high (3.6%). although it is an

improvement when compared against the prevalence rate (4.2%) in 2005.


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Chapter 3: Medical (or Health Care) Wastes and Legal Provisions

3.1 Definition

Medical or Health Care wastes are by-products of health care that includes sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices and radioactive materials. Poor handling of Medical Waste especially those emanating from HIV/AIDS management exposes health care workers, waste handlers and the community to disease and injuries. Although prevention and management of HIV/AIDS help to limit the spread of the deadly scourge and prolong the lives of carriers, the activities also generate wastes and by-products that are hazardous to both human health and the environment. Wastes emanating from HIV/AIDS management include used condoms, hypodermic syringes, needles, hormonal preparations, expired medicines and sanitary towels.

3.2 Health Impacts

HIV/AIDS medical waste is a reservoir of potentially harmful micro-organisms which can infect hospital patients, health-care workers and the general public. Major risks associated with HIV/AIDS medical waste include infections with HIV, hepatitis, sexually transmitted infections (STIs), and other diseases transmitted via body fluids or environmental pollution. The wastes and by-products can also cause injuries, e.g. radiation burns or sharps-inflicted injuries; poisoning and pollution, whether through the release of pharmaceutical products, in particular, antibiotics and catatonic drugs, through the waste water or through toxic elements or compounds such as mercury or dioxins. According to a World Health Organization (WHO) situation analysis regarding health-care waste, such risks are greatest among health care workers, waste handlers, scavengers retrieving items from dumpsites, people receiving injections with previously used needles or syringes, and children who may come into contact with contaminates by playing in areas without restricted access to waste disposal sites. The WHO report also cites “data taken from health care settings” indicating that “a person receiving one needle stick injury from a contaminated sharp used on an infected patient has a probability of 30%, 1.8%, and 0.3% of being infected by Hepatitis B, Hepatitis C and HIV, respectively.” Even treatment and disposal of health care waste which aims at reducing risks, may pose indirect health risks through the release of toxic pollutants into the environment during treatment or disposal if badly done.

3.2 Sources of HIV/AIDS Medical Waste

The major sources of HIV/AIDS medical waste are hospitals, clinics, laboratories, blood banks and mortuaries; while the minor sources are dental clinics, pharmacies, etc. The main actors involved in medical waste management are:

• HCFs that generate the waste; • service providers who collect the waste from the HCFs and transport it to the

treatment facilities; and • treatment facilities that process the waste to make it safe for final disposal.

Based on WHO guidelines and the Basel Convention’s Annexes I, II, VIII and IX classification, medical waste can be broken down into the major categories presented in Table 3.1.


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Table 3.1: Major Categories of Medical Waste Waste type Description

1. Infectious waste Infectious wastes are susceptible to contain pathogens (or their toxins) in sufficient concentration to cause diseases to a potential host. Examples include discarded materials or equipment, used for the diagnosis, treatment and prevention of disease that has been in contact with body fluids (dressings, swabs, nappies, blood bags etc). It also includes liquid waste such as faeces, urine, blood or other body secretions.

2. Pathological and anatomical waste Pathological waste consists of organs, tissues, body parts or fluids such as blood. Anatomical waste consists in recognizable human body parts, whether they may be infected or not.

3. Hazardous pharmaceutical waste Pharmaceutical waste includes expired, unused and contaminated pharmaceutical products, drugs and vaccines. This category also includes discarded items used in the handling of pharmaceuticals like bottles, vials and connecting tubing.

4. Hazardous chemical waste Chemical waste consists of discarded chemicals (solid, liquid or gaseous) that are generated during disinfecting procedures. They may be hazardous (toxic, corrosive, flammable or reactive) and must be used and disposed of according to the specification formulated on each container.

5. Waste with a high content of heavy metals Waste with high contents of heavy metals and derivatives are highly toxic (e.g. cadmium or mercury from thermometers or manometers).

6. Pressurized containers Pressurized containers consist of full or emptied containers or aerosol cans with pressurized liquids, gas or powdered materials

7. Sharps Sharps are items that can cause cuts or puncture wounds (e.g. needle stick injuries). They are highly dangerous and potentially infectious waste. They must be segregated, packed and handled specifically within the HCF to ensure the safety of the medical and ancillary staff.

8. Highly infectious waste This includes microbial cultures and stocks of highly infectious agents from medical laboratories. They also include body fluids of patients with highly infectious diseases.

9. Genotoxic/cytotoxic waste Genotoxic waste includes all the drugs and equipment used for mixing and administration of cytotoxic drugs. Cytotoxic drugs or genotoxic drugs are drugs that have the ability to reduce the growth of certain living cells and are used in chemotherapy for cancer.

10. Radioactive waste Radioactive waste includes liquids, gas and solids contaminated with radio nuclides whose ionizing radiations have genotoxic effects. These include x- and g-rays as well as a- and b- particles.

Source: Safe Management of Wastes from Health-Care Activities, WHO 1999


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3.3 Health Care Waste Management

Improper handling of health care waste (HCW), especially which due to HIV/AIDS management, can create harmful effects and reduce the overall benefits of health care. Generally, lack of awareness about the health hazards, poor management practice, insufficient financial and human resources and poor control of waste disposal are the most common problems connected with general medical waste management in developing countries. Most developing countries do not have appropriate regulations to cover medical waste and where these regulations exist they are not effectively enforced. A major issue is the lack of clarity on whose responsibility is it to handle and dispose medical waste. According to the 'polluter pays' principle, this responsibility lies with the waste producer i.e. the health care provider (hospitals, maternity homes etc).

Urgent improvements are required in the following key areas:

- build-up of a comprehensive system addressing responsibilities, resource allocation, handling and disposal;

- awareness raising and training about risks related to health-care waste, and safe and sound practices; and

- selection of safe and environmentally-friendly management options, to protect people from hazards when collecting, handling, storing, transporting, treating or disposing of waste.

3.4 Legal and Regulatory Framework

This section reviews the current legal provisions for Health Care Waste Management (HCWM) in Nigeria. Currently, there are no specific provisions concerning the handling of wastes emanating from HIV/AIDS management. Legal and institutional HCWM policies on HCWM constitute the essential backbone for safe management of Health Care Waste (HCW) since they will:

• Establish a National Health Care Waste Management Policy compatible with the technical, institutional and financial capacities of the HCFs in Nigeria.

• Support the National Health Care Waste Management Plan, National Health Care Waste Management Policy, and National Health Care Waste Management Guidelines.

• Define the duties and responsibilities of each actor involved in HCWM in Nigeria.

• Set-up legal regulation of HCWM systems within the HCFs. There are a number of relevant government policies at Federal and State levels that are related to giving direction towards a safe and healthy environment which depends largely on the effective management of HCW in the country. However, they are scattered and there is no particular legislation specifically dealing with HCWM in Nigeria as of today.

3.4.1 Review of the Existing Environmental and Health Legislations

At an international level, Nigeria has ratified the Basel Convention on the Control of

Transboundary Movements of Hazardous Waste and their Disposal (1992). It is also party to the Stockholm Convention on the Persistent Organic Pollutants (2002). Although currently there is no specific legislation, regulations or bye-laws for the management of heath care waste in Nigeria, there are relevant laws and regulations pertaining to the protection of the environment and health:


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• Decree no 58 of 1988 establishes the Federal Environmental Protection Agency with: a) the responsibility to monitor and help enforce environmental protection measures; b) the duty to co-operate with Federal and State Ministries, Local Governmental Councils and research agencies on matters and facilities relating to environmental protection; c) the powers to establish standards, inspect, search, seize and arrest offenders.

• Decree no 42 of 1988 Harmful Waste (Special Criminal Provisions, etc) prohibits the carrying, depositing and dumping of harmful wastes (injurious, poisonous, toxic or noxious substance) and prescribes penalties for those found guilty of improper practices.

• Decree no 86 of 1992 sets out the procedures and methods for environmental impact assessments on both public and private projects and states that the “construction of incineration plants” requires an environmental assessment.

Three regulations dealing with environmental issues have been identified including:

• S.I. 8 National effluent limitation of 1991 which makes it mandatory for industrial facilities to install anti-pollution equipment and make provision for effluent treatment. It also prescribes maximum limits of effluent parameters allowed for discharge.

• S.I. 9 National pollution abatement in industries and facilities generating wastes of 1991 imposes restrictions on the release of toxic substances and stipulates requirements for monitoring of pollution to ensure that permissible limits are not exceeded.

• S.I. 15 Management of Solid and Hazardous Wastes Regulation of 1991 deals with facilities that generate solid and hazardous waste. It also covers hazardous waste treatment and disposal facilities and indicates requirements for such facilities including contingency planning, emergency procedures, and alike. Part 12 of this regulation provides for the tracking of wastes from their point of generation to the final disposal with specific details regarding HCW.

Nigeria’s National Policy on Environment was first published in 1989 and revised in 1999. It describes strategies for achieving the policy goal of sustainable development. Sanitation and waste management as well as toxic and hazardous substances are presented. No specific mention is made of HCW, although a number of points can be applied to hazardous substances.

There are several Legislation policies, guidelines, plans and blueprints that are applicable to HCWM in Nigeria. They are as follows:

National Health-Care Waste Management Policy 2007 Summary. This document presents the national policy on waste management in Nigeria taking into account three

(3) sections-(i) General consideration and institutional mechanism in policy implementation at national level, (ii) Requirements for management of HCW in the medical institutions including regulation and definition of institutional Health Care Waste Management Plans.

Definition. The policy stipulates that HCW generated by both public and private medical institutions in Nigeria must be safely handled and disposed of by these medical institutions.

Comments. This document contains specific formulated policies presently been used as well as a laid down framework of lines of responsibilities for all parties involved.

Suggestions. There would certainly be the need for these policies to be formulated in the context of the present situation thus giving for a realistic implementation and adherence by all medical institutions involved to obtain effective results.


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National Health-Care Waste Management Guidelines 2007 Summary This comprehensive document presents guidelines and strategies for the sustainable management of

HCW taking into account waste generation, waste types and waste treatment technologies. Also highlighting a number of critical areas and possible solutions.

Definition Hazardous HCW is of primary concern in Nigeria, due to its potential to cause diseases and/or injuries. Hazards associated with HCW should be incorporated into Nigeria’s HCWM legal, regulatory, technical and informational documents.

Comments HCWM is constitutionally the responsibility of the FMEH&UD and SEPAs, with necessary input and support from the health ministries. Formulation and implementation of HCWM policies and regulations rest with the FMEH&UD in collaboration with FMOH.

Suggestion. There is certainly the need for HCWM planning, formulating and implementing bodies to take into consideration the challenges procuring pragmatic and affordable HCWM disposal technologies.

National Health-Care Waste Management Plan 2007 Summary. This document presents strategies for the management of HCW taking into account the technical,

financial and legal aspects, as well as public awareness, discussing also responsibility of the different levels of government (Local, State and Federal ) and furthermore highlighting critical areas and possible solutions.

Definition. A NHCWM plan looks at practical steps to ensure that hazardous and non-hazardous medical wastes are managed properly to protect humans and the environment against the adverse effects which may occur as a result of indiscriminate handling of such wastes.

Comments. This document provide basic information about the development and implementation of HCWM plans as well as HCW types, treatment and disposal methods, also thus defining duties and responsibilities of staffs for different categories of HCFs in Nigeria.

Draft blueprint on Municipal Solid Waste Management in Nigeria 2000 Summary This comprehensive document presents strategies for the sustainable management of municipal waste

which take into account technical, legal and financial as well as public awareness aspects. It discusses the responsibilities of the different levels of authority (local government, state and federal) and highlights a number of critical areas and hints possible solutions.

Definition An integrated municipal solid waste management strategy is advocated. It is made up of a series of steps that comprise, source reduction, recycling, incineration and land filling.

Comment Solid waste management is constitutionally of the responsibility of the local government councils which in many instances don’t have the means of enforcing current rules. This situation will have to be addressed by getting a better co-operation from the Nigerian Police Forces.

Suggestions There will most certainly be the need for harmonizing laws/bylaws or existing regulations within each state and ideally at national level so as to avoid potential inter-state movements of certain wastes.

Blueprint: Handbook on Hazardous Waste Management ? Summary This document provides a number of definitions and strategies regarding hazardous waste management

as well as a categorization scheme based on the Basel Convention on Control of the Trans-boundary Movements of Hazardous Waste and their Disposal, signed and ratified by Nigeria.

Definition see handbook for details

Comment A few examples of industries which have adopted environmentally cleaner production practices are given, demonstrating that an ecological approach can also be economically interesting.


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Blueprint on Environmental Enforcement, a Citizen’s Guide ? Summary This document aims at defining who the enforcers are (FMEH&UD, SEPA, LGA); how compliance,

monitoring and inspections are conducted as well as types of enforcement actions and tools available. Citizens are encouraged to play an active role both by complying with environmental laws/rules at home and on the job as well as signalling any suspect activities they may notice.

Definition No specific definitions in relation with HCWM issues provided

Comment Suggests informing the general public about their duties and rights regarding environmental issues. To get the message across, it will nevertheless be necessary to conduct information campaigns within schools and with the use of the media.

Blueprint on compliance monitoring inspections ? Summary This guide provides some basic information about the different types of inspections and how to carry

them out.

Definition No specific definitions in relation with HCWM issues provided

3.4.2 Review of Hospital Health Care Waste Regulations

The proper management of HCW depends to a large extent on strong HCFs administration and organisation. HCFs should have well organized HCWM procedures with explicit HCWM rules. These resources must be made readily available as a written document to all personnel of the facility. HCWM regulations for hospitals must demand that financial and material resources are made available so that HCWM procedures can be safely and routinely practiced. Nigeria now has a National Waste Management Plan. This will be used in addition to this project-specific Medical Waste Management Plan (MWMP).

3.4.3 Need for Regulation and Plan for Handling of Wastes from HIV/AIDS

management

Over the last five years, public sector procurement of the male condom has grown substantially in Nigeria. The number of HIV Counseling and Testing (HCT) centres has also soared, and long-term care of People Living With HIV/AIDS (PLWHA) has moved largely from hospitals to communities and households. Also, public sector procurement of injectable contraceptives and female condom has increased. Increases in procurement suggest an increased utilization of these contraceptive methods and a commensurate increase in the generation of wastes. Considering the serious risks posed by wastes generated by HIV/AIDS management, there is an urgent need for a regulation and plan on handling wastes emanating from HIV/AIDS management. Already Nigeria has a National Health Care Waste Management Plan (NHCWMP). This document will provide the framework for handling wastes as a result of the Second HIV/AIDS Programme Development Project (HPDP2).

3.5 National Health Care Waste Management Plan

There is a current National Health Care Waste Management (NMCWM) Plan which identifies the indicators to be tracked, specific tasks to be executed and assigns responsibility for waste collection to specific agencies.

For the national plan to be effectively implemented, all HCFs in the country need to develop standardized plans based on their existing needs. Such plans should focus on treatment, recycling, transportation and disposal options through safe and cost effective treatment and disposal methods.

The most critical needs for the implementation of the national plan are funding and skilled/well-trained manpower. The critical issues identified during the study include the following:


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- Poor medical waste management practices in HCFs and government disposal sites with regard to handling and disposal

- Lack of waste generation data - Inadequate waste treatment and disposal equipment - Inadequate knowledge among those involved in medical waste management - Lack of awareness on medical waste among health workers and the general public - Poor management practices at hospitals and dumpsites - Lack of code of conduct and technical guidelines for safety measures

This project - specific medical waste management plan will operate within the confines of the National Health Care Waste Management Plan and seek ways and means that it will operationalize the action plan; especially the priority three year action plan.


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Chapter 4: Analysis of Medical Waste Management

An analysis of the current situation was conducted with respect to Medical Waste generation segregation, collection, transportation, and disposal. Medical wastes includes infectious wastes such as; swabs, syringes, blades, gloves are mostly mixed with municipal waste and disposed in open dumps where they are either burnt or left to decay.

Existing waste management facilities differ among hospitals, it consists mostly of:

- Incinerators built with primary and secondary burners, and in some cases, drum incinerators, which do not have air pollution abatement facilities;

- Autoclaving; - Chemical disinfection - Microwave irradiation - Open ditches; sanitary landfills - Pit latrines and soak-away; - Transportation of medical waste to off-site disposal sites; and - Use of public drainage for infectious liquid disposal.

In urban areas, unregulated practices by both public, private hospitals and private waste collectors has resulted in dumping of medical waste (infectious and sharps) at municipal dump sites. Scavenging at these disposal sites pose severe public health risks. Possibilities of infections are very high considering the fact that scavengers do not wear any form of personal protection.

4.1 Medical Waste Composition

The average distribution on types of medical waste for purposes of waste management planning is approximately as follows:

- 80% general domestic waste; - 15% infectious and biological (or pathological) waste; - 3% chemical or pharmaceutical waste; - 1% sharps; and - Less than 1% special waste, such as radioactive, cytotoxic, photographic wastes,

pressurized containers, broken thermometers, used batteries, etc.

The quantity of these wastes generated varies greatly between the different categories and location of HCFs. Variations in the composition of waste raises serious issues at the local level which require different approaches with respect to necessary medical waste management procedures to be applied in order to achieve sustainability. The variations may be due to several factors among which are differences in HCF specialization, numbers of qualified health care personnel available, medical waste management practices prevailing as well as recycling and reuse.

4.2 Medical Waste Handling Practices

Medical waste handling is critical in minimizing Health Care associated risks to human health and the environment. The most significant risk occurs during transportation, this highlights the need for regulations and control measures to control segregation. In this respect, the following are necessary:

• Segregation of Medical Waste

Segregation of wastes (infectious, non-infectious, sharps, anatomical parts) generated within hospitals helps in identifying the categories of waste and significantly reduces the risk associated with waste handling. At some teaching hospitals, wastes are segregated into various components.


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- Sharps are systematically stored in separate sharp containers;

- Infectious wastes are stored in yellow coloured containers,

- Anatomical wastes are stored in red coloured containers

- Other medical wastes are collected together into a variety of labeled waste bins and covered.

This practice is however not followed in the other health care institutions visited where all wastes are dumped in the same waste bin.

• Injection Safety

The disposal of sharps is unsatisfactory in many public HCF. This poses significant risk to patients, health workers and the surrounding communities. Although the reuse of syringes and needles was not recorded in most HCFs visited, this cannot be ruled out in the rural areas. Safe disposal of injection is a major cause of concern with respect to the spread of communicable diseases like hepatitis B and HIV/AIDS.

• Waste Collection

Few hospitals have treatment facilities (about 15%) for the wastes generated; hence most of the facilities transport waste off-site for disposal. Where there are disposal sites, the wastes are not removed on schedule and are not properly transported to the disposal site. At some of the private hospitals, collection of waste is limited to once a day when the cleaner comes in the morning to clean the entire facility. Storage and collection was observed to be most organized at general and teaching hospitals.

• Waste Transportation

Some facilities gather the wastes in bags and cartons and then transported off-site in secure trucks. In the rural areas, the wastes are often buried or burnt within the facility. At the Ikeja hospital (Lagos), sharps and other wastes are transported to a private landfill for burial while anatomical and pathological wastes are buried at Atan Cemetery.

• Waste Disposal

Current disposal practices varied depending on the category of the facilities, and type of disposal facilities available. All categories of infectious wastes were burnt except placenta and other anatomical wastes that are buried.

The scenario is different at some of the secondary, primary and private health centers visited. At the private clinics located in the semi-urban and rural areas, there are no significant differences in the way the medical waste and sharps are disposed. All waste are either buried or transported and dumped at the public dumpsite. Table 5.1 shows the findings from field assessment as regards handling of waste emanating from management of HIV/AIDS.


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Table 4.1: Findings from Field Assessment Waste Disposal Practice Risks/Concerns Sharps and Used Medical Supplies Incinerated disposed in pits or in the

open, collected by specialized firms, mixed with general waste

Risk of infections at community level, exposure of garbage workers to infection

Condoms Via Solid Waste, pit laterines and toilets

Exposure of children, unsightly and nuisance at community level, risks of disease acquisition, no disposal guidelines provided, blockage of sewage system

Sanitary Materials Collected by specialized firms, collected and burned in an onsite incinerator, concealed and disposed with general garbage, left discarded inside rooms

Inadequate PPEs for cleaners, blockages of toilet drains , no posters to inform client on proper disposal, no disposal bins for lodges

4.3 Responsibility for Medical Waste Management

Responsibilities for waste management are not well defined in most HCFs except in Tertiary and Secondary HCFs. It was observed that there were no adequately trained and competent personnel assigned to waste handling at most institutions. Most institutions do not have Environmental Health Officers and have delegated this duty to administrative staff.

In Tertiary and Secondary HCFs, Medical waste Management Committees should be constituted and should include:

− Chief Medical Officer,

− Head of Hospital Departments,

− Chief Pharmacists,

− Radiation Officer,

− Financial Controllers,

− Senior Nursing Officer/ Head Matron and

− Hospital Administrator. In Primary HCFs (Rural and Urban), Medical Waste Management Committees should be constituted and should include:

- Senior Nursing Officer/Matron - Hospital Administrator - Nurses

Employers have a number of legal responsibilities which include:

− developing and maintaining a safe work environment and safe work practices;

− ensuring that hospital activities complies to state and national environmental standards;

− providing staff training and education for the safe handling of waste. Employees also have responsibilities which include:

− complying with safety instructions and the use of safe work practices for their own protection and for the protection of other staff and the public;

− actively supporting environmental initiatives introduced by the waste management committee;

− comply with the requirements for the handling of chemical substances according to Material Safety Data Sheets (MSDS).


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Chapter 5: Medical Waste Generation and Management Practices

This chapter analyses the present status of medical waste generation and management in Nigeria and subsequently recommends guidelines for collection, on-site handling, storage, transportation, treatment and safe disposal of medical wastes. Current management practices constitute both a public health and environmental hazard. When dump sites are visited, many scavengers can be seen sorting for recyclable materials, a practice which is dangerous for the scavengers. In addition, it was found that some staff in HCFs are unaware of the hazards of medical wastes.

It is concluded that a new management system, which consists of segregation, material substitution, minimization, adequate treatment and sanitary land filling should be encouraged.

The HIV/AIDS Waste generated with a HCF should follow an appropriate and well defined stream from their point of generation until their final disposal. The stream is composed of various steps as seen in Figure 5.1.

Step Location Health Care Waste Stream Key points

0 Waste Minimization Not recommended for HIV/AIDS

infectious waste

1

2

In HIV/AIDS

Medical Unit of HCF

One of the most important steps to reduce risk and amount of waste

3

Protective equipment, sealed containers

4

Lockable easy to clean storage rooms; limited storage time of 6 hrs

5

Inside HCF

Adequate storage room, limited of max. 6 hrs

6

Appropriate vehicle and consignment note. HCF is informed about final

destination

7 Outside

HCF Appropriate vehicle and consignment

note to ensure final destination

Figure 5.1: Synopsis of the HIV/AIDS Waste Stream

5.1 Waste Generation

The medical wastes are generated from various sources. These sources can be classified as major or minor. The major sources include tertiary and secondary institutions i.e. teaching and specialist hospitals while minor sources include primary health care institutions including private hospitals, private laboratories, public health centers, dental clinics and pharmacies. The composition and quantity of the waste is often a characteristic of the source. For example, the operating theatres and surgical wards generate mainly anatomical waste such as tissues, organs, body parts and other infectious waste.

- Solid Waste

Solid waste generation depends on numerous factors, such as category of health-care institution, the proportion of patients treated on a daily basis and the degree of sterilization of the HCF. Hence, the teaching and specialist hospitals generate larger quantities of waste per


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unit than other facilities. Solid wastes generated from healthcare activities include but not limited to the following:

• General waste – e.g. paper, cartoons, plastic, food items, bottles etc

• Blood-soaked bandages

• Culture dishes and other glassware

• Discarded surgical gloves – after surgery

• Discarded surgical instruments – scalpels

• Needles – used to give shots or draw blood

• Cultures, stocks, swabs used to inoculate cultures

• Removed body organs – tonsils, appendices, limbs, etc.

• Lancets – the little blades the doctor pricks your finger with to get a drop of blood.

- Liquid Wastes

Liquid wastes generated from Health Care activities include excreta, bath water from wards and waste water from laboratories (specimens, reagents etc), operating theatres and mortuaries. Some have highly infectious potential. Excreta are channeled into septic tanks that are emptied periodically or into various types of treatment plants. Most of the other liquid waste are poured down the drains of sinks and flow into open drains (gutters) which enter the external sewerage system ending up in water bodies draining the area. In some cases (particularly in the rural areas where plumbing facilities are rudimentary) some of these liquid wastes end up on the ground or on plants in the vicinity of the facilities.

- Air Emissions

Air emissions generated from healthcare activities are few compare to solid and liquid waste. Emission sources include sterilization process, catering and laundry activities. Other sources include open burning of refuse and incineration of infectious wastes. This emission may be in the form of vapour and smoke. Some facilities utilizes electric generators to augment power supply, these generating sets are powered by diesel or gasoline and result in emission of priority pollutants (NOx,SOx,CO2 etc).

5.1.1 Waste Categories

The following classification of medical waste in Nigeria based on the point of generation, method of storage and the treatment options available by the health establishments are as follows:

Table 5.1: Typical Waste Generated in Hospitals

Classification /Description Content / Examples

General Waste

This are similar to domestic waste, which are not harmful e.g. papers, cartoons, offices, kitchen etc.

Cardboard, plastic materials, kitchen waste ash, saw dust, pieces of wood etc.

Infectious Waste

This are generated at in- and out-patients areas and are likely to contain pathogenic microbes

Microbiological laboratory waste potentially infected blood and human tissue

Sharps

Sharp edged waste stained or contaminated with blood or body fluids e.g. needles, syringes etc.

Needles syringes, surgical blades, scalpels, test tubes, ampoules, glass instruments, pipettes


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Patient Waste

Include waste generated from in or outpatient activities, which may be contaminated with blood or body fluids from surgery, injection room etc

Stained or contaminated material (e.g. soiled cotton wool , used bandages/dressings, gloves, linen blood transfusion bags, urine, faeces

Culture / Specimen

Clinical specimen, laboratory culture and human tissue. Culture plus specimen (e.g. experimental specimen tissue culture, urine, stool). Urine faeces (stool) from laboratory

Pathological / Organic Human Tissue

This includes amputations and other body tissue resulting from surgery, autopsy, and birth. They require special treatment for ethical reasons.

Internal body organs, amputated limbs, placentas, foetus, human liquid wastes ( urine, blood products)

Hazardous Waste

consist of materials hazardous characteristics and therefore require special management

pharmaceutical , laboratory, organic substances, heavy metals and other chemical contamination

Pharmaceutical Waste

These are waste generated from the pharmacy Expired drugs, plastic or glass containers

Photographic Chemical Waste

Any waste material solid or liquid produced from image processing at the radiology department

Photographic developer/ Fixer solution X-ray photographic films

Radioactive Waste

Any solid liquid or pathological waste contaminated with radioactive isotopes of any kind

Solid- papers, gloves, cotton swabs, needles (sharps), equipment etc. excretion, gastric content Spent radiation sources,

Laboratory Waste

This is made up of basically spent chemicals for research and analytical laboratories and pharmaceutical companies

Acid, Alkali, organic substances, Solvents and heavy metals/Chromo sulphuric, Hydrochloric and Oxalic acid & Glacial acetic

Acids Peracetic acid , acetic acid

Alkali Sodium/Potassium Hydroxide, Ethanol, etc.

Solvents alcohol, formalin

Organic Substances paraffin, phenol, and polyvinyl chloride tape

Heavy Metals Mercury from thermometers

Incinerator Ash and Sludge

Waste generated from the combustion of waste which have to be disposed in a land fill site

Incinerator fly ash and its residues, leachates

5.2 Waste Management Practices

5.2.1 Segregation of Waste and Packaging

- Solid Wastes

Some health institutions visited practice segregation based on WHO/FMOH infection control sensitization programs as seen in Table 5.2. Although, there are no official waste segregation policies or system for categorization of medical wastes. Sharps (needles and syringes) and pathological wastes (e.g. placenta and body parts) were observed to be separated from the rest of the waste in most facilities.

Table 5.2: Recommended Colour-Coding for Health Care Waste (WHO/FMOH) Type of waste Colour of container and markings Type of container Highly infectious waste Yellow, marked “HIGHLY

INFECTIOUS” Reusable plastic container lined with strong leak-proof plastic bag capable of being incinerated

Other infectious waste, pathological and anatomical waste

Yellow Reusable plastic container lined with strong leak-proof plastic bag capable of being incinerated

Sharps Yellow, marked “SHARPS” Puncture proof container

Chemical and pharmaceutical waste

Brown Leak-proof bag or container

General health care waste Black Container lined with plastic bag


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Needles and syringes were collected into specially designed boxes (Figure 6.1). See Annex 1 for specifications of sharp containers. When these boxes are not available, many institutions use improvised boxes with holes at the top. Few institutions especially in the rural areas however still combine sharps with general waste.

UNICEF & WHO Safety Box: Cheaper Option

HDPE boxes: a much more expensive option

Figure 5.2: Boxes for Sharps Disposal

5.2.2 Treatment of Waste

- Chemical Disinfection

This is used in some facilities for treating pathological waste in the form of placenta tissue prior to burial. Few institutions chemically disinfect needles before burning or burial.

- Sterilization

Autoclaves are principally used in most facilities to disinfect instruments and theatre linings and not for waste treatment. In rural facilities, steam disinfection by boiling is often employed, although this is not very effective as temperatures reached are not up to the required 1200oC attained in autoclaving.

5.2.3 Waste Disposal Practices

- Burial

Placentas are usually buried. Sometimes the hole is very shallow with a high potential for being dug up by animals. Few hospitals have private off-site sites for burial. Other body parts (e.g. amputated limbs etc) are incinerated where incinerators are available or buried in public cemeteries.

- Incineration

Modern and efficient incinerators are available only in tertiary health centers e.g. National Orthopaedic Hospital, Igbobi and University College Hospital, Ibadan. Improvised (brick and drum) incinerators were observed in some hospitals for needles and syringes after immunizations. They are quite effective, but generate considerable air pollution. In rural areas, the open burning is applied to treat general, sharps and infectious wastes.

- Open Dump Sites

Open dumps are the disposal method currently employed for most of the solid waste i.e. infectious, general, pharmaceutical and in some cases, sharps. Currently, the dumping grounds are not engineered to serve as sanitary landfill sites. They therefore constitute a high risk potential for the spread of infections through run offs during rains and contamination of surface and ground water.


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- Septic Tanks and Public Drains

Excreta are channeled into septic tanks and emptied often or into treatment plants e.g. National Orthopaedic Hospital – Igbobi and LUTH. Other liquid wastes are emptied into sinks and drains thereby entering natural drainage systems. In rural areas, liquid wastes are discharged into bushes and may enter water bodies draining the area.

5.3 Potential Impacts of Existing Medical Waste Management Practices

- Soil Pollution

There is a high risk potential for infection and chemical contamination of soil, particularly from liquid wastes flowing into soil. The potential of contamination from untreated sharps, anatomical and infectious wastes buried or dumped indiscriminately may lead to the entry of pathogens and chemicals into the food chain.

- Surface and Groundwater Contamination

There is a high risk potential for infectious and chemical contamination of streams, rivers and lakes from effluents from health-care facilities flowing into drains and run-off from soil during rains following dumping of infectious and chemical wastes. The potential for groundwater contamination from buried infectious wastes, sharps and body parts is also significant.

- Occupational Health and Safety Hazards

Most waste handlers are unaware of the potential risks involved in handling medical waste; in most cases they do not have adequate protective clothing and disinfectants. They are exposed to a high risk potential of infection following injuries from sharps, handling of infectious materials and human parts.

There is the need for selection of environmentally and socially friendly options to minimize occupational injuries during collection, handling, storage, transportation, treatment and disposal of medical waste.

- Transport of Health Care Wastes within the institutions

WHO guidelines require that waste bags should be made of polyethylene with minimum thickness of 150 micron and resistant to puncture during transportation. In order to reduce the cost for this task, most of the plastic bags manufactured do not comply with this requirement. These bags are easily torn and their content which may also be infectious can spread into containers, vehicles and the environment.

5.4 Existing Disposal Facilities

There are disposal sites all over the country particularly open dumps. There are currently no sanitary landfills in Nigeria. These are unsuitable for the disposal of hazardous and medical waste and poses serious public health hazard. Few of these sites are discussed below: The consultants visited some disposal sites in Lagos and Abuja; and the results were:

Lagos State

− Ojota

The dumpsite covers an area of about 42 hectares, and situated in the northwestern part of Lagos. It was originally a burrow pit from where lateritic soil was mined. The facility is fenced round and is presently managed by the Lagos Waste Management Authority (LAWMA). The dumpsite site is surrounded by industrial and residential communities; hence it poses high risk to both ground and surface waters. There is also the risk of air pollution from open burning of wastes at the site. For the facility to be effective for carcass disposal, the ground has to be reconstructed and properly lined to retain fluids and other effluents.


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− Isolo

The Isolo landfill is located in the West-Central area of Lagos and sits on 7.5 hectares. It is situated in a low-lying flood prone area west of residential facilities which poses a high possibility of groundwater contamination in the area. The dumpsite has been in operation since 1981 and is managed by Lagos State Waste Management Authority (LAWMA). All sorts of wastes are disposed off at this landfill including medical wastes. About 80% of the wastes received at this site are household wastes. Toxic and hazardous waste are reportedly not received at this landfill.

− Agege

This landfill has been in operation since 1983 and is situated in the outer northwestern portion of Lagos. It covers an approximate area of 5 hectares and is bordered on all sides by residential communities. Within the facility is a 30m x 150m x 7m deep retention pond. Waste including asbestos sludge from industrial facilities, domestic, medical and other toxic and hazardous wastes are dumped at this facility.

The landfill is not lined and as such there is high risk of groundwater contamination (leachates) and air pollution (open burning). There is also potential risk to public health from scavenging.

F.C.T. Abuja

Waste is dumped at a designated dumpsite which covers approximately 4 hectares of land. All sorts of waste are dumped there including medical waste. There is no payment for disposal, this just a large area that is covered with scattered waste. There is also no coverage of dumped waste hence waste is easily blown by wind.


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Chapter 6: Technologies for Medical Wastes Disposal in HPDP2

Medical wastes generated within health-care facilities under the HPDP2 should follow an appropriate and well-identified stream from their point of generation until their final disposal. This stream is composed of several steps that include: generation, segregation, collection and on-site transportation and offsite transportation, treatment and disposal. The various medical wastes treatment and disposal options are briefly described below.

6.1 Medical Waste Treatment and Disposal Technologies

The choice of treatment and disposal method for medical wastes depends on factors, many of which depend on the local conditions:

- disinfection efficiency; - health and environmental considerations; - volume and mass reduction; - occupational health and safety considerations; - quantity and type of wastes for treatment and disposal; - capacity of treatment and disposal technologies; - infrastructure requirements; - locally available treatment options and technologies; - options available for final disposal; - training requirements for operation of the method; - operation and maintenance considerations; - location and surroundings of the treatment site and disposal facility; - investment and operating costs; - public acceptability; and - regulatory requirements.

The different available methods are considered below.

6.1.1 Sterilization

− Autoclaving

Steam autoclave treatment combines moisture, heat and pressure to inactivate micro-organisms. Steam autoclaves are constructed with a metal chamber to withstand the increased pressure/temperature. Saturated steam is pumped into the autoclave at temperatures around 160°C. The pressure in the vessel is maintained at 5 bar gauge for a period of up to 45 minutes to allow the process to fully 'cook' the waste. At the appropriate levels of time (> 60 min), temperature (>121°C), and pressure (100 kPa) effective inactivation of all vegetative microorganisms and most bacterial spores can be achieved. Preparation of material for autoclaving requires segregation to remove unsuitable material and shredding to reduce the individual pieces of waste to an acceptable size. Autoclaves are typically used in hospitals for the sterilization of reusable medical equipment. They allow for the treatment of limited quantities of waste and are therefore commonly used only for highly infectious waste, such as microbial cultures or sharps.


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Figure 6.1: Flow diagram of a Typical Autoclave/Steam Sterilisation Plant

− Microwave Irradiation

Microwave irradiation is a thermal disinfection system designed for treating and rendering infectious medical waste safe for conventional disposal. In microwave treatment, a loading device transfers the wastes into a shredder, where it is reduced to small pieces. The waste passes through a preparative process of segregation to remove undesirable material, and then it is triturated, pulverized, and compressed prior to its disinfection. The shredded material is subjected to steam and heat by microwave energy to disinfection temperature. Since the technology does not involve the application of steam, there is a minimal generation of wastewater stream, and with the appropriate conditioning it can be recycled to the system. Since electricity is the main source of energy for operating this technology, gas emissions are also minimal compared to autoclaving.

Inputs: HIV/AIDS MW

W ater (if was te is dry)

Power to feed mic rowave generator

Process: Feeding system Size reduction Heat and

mic rowave treatment

Compaction Unloading to container/t ruck

Transport to landfill

Outputs: W ater vapour Waste water Landfilling of treated waste

Figure 6.2: Flow Diagram of a Typical Microwave Plant

6.1.1.1 Advantages and Disadvantages of Sterilisation Technologies

The main advantages and disadvantages of autoclaving and microwaving, technologies are in many ways similar as listed in the Row 1 of Table 6.1. There are however some differences that are highlighted in Rows 2 to 4 of the same Table. 6.1.

Gas Emissions

Gas Cleaning

In p u ts : H IV /A ID S M W

S t e a m g e n e r a te d

fr o m fr o m g a s / o il

P r o c e s s : F e e d i n g s y s te m S i z e r e d u c ti o n H e a t a n d p r e s s u re t r e a tm e n t C o m p a c ti o n U n lo a d in g t o

c o n t a in e r /t r u c k T r a n s p o r t to

l a n d f il l

O u t p u ts : W a s t e w a t e r a n d w a t e r v a p o u r W a s te w a te r L a n d fi l l i n g o f

t r e a te d w a s t e


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Table 6.1: Advantages and Disadvantages of Autoclaving and Microwaving

Advantages

Disadvantages

Autoclaving, Microwaving, (Cross cutting) High sterilisation efficiency under specified conditions; Volume reduction depending on type of shredding / compaction equipment used; Generation of harmful dioxins and furans very low and often below detection limits; Low risk of air pollution; Moderate operational costs; Easier to locate as generally more acceptable to neighbouring communities than for incineration; Recovery technologies can be used on sterilised waste, e.g. for plastics if not shredded and if safe for human contact

Not suitable for pathological waste and chemical waste, including pharmaceuticals and cytotoxic compounds; Good HCW segregation required; No or limited mass reduction; Shredders are subject to breakdowns and blockages and repairs are difficult when the HCRW is infectious; It is not possible to visually determine that HCRW has been sterilised; HCRW is not rendered unrecognisable or unusable if not shredded either before or after sterilisation; Significant monitoring costs to demonstrate compliance with sterilisation standards; Treated HCRW must be disposed to landfill, but it should not be accessible to humans or animals due to the presence of sharps as well as the risk of infection if not effectively treated; Air filtration is needed; Operation requires highly qualified technicians.

Autoclaving Proven system that is familiar to health-care providers; Relatively high sterilisation temperature.

Significant amounts of volatile organic carbon compounds produced; Contaminated water must be discharged to sewer; HCRW and containers must have good steam permeability, especially if there is no prior shredding; No volume reduction.

Microwaving Low capacity units are available for small HCRW producers e.g. clinics and GP’s; Moderate investment costs; Low sterilisation temperature may reduce energy costs.

Unsuitable for very high quantities of contaminated metal (e.g. needles from inoculation campaigns); Low sterilisation temperature increases time required for treatment.

6.1.2 Chemical Disinfection

Chemical disinfection is used routinely in health care to kill micro-organisms on medical equipment and on floors and walls and is now being extended to the treatment of HCW. Chemicals are added to the waste to kill (inactivate) the pathogens it contains; this treatment usually results in disinfection rather than sterilization. Chemical disinfection is most suitable for treating liquid waste such as blood, urine, stools, or hospital sewage. However, solid - and even highly hazardous - health-care wastes, including microbiological cultures, sharps, etc., may also be disinfected chemically, with some limitations. The most frequent chemical disinfectants are:

- Chlorine - is a very active against micro-organisms. In case of possible HIV/AIDS infectious materials, concentration of 5 g/litre of chlorine is recommended.

- Formaldehyde - which is an active gas against all micro-organisms except at low temperature (<20°C); the relative humidity must be near 7 %. This disinfecting product is recommended for Hepatitis.

6.1.3 Incineration

Incineration is a high-temperature dry oxidation (combustion) process that reduces organic and combustible waste to inorganic and incombustible matter. The process is usually selected to treat wastes that cannot be recycled, reused, or disposed of in a landfill. Three basic kinds of incineration technology are of interest for treating health-care waste:

− double-chamber pyrolytic incinerators, which may be especially designed to burn infectious health-care waste;


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− single-chamber furnaces with static grate, which should be used only if pyrolytic incinerators are not affordable;

− rotary kilns operating at high temperature, capable of causing decomposition of genotoxic substances and heat-resistant chemicals.

Incinerators designed especially for treatment of medical waste should operate at temperatures between 900 and 1200°C. All types of incinerator, if operated properly, eliminate pathogens from waste and reduce the waste to ashes. However, certain types of health-care wastes, e.g. pharmaceutical or chemical wastes, require higher temperatures for complete destruction.

Inputs: HIV/AIDS MW Electrici ty, support fuel (oil/gas) & ai r

Support fuel (oil/gas) & air

Coling water (circulated)

Process: Feeding system Primary

combustion chamber (solids

and gases)

Secondary combustion

chamber (fl ue gases)

Boiler/heat exchanger/cooling

system Flue gas cleaning

system Stack

Outputs: Bottom ash (l andfill ed)

Heat and/or hot water (to be utilised)

Cleaned flue gas (to the air)

Dry process: Chemicals or

Wet Process : chemicals + water

Dry process : Fly ash + used chemicals

(landfilled) or Wet

process: F ly ash + sludge (landfilled) and

waste water (sewer system)

Figure 6.3: Flow Diagram of a Modern Incineration Plant.

Table 6.2: Characteristics of Waste Suitable/Unsuitable for Incineration

Suitable Waste Unsuitable Waste

• Low heating value: above 2000 kcal/kg (8370 kJ/kg) for single-chamber incinerators, and above 3500kcal/kg (14640kJ/kg) for pyrolytic double-chamber incinerators.

• Content of combustible matter above 60%.

• Content of non-combustible solids below 5%.

• Content of non-combustible fines below 20%.

• Moisture content below 30%.

• Pressurized gas containers.

• Large amounts of reactive chemical waste.

• Silver salts and photographic or radiographic wastes.

• Halogenated plastics such as PVC.

• Waste with high mercury or cadmium content, such as broken thermometers, used batteries etc

• Sealed ampoules or ampoules containing heavy metals.

Incineration equipment should be carefully chosen on the basis of the available resources and the local situation, and of risk–benefit considerations balancing the public health benefits of pathogen elimination before waste disposal against the potential risks of air or groundwater pollution caused by inadequate destruction of certain wastes.

− Double Chamber Pyrolytic (Controlled Air) Incinerators

This the most reliable and commonly used treatment process for medical waste incineration. It comprises a pyrolytic chamber and a post-combustion chamber and functions as follows:

− The waste is thermally decomposed through an oxygen-deficient, medium-temperature combustion process (800–900°C), producing solid ashes and gases. The pyrolytic chamber includes a fuel burner, used to start the process.


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− The gases produced in this way are burned at high temperature (900– 1200°C) by a fuel burner in the post-combustion chamber, using an excess of air to minimize smoke and odours.

Adequately maintained and operated pyrolytic incinerators of limited size, as commonly used in hospitals, do not require exhaust-gas cleaning equipment. Their ashes will contain less than 1% unburnt material, which can be disposed of in landfills.

− Rotary Kilns

A rotary kiln comprises a rotating oven and a post-combustion chamber. They are suitable for burning chemical and medical waste. The axis of a rotary kiln is inclined at a slight angle to the vertical (3–5% slope). The kiln rotates 2 to 5 times per minute and is charged with waste at the top. Ashes are evacuated at the bottom end of the kiln. The gases produced in the kiln are heated to high temperatures to burn off gaseous organic compounds in the post-combustion chamber and typically have a residence time of 2 seconds. Rotary kilns may operate continuously and are adaptable to a wide range of loading devices. Those designed to treat toxic wastes should preferably be operated by specialist waste disposal agencies and should be located in industrial areas.

− Single-chamber incinerator

In single chamber incinerators the combustion is initiated by addition of fuel and then continues unaided. Air inflow is usually based on natural ventilation from the oven mouth to the chimney; if this is inadequate, however, it may be assisted by mechanical ventilation. Periodic removal of soot and slags is essential. Atmospheric emissions will usually include sulphur dioxide, hydrogen chloride, and hydrogen fluoride, black smoke, fly ash (particulates), carbon monoxide, nitrogen oxide, heavy metals, and volatile organic chemicals. To limit these emissions, the incinerator should be properly operated and carefully maintained, and sources of pollution should be excluded from the waste to be incinerated whenever possible.

6.1.3.1 Advantages and Disadvantages of Incineration

The main advantages and disadvantages of incineration as a technology for HIV/AIDS Medical Waste treatment are listed in Table 6.2.


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Table 6.3: Advantages and Disadvantages of Incineration

Advantages of incineration Disadvantages of incineration

� Safe elimination of all infectious organisms in the HCRW at temperatures above ~700oC;

� Flexible, as it can accept pathological HIV/AIDS

MW and depending on the technology, chemical / pharmaceutical HCRW;

� Residues are not recognizable; � Reduction of the HIV/AIDS MW by up to 95% by

volume or 83% to 95% by mass (typically 5-17% ash remains). Depending on the type of flue gas cleaning system used, additional residues are being generated which limits the volume and weight reduction;

� Well proven technology; � No pre-shredding or post-shredding required; � No special requirements for packaging of HCRW; � Full sterilisation is assumed to have occurred

provided the high temperatures are maintained and the ash quantity is adequate. No monitoring of sterilisation efficiency is required.

� Normally higher investment costs for incinerator with flue gas cleaning system than for non-thermal technologies;

� Point source of emissions immediately to the air (as

opposed to attenuated emission of CH4 and CO2 from landfill waste body over a period of decades);

� Production of the highly hazardous dioxins and

furans and heavy metals must be minimized and controlled;

� High cost to monitor gas emissions and demonstrate

compliance to emission standards; � Solid and liquid by-products must be handled as

potentially hazardous waste (may not apply to bottom ash if HCW is well sorted and flue gas cleaning residues handled separately);

� Incineration is perceived negatively by many sectors

of the community; � PVC and heavy metals in the HCRW provide a

significant pollutant load on the gas cleaning system (and for heavy metals on the quality of bottom ash also).

This report recommends the following technologies for the disposal of HIV/AID medical wastes:

Table 6.4: Recommended Treatment and Disposal Technology for Health Care Facilities

Facility Type Recommended Technology

Primary Healthcare Facility (Rural Area)

- De Monfort Incinerators - Chemical disinfection

Primary Healthcare Facility (Urban Area)

- De Monfort Incinerators - Chemical disinfection

Secondary Healthcare Facility e.g. General Hospital

- De Monfort Incinerators - Autoclaving

Tertiary Healthcare Facility e.g. University Teaching Hospitals

- Pyrolytic incinerator - Autoclaving

Regional Waste Disposal Sites - Modern Pyrolytic Incinerators


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Chapter 7: Institutional Arrangements and Implementation Responsibilities

The overall institutional architecture of the project will remain largely the same with operations being coordinated by NACA at the Federal level and the SACAs at the State level as in the first phase. Capacity-building activities under the first project have strengthened these organizations considerably. Nationally, the project will be placed under the overall responsibility of NACA, the National Agency for the Control of AIDS. NACA was the implementing agency for Project 1 and has performed well. In 2008 NACA, which had been a committee under the Presidency, was made a government agency established by law. NACA has overall responsibility in the country for setting HIV/AIDS policy and ensuring the coordination of HIV/AIDS activities across ministries. Within the proposed project, NACA is responsible for setting priorities for action and financing, approving eligible action plans prepared by Federal Ministries and national civil society organizations proposing multi-state programs for HAF financing, monitoring the epidemiological situation in the country, and evaluating the national response. Under the previous project, NACA’s capacity was strengthened considerably particularly on financial management and procurement issues. At the Federal level NACA will be responsible for implementing all project activities with Federal ministries and parastatals was well as managing the Federal level HAF activities. NACA will also manage capacity-building activities at the Federal level. NACA’s role vis a vis the SACAs is to provide the overall national strategic direction within which States will tailor their activities based on the particular characteristics of the State epidemic. NACA will provide technical assistance to the States across the full-range of project activities including the HAF, the Public sector component and overall M&E. NACA will organize the work planning exercises and review all state work plans and procurement plans before processing by the World Bank (see work planning flow chart below). It will also promote the sharing of best practice experiences and develop capacity-building activities to address needs at the State level. At the state level, project activities will be based in the State Action Committees on AIDS (SACAs). The SACAs are responsible for developing state priorities for action, reviewing and approving proposals prepared by state Ministries, and by NGOs and communities requesting funding through the HAF at the state level, as well as monitoring the epidemic in the state, and evaluating the performance of state implementing agencies. All states now have SACAs and in eight states SACAs have been transformed into legally established government agencies. Agency status will provide access to on-going financial support from the state and gives the SACAs a better institutional platform from which to coordinate other partners. The project will encourage other states to establish agencies. Each SACA will be required to maintain a core group of staff designated to support the project: these include the project manager, the accountant, the internal auditor, the procurement officer, the community mobilization officer and the monitoring and evaluation officer. With respect to the implementation of this Medical Waste Management Plan (MWMP), it is recommended that each PIU (SACA) recruits an environmental specialist/consultant on a part time basis that will be responsible for following up the recommendations of the MWMP. Alternatively a consultant should be recruited to do same task and could provide information as and when necessary during World Bank supervision missions.


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Capacity building in medical waste management issues is very essential during project implementation.

7.1 Training Needs Assessment

Correct attitudes for effective medical waste management result from knowledge and awareness regarding the potential risk of health-care and administrative procedures for handling the waste. Apart from a general understanding of the requirements of waste management, each category of personnel (doctors, nurses, ward attendants, cleaners, administrative staff, waste transporters, dumpsites, hospitals etc.) needs to be trained. For the training to be successful and to lead to the desired objective, participants must become aware of the risks linked to medical waste management.

The principal groups involved in waste generation and management are:

- Primary group: (i) management and administrative staff; (ii) medical and laboratory staff; (iii) ward attendants, caretakers, ground workers and other support staff; and

- Secondary group: patients, visitors, scavengers and the local communities, waste collectors/transporters, disposal site operators etc.

The training needs identified based on interview of the categories of actors involved are presented below:

Health Care Staff

Administrative staff

- Information on potential risks and advice about health and security - Basic knowledge of procedures of medical waste collection, storage, transportation,

treatment and final disposal including the management of risks. - Use of protection and security equipment - Medical waste management guidelines - Financial resources to be allocated to waste management.

Doctors, nurses, midwives, etc.

- Information on the risks; advice about health and security - Basic knowledge about procedures of HCWM waste collection, storage, transportation,

treatment and final disposal including the management of risks. - Use of protection and security equipment (protective clothes) - Strategies to control and ensure that used disposable equipment/materials are placed in

appropriate disposal and collection facilities and to ensure that all patients are safe from injury or hazards resulting from medical waste

- HCW segregation at source - Staff orientation on the guidelines for waste management - Good practices on medical waste

Cleaners, ward attendants, grounds attendants, other personnel in touch with waste, etc.

- Information on the risks; advice about health and security - Basic knowledge about procedures of medical waste collection, storage, transportation,

treatment and final disposal including the management of risks. - Collection and transportation of waste containers - Use of protection and security equipment (protective clothes) - Good practices on medical waste


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Waste Management Company Personnel

Waste Management Operators

- Information on the risks; advice about health and security - Basic knowledge about procedures of wastes handling, including risk management. - Use of protection and security equipment.

Waste Transportation Staff

- Risks linked with waste transportation; - Procedures for waste handling: loading and unloading; - Equipment such as vehicles for waste transportation; - Protection equipment.

Treatment Systems Operators

- Treatment and operating process guidelines; - Health and security related to the operating system; - Procedures in emergency cases and help; - Technical and maintenance procedures; - Control of waste production;

Disposal Managers

- Information about health and security - Control of scavenging activities and recycling of used instruments; - Protection equipment and personal hygiene; - Secure procedures for the management of wastes at the disposal site; - Measures concerning emergency cases and help.

Others

Patients and visitors

- Advice on basic medical waste management - Proper use of waste containers

7.2 Training Strategy

The training strategy shall operationalize the NMWMP in all health-care facilities by promoting the emergence of professionals in waste management; raising the sense of responsibility of healthcare personnel; and safeguarding health and security of health staff and waste handlers. Annex B gives an indicative table of training courses and personnel needed.

The training plan shall be structured around the following principles:

- Train-the-trainers: this involves training the senior Public Health Officers at the state who in turn will roll out training courses in their states.

- Training health-care staffs: already trained senior Public Health Officers will train other HCFs staff. These training sessions will be held in each local government area (LGA);and

- Training medical waste management supporting staffs in health centers (Cleaners, transporters, incinerator operators and waste handlers. These training sessions will be held in every healthcare facility and will be conducted by already trained hospital staff.


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7.3 HIV/AIDS Medical Waste Management Plan

The implementation plan of the HIV/AIDS MWMP from 2009 to 2013 can be seen in Table 7.1. The table lists the various activities and indicates the periods of implementation over a five (5) year period.

Table 7.2 gives a break down of the details of The Waste management activities in each HCF. Cost implications of the Table can be seen in Annex G .

The HIV/AIDS MWMP would be implemented by the FMOH in pursuant to the implementation of HPDP2 and supervised by NACA and SACAs in the 37 states in Nigeria.


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Table 7.1 HIV/AIDS Medical Waste Management Plan

Table

Activities FY 2009 FY 2010 FY 2011 FY 2012 FY 2013

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

HIV/AIDS Waste Management Plan

HIV/AIDS WMP Workshop Site Selection Survey Meetings/Feedback with stakeholders

Procurement of equipment Incinerator Septic tanks Civil works & Installation of equipments. Sharp Boxes Personal Protective Equipments

Awareness Sourcing of IEC materials Pre-testing Adaptation & Translation Production Distribution

Training Development & Revision of Training Guidelines Printing of Guidelines Recruitment of Training consultant Preparation of training materials Training of Trainers Training of HCF Staff Refresher Training for Trainers Refresher training of Healthcare staff Monitoring & Evaluation Develop Reporting Formats Implementation of M&E Annual Review of Programme


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7.2 HIV/AIDS Medical Waste Management Plan

ACTIVITY IMPACTS MITIGATION INSTITUTIONAL ARRANGEMENTS

MONITORING & EVALUATION

TIMELINE (YEAR)

1. GENERATION

Negative Impacts

Hazardous and infectious wastes are always generated hence need to reduce the volume through: - -shredding and compaction -Training of medical personnel and non medical staff on waste management

Lead agency – NACA, SACA. Other stakeholders - All HCFs

Volumes of healthcare waste generated and well managed

Continuous

2. SEGREGATION

Negative Impacts

-Provision of colour coded waste bins and liners -Special attention given by cleaners to waste management from HCT -Sharps generated should be disposed of in the provided safety box. -Other waste generated from the testing unit should be disposed of appropriately in the provided bio-hazard bags

Waste management Department (WMD) in each HCF

Rate of use of colour coded bags and separation of waste by type.

Continuous

3. STORAGE

Negative Impacts

-Proper and adequate facilities should be provided for HCT waste such as safety boxes, waste bags and storage bins. -Limit level of safety boxes should not be exceeded. -Collection sites should be well protected to avoid waste being blown away by wind and also to prevent leakages. -Scavenging should be highly pre vented. -Storage of wastes should be according to colour coded bags.

Lead Agency: - NACA, SACA Other stakeholders Waste Management Department in each HCF to lead in enforcement of safe storage standards through linkage to generating units.

Volume of healthcare wastes properly stored

Continuous


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ACTIV ITY IMPACTS MITIGATION INSTITUTIONAL ARRANGEMENTS


TIMELINE (YEAR)

4. (b) COLLECTION FOR DISPOSAL

Negative Impacts

-Safety boxes and infectious waste should be taken straight from the collection point to the incinerator or sanitary landfill. -Waste should be collected in groups according to their colour codes -There should be adequate protective gear -There should be effective collection procedure and standards.

Collection is the primary responsibility of - State Environmental Protection Agency (SEPA) -Contracted collectors

Implementation of Collection procedure and standards

Continuous

5. TRANSPORTATION

Negative Impacts

For effective transportation of healthcare wastes, the following measures are necessary -appropriate routing and timing -relevant transportation vehicle -Collection trucks should be properly maintained to avoid mechanical breakdown.

-State Environmental Protection Agency (SEPA) -Contracted collectors

Frequency and effectiveness of waste disposal

Continuous

6. DISPOSAL

Negative Impacts

-There should be an effective and functional incinerator -waste from septic tanks should be properly collected and disposed of when full. -provide a properly engineered and well maintained sanitary landfill. -open air burning of waste within the HCF should be highly discouraged.

State Environmental Protection Agency (SEPA)

- functional incinerators -well managed sanitary land fills -availability and use of any other appropriate wastes disposal method

Continuous

7. CAPACITY BUILDING

(TRAINING, INFORMATION SHARING)

Negative Impacts

Capacity building should be carried out at all levels from generation to disposal through appropriate training, media and other forums. There is need to have sensitization action plan and measure impact

SACA to lead in ensuring that internal capacity is built All other stakeholders including the Waste Management Department in each HCF

Training plan, Number trained, Curriculum developed, Training reports

Continuous


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ACTIV ITY IMPACTS MITIGATION INSTITUTIONAL ARRANGEMENTS



Development of training curriculum/modules National Level -Operational level -Waste handlers -Community Level

curriculum/ development and implementation for all levels

Community awareness and advocacy - IEC materials in various languages - radio, newsletters and TV programmes to sell ideas

Available BCC/IEC materials

Continuous

Community training

Staff training on short courses and educational tour

- As above

Promote public-private partnership Through stakeholders coordination, workshops and meetings

4. RESEARCH Negative impacts

-Site Selection Survey -inventory of health care wastes facilities – type, location, condition, number -research on technological options -research on community level disposal methods -characterisation and quantification of wastes

WMD lead in implementation of the research and survey activities

-Survey reports, Research findings disseminated, Research recommendations implemented

First quarter of first year


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7.4 Cost Estimate for of HIV/AIDS Medical Waste Management Plan

The Budgetary estimate for the implementation of HIV/AIDS Medical Waste Management Plan has been prepared as follows: 7.4.1 Capital Expenditure budget

This involves:

• Estimated Cost of Equipments such as incinerators to be purchased

• Purchase of Sharp boxes (containers)

• Purchase of Disposable and Non-disposable containers (Annex A.1.2 gives details for containers to be used)

• Cost of awareness

• Cost of Training

• Cost of Personal Protective Equipments (PPEs)

• Training and creation of awareness

• The purchase of all equipment including consumables and maintenance for the first one year

7.4.2 Recurrent (Operational) Budget

This would adequately run the program in a calendar year including:

• The cost of maintenance and consumables

• But excluding the cost of replacement of long lasting capital equipment.

7.4.3 Assumptions Made

In developing the budget, the following assumptions have been made.

• Manpower costs are taken to be close to zero as it is assumed that health care workers will not earn any additional pay for implementing this program. There will however be training costs, which are factored as part of this plan.

• Training costs are at two levels. Ad hoc training that will be given to workers/stakeholders already existing at this point in time. And secondly students who will be in training once the program starts and will be trained once a new curriculum is effected.

• Resource persons and participants will be sourced within the states and FCT Abuja.

• Maintenance costs are set at the rate of 6% for large-scale permanent equipment/ buildings e.g. incinerator.

• Smaller pieces of equipment are depreciated at the rate of 50% and are to be replaced every 5th year.

• All disposable HCW containers would be discarded on a monthly basis to avoid spread of infection.

• Non-disposable containers are to be emptied on a daily basis from the work units.

• It is proposed that the training program will be implemented within the first two years of the implementation period of the plan.

7.4.5 Estimated Cost for Medical Waste Management Implementation Budget In estimating the cost of implementing the HIV/AIDS Waste Management Plan, three Scenarios are shown in Table 7.3 were created and an estimated budget of $10 million was set aside to implement the plan in 37 states (36 states and the F.C.T. Abuja). It should also be noted that NACA would prefer to step up its HIV/AIDS intervention in the Primary HCFs.


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Scenario 3 presents the best option for nationwide implementation of the HIV/AIDS WMP in approximately 999 HCFs (481 Rural Primary HCFs and 518 Urban Primary HCFs) across the 37 states. The Indicative Budget for Scenario 3 is Ten Million, Two Hundred and Five Thousand, Four Hundred and Seventy Thousand US Dollars ($10,205,470).

Table 7.3: Break down of Total Indicative Budget for HIV WMP SCENARIO 1 SCENARIO 2 SCENARIO 3

HCF Category

Total Cost Per HCF Category

($)

No of Facilities

intervened in 37 states


for 37 states ($)

No of Facilities



for 37 states ($)

No of Facilities

intervened in 37 states

Total Estimated


($)

Tertiary HCFs 128,576 37 4,757,312 0 0 0 0

Secondary HCFs 126,825 37 4,692,535 37 4,692,535 0 0

Primary HCFs (Urban) 10,571 37 391,127 222 1,955,635 518 5,084,651

Primary HCFs (Rural) 9,130.68 37 337,835 333 2,364,846 518 4,729,692

Total Indicative Budget 148 10,178,809 555 10,079,813 1036 10,205,470

Table 7.3 gives a comparison of the breakdown of estimated cost across the four (4) HCF categories. The break down of the total estimated cost to develop a HIV/AIDS Waste Management Plan and the breakdown at each HCF category can been derived in Tables 7.4, 7.5, 7.6, 7.7 and 7.8 respectively.


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Table 7.4: Break down of HIV/AIDS Medical Waste Management Implementation Budget across all HCF levels

Tertiary HCF Secondary HCF Primary HCF (Urban) Primary HCF (Rural)

ITEM Frequency Per

annum Day Quantity

Cost per Annum

($) Quantity

Cost per Annum

($)

Primary HCF

Quantity

Cost per Annum

($)

Primary HCF

Quantity

Cost per Annum

($)

ANNUAL TOTAL

($)

Incinerator 1 1 100,000 1 100,000 0 1 0

Incinerator installation 1 1 500 1 500 1 0 1 0

Septic Tanks 1 1 833 1 833 1 500 1 500

Weighing Machines 1 3 80 5 125 2 50 5 25

Trolleys 1 10 500 5 250 3 150 10 100

Sanitary landfills 1 0 0 0 0 1 500 1 500

Equipment

Cost of Collection by Trucks 12 1 200 1 200 1 600 1 600

Type E (Tall Sharp Containers 5-10 Litre)

208 1 1,127

1 563 8

282 8

281.6666667

Sharp Boxes

Sharp Box Installation 1 0 0 0 0 8 0 8 0

Type F 2-6 Litre 1 0 0 0 0 150 0 150 0

Type G 8-10Litre 1 0 0 0 0 80 0 80 0

Special Containers Installation 1 0 0 0 0 230 0 230 0

Receptacles/Biohazards bags 1 208 21 156 16 150 5 1 5.2

Special containers

Liners(1 bundle=20 bags) 72 2 600 1 300 80 300 5 300

Radio 1,050 1050 500 375

TV 750 750 500 375

IEC/BCC 2,000 2000 1250 1000 Awareness

Newsletter 200 200 250 250

Train the Trainers 3 2,500 2,500 0 0

HCF staff 3 2,083 2,083 2,000 1500 Training

HCF support staff 3 2,083 2,083 2,000 1500

Aprons/Overall Coat 1 25 250 15 150 15 50 15 30

Hand Gloves 6 25 125 15 75 15 25 15 15

Personal Boots 1 25 833 15 500 15 167 15 100

Personal Gas mask 6 25 125 15 75 15 25 15 15

Personal Protective Equipment (PPE)

Safety Goggles 1 25 31 15 19 15 6 15 3.75

Sub-Total per category 115,892 114,272.70 9,160 7,475.62 246,801

Recurrent Cost 995.00 1023 450.00 825 2,842.50

Total per category 116,887 115,295.70 9,610 8,300.62 249,643

Contingency 10% of Total 11,688.72 0.00 11,529.57 0.00 960.98 0.00 830.06 24,964.28

Grand Total per category 128,576 126,825.27 10,571 9,130.68 274,607


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Table 7.5: HIV/AIDS Tertiary Health Care Facility Medical Waste Management Plan Expenditure

Year One

ITEM

Quantity Frequency per year

Initial Unit Cost

Total Cost per Annum

(Naira)


($)

Recurrent Costs Per

Annum ($)

ANNUAL TOTAL

($)

Incinerator 1 1 12,000,000 12,000,000 100,000

Incinerator installation 1 1 60,000 60,000 500

Septic Tanks 1 1 100,000 100,000 833

Weighing Machines 3 1 3,204 9,612 80

Trolleys 10 1 6,000 60,000 500

Sanitary landfills 0 1 60,000 0 0 0

Equipment

Cost of Collection by Trucks 1 12 2,000 24,000 200 150

Type E (Tall Sharp Containers 5-10 Litre) 1 208 650 135,200 1,127 845 Sharpe Boxes

Sharp Box Installation 0 1 6,720 0 0

Type F 2-6 Litre 0 1 1,260 0 0 0

Type G 8-10Litre 0 1 1,860 0 0 0

Special Containers Installation 0 1 3,000 0 0

Receptacles/Biohazards bags 208 1 12 2,496 21 0

Special Containers

Liners(1 bundle=20 bags) 2 72 500 72,000 600 0

Radio 126,000 1,050

TV 90,000 750

IEC/BCC 240,000 2,000

Awareness Newsletter 24,000 200

Train the Trainers 300,000 2,500

HCF staff 250,000 2,083

Training HCF support staff 250,000 2,083

Aprons/Overall Coat 25 1 1,200 30,000 250

Hand Gloves 25 6 100 15,000 125

Personal Boots 25 1 4000 100,000 833

Personal Gas mask 25 6 100 15,000 125

Personal Protective Equipment

Safety Goggles 25 1 150 3,750 31

Sub-Total 13,907,058 115,892 995.00 116,887

Contingency 10% of Total 11,688.72

Grand Total 128,576


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Table 7.6: HIV/AIDS Secondary Health Care Facility Medical Waste Management Plan Expenditure

Year One

ITEM Quantity Frequency per year

Initial Unit Cost

Total Cost per Annum (Naira)


($)

Recurrent Costs Per Annum

Annual Total

($)

Incinerator 1 1 12,000,000 12,000,000 100,000

Incinerator installation 1 1 60,000 60,000 500

Septic Tanks 1 1 100,000 100,000 833


Trolleys 5 1 6,000 30,000 250

Sanitary landfills 0 1 60,000 0 0 0

Equipment


Type E (Tall Sharp Containers 5-10 Litre) 1 104 650 67,600 563 423 Sharpe Boxes

Sharp Box Installation 0 1 6,720 0 0 0

Type F 2-6 Litre 0 1 1,260 0 0 0

Type G 8-10Litre 0 1 1,860 0 0 0

Special Containers Installation 0 1 3,000 0 0 0

Receptacles/Biohazards bags 156 1 12 1,872 16 0

Special Containers

Liners(1 bundle=20 bags) 1 72 500 36,000 300 0

Radio 126,000 1050

TV 90,000 750

IEC/BCC 240,000 2000 Awareness

Newsletter 24,000 200

Train the Trainers 300,000 2,500

Training HCF staff 250,000 2,083

HCF support staff 250,000 2,083

Aprons/Overall Coat 15 1 1,200 18,000 150

Hand Gloves 15 6 100 9,000 75

Personal Boots 15 1 4000 60,000 500

Personal Gas mask 15 6 100 9,000 75

Personal Protection Equipment

Safety Goggles 15 1 150 2,250 19

Sub-Total 13,712,722 114,272.7 1,023 115,295.70

Contingency 10% of Total 11,529.57

Total 126,825.27


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Table 7.7: HIV/AIDS Primary Health Care Facility MWM Plan Expenditure (Urban)

Year One

Item

Quantity Frequency per

year Initial Unit

Cost

Total Cost per Annum (Naira)

Total Cost per

Annum ($)


ANNUAL TOTAL

($)

Incinerator 0 1 12,000,000 0 0

Incinerator installation 0 1 60,000 0 0

Septic Tanks 1 1 60,000 60,000 500


Trolleys 3 1 6,000 18,000 150

Sanitary landfills 1 1 60,000 60,000 500 375

Equipment

Cost of Collection by Truck 1 48 1,500 72,000 600 450

Type E (Tall Sharp Containers 5-10 Litre) 1 52 650 33,800 282 0 Sharpe Boxes Sharp Box Installation 0 12 6,720 0 0 0

Type F 2-6 Litre 0 1 1,260 0 0 0

Type G 8-10Litre 0 1 1860 0 0 0


Receptacles/Biohazards bags 52 1 12 624 5 0

Special Containers

Liners(1 bundle = 20 bags) 1 72 500 36,000 300 0

Radio 60,000 500

TV 60,000 500



Train the Trainers 0 0

Training HCF staff 240,000 2,000

HCF support staff 240,000 2,000

Aprons/overall coat 5 1 1,200 6000 50

Hand Gloves 5 6 100 3000 25

Personal Boots 5 1 4000 20000 167

Personal Gas mask 5 6 100 3000 25


Safety Goggles 5 1 150 750 6

Sub-Total 1,099,174 9,160 450.00 9,610

Contingency 10% of Total 960.98

Total 10,571


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Table 7.8: HIV/AIDS Primary Health Care Facility MWM Plan Expenditure (Rural)

Year One

ITEM Quantity Frequency Per Annum

Initial Unit Cost


(Naira) Total Cost per

Annum ($)


ANNUAL TOTAL

($)

Incinerator 0 1 12,000,000 0 0

Incinerator installation 0 1 60,000 0 0

Septic Tanks 1 1 60,000 60,000 500


Trolleys 2 1 6,000 12,000 100

Sanitary landfill 1 1 60,000 60,000 500 375

Equipment


Type E (Tall Sharp Containers 5-10 Litre) 1 52 650 33,800 281.6666667 0 Sharpe Boxes

Sharp Box Installation 0 12 6,720 0 0

Type F 2-6 Litre 0 1 1,260 0 0 0

Type G 8-10Litre 0 1 1860 0 0 0


Receptacles/Biohazards bags 52 1 12 624 5.2 0

Special Containers

Liners (1 bundle = 20 bags) 1 72 500 36,000 300 0

Radio 45,000 375

TV 45,000 375



Train the Trainers 0 0

HCF staff 180,000 1500 Training

HCF support staff 180,000 1500

Apron/Overall Coat 3 1 1,200 3600 30

Hand Gloves 3 6 100 1800 15

Personal Boots 3 1 4000 12000 100

Personal Gas mask 3 6 100 1800 15


Safety Goggles 3 1 150 450 3.75

Sub-Total 897,074 7,475.62 825 8,300.62

Contingency (10% of Total) 830.06

Total 9,130.68


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Chapter 8: Monitoring and Evaluation

Monitoring is required to follow-up on decisions made to intervene in various activities of medical waste management in order to protect human health and the environment. This can be achieved through periodic internal and external processes of monitoring and evaluation on a continuous basis, at all institutional levels. In this way management will be able to assess compliance with regulatory requirements at national, state and local levels. To ensure that objectives of the HIV/AIDS MWMP are achieved, the implementation of the plan has to be monitored by both internal and external bodies including the Federal and States Ministries of Health and Environment. These ministries will determine their respective monitoring tools and will work jointly within the monitoring and evaluation mechanism of the proposed project.

8.1 Monitoring and Evaluation Objectives

The aim of the M&E is to establish appropriate criteria to address potential negative impacts of MWM and to ensure that unforeseen impacts are detected and the mitigation measures implemented at an early stage. Specific objectives of the monitoring plan are to: � ensure that any additional impacts are addressed appropriately; � check the effectiveness of recommended action plans and mitigation measures; � ensure that the proposed mitigation measures are appropriate; � demonstrate that medical waste management is being implemented according to plan and

existing regulatory procedures; and � provide feedback to implementing agencies in order to make modifications to the

operational activities where necessary.

8.2 Monitoring Indicators

The following will be used to monitor progress in implementing the HIV/AIDS MWMP: At the National and State Level:

• Development of National Environmental Health Policy and technical safety guidelines on medical waste management;

• Enactment of necessary legislation governing, regulating and creating community awareness campaigns addressing medical waste concerns;

• Development of relevant institutional arrangements to plan and implement policies for addressing medical waste concerns;

• Development of human resource capacity in all health care facilities;

• Development of an Management Information System (MIS) on waste generation;

• Development of collaborative mechanisms with private sectors and development partners to finance waste treatment/disposal facilities; and

• Development of database for inventorying the types of waste and volume generated by HCFs nationwide.

At the HCF level:

• Awareness Creation: o Number of people sensitized or reached with MWM messages, o Number of IEC/BCC materials distributed

• Capacity Building: o Number of Trainers Training in MWM, o Number of medical and support staff trained in MWM, o Number of HCFs with MWM Team, o Number of HCFs with budget for MWM;


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o % of health personnel and support staff that are knowledgeable in MWM

• Management of SHARPS: o Number of incinerators and septic tanks operational, o Quantity of Sharps /number of safety boxes incinerated,

• Personal Protective Equipments (PPEs): o Quantity and type of PPEs distributed, o Number of people who received PPE,

• Knowledge of MWM among health personnel and support staff, o Incidence of hospital based/acquired infections, o Number of reported cases of needles/sharps injuries o Number of HIV/AIDS and /or Hepatitis B transmitted due to needle /sharp

injuries;

The monitoring of environmental effects is necessary to ensure that predicted impacts are addressed effectively and efficiently through the mitigate measures indicated. Specific monitoring indicators for consideration include the following:

Internal Packaging and Storage

- Separation of waste (at point of generation) - Storage bins / bags - Frequency of removal

External Packaging and Storage

- Segregation of waste - Storage area - Frequency of waste removal - Amount of waste generated per day

Transportation

- Identification of waste management contractor (accredited or certified) - Conditions for transportation - Equipment/vehicles (to prevent scattering, spillage, odour nuisance and leakage).

Treatment and Disposal

- Incineration - Sterilisation by Heat - Disinfection by steam - Chemical disinfection - Sanitary Landfill

Administration

- Establishment / functioning of a Waste Management Officer and Waste Management Committee

- Availability of waste management plans - Collection and Analysis of data

8.3 Monitoring Plan

An effective control of medical waste and monitoring of facilities should be carried out regularly, in order to maintain and improve management of the waste. Measures should be adopted to ensure that problems and risks involved are identified while enhancing safety and preventing the development of future problems.

Compliance and enforcement with legislation shall be ensured through co-coordinating and regulatory bodies. These bodies should include FMOH, FMEH&UD, SMOH, SEPAs. They shall undertake regular monitoring of these facilities, with the aim of establishing long-term


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sustainability in medical waste management. The bodies shall ensure compliance with the following:

- Segregation i.e. sharps, pathological, hazardous and radioactive waste from other waste. Picture stickers shall be used in rural areas for identification.

- Collection routines including packaging and labeling - On-site treatment procedures like sterilization, disinfection and incineration. It should be

ensured that the incinerator plant continually burns its materials at a temperature of 1200°C and above to eliminate the release of dioxins

- Storage into appropriate, labeled and adequate containers for both internal and external storage.

- Transportation i.e. needs and conditions including certification. - Worker safety measures - Disposal at sanitary landfills, cemetery or crematorium.

To ensure effective record keeping, each health institutions shall keep records on:

- The type and volume or weight of waste generated - The means of transportation, type and volume transported - Commissioned waste contractor (company name, type of license, treatment and disposal. - Disposal method - volume incinerated, volume treated and disposed

8.4 Monitoring of HIV/AIDS Waste Management Plan Implementation

There is a current National Health Care Waste Management (NMCWM) Plan which identifies the indicators to be tracked, specific tasks to be executed and assigns responsibility for waste collection to specific agencies.

For the national plan to be effectively implemented, all HCFs in the country need to develop standardized plans based on their existing needs. Such plans should focus on treatment, recycling, transportation and disposal options through safe and cost effective treatment and disposal methods.

The most critical needs for the implementation of the national plan are funding and skilled/well-trained manpower. The critical issues identified during the study include the following:

- Poor medical waste management practices in HCFs and government disposal sites with regard to handling and disposal

- Lack of waste generation data - Inadequate waste treatment and disposal equipment - Inadequate knowledge among those involved in medical waste management - Lack of awareness on medical waste among health workers and the general public - Poor management practices at hospitals and dumpsites - Lack of code of conduct and technical guidelines for safety measures

This HIV/AIDS MWMP will operate within the confines of the National Health Care Waste Management Plan and seek ways and means that it will operationalize the action plan; for the total duration of the HPDP2.


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Chapter 9: Public Awareness and Consultation

To ensure the successful implementation of this plan, the NACA and SACAs have responsibilities to effectively engage stakeholders in achieving its objectives for the benefit of all. The implementation of the plan depends on the meaningful participation of all stakeholders for success. The public awareness process will be focused on informing the general public and scavengers about potential dangers associated with medical waste handling.

The scope of this Public Awareness Plan includes the entire participating states of the proposed project where the plan will be implemented. It describes the avenues that will be used to convey the plan implementation information to the public.

9.1 Objectives

This public awareness/consultation plan provides a framework for achieving effective stakeholder involvement and promoting greater awareness and understanding of issues so that the plan can be effectively implemented on-time to the satisfaction of all concerned.

To ensure effective implementation of this plan, the NACA shall be committed to the following principles:

− promoting openness and communication;

− ensuring effective stakeholder involvement in the development of the project;

− increasing public knowledge and understanding of the project implementation process;

− using all strategies and techniques which provide appropriate, timely and adequate opportunities for all concerned parties to participate; and

− evaluating the effectiveness of the engagement plan in accordance with the expected outcomes.

−

9.2 Potential Stakeholders

The potential stakeholders in the implementation of this plan include the following:

− Patients and visitors

− Government Agencies e.g. Ministries of Health, Environment and Information

− Medical and Paramedical Professionals

− Educational Institutions e.g. Medical Schools, Teaching Hospitals

− Planning Authorities e.g. Town Planning

− Waste Management Authorities e.g. (Lagos State Waste Management Agency - LAWMA)

− Other Regulatory bodies e.g. Nigerian Medical Association etc.

9.3 Consultation Strategies

The focus of this public involvement program/plan is to inform the public and invite input relating to the plan and its implementation. As elements of the plan proceed from planning into execution, the NACA’s objective will be to maintain the public awareness and understanding of the plan. The implementing agencies (SACAs) shall execute a program comprising seven strategic elements to accomplish the public awareness objective. A comprehensive public awareness program will include the following:


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- Develop and distribute a project newsletter - Develop presentations and organize seminars and workshops - Develop and maintain a project web site - Develop radio and television adverts - Establish and maintain a project telephone information line - Prepare project press releases - Prepare posters and erect billboards

The objective of the public awareness program is to convey information to the public and interested groups. By utilizing a multi-faceted approach to convey information, the success of the effort is optimized. The Public Awareness Plan describes the general approach and specific benefits of each element of the program.

- Newsletters

Newsletters will be written in all major Nigerian languages to include project progress and information, calendars of events, telephone numbers, and information about the web site, location maps, and photographs of ongoing efforts. The newsletters will be printed and distributed quarterly throughout the implementation period. Newsletters differ from press releases in that a newsletter will have a smaller audience, greater depth of reporting, and more issues presented than a press release. Each newsletter will explain how to provide input into the plan. Newsletter shall be distributed through the 36 states and the federal capital in hospitals and other HCFs.

Newsletter distribution points will be identified on the project Web site, and via press releases distributed to the local media. Although the primary method of distribution will be at established distribution points, newsletters will be mailed out upon specific request. .

- Seminars and Workshops

Seminars and workshops will offer the public an opportunity to listen to the experts on different aspects of the plan. These meetings will be broadcasted on local television and radio stations. This will offer the public a convenient opportunity to take advantage of this information.

Newsletters, website, and press releases will advertise the schedule of seminars and workshops. Workshops shall be conducted annually throughout the period of the plan implementation. Other presentations will also be made throughout the plan implementation period on as need basis but will be limited to a reasonable number.

- Radio and Television Adverts

Radio jingles and TV adverts/announcements shall be developed and aired in all the states of the federation in all major languages. Pertinent information will be offered at intervals to maintain viewers’ interest on the topic. Two radio jingles and two TV announcements shall be broadcasted in English and the major languages every month, totaling 48 radio and TV messages in major languages per annum.

- Posters and Billboards

Posters and billboards shall be pasted and installed in strategic places to make them accessible to the general public. The public awareness plan would be effective since several medium would be used as part of a coordinated program. Although some strategies may be more effective than other elements, combining several techniques and different media in conveying plan/project information to the public would create an optimal approach.


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References

1. Avian Influenza Control and Human Pandemic Preparedness and Response Project Medical

Waste management Plan for the Federal Republic of Nigeria

2. Environmental Assessment Sourcebook. Volume II: Sectoral Guidelines. World Bank

Technical Paper No 140, Environmental Department, The World Bank. Washington, DC.

3. Feasibility Study for Sustainable Health Care Waste Management Scenarios for Gauteng,

South Africa Gauteng Department of Agriculture, Conservation, Environment and Land

Affairs ,2003.

4. Harmonized Plan for Health Care Wastes in the Corridor Countries –Joint Regional Project

for Prevention Care and Support of HIV/AIDS along the Abidjan –Lagos Transport Corridor,

The World Bank, 2006.

5. Integrated Strategy and Action Plans for Sustainable HCW Management in Gauteng, South

Africa - Gauteng Department of Agriculture, Conservation, Environment and Land Affairs,

September 2003

6. National Health Care Waste Management Plan for Kenya, 2005

7. National Health Care Waste Management Plan of the Federal Republic of Nigeria, 2007.

8. National Health Care Waste Management Policy of the Federal Republic of Nigeria, 2007.

9. National Health Care Waste Management Guidelines of the Federal Republic of Nigeria,,

2007.

10. Preparation of National Health-care waste management plans in Sub-Saharan countries:

Guidance Manual. - Secretariat of the Basel Convention and World Health Organization,

2004.

11. Suggested Guiding Principles and Practices for The Sound Management of Hazardous

Hospital Wastes, World Health Organization, 1999.

12. Health-Care Waste Management: Rapid Assessment Tool for Country Level -World Health

Organization, 2005.


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Annex A – Disposable HCW Containers

A.1 Specification for Disposable Containers

A.1.1 Sharps Containers

Note: • These types of sharps containers will only be used during Phase 3, at which time these more

sophisticated containers will be applied to segregate needles from syringes in a safe manner, thereby allowing significant savings in container consumption. Until Phase 3, the 5-litre UNICEF safety boxes will be used.

• The ranges of containers will ultimately be limited to what is readily available for Kenya, thereby keeping the costs down.

Due to the different rates at which infected sharps are generated as well as the particular requirements for different applications of Sharps Containers, there is a need for a range of Sharps Containers to be made available to the HCFs, leaving it up to the respective HCFs to make a decision on the type of container that would best meet their particular needs. The risk of physical injuries and infection from sharp objects used in hospitals and clinics is high, resulting in a need for Sharps Containers to meet certain minimum standards in terms of user friendliness, robustness and also the effort required for people to gain access to, or come into contact with sharps previously disposed off. The following requirements are to be met in the supply of Sharps Containers: A1.1.1 Range of Sharps Containers required: 1. The following generic types of Sharps Containers must, as a minimum form part of the

supply made available for ordering by the Facilities:

(a) Type A: 1-4 litre sharps container; (b) Type B: 4-8 litre sharps container; (c) Type C: 8-15 litre sharps container; (d) Type D: 15-25 litre sharps container; (e) Type E: Tall slim sharps container with a minimum height of 600 mm and capacity of

between 5 litre and 10 litre for long sharps. 2. A minimum of one Sharps Container of type B or type C must be of the horizontal loading

type.


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Co

nta

iner

T

yp

e.

Sh

arp

s C

on

tain

er.

Sh

arp

s C

on

tain

er.

Sh

arp

s C

on

tain

er.

Sh

arp

s C

on

tain

er.

Ta

ll S

ha

rps

Co

nta

iner

.

Container Category

A B C D E

Capacity (litre) 1-4 4-8 8-15 15-25

5-10 litre.

600 mm tall.

Minimum volume increase (litre)

3 4 7

Material allowed for container

Po

lyp

rop

yle

ne

or

po

lyet

hy

len

e

Po

lyp

rop

yle

ne

or

po

lyet

hy

len

e

Po

lyp

rop

yle

ne

or

po

lyet

hy

len

e

Po

lyp

rop

yle

ne

or

po

lyet

hy

len

e

Po

lyp

rop

yle

ne

or

po

lyet

hy

len

e

Handle required. - - Yes Yes -

Allowable material for handle.

- -

Po

lyp

rop

yle

ne

or

po

lyet

hy

len

e

Po

lyp

rop

yle

ne

or

po

lyet

hy

len

e

-

Wall Bracket required.

- Yes Yes - -

Nursing trolley Bracket req.

- Yes - - -

Wall/trolley Bracket material.

- Mild / stainless Steel

Mild / stainless Steel

- -

Wall Bracket coating.

-

Powder coated / galvanise

Powder coated / galvanise

- -

Container colour. Yellow Yellow Yellow Yellow Yellow

Constituents not allowed in dye.

No heavy metals

No heavy metals

No heavy metals

No heavy metals

No heavy metals

Printing Colour. Red Red Red Red Red

Constituents not allowed in ink / paint.

No heavy metals

No heavy metals

No heavy metals

No heavy metals

No heavy metals

A.1.2 Specification of Reusable Containers

The following generic types of Reusable Containers must form part of the supply made available for distribution to Facilities: (a) Type A: 600 to 800-litre wheelie bins, primarily for use in Hospitals; (b) Type B: 200 to 300-litre wheelie bins, primarily for use in Clinics, as well as for transport

of Specican Containers containing pathological waste from hospitals. (These are

typically the 240-litre wheelie bins).


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(c) Type C: 50 and 100 litre reusable plastic box containers.

80

FRONT SIDE

BASE

JC 02-10-08 Roto Moulded Box 100 litre 02.wpg

100 Litre Roto- moulded bofor Infectious Waste

NACA

275

30

550

80

FRONT SIDE

BASE

JC 02-10-08 Roto Moulded Box 100 litre 02.wpg

100 Litre Roto- moulded bofor Infectious Waste

NACA

275

30

550

25

25

25 25

540

440

20

25

440

340

275


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SIDE

JC 02-11-02 Wall Mounted Bracket for 32 L bin 01.wpg

A A

315

r = 20

( internaldimensions)

100

FRONT

6 mm ø hard-drawn steel

wire

VIEW A - A

6 mmdomed

nutEND DETAILOF ‘HOOP’

7 ø hole

‘HOOP’

3 mmplay

40

310

30 x 5 mmm.s. flat bar

25040

All holes 7 mm ø

HOLE DRILLING DETAILS: TOP FLAT BAR

200

FRONT END

Detail of bracket

Sharps bracket hooks over top rail and around leg of trolley

JC 02-11-01 Sharps Container Bracket for Nursing Trolley.wpg

1,5 mm mildsteel plate

rod or flatstrip weldedto back ofplate

B Specification for HCW Brackets and Baskets

B.1 Wall-Mounted Bracket for 32 Litre Bin

All dimensions in millimetres 1. Dimension tolerances + -3 mm, except otherwise indicated 2. Bend radii (wire & flat bar):15< mm> r 5mm

C.1 Sharps Container Bracket for Nursing Trolley


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370

190125 125

45° Detail30

FRONT SIDEJC 02-11-03 Wall Mounted Basket 02.wpg


wire

Note: Thesejoints are ‘in

plane’

55

250

30 x 5 mmm.s. flat bar

7 mm øholes

2. Bend radii (wire & flat bar): 15 mm < r > 5 mm

TOP VIEW OF UPPER FLAT BAR(lower flat bar similar but shorter)

370

55

11 +/-1

40

370

190125 125

45°

Detail

30

FRONT SIDE

5 mm øwire hook

JC 02-10-04 Nursing Trolley Basket 05.wpg

(Note: There are twohooks per basket)


wire

Note: Thesejoints are ‘in

plane’

50 50

C.3 Wall-Mounted Basket for HCRW Bag Note. 1. Dimension tolerances + -3 mm, except otherwise indicated

2. Bend radii (wire & flat bar):15< mm> r 5mm

C.4 Nursing-Trolley Basket for HCRW Bag

All dimensions in millimetres Note: Dimension tolerances + -3 mm, except otherwise indicated


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Annex B: Training Schedule for Staff and Support Staff of Health Care Facilities Category of target group Training subject

A B C D E F G H

Basic knowledge about medical waste

Waste categories

Hazardous potential of certain waste categories

Transmission of hospital acquired infection

Health risk for health care personnel

Proper behaviour of waste generators

Environmentally sound handling of residues

Waste avoidance and reduction possibilities

Identification of waste categories.

Separation of waste categories

Knowledge about appropriate waste containers

Proper handling of waste

Adequate waste removal frequency

Safe transport containers and procedures

Recycling and re-use of waste components

Safe storage of wastes

Cleaning and maintaining of collection, transportation and storage facilities

Cleaning and maintenance of sanitation facilities, drains and piping.

Handling of infectious laundry

Handling of chemical and radioactive waste, outdated drugs.

Maintenance of septic tanks and other sewage treatment facilities

Maintenance and operation if incinerator for infectious wastes.

Maintenance and operation of waste pits and landfill site.

Safety regulation in waste management, protective clothing.

Emergency regulation in waste management

Establishment of a waste management system

Establishment and implementation of a waste management plan.

Sampling of waste quantities, monitoring, and date collection.

Monitoring and supervision of waste management practices

Cost monitoring of waste management

Establishment of a chain of responsibilities

Set-up of occupational safety and emergency regulations

Interaction with city assemblies or private sector waste handling structures.

Public relation and interaction with local community.

A- Management & administrative staff B- Medical laboratory staff C- Ward attendants, caretakers, ground workers and other support staff. D- Patients and visitor E- Waste management facility operator F- Waste collection and transportation staff G- Treatment system operators.

H- Disposal managers.


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Annex C: Data Collection Instruments

C.1 Data entry form

Generic Data Entry Form Medical Waste Weighing Form

Number of Beds in the Hospital…………………………………………

Number of out-patients per day/Month……………………………………..

Point of generation Quantity generated by Waste Category/Type (in Kgs)

Area Clinical waste (Yellow bag)

Pathological waste

(Red bag) Sharps (Box)

Cytotoxic waste (Purple bag) Remarks

Out-patient

Ward 1

Ward 2

Ward 3

Ward 4

Ward 5

Ward 6

Ward 7

Ward 8

Ward 9

Ward 10


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Ward 11

Ward 12

Eye Ward

Amenity Ward

Maternity Wing

Theatre B.T.L

Theatre Labour

Main Theatre

Laboratory

Pharmacy

Total

Name of respondent……………………………………….. Signature………………………………. Categories of wastes defined

1. Box: Sharps include needles and syringes, razor and scalpel blades, broken ampule bottles etc. 2. Red Bags: Pathological waste include amputations, histological specimen, biopsies and autopsies, rejected blood, placenta, foetuses and other tissues

organs 3. Yellow Bags; Clinical waste include used gloves, soiled cotton wool, bandages, POPC, pads, giving lines etc 4. Purple Bags; Cytotoxic wastes include expired drugs, unfinished drugs, spilled drugs, radioactive wastes etc


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C.2 Survey Questionnaire for HCWM

Survey Questionnaire for Medical Waste Management

QUESTIONNAIRE

Health Facility (name, location): _______________________________________ _______________________________________ _______________________________________

Type/Category of Health Facility (tick one): Tertiary: Specialist, National, Federal, Teaching Hospitals Secondary: State Gen. Hospitals, Sub-HCF Hospital, Private Hospitals

Primary; Health Centre, Dispensary HCT


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No. of inpatients: ___________ /day

No. of outpatients: ___________ /day

No. of beds (total): ___________ /day

Including ___________ in _______________ ward

(no.) (type of ward)

___________ in _______________ ward (no.) (type of ward)




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Type of solid waste produced and estimated quantity (Consult classification and mark X where waste is produced)

So

urc

es

Gen

era

l

Pa

tholo

gic

al

Lab

ora

tory

Infe

ctio

us

Sh

arp

s

Ph

arm

ace

uti

cal

Est

. q

ua

nti

ty

(kg

/day)

Est

. Q

ua

nti

ty

(vol.

/da

y)

Patient services

Medical

Surgical

Isolation ward

Emergency

Outpatient clinic

Radiology

Laboratories

Biochemistry

Microbiology

Haematology

Research

Pathology


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Waste segregation, collection, storage, and handling

Describe briefly what happens between segregation (if any) and final disposal of:

Sharps _______________________________________

_______________________________________ Pathological waste _______________________________________

_______________________________________ Infectious waste _______________________________________

_______________________________________

______________________________________ Pharmaceutical waste _______________________________________

_______________________________________ Pressurized containers _______________________________________

_______________________________________

Support services

Blood bank

Pharmacy

Central sterile supply

Laundry

Kitchen

Administration

Public areas


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Waste segregation, collection, labelling, transport, and disposal

1.

Ha

nd

lin

g o

f se

gre

ga

ted

w

ast

e

Sh

arp

s

Pa

tholo

gic

al

wa

ste

Infe

ctio

us

wa

ste

La

bo

rato

ryw

ast

e

Ph

arm

ace

uti

cal

wa

ste

Pre

ssu

rize

d

con

tain

ers

Indicate by X the type of waste (if any) that is segregated from general waste stream.

Where is the segregation taking place (i.e. operating room, laboratory, among others)?

What type of containers/bags (primary containment vessels) are used to segregate waste (bags, cardboard boxes, plastic containers, metal containers, among others)? describe accurately.

What type of labelling, colour-coding (if any) is used for marking segregated waste? Describe

i. Who handles (removes) the segregated waste (designation of the hospital staff member)?

ii. Is the waste handler using any

protective clothing (gloves, among others) during waste handling? Yes/No.

What type of containers (plastic bins, bags, cardboard boxes, trolleys, wheelbarrows, safe boxes, metal containers, among others) are used for collection and internal transport of the waste? Describe.


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Where is the segregated waste stored while awaiting removal from the hospital for disposal? Describe.

Describe briefly the final disposal of segregated waste (taken to municipal landfill, buried on hospital grounds, incinerated (external incinerator, own incinerator), open burned, removed from premises, among others)

If removed from premises; who is responsible for removal? Health facility/self, private collector, State Environmental protection Agency

If removed from premises; what form of transport is used? Enclosed waste track, open waste track, open pick-up, among others

How often is the waste removed from site?

Daily

3 – 4 times per week

1 – 2 times per week

Once a week

Every two weeks

Once a month

Less often

2. Is safety clothing issued to staff involved in medical waste collection, i.e. gloves, aprons, among others Yes No

3. If yes, please list the safety clothing/items issued to medical waste collectors and the frequency of issue:


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Items issued Daily Weekly Monthly As Needed Aprons

Gloves

Goggles

Gas masks

Safety shoes

Overhauls

Others (specify)

4. Which of these waste collection, handling, transport and disposal activities are undertaken by Health-care staff and which are outsourced? List the party responsible for that activity, where the activity is outsourced and the start and end dates of the contract entered into:

ACTIVITY RESPONSIBLE PARTY (self/facility, Environmental

Protection Agency, Private collector, among others) NAME OF THE RESPONSIBLE

PARTY/PRIVATE COLLECTOR Collection

Handling

Transport

Incineration

Disposal

Personnel involved in the management of Health-care waste

1. (a) Designation of person(s) responsible for organization and management of waste collection, handling, storage, and disposal at the hospital

administration level. _________________________________________________________________________ _________________________________________________________________________

(b) General qualification and level of education of designated person. ________________________________________________________________________ ________________________________________________________________________


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(c) Has he/she received any training on hospital waste management? Yes No If yes, what type of training and of what duration? ________________________________________________________________________ ________________________________________________________________________

2. Indicate the number of persons involved in the collection, handling, and storage of Health-care waste, their designation, their training in solid waste handling and management, and the number of years of experience of this type of work.

Number Designation Training Experience

iii. Do the waste management staffs have job descriptions detailing their tasks? Yes No

iv. Are instructions/training given to newly hired waste management staff? Yes No

v. If yes, please indicate what form of instructions/training is given to newly hired waste management staff?

� A – If external training, the name of the training institution � B – The duration of the training � C – The qualifications of the training instructor


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IN – SERVICE TRAINING EXTERNAL TRAINING

A – Name of external training institution

B – Duration of training - 1 to 3 months - 3 to 6 months - 6 months to 1 year - 18 months - 2 years - Others (state)

C – Instructor Qualifications - Diploma in Waste Management - Diploma in Public Health - Others (state)


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Health-care waste management policy 1. Are you aware of any legislation applicable to Health-care waste management? Yes No If yes, please list the legislative Acts: ________________________________________________________________________ ________________________________________________________________________ 2. Are you aware of a document outlining the hospital waste management policy? Yes No If yes, give title of document (and attach a copy if possible): ________________________________________________________________________ ________________________________________________________________________ 3. Is there a manual or guideline document on management of Health-care waste available? (a) In the Ministry of Health? If yes, give title of document: Yes No ________________________________________________________________________ (b) In your Health facility? Yes No If yes, give title of document: ________________________________________________________________________ 4. (a) Does your Health facility have a Waste Management Plan? Yes No If yes, please attach a copy. (b) Does your Health facility have a Waste Management Team (or Teams)? Yes No If yes, please list the members by designation:


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S/No Team Formation Designation in HCF Unit/Department in HCF Name

Team Leader

Team Member

Team Member

Team Member

Team Member

Waste Handling Staff




5. Are there clearly defined procedures for collection and handling of wastes from specified units in the Health facility? Yes No

6. Do you have a Policy/Guideline outlining the steps in case of injury (e.g. needle-stick injury) or contamination of a medical waste worker?

Yes No

7. Is there any emergency procedure available in your Health facility for Staff members handling Health-care waste? Yes No 8. Please indicate how the present waste collection, handling, transport, and disposal responsibilities are defined in the job descriptions of the staff involved: (Cite appropriate statement or provide copies if possible). ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________


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10. How are the present waste collection, handling, and disposal responsibilities defined in the job descriptions of the staff involved? (Cite appropriate statement or provide copies.) ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Financial implications of Medical Waste Management 1. How is your medical waste management funded? 2. Please provide details of amount spent for the last financial year and amounts allocated for the present financial year Annual Budget How Funded N. 2008/2009 N. 2009/2010 N. 2010/2011 N2011/2012 Medical waste management allocation

Vote number/Item number

Others (specify)


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3. What are the average annual costs incurred to render the following specific components of medical waste management services? Capital Expenditure

Naira Operational Expenditure

Naira Overhead Costs

Naira Total Annual Costs

Naira Containers/bins/boxes e.t.c

Handling Costs

Protective Clothing’s

Collection Costs

Disposal Costs

TOTAL ANNUAL COSTS

General aspect 1) Give a brief general account of the problems you encounter in relation to medical waste management in the health facilities within your area of

jurisdiction ………………………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2) Comment on the financial implications of Health-care waste management with respect to adequacy and/or limitation of the same

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...


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Observation /Checklist 1. Type/design of vehicle used for the collection and transportation for waste

…………………………………………………………………………………………………………………………………………………………………………...........................................................................................................................................................................................

2. Type/design of waste storage receptacles used

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

3. Availability of protective gear for the waste handlers

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

4. Visible waste disposal option within the health facility compound (e.g. waste burial pit, crude

burning site, e.t.c). 5. Presence of an incinerator either within the health facility compound or

elsewhere……………………………………………………………………………………………………………………………………............

6. Treatment of waste prior to disposal …………………………………………………………………………………….......................

....................................................................... 7. Colour-coding/labelling of waste prior to disposal …………………………………………………………………………………….......................

....................................................................... 8. Carrying out of waste segregation within the health facility …………………………………………………………………………………….......................

.......................................................................

9. Packaging of waste destined for disposal……………………………………………………………………………………………………………… ………………………………………………………….


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C.3 Short Questionnaire for Health Care Facilities Officers

FEDERAL/ STATE MINISTRY OF HEALTH

HIV/AIDS WASTE MANAGEMENT QUESTIONNAIRE

Short Questionnaire for HCF Public Health Officers

HCF...........................................................State………………………………………….. LGA………………………………

Instructions:

. Please give correct information about your HCF and where possible make verification

visits to ascertain the correct position on the ground. Use your Divisional Public Health

Officers where appropriate.

. Circle the correct option or write your answer where appropriate.

1) Does your HCF have an incinerator? a. Yes b. No

2) What type of incinerator(s) do you have in your HCT facilities?

Type of incinerator Number of Combustion Chambers

Number functional

Number not functional

Number Repairable

a Stone built

b Brick built

c Electric powered

blower model

d Others (Specify)

3) What type of fuel is used in the HCF?

Type of fuel used Number of Incinerators involved

1 Kerosene

2 Diesel

3 Wood

4 Waste paper

5 Generators

6 Electric powered

4) What type of incinerator(s) do you have in Private and Mission facilities?

Type of incinerator Number Functional

Number of chambers

Number not functional

Number Repairable

a Stone built

b Brick built

c Electric powered

blower model

d Others (Specify)


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6) Please provide the following details for each incinerator: Incinerator 1 Incinerator 2 Incinerator 3 Incinerator 4

In working order

Being used

Kilowatt Rating

Hours operated per day

Percentage Downtime

How long in use

What type

Does it have scrubbers - Yes

Oil used per week - Litres

15) What method(s) do you use in disposing of medical waste in your Hospital?

a. Incinerator b. Crude dumping c. Burning in shallow pits d. Collected by municipal councils e. Others (specify)

16) What method(s) do you propose for your HCF in the disposal of health care waste?

a. Incinerator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. b. Burning and burial ............................ ...............

c. Reverse Logistics ... ................................ d. Others (specify) ... ....................................

Filled in by (Name)

......................................................................................... ..Des

ignation ............................................................................ .

Date .........................


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Annex D: List of People Met

NAME DESIGNATION DEPARTMENT/AGENCY MINISTRY Dr (Mrs) Taiwo Director , Public Health Department Lagos State Ministry of Health

Dr T. Arowolo State Coordinator State HIV/AIDS Program Lagos State Ministry of Health

Mrs O. Bashorun PMTCT Program Lagos State Ministry of Health

Mrs A. A. Adejumobi Monitoring and Evaluation officer HIV/AIDS Program Lagos State Ministry of Health

Dr Lajide Coordinator LSACA/Lagos Abidjan Corridor Project Lagos State Ministry of Health

Dr Jide Coker Head / Coordinator National AIDS/STDs Control Program (Dept of Public Health) federal Ministry of Health

Dr. Gbenga Ijeodole MO Logistics National AIDS/STDs Control Program (Dept of Public Health) federal Ministry of Health

Dr Emeka Asadu Head Treatment Care and Support (Dept of Public Health) federal Ministry of Health

Dr A.O. Sowande Country Director John Snow Incorporated/MMIS US Agency for International Development

Mr Iyortim Isa HIV-TB Prevention Manager John Snow Incorporated/MMIS US Agency for International Development

Mr Kelechi Amaefule Health Care Waste Management Adviser John Snow Incorporated/MMIS US Agency for International Development

Mr. Stuart King Chief Operating Officer NACA The Presidency

Dr Akudo Ikpeazu Relationship Manager for Line Ministries NACA The Presidency

Dr. Adenike Ojo Consultant NACA The Presidency

Mr. Alex Ogundipe Director of Policy NACA The Presidency

Ms Jo Nichols Senior HIV/AIDS Specialist World Bank Country Office Nigeria

Dr Abu Amos Senior Environmental Specialist World Bank Country Office Nigeria

Joe Odogwu Vice President Society for Family Health (SFH) Abuja , Nigeria


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Annex E: HCWM Procedures to be Applied in Health-Care Facilities

The following lines provide guidance for the implementation of Medical Waste Management (MWM) plans in HCFs. The plan should be consigned in a document that contains:

• The duties and responsibilities for each category of staff within the HCF who will generate HCW or be involved in their management

• . An estimation of the quantities of hazardous and non-risk MW generated annually;

• . The human resources, equipment and budget required annually to implement the HCWM plan;

• A manual synthesising all the procedures for the management of HCW in the establishment with a special mention for the categories of HCW requiring specific treatment, such as autoclaving, before final disposal. This manual should also contain time-tables including frequency of waste collection from each ward and department, a map of the HCF showing the different collection points, storage and treatment locations;

• Monitoring procedures to trace HCW inside the HCF and to ensure HCWM rules are respected;

• . Procedures to be followed by the HCF staff should be displayed at strategic points (i.e. nurse rooms, bin locations, temporary and central storage points, etc);

• . Training courses and programmes for all categories of HCF staff;

• . Contingency plans for storage or disposal of hazardous HCW in the event of a breakdown of the treatment/disposal facility

• . Emergency procedures in case of spillage/accidents should also be foreseen. Are detailed hereunder the steps that should be taken at anytime to ensure a smooth implementation of a HCWM plan inside major hospitals. In minor health-care facilities, proper Assignments and rigorous managerial procedures are often sufficient to ensure a smooth implementation of a limited but efficient HCWM plan. At HCF level, the development of a MWM plan can be divided into six majors’ steps as described hereafter Step 1: Designate a coordinator The preparation of a HCWM plan must begin with commitments from the Director of the HCF and senior directors who should designate a Health-Care Waste Management Officer (HCWMO) with overall responsibility for the development and the monitoring of the HCWM plan as well as the day-today operation of the HCWM system. Because (too) many committees already exist in the many HCFs, one does not recommend to create a HCWM committee at Hospital level but to assign already existing committees (e.g. Infection Control Committees) with the approval and periodic review of the MWM plan.


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Step 2: Conduct a MWM Survey A survey should be conducted on the current MWM situation within the hospital in order to Identify the necessary improvements. In close cooperation with head nurses from the medical Departments, the HCWMO should be responsible in coordinating the survey and analyzing the results as well as reviewing and assessing the existing waste management situation. In the same way the mission carried out this analysis at national level, every HCWMO should do it in his/her HCF

• Compile general information: types of waste generated in the health-care establishment, number of beds, occupancy rates, number of medical departments, etc;

• . Conduct a waste generation survey: waste composition, waste quantity, sources of generation and number of beds in use. The survey results should be presented in the form of average daily quantities of waste generated (in kg) in each MW category from each department

• . Conduct a critical review of existing waste management practices, (i.e. segregation, storage, collection transport, treatment and disposal,

• . Quantify the number of trolleys, containers and other equipment used in waste handling, collection a transportation;

• Identify the costs related to waste management and;

• Assess existing safety (e.g. protective clothing) and security measures (e.g. in case of spills and chemicals accidents);

• Evaluate the contingency measures applied in case of a breakdown of HCW treatment units or during close down for planned maintenance (e.g. safe procedures for handling laboratory wastes in case of breakdown of the autoclave);

• . Raise awareness amongst health-workers;

• . Prepare drawings or sketches of the HCF showing, storage areas for hazardous and other types of waste, on-site treatment facilities, waste collection trolleys routes through the HCF (e.g. routes for transportation of general and hazardous waste outside medical department), areas for washing and disinfecting waste collection trolleys, etc;

• Prepare drawings of each medical department, floor or building showing: location of individual HCW collection points (at least for medical waste, sharps and domestic waste), location of temporary storage areas/containers, routes for internal transport of waste in medical departments (at least for hazardous waste), location of equipment for disinfection.

Prepare drawings and specifications of: PE waste bags (thickness, width and length), containers (for medical waste and sharps, etc.), trolleys and wheeled containers for internal collection and, transport, protective clothing to be used in the handling of each category of waste (e.g. gloves, masks, plastic aprons, overalls,


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Step 3: Set-up an Action Plan Making recommendations

Based on the results obtained from Steps 1 and 2, the committee (e.g. Infection Control Committee) and the HCWMO should prepare recommendations on how to improve HCWM in the HCF. These Recommendations should include staff responsibilities and roles, training needs, staff and equipment resources. The following are basic actions for achieving the goals of the WHO minimal programme to improve the management of MW:

• Assessment of waste production (waste generation and composition);

• Assessment of the local handling, treatment and disposal options;

• Segregation of MW into hazardous and general (or municipal) waste;

• .Establishment of internal rules for waste handling (e.g. storage, colour coding or signs, bag/container filling closing and labelling,

• Ensuring workers’ training and safety at work (e.g. training on the safe use of chemicals for waste disinfection);

• Assignment of responsibilities within the health-care establishment;

• . Choice of suitable or better treatment and disposal options. Setting priorities for HCWM improvements Medical departments should first focus on the safe practices/procedures for HCW segregation, internal collection and storage. These measures have the greatest impact in reducing poor hygiene

practices. Improvements with respect to waste segregation, internal storage and collection in medical departments should consist, at least, of the following:

a) Segregation

• . Separation of health-care waste into three categories (general waste, hazardous health-care waste and sharps);

• Colour coding of bags/containers to differentiate between waste categories;

• . Use of posters and checklists to help segregate the waste;

• Use of labels for closed yellow-bagged waste;

• Use of holders to contain highly infectious waste bags/containers;

• . Existence of safety measures (protective clothing etc.) and emergency response (in case of needle-stick injuries, etc.);

• . Awareness-raising and hands-on training. b) Internal Storage

• . Separate temporary storage areas and containers for hazardous and general wastes;

• Temporary storage areas/containers located away from patient areas;

• . Fixed collection schedule for temporary stored bagged waste;

• Periodic cleaning and disinfection of temporary storage areas and containers. c) Internal transport

• . Fixed collection schedule for each waste category (three-bin system) dedicated trolleys and wheeled containers (leak proof with cover) for collection and transport of hazardous waste;

• Colour coding system or (if not feasible) colored signs for trolleys and wheeled containers to differentiate between trolleys for general and hazardous waste;

• . Periodic disinfection and cleaning of trolleys and wheeled containers;

• . Existence of safety measures (e.g. protective clothing) and emergency response (e.g. in case of spills, occupational injuries);

• . Awareness-raising and hands-on training.


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Costs associated with HCWM improvements

The cost of HCWM improvements depends upon the nature of the improvements; e.g. the total cost of introducing segregation of waste includes the cost of purchasing plastic bags and containers, of trolleys and wheeled containers and their maintenance, and of separate transportation. Waste minimization, segregation and recycling can greatly assist in the cost reductions increasingly required by HCFs, by reducing disposal costs As a general guideline, the final cost of HCWM improvements may consist of the following:

• . Capital investment cost (e.g. purchase of trolleys and wheeled containers);

• . Operating costs: labour, consumables (e.g. purchase of plastic bags);

• . Cost of maintaining equipment or improving buildings (e.g. creation in medical departments of separate temporary storage areas for yellow and black-bagged waste);

• Costs of contracted HCWM services (e.g. collection of segregated waste by contractual services);

• Treatment and disposal costs (by private or public sector);

• Miscellaneous.

Implementing the proposed HCWM improvements

Arrangements for the implementation of HCWM improvements should be stated in the HCWM plan. A work plan or protocol comprising practical approaches/steps for safe implementation of waste management improvements in each medical department should be developed by the HCWMO / Infection

Control Committee in close cooperation with the head nurses of medical departments It may be preferable to test the proposed HCWM improvements first in one or two departments This approach also provides practical training for staff. Subsequently, the improvements can be in extended to other parts of the HCF. The work plan for implementation of HCWM improvements each medical department may include the following:

• . Methods and timetable for implementing HCWM improvements and definition of responsibilities and roles;

• . Checklists to assist nurses during the implementation process;

• Training and awareness-raising activities to introduce procedures for implementation of planned activities. The following subjects may be considered for training and awareness-raising activities: 1) proper procedures and precautions for segregation, handling, storage and disposal of hazardous HCW, 2) proper emergency procedures during a hazardous HCW spill or exposure, 3) health hazards associated with mishandling hazardous HCW, 4) organizational process for reporting hazardous materials and waste spills or exposures;

• . Detailed information on safety practices and emergency response in case of incidents or accidents associated with HCWM (e.g. occupational injuries, spillage of hazardous waste, exposure to cytotoxics) and in case of disease outbreaks (e.g. cholera);

• . Health surveillance and control (e.g. immunization against HBV and tetanus) and provision of information on rapid access to post exposure prophylaxis

• . Measures to control and monitor the implementation of waste management improvements. By reviewing performance data every few months modifications can be made to the waste management system;

• Contingency measures, including instructions on storage or evacuation of HCW in case of

breakdown of treatment units or during close down for planned maintenance.


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Step 4: Draft the HCWM plan Based on the results of the situation assessment phase and its recommendations, the HCWMO should then draft the HCWM plan. If necessary, he/she should ask for advice, information and support from the MOH . The content of the draft of the HCWM plan can be as simple or as complex as desired by the management of the health-care institution. However, all HCWM plans should address the following three aspects:

• . Clear and open examination of the current HCWM situation (Step 2).

• Analysis of what resources are available for improving HCWM and the possible options for improvements

• Preparation of a detailed set of arrangements to implement the proposed waste management improvements

o arrangements for training staff; o acquiring new waste storage; o handling; o treatment and disposal equipment; o a timetable for implementation (Step 3) o .

An HCWM plan should show its linkage with other hospital management plans, if they exist (e.g. Safety management plan, security management plan, emergency preparedness plan, equipment investment plan). Weakness in the linkages with these management plans and lack of cooperation and coordination with related executive officers may affect the effectiveness of the HCWM improvements/plan implementation Step 5: Approve the HCWM plan and start implementation The draft of the HCWM plan should be discussed by the Executive Committee and submitted for approval by the institution’s management. Once approved, the implementation of the HCWM plan should be of the responsibility of the Director of the HCF. The HCWMO or the Infection Control Committee, in charge of monitoring the operation of the HCWM system, may also be delegated by the Director the responsibility for the HCWM plan implementation Step 6: Review the HCWM plan

• . Operation of the HCWM system in HCFs cannot be efficient or optimized in the long run unless there is a periodic review of the HCWM plan. With respect to the process of review it is recommended that a periodic review (e.g. every 2 years) of the HCWM plan be carried out by the Infection Control Committee.

• The infection Control Committee meets periodically (e.g. monthly) to monitor the

implementation of the HCWM plan and determine whether the approved HCWM improvements

need review or adjustment


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Annex F: Health Care Waste Management Procedures to be Applied in Medical Laboratories

The management of HWC remains a sensitive issue since highly infectious waste are often generated there. International standards procedures of highly infectious waste management plan should therefore be respected. They are summarized in the table below. Consequently each laboratory should be equipped with the adequate materials and rigorous protocols set-up to ensure pre-treatment of highly infectious waste before it joins the other medical waste for treatment/disposal. Highly infectious waste from medical laboratories, such as media or culture plates should be collected in leaf proof yellow bags or containers suitable for autoclaving and properly sealed. Ideally, each laboratory should have an autoclave room dedicated for specific pre-treatment of this kind of waste only. No office waste or other kind of miscellaneous waste should be placed in this room which shouldn’t be either used for waste storage. Once disinfected medical laboratory waste should be collected and treated with infectious HCW. If a distinct autoclave isn’t available at the medical laboratory to ensure a thermal treatment, highly infectious waste should be disinfected in a solution of sodium hypochlorite in concentrated form and left overnight. It should then be discarded in a specific yellow bag, properly sealed before joining the hazardous HCW.

STEP ACTION

Segregation Highly infectious waste should be: • kept in the medical area until it is pre-treated; • segregated from other general and medical waste; • placed immediately into leak-proof bags or containers

Pre-treatment Highly infectious waste should be immediately pre-treated (i.e. autoclaved or chemically treated) before joining the other medical waste.

Packaging Yellow bags should be labeled with the biohazard symbol and clearly marked with the words “highly infectious waste” with a comment on whether it has been pre-treated or not.

Labeling Yellow bags should be labeled with the name of the institution and department, type of waste, date, name and signature of person sealing the bag/container.

Storage, Transport and treatment

Disinfected highly infectious waste packaged in yellow bags is no longer regarded as highly infectious and can therefore leave the medical area with other yellow-bagged waste, stored transported and disposed of

Procedures for the management of highly infectious waste During the handling of HCW in medical laboratories, a number of precautions should be taken To avoid cross-contamination, such as:

o The re-useable laboratory items should never be mixed with disposable ones; o The contaminated items must be autoclaved or alternatively chemically disinfected and should

never be discarded with general waste


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o ; Single-use/disposable laboratory items must be autoclaved and never discarded with general waste;

o All sharps (including broken glass) must be autoclaved and never discarded with general waste.

They must be disposed of in approved yellow sharps containers.


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Annex G: HIV/AIDS Medical Waste Management Plan (2009 - 2014)

ACTIV ITY IMPACTS MITIGATION INSTITUTIONAL

ARRANGEMENTS COST IN US$ MONITORING &

EVALUATION TIMELINE (YEAR)

5. GENERATION

Negative Impacts

Hazardous and infectious wastes are always generated hence need to reduce the volume through: - -shredding and compaction -Training of medical personnel and non medical staff on waste management

Lead agency – NACA, SACA. Other stakeholders - All HCFs

Nil Volumes of healthcare waste generated and well managed

Continuous

6. SEGREGATION

Negative Impacts

-Provision of colour coded waste bins and liners -Special attention given by cleaners to waste management from HCT -Sharps generated should be disposed of in the provided safety box. -Other waste generated from the testing unit should be disposed of appropriately in the provided bio-hazard bags

Waste management Department (WMD) in each HCF

Tertiary HCF -$1,748 Secondary HCF -$879 Primary HCF (Urban)-$587 Primary HCF (Rural) -$587

Rate of use of colour coded bags and separation of waste by type.

Continuous

7. STORAGE

Negative Impacts

-Proper and adequate facilities should be provided for HCT waste such as safety boxes, waste bags and storage bins. -Limit level of safety boxes should not be exceeded. -Collection sites should be well protected to avoid waste being blown away by wind and also to prevent leakages. -Scavenging should be highly pre vented. -Storage of wastes should be according to colour coded bags.

Lead Agency: - NACA, SACA Other stakeholders Waste Management Department in each HCF to lead in enforcement of safe storage standards through linkage to generating units.

Volume of healthcare wastes properly stored

Continuous


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8. (a) COLLECTION

WITHIN GENERATING FACILITIES

Negative impacts

Mitigation measures will include -Adequate protective gear such as hand gloves, boots, aprons e.t.c. -Provision of appropriate bin trolleys. -Waste bags should be collected on a regular basis from units within the HCF -Safety boxes should be collected immediately once the limit level is reached. Adequate care should be taken when handling safety boxes. -Collection procedure and standards should be developed by the HCF

-Waste Management Officers to supervise generators within their units -waste handlers to handle the wastes

Tertiary HCF -$1864 Secondary HCF -$1319 Primary HCF (Urban) -$423 Primary HCF (Rural)-$263.75

Implementation of Collection procedure and standards

Continuous

(b) COLLECTION FOR DISPOSAL

Negative Impacts

-Safety boxes and infectious waste should be taken straight from the collection point to the incinerator or sanitary landfill. -Waste should be collected in groups according to their colour codes -There should be adequate protective gear -There should be effective collection procedure and standards.

Collection is the primary responsibility of - State Environmental Protection Agency (SEPA) -Contracted collectors

Tertiary HCF -$280 Secondary HCF -$325 Primary HCF (Urban)-$200 Primary HCF (Rural)-$175

Implementa-tion of Collection procedure and standards

Continuous

9. TRANSPORTATION

Negative Impacts

For effective transportation of healthcare wastes, the following measures are necessary -appropriate routing and timing -relevant transportation vehicle -Collection trucks should be properly maintained to avoid mechanical breakdown.

-State Environmental Protection Agency (SEPA) -Contracted collectors

Local authorities and contracted firms to bear the cost

Frequency and effectiveness of waste disposal

Continuous

10. DISPOSAL

Negative Impacts

-There should be an effective and functional incinerator -waste from septic tanks should be properly collected and disposed of when full. -provide a properly engineered and well maintained sanitary landfill. -open air burning of waste within the HCF should be highly discouraged.

State Environmental Protection Agency (SEPA)

Tertiary HCF -$101,333 Secondary HCF -$101,332 Primary HCF (Urban)-$1000 Primary HCF (Rural)-$1000

- functional incinerators -well managed sanitary land fills -availability and use of any other appropriate wastes disposal method

Continuous

Capacity building should be carried out at all levels from generation to disposal through appropriate training, media and other forums. There is need to have sensitization action plan and measure impact

SACA to lead in ensuring that internal capacity is built All other stakeholders including the Waste Management Department in each HCF

Training plan, Number trained, Curriculum developed, Training reports

Continuous

11. CAPACITY BUILDING (TRAINING, INFORMATION SHARING)

Negative Impacts

Development of training curriculum/modules curriculum/


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National Level -Operational level -Waste handlers -Community Level

development and implementation for all levels

Community awareness and advocacy - IEC materials in various languages - radio, newsletters and TV programmes to sell ideas

Tertiary HCF -$4000 Secondary HCF-$4000 Primary HCF (Urban)-$2500 Primary HCF (Rural)-$2000

Available BCC/IEC materials

Community training Tertiary HCF -$6666 Secondary HCF -$6666 Primary HCF (Urban)-$4000 Primary HCF (Rural)-$3000

Staff training on short courses and educational tour

- Amount indicated above As above

Promote public-private partnership Through stakeholders coordination, workshops and meetings

12. RESEARCH Negative impacts

-Site Selection Survey -inventory of health care wastes facilities – type, location, condition, number -research on technological options -research on community level disposal methods -characterisation and quantification of wastes

WMD lead in implementation of the research and survey activities

Nil -Survey reports, Research findings disseminated, Research recommendations implemented

First quarter of first year

o

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