53652 Health Care Waste Management at a glance Health care waste management (HCWM) is a · control zoonoses (diseases passed to humans process to help ensure proper hospital hygiene and through insects, birds, rats and other animals); safety of health care workers and communities. It · cut cycles of infection; includes planning and procurement, construction, staff · easily and cost-effectively address health care training and behavior, proper use of tools, machines worker safety issues, including reducing risk of and pharmaceuticals, proper disposal methods inside needle sticks; and outside the hospital, and evaluation. Its many · prevent illegal repackaging and resale of dimensions require a broader focus than the tradi- contaminated needles; tional health specialist or engineering point of view. · avoid negative long-term health effects; eg, cancer, from the environmental release of toxic substances Advantages of good HCWM such as dioxin, mercury and others. The need for proper HCWM has been gaining HCW can be subdivided into various categories recognition slowly. It can: (Table 1). Segregation of different waste categories · help control nosocomial diseases (hospital acquired is critically important to enable proper disposal. infections), complementing the protective effect of Approximately 80% of all HCW can be disposed proper hand washing; of through regular municipal waste methods. The · reduce community exposure to multi-drug resistant other 20% can create serious health threats to bacteria; health workers and communities if not disposed · dramatically reduce HIV/AIDS, sepsis, and of properly. Disposal methods vary according to Hepatitis transmission from dirty needles and other type of waste, local environment, available technol- improperly cleaned/disposed medical items; ogy, costs and financing, and social acceptance Table 1: WHO categories of health care waste Waste category Description and examples infectious waste waste suspected to contain pathogens, eg laboratory cultures, waste from isolation wards, tissues (swabs), materials or equipment that have been in contact with infected patients, excreta pathological waste human tissues or fluids, eg body parts, blood and other body fluids, fetuses sharps sharp waste, eg needles, infusion sets, scalpels, knives, blades, broken glass pharmaceutical waste waste containing pharmaceuticals, eg pharmaceuticals that are expired or no longer needed, items contaminated by or containing pharmaceuticals (bottles, boxes) genotoxic waste waste containing substances that are capable of causing damage to DNA, eg waste containing cytostatic drugs (often used in cancer therapy), genotoxic chemicals chemical waste waste containing chemical substances, eg laboratory reagents, film developer, disinfectants that are expired or no longer needed, solvents wastes with high content Batteries, broken thermometers, blood-pressure gauges, etc. of heavy metals pressurized containers gas cylinders, gas cartridges, aerosol cans radioactive waste waste containing radioactive substances, eg unused liquids from radiotherapy or laboratory research, contaminated glassware, packages or absorbent paper, urine and excreta from patients treated or tested with unsealed radionuclides, sealed sources June 2003 (due to religion, customs, etc). Each facility or health HCWM is most effective when proper methods are authority must assess local conditions and decide on employed at each step, from planning and procure- appropriate HCW solutions; there is no single best ment through disposal. The first step should be method or method mix. Table 2 summarizes currently determining realistic options for HCWM given the available disposal methods and some of their advan- budget, technology, and local community prefer- tages and disadvantages. ences. Different aspects of health care waste must be considered when choosing the appropriate treatment HCW handling and disposal technology (such as volume, temperature, whether the waste is liquid or solid, hazardous or infectious). The stages in HCWM are: production of waste within a hospital ward, segregation of waste, ward storage, Once procurement is initiated, staff must be trained onsite transportation and treatment (if any), onsite cen- to work within a system of accountability, from tral storage, offsite transportation, treatment, and final correctly segregating waste and labelling every disposal. Dealing with such a comprehensive subject bag/container, to proper storage at each point of the which impacts the construction and functionality of cycle and safe transportation and disposal of HCW. health facilities, can be daunting. Several agencies Most importantly, management staff must be trained (WHO, the World Bank) and NGOs (Health Care to monitor activities at each point in the cycle and Without Harm) have developed useful guidelines on maintain standards. the topic (see resource list on p4). Table 2: Factors influencing the effectiveness of treatment technologies Type of treatment & Factors that influence disposal method effectiveness Concerns burial, encapsulation ­ depth of groundwater ­ no disinfection (simple, inexpensive) ­ depth, size of trench/pit ­ can handle small volumes only ­ lining of burial pit (non-porous) ­ potential of being unburied (if pit is only ­ sealing method/material soil covered, or waste not encapsulated) ­ presents a danger to community if not properly buried incineration ­ turbulence/mixing ­ may produce emissions and hazardous (disinfects and greatly reduces ­ waste moisture content ash containing dioxins, metals and furans volume, produces secondary ­ combustion chamber filling depending on the type of waste burned waste streams) ­ temperature/residence time ­ may require pollution control equipment to ­ maintenance/repair meet local environmental regulations ­ public acceptance of incineration tends to be low ­ expensive to build, operate and maintain steam autoclave ­ temperature and pressure ­ mostly for reusable materials & instruments, (disinfects only, little reduction ­ steam penetration and to sterilize disposable sharps before of volume unless used with ­ waste load size disposal. shredder, produces secondary ­ treatment cycle length ­ can only treat some types of HCW waste stream) ­ chamber air removal ­ some models cannot handle high volumes ­ model (many available) ­ requires electricity and water ­ some models have high capital, maintenance and operation costs microwave ­ waste characteristics ­ expensive, needs good infrastructure (disinfects, some reduction ­ waste moisture content ­ requires training and oversight for medium of volume, produces secondary ­ microwave source strength to high effectiveness waste stream) ­ microwave exposure duration ­ effectiveness very dependent on type of ­ waste mixture extent technology used chemical/mechanical ­ chemical concentration, ­ can increase the volume of waste treatment temperature & pH levels ­ worker safety issues prominent (disinfects, no volume reduction, ­ chemical contact time ­ personnel intensive volume can increase, produces ­ waste/chemical mixing ­ may not adequately disinfect AD syringes, secondary waste streams) ­ recirculation or flowthrough disinfection process needs to be verified option Health care waste management project cycle Assess environmental impact (including cost) of procurement items and Train staff in treatment technologies. proper HCWM, Develop strategic worker safety and plan and review infection control. regulations. Develop pilot projects. Monitor pilots: fiscal, behavioral Develop onsite standards and technological for waste treatment and aspects. disposal at health care Integrate pilot facilities. evaluation results into nationwide effort. HCW worker safety and of proper HCWM, and their roles and responsibili- ties. Information about cleaning techniques and procurement issues protocols should be prominently displayed. To ensure worker safety, it is normally necessary to Appropriate vaccinations and barrier mechanisms procure plastic bags, trash bins, `sharps' containers, such as gloves and masks should be made available and sometimes even special trucks. It is sometimes to all staff coming in contact with HCW, including advisable to ensure access to disposable gloves and cleaning staff and engineers. other protective equipment for staff (eg boots, aprons, thick rubber gloves), needles and syringes, laboratory Who is responsible for HCWM? equipment, cleansing agents, and tubes/hoses/other Normally nurses and cleaning staff, inspectors, items associated with diagnostic and intensive care engineers, and drivers are responsible for day to machines. Disposable items increase the amount of day HCWM. Budgetary, procurement, regulatory, HCW each hospital or health care facility produces, and training aspects are overseen by facility man- and have cost implications. agement/administration. Hospitals could hold It is wise to ensure proper hygienic methods for department heads responsible for proper manage- cleaning reusable items within a health facility, such ment and disposal of waste generated in their as linens, laundry, reusable tools (surgical etc), and departments. HCWM should have high priority, foodstuffs. Availability and costs of associated utility and involve the highest authorities at each facility. systems such as sewerage, hot and/or cold water, In general, rural and urban areas differ greatly, electricity, sources of heating, etc, must be consid- even within regions or countries, so it is important ered. Sometimes new equipment is procured without to check the management aspects in both areas. considering available utilities, recurrent costs and Proper HCWM extends beyond the hospital to the repairs, and then stands unused because it is not disposal site. Traditionally, there has been a discon- connected to the municipal system (eg sewerage) nect of accountability between what occurs on the or because recurrent costs are too great. premises of a health care facility and what occurs Training all health care workers in techniques after HCW leaves the facility. More and more, this is associated with newly procured items and medical no longer the case as NGOs and local communities equipment is crucial to proper HCWM. All workers have been very active in organizing against facilities in the facility need some training on the importance that do not monitor the results of waste disposal offsite. Project managers are well advised to follow the route of HCW until its ultimate disposal and Key References inquire after the secondary waste streams that might be created. World Health Organization www.healthcarewaste.org Includes a database on Do's and Don'ts different types of treatment technologies and links to WHO documents on HCWM. DO ensure that a good system is in place for segre- gating different types of waste and that each type is www.noharm.org Healthcare Without Harm disposed of in an appropriate and safe way. This focuses on treatment technologies other than DO train all levels of health care staff (administrators, incineration. It is a very good source for all stages doctors, nurses, cleaning staff, lab. technicians and of HCWM. engineers) to help ensure that the materials and www.pqmd.org The Partnership for Quality Medical methods chosen are used correctly and consistently. Donations Focuses on chemical and pharmaceutical DO vaccinate all workers who come into contact with waste after drug donations. A new drug donation HCW against hepatitis B virus. strategy aims to reduce waste and increase informa- tion flow. DO monitor costs throughout project implementation in order to determine whether projections are correct http://melissa.org/cwg/ Home page of the and to provide data for better future cost estimates. Collaborative Working Group (CWG) for the promotion of Solid Waste Management (SWM) in DO make reasonable adjustments to the project when lower- and middle-income countries. Scroll down to monitoring progress and costs. recent SWM publications, see especially No. 5, a DO be realistic. Many countries want the very best technical guide to planning, design and operation of and latest technology but don't have the necessary solid waste landfills in middle- and lower-income resources for sustained use. Proper HCWM can be countries, and No. 4, a summary Decision-Makers' viewed as a step-wise process, with gains made Guide to Solid Waste Landfills. every few years. The most important goal is to www.worldbank.org/hnp The World Bank HNP ensure the health and safety of health care workers group Click on "Tools and Guidelines" to find The and the local community. WHO is an excellent Health Care Waste Management Guidance Note. resource for the various options available (see Key References). www.worldbank.org/phataglance Safe Injection at a DON'T forget to engage hospital staff in HCWM deci- glance sions. Normally, as a HCWM project progresses, www.injectionsafety.org Safe injection global staff will begin offering serious and substantive network (SIGN) advice and ideas for improvement within local con- straints. Key Contacts DO consider and consult with the local community. World Bank: Jean Roger Mercier Project acceptability within the local community is key (jmercier@worldbank.org) for good practices and and project managers need to get early advice and guidelines for Safeguard Policy compliance. understand socio-economic factors and local con- Tawhid Nawaz (tnawaz@worldbank.org) of the HNP cerns. Communities can become surprisingly emo- quality assurance team. tional about HCWM, especially if it touches on WHO: Richard Carr (carrr@who.int) HCWM, Yvan cultural biases regarding various types of waste. It is Hutin (SIGN@who.int) Safe injection global network important to address these issues seriously and (SIGN) resolve any concerns quickly: a project that might be viewed as a success internally could be viewed nega- Candace Chandra (Candace@canarystrategies.com) tively by the community. HCWM and infection control consultant. Expanded versions of the "at a glance" series, with e-linkages to resources and more information, are available on the World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp