Management of waste from

injection activities at district level

Guidelines for District Health Managers

WHO Library Cataloguing-in-Publication Data

Management of waste from injection activities at the district level : guidelines for district
health managers.

1.Medical waste disposal. 2.Needles. 3.Guidelines. I. World Health Organization.

ISBN 92 4 159428 4 (NLM classification: WA 790)

ISBN 978 92 4 159428 8

World Health Organization 2006

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Printed by the WHO Document Production Services, Geneva, Switzerland

ii
 TABLE OF CONTENTS
INTRODUCTION ................................................................................................................................... 1
Why such a Guide?........................................................................................................................................1
Why focus on sharps? ...................................................................................................................................2
How is this Guide structured? ........................................................................................................................2

1. ASSESS THE SITUATION IN YOUR DISTRICT ....................................................................................... 3

Checklist of actions ........................................................................................................................................3
Tools you can use ..........................................................................................................................................4

2. WASTE HANDLING, TREATMENT AND DISPOSAL OPTIONS .................................................................. 6

Handling and disposal options when syringes and needles are not separated.............................................6
Handling and disposal options when syringes and needles are separated...................................................7

3. CRITERIA FOR SELECTING APPROPRIATE WASTE TREATMENT AND DISPOSAL STRATEGY ................. 11
Alternative 1: Regular sharps waste collection for central treatment...........................................................11
Alternative 2: Controlled burial on premises for remote areas or small facilities .........................................11

4. ESTIMATE EQUIPMENT NEEDS FOR INJECTION WASTE ..................................................................... 13

Checklist of actions ......................................................................................................................................13
A Tool you can use ......................................................................................................................................14

5. ENSURE THE SUSTAINABILITY OF YOUR STRATEGY/PLAN OF ACTION ............................................... 15

Check national health-care waste management policy ...............................................................................15
Ensure basic waste management requirements are understood ................................................................15
Ensure long-term compliance with health-care waste management practices............................................15
Ensure technical assistance to improve waste management practices ......................................................15

6. CALCULATE AND COMMUNICATE NEEDS TO HEALTH AUTHORITIES .................................................. 16

Estimate investments needed......................................................................................................................16
Estimate financial resources needed to cover recurrent costs ....................................................................16
Where relevant, organize a centralized health-care waste treatment system .............................................16
Write a report outlining results and recommendations and a Plan of Action ...............................................16
Organize purchasing of material and transport............................................................................................17

7. SET UP A MONITORING SYSTEM & EVALUATION SYSTEM ................................................................. 18

Organize the supervision of health-care waste management .....................................................................18
Evaluate the waste management strategy...................................................................................................18

SUMMARY - STEPS TO IMPLEMENT A SAFE WASTE MANAGEMENT PLAN ............................................... 19

iii
Acknowledgements

The World Health Organization is extremely grateful to the following experts

for their valuable contributions to this document:

Ccile Arnaud, Emergence

Franck Bouvet, Emergence
Pierre Lorillou, Emergence

and

Members from Program for Appropriate Technology in Health

Members from John Snow, Inc.

The individuals from the World Health Organization having participated in

the preparation of the document include:

Diana Chang Blanc, Expanded Programme on Immunization,

Immunization Vaccines and Biologicals, WHO-Geneva

Yves Chartier, Water, Sanitation and Health, Public Health and

Environment, WHO-Geneva

Eric Laurent, Immunization Quality & Safety, CDS/VPI, WHO Regional

Office for Europe

Raki Zghondi, Urban Health and Environment, WHO Regional Centre for
Environmental Health Activities (CEHA), Amman, Jordan

Editors:
Yves Chartier and Elisabeth Woolnough, Water, Sanitation and Health,
Public Health and Environment, WHO-Geneva

iv
INTRODUCTION

WHY SUCH A GUIDE?

Inadequate management and disposal of waste generated by injection activities such as sharps and
infectious waste can have a negative impact, either directly or indirectly, on the health of medical staff and
waste handlers, as well as on the community and environment. Much attention has been paid to tertiary
health-care facilities located in urban areas where financial and human resources are more readily available.

However, due to financial and institutional constraints, limited efforts have been made to provide District
Management Teams with simple and adequate guidelines to set-up health-care waste management plans for
primary and secondary health-care facilities. In particular, management of waste from mass and routine
injection activities remains problematic as significant quantities of disposable or auto-disable syringes and
needles are generated, for which there must be safe disposal options.

This guide is designed as a simple and practical tool to help District Health Managers elaborate a realistic
District level plan to reduce improper disposal of waste from injection activities.

This guide puts a special emphasis on the management of sharps.

WASTE CATEGORIES GENERATED IN INJECTION ACTIVITIES ARE AS FOLLOWS:

Used sharps (most hazardous)

Needles
Lancets
Broken glass (vials, flasks)

Waste materials possibly contaminated by body

fluids
Syringes without needles
Gloves, gowns, masks
Gauze, dressings, swabs
Containers for medical purposes

General Waste
Packages, boxes, papers
Disposable cups, plates
Food and drink packaging
Tissues, paper towels

1
WHY FOCUS ON SHARPS?
If they are not properly handled and disposed of, sharps and more specifically needles are considered the
most hazardous category of health-care waste for health-care workers and the community at large. This is
because needle-stick injuries can easily occur and carry a high potential for infection.

THE RISK OF ACCIDENTS WITH SHARPS:

Children playing with syringes Stick injury of medical staff Needle stick injuries may
and needles may be infected is a major source of infection cause Hepatitis B & C, HIV,
by needle-stick injuries sepsis etc.

HOW IS THIS GUIDE STRUCTURED?

This guide is divided into seven sections and includes a poster which can be widely reproduced and
distributed to health-care facilities. The sections correspond to the seven major steps District Health Officers
should implement to improve sharps management, protect public health, limit the risk of needle-stick injuries
and reduce negative effects of waste on the environment. A chronological checklist of actions, illustrations,
as well as practical tools, are included.

2
STEP 1. ASSESS THE SITUATION IN YOUR DISTRICT

CHECKLIST OF ACTIONS


Create an inventory (list and map) of all health-care facilities in the district including mobile sites,
health-posts, primary health-care centres, district hospitals;

For each health-care facility, record access and logistical constraints throughout the year (taking
into account seasonal variations);

Categorize and estimate the quantities of sharps generated (disposable syringes, lancets and other
waste materials);

Review waste handling, treatment and disposal practices and identify facilities with dangerous
practices requiring urgent action.

This assessment should result in the identification of existing good practices and the prioritization of areas
requiring improvements. For example:

Good practices Poor practices

Waste segregated into infectious and non No segregation of waste into infectious and
infectious waste. non infectious matter, garbage contains
syringes.
Entire syringe or needles collected in a
puncture and leak proof container (with colour Waste disposed of in unprotected open
coding or bearing a biohazard sign/symbol). dumps.
Alternatively, needles are removed
Reported cases of needle stick injuries in the
immediately after injection via needle remover
community.
and disposed of on site.
Lack of staff awareness about the risks from
Non-sharp infectious wastes are collected in
potentially infectious materials or blood-borne
bags (with colour coding or bearing a
diseases.
biohazards sign/ symbol).
Lack of know-how among staff in waste
Infectious waste bags and sharp containers
handling.
are safely handled and transported (on-site).
Insufficient staff and time dedicated to proper
Infectious waste bags and sharp containers
waste management (staff overload).
are stored in secured places prior to
transportation for treatment/disposal. Lack of supplies (PPE, Bags, sharp
containers) and/or improper use of those
Availability and use of Personal Protective
supplies.
Equipment (PPE) and facility for washing
hands for all persons handling waste. Lack of money and know-how to build
infrastructure.
Immunization of staff against Hepatitis B virus
(HBV). Weak management and supervision of the
waste management stream.
Regular supervision and correction of
problems.

3
TOOLS YOU CAN USE

The following check list could be used for assessing existing practices:

Name of the facility :

Location : Answer Details
Total number of workers :

Is there a designated person in charge of waste

1
management in the facility?
Is there a written standard operating procedure
2
(SOP) for waste management in the facility?
3 Is there a system for segregation of waste in place?
Are the staff aware of risks associated with improper
4
waste handling?
For mass immunization
campaigns?
5 Are auto-disable syringes used for injection? ..
For routine injection activities?

6 Are syringes discarded with their needles attached?

7 Are needles separated from syringes after injection?

By hand, needle cutter, needle
8 If yes, how are they separated? removal can/boxes, locally made
devices
WHO safety boxes, rigid plastic
9 What type of containers are used for sharps waste? safety containers, open bins.
What colour?
What type of containers are used for non-sharp
10 Bags, boxes, bins. What colour?
infectious waste?
needle
Are syringes and needles disinfected before final
11 . ..
disposal?
syringe
12 If yes, how are they disinfected? Autoclave, boiled water, chlorine...

Shredding, encapsulation on-site

13 Are they processed in another way? . .
Shredding, encapsulation off-site

Open dumps, Protected pit, on-

What is the method of final disposal of all infectious
14 site incineration, controlled landfill,
sharps?
municipal facility
15 Is there a secured waste storage area on site?

How are safety boxes, bins, waste bags transported By hand, wheeled waste vehicles,
16
within the facility? wheelie bins or trolleys
By hand, using public transport,
How are safety boxes, bins, waste bags transported shared-use vehicles, dedicated
17
outside the site of the facility? waste vehicles, motorcycle or
bicycle.
18 For how long, on average, is waste stored on-site?

19 Is there a specific budget for waste management? % of total budget or amount

4
 It may be helpful to construct/design and use a map of the district when quantifying waste generated in
each facility which needs to be processed at a chosen site. Such a map would show the facilities generating
infectious waste, the approximate quantities generated per month, and the sites that have the capacity to
dispose of such waste because they have adequate infrastructure, staff, transport, etc.. An example is given
below:

Health Center C
Hospital C
875 syringes
14,500 syringes
per month
per month. Autoclave or
5 min to hosp C
incinerator
with additional capacity
for 10,000
syringes/month

Health-Center A
300 syringes
per month
20 min. to hosp A Hospital A
2500 syringes per month
Autoclave or incinerator
with additional capacity
for 50,000
syringes per month
Health Post 3
Health center B 300 syringes
200 syringes per month
Health Post 1
per month 2 hrs to hosp C
40 syringes
40 min to hosp A
per month
2 hrs to hosp C
Health Post 2
Source: PATH 166 syringes
per month
3 hrs to hosp C
Note. this specific mapping considers only syringe/needles. The volume of non-sharps infectious waste
should be included to show a complete picture of waste generated

The following table may help you quantify the infectious waste generated by health facilities in your district
and identify facilities that have the capacity to treat and dispose of waste from neighbouring facilities.
Accessibility is defined as the possibility for a vehicle to travel on a regular basis to the waste treatment and
disposal site depending on weather conditions.

District of: Date of survey: Filled by:

Health care setting Logistics Sharps

Name Type Location Final Distance Road Accessibility Type of Quantity

treatment (Km) condition syringe Nb/month
& disposal
site

Total
district/month

5
STEP 2. WASTE HANDLING, TREATMENT AND DISPOSAL OPTIONS
HANDLING AND DISPOSAL OPTIONS WHEN SYRINGES AND NEEDLES ARE NOT SEPARATED
A/ Collection of syringes with needles attached:

WHO UNICEF cardboard Safety boxes

These puncture and leak proof boxes are specifically
designed to receive syringes with their needles
attached. Minimal capacity: 100 syringes. Should not
be reused. Cost approximately 1 US $.

Puncture resistant plastic Safety boxes

These plastic boxes are puncture resistant and
slightly more expensive than cardboard Safety
boxes. Supplies might be more difficult to find for
small and medium-sized health care facilities.
Capacity: 100 syringes. Should not be reused. Cost
approximately 2 to 3 US $.

Locally available puncture resistant cardboard

boxes or plastic bottles
In small health-care facilities, in case of supply
shortages of cardboard or puncture resistant plastic
safety boxes, alternative solutions can be
implemented to store used syringes. For example,
puncture and leak proof boxes or thick plastic
containers that can be closed can serve as adequate
replacements. Open boxes, bleach bottles and thin
plastic containers are not appropriate. Any
receptacles used for this purpose should be labelled
as containing hazardous sharps waste.

B/ Treatment and disposal options for filled safety boxes

On site burial / burial on premises (option for small facilities with open land that cannot transport to a

centralized facility):

Controlled burial in protected or concrete pit on

premises
Both cardboard and plastic safety boxes may be
buried on premises in a controlled manner. A fence
should restrict the access to the pit. In unstable soils,
the sides of the pit should be lined with brick or
concrete to prevent collapse. A 10-15 cm layer of
earth should be placed on each layer of waste and
the pit should be filled with soil or concrete until the
contents reach 50 cm of the hole surface. Once
closed, the site should be marked to prevent future
digging. Open dumping of boxes/bagged waste
should be avoided.

6

Off-site treatment at a centralized facility:

Collection of safety boxes for off-site treatment

Safety boxes should be collected on a regular basis
(by vehicle or even by bicycle) and sent to a
centralised treatment facility for autoclaving
(saturated steam at high temperature) or for proper
incineration. Tops of safety boxes should be closed
and sealed.

Autoclaving
After receipt at the centralized facility, syringes may
be sterilized in an autoclave (saturated steam at high
temperature) restricted to waste treatment only.

High temperature incineration (850C)

(Ideally plastic should not be incinerated).
The temperature must be at least of 850 degrees to
ensure minimal emission of toxic gases. Low-cost,
high temperature incinerators are now affordable for
medium-sized health-care facilities. Operating
procedures based upon design and distance from
populated areas should be carefully respected. For
this purpose, only well trained staff should operate
the incinerator. Proper operation procedures must be
followed to ensure high temperatures are adequately
reached.
Note: open burning should not be considered as an
option because of the risk it represents for staff and
communities and to the environment.

HANDLING AND DISPOSAL OPTIONS WHEN SYRINGES AND NEEDLES ARE SEPARATED
A/ Separation of needle and plastic syringe:

Needles may be separated with a remover:

Needle remover
Immediately after injection, the tip of the used syringe
is placed in the needle remover and a lever pressed.
A blade then cuts the hub of the syringe so that the
needle drop into a protective container. A needle
cutter costs from 20 to 80 US $, does not require
electricity and is easy to use. It is therefore equally
suitable for small and large-sized health-care
facilities. Cost of a needle container: 0.15 to 1.0 $
(the contents of the container can be discarded so
that the protective container can be re-used). There
should always be one unit kept at the site of every
injection session.

7
Disposable needle remover (or hub cutter)
The disposable version of the needle remover is a
rigid plastic box specifically designed with a blade to
cut the syringe at hub level. It can store 400 to 600
needles safely. The box is then disposed along with
the needles inside. Because it is compact and
lightweight, it is well-adapted for outreach use. This
device does not cut all syringe types. Cost about 2
US$.

Note: WHO is currently not promoting needle removers; nevertheless, it is recognized that the
removal of needles immediately after injection offers advantages for the management of waste
disposal; therefore one should consider the risk-benefit of introducing such devices.

If luer slip syringes are used, hub and needle are simply removed by applying slight pressure:

Needle Remover Can (detachable needle

syringes)
This is a puncture proof metal box with a hole in the
lid. The needle is removed when the used syringe is
inserted and light pressure is applied to release the
needle. The average capacity is 100 needles and the
cost ranges between 0.5 to 4 US$.

Thick plastic or steel container with an oval hole

in the lid
In small and remote health-care facilities this can be
a useful alternative to safety boxes. However one
must be very careful to avoid spillage during
separation of the needle and syringe. When full, the
container can be autoclaved before disposal or must
be sealed tightly before burial in a pit. Other sharps
may also be discarded in such containers.

B/ Disposal of needles:

Needles must be disposed of in a sharps pit or buried:

Sharps pit
This is a 1 m3 concrete lined protected pit with a
cement lid. Disposal is through a plastic or metal
pipe. It is a good option for sharps disposal in
medium and small health-care facilities. However it
should not be used in areas subject to floods or
where the water table is near the surface. Needle
containers can be discarded in entirety or contents
are emptied directly in the pit.

8
Encapsulation
Encapsulation means surrounding dangerous
materials with a substance that will harden.
Encapsulation ensures that needles are stuck in a
material, so that used needles cannot be harmful or
reused. Filled needle containers are placed in a
metal drum or a high-density plastic container up to
of the final capacity. An immobilizing material such
as fresh cement, bitumous sand or clay is added in
the container. Once dry, the container is sealed and
disposed of in a land fill or buried on site.

C/ Disposal of used plastic syringes:

Segregation

Immediately after needle removal, plastic syringes

should be discarded in an appropriately colored
container with a plastic liner bag. If syringes are to be
disinfected and sent for recycling, they should not be
mixed with other potentially infectious waste.

C1. On-site treatment:

Shredding

Plastic syringes may be shredded in a hand mill or an

electric shredder so as to reduce their volume. After
shredding they may be buried on-site (see On site
burial / burial on premises)

C2. Preparation for transport to centralized facility:

Chemical disinfection
Syringes may be sterilized through exposure to
bleach (0.5% chlorine solution) for at least 30
minutes. They should not be disassembled.

9
Boiling water
Syringes may be disinfected in a batch of boiling
water for 20 minutes. They should not be
disassembled.

C3. Collection and transport to a centralized facility:

Collection of plastic syringes for off-site disposal

or recycling
Plastic syringes are collected on a regular basis and
sent to a centralised treatment facility for disposal or
recycling.

C4. Treatment at a centralized facility:

Shredding

Plastic syringes may be shredded in a hand mill or an

electric shredder so as to reduce their volume. After
shredding they might be disposed of in a land fill.

Recycling of syringes

Recycling is an economically and environmentally sound option for plastic syringes (valuable polypropylene
and polyethylene). However, if no plastic recycling plant exists or if distances to the plant from the facilities
makes transport costs too expensive, syringes may be disposed of after disinfection with municipal waste.

10
STEP3. CRITERIA FOR SELECTING APPROPRIATE WASTE TREATMENT
AND DISPOSAL STRATEGY

ALTERNATIVE 1: REGULAR SHARPS WASTE COLLECTION FOR CENTRAL TREATMENT

Regular waste collection for central treatment is a valuable option provided that:

A central facility with adequate capacity exists;



Health care facilities have all-year accessibility to and are at reasonable distance from the central
treatment facility;


A means of transport is available (truck, car, bicycle etc);


Financial resources for fuel and a driver are available (considering distances of the route);


Waste should be collected at least once a month and ideally once a week.

ALTERNATIVE 2: CONTROLLED BURIAL ON PREMISES FOR REMOTE AREAS OR SMALL FACILITIES

A sharp pit may be a valuable option for the disposal of needles in remote health-care facilities with no
access to central treatment provided that :

Needle removers are available and practical at all injection stations;


The region is not subject to heavy rainfalls and floods (otherwise consider sharps barrel);


The water table is deep enough to avoid contamination of water;


Skills, material and financial resources are available for the building of a sharp pit.

If no sharps pit in use, pits for the burial of infectious waste, including sharps may be a valuable option for
the disposal of needles provided that:

Encapsulation of needles before disposal is ensured;


Space is available on premises;


The water table is deep enough to avoid contamination of water;


Financial resources are available for minimal training and for the construction of a fence;


Human resources are available for supervision.

Note: The most feasible disposal options should be considered taking into account local conditions, available
resources and constraints of health-care facilities. Then the best disposal strategy should be discussed with
representatives of health-care facilities.

11
Based on the assessment of the existing situation (Step1) and the review of possible treatment and disposal
options (Step2), a strategy for treatment and disposal of health care waste can be selected. The following
criteria should be considered in the selection process to ensure that the chosen strategy is appropriate to the
local context and that adequate resources are available.

Selection Criteria

The distance to legally approved treatment facilities for final disposal

must be reasonable
Off-site final disposal of Means of transport and a reliable road infrastructure should be available
infectious waste
Vehicle should be disinfected after transporting infectious waste material
Quantity of daily waste generated should be sufficient to justify transport
costs
On-site final disposal of
Only if above conditions are not met
infectious waste

Relevant for most health-care facilities assuming a safe needle remover

Separation of needle from device is selected for the separation process
syringe A sharps pit or needle barrel must be available on site
Inappropriate if there is no proper disposal of sharps afterwards
Relevant for most health-care facilities that are out-of-reach of transport
Sharps-pit to bury to facilities with better options for final disposal
sharps/needles
Inappropriate in regions with heavy rains and floods or shallow water
table. A sharps barrel can be used in these situations.
Proper training of staff for operating procedures is necessary
Autoclave Availability of device and spare parts locally
Monitoring equipment needed

Proper materials, qualified construction and training for operating

procedures are necessary
Construction of an
incinerator Space is needed on premises to allow a minimal distance of 250 m from
populated areas and maximal dispersion of gas emissions.
High chimney is also required (higher than nearby roofs)
Not suitable in case of a shallow water table (bottom of the pit should be
1.5m higher than the groundwater level) or in seasonally flooded area
Controlled burial
Burial site should be fenced
Sufficient land available
Sufficient land available if burying on site
Encapsulation
Encapsulation material necessary
If no other option is possible, municipal landfill is better than open dumps
Municipal landfill Encapsulation of sharps, mutilation beyond usability and disinfection of
plastic syringes is necessary

12
STEP 4. ESTIMATE EQUIPMENT NEEDS FOR INJECTION WASTE
On the basis of the selected strategy, an action plan and an assessment of equipment needs can be
implemented as follows:

CHECKLIST OF ACTIONS


Estimate the total quantities of waste to be treated in each health-care facility per month


Calculate the total number of safety boxes required for sharps per month


Assess equipment and infrastructure for waste handling, treatment and disposal


Design and secure storage area for waste (locked and safe)


Assess existing personnel


Assess existing budget

13
A TOOL YOU CAN USE
In order to calculate the number of safety boxes (for instance)

2. Calculating the daily production of filled safety boxes

The disposal of the safety boxes on a daily basis must be ensured in each health-care facility. The calculation of the daily production of safety boxes helps in
organizing the everyday logistics. It could be on weekly basis according to the number of injections performed.

Number of staff providing injections S=

Average number of injections performed per staff per day Id =
Total number of syringes used daily Sd = Sd = S * Id
Capacity of a safety box C= 100 or 400
Daily number of safety boxes to be disposed of at the focal centre Bd = Bd = Sd / C (boxes/day)

3. Estimating the costs for waste treatment and disposal

3.1. Sharp collection costs

Item Cost / box x Nb boxes = Total

safety boxes Total

3.2. Waste handling costs

Item Cost / unit x Nb units = Sub-Total

protective clothes
plastic bags
adhesive tape
etc Total

3.3. Minimum investment costs for waste treatment and disposal equipment

Incinerator (ratio plan 15 $ / 1000 syringes disposed of) (Sd / 1000) * 15 Total
Autoclave etc.
3.4. Minimum recurrent costs

Human resources
daily rate
nb of workers nb of days Sub-Total
x ($ / day) x =

Combustible (wood, fuel)

quantity used / day unit price ($) nb of days = Sub-Total
x x
Total

Total costs (3.1 to 3.4)

14
STEP 5. ENSURE THE SUSTAINABILITY OF YOUR STRATEGY/PLAN OF
ACTION

CHECK NATIONAL HEALTH-CARE WASTE MANAGEMENT POLICY

Find out existing national policy/standards and guidelines for health-care waste management


Check for specific regulations towards emission control and pollution from incinerated waste


Check for specific regulations concerning transport of waste


Make recommendations in accordance with national guidelines and relevant legislation

ENSURE BASIC WASTE MANAGEMENT REQUIREMENTS ARE UNDERSTOOD

Organize visits to facilities with good ongoing waste management practices


Set up a short training program with the following components :
Legal framework and duty of care towards health-care waste handlers
Policy for needle stick injuries among health personnel (assessment, treatment, reporting)
Use of auto-disable syringes
Basics of waste segregation and colour coding
Consequences of unsafe treatment and disposal methods on the environment and public
health
Handling, treatment and disposal of safety boxes and sharp boxes
Pre-treatment of syringes (disinfection, shredding, encapsulation)
Internal and external transport safety
Consignment note and documentation for external transport
For facilities where waste is treated on-site add the following items to your training curriculum
Drawbacks of open waste dump and uncontrolled incineration
Construction of a sharps pit/needle barrel
Controlled burial on premises

ENSURE LONG-TERM COMPLIANCE WITH HEALTH-CARE WASTE MANAGEMENT PRACTICES

Designate responsibility to district and local representatives for the waste management supervision


Make sure roles and responsibilities of local healthcare workers are well explained and understood


Help health-care facilities in the elaboration of their code of practice for waste handling


Distribute documents explaining waste handling basics for staff but also for the information of local
community


Pedagogic posters for example may be posted in the entrance to health care facilities


Set up a set of indicators to monitor quality of waste management, provide guidance or examples
of quality of waste management indicators

ENSURE TECHNICAL ASSISTANCE TO IMPROVE WASTE MANAGEMENT PRACTICES

Determine which facilities need assistance for building of infrastructures or use of specific material


Organize technical assistance for building and maintenance of new infrastructure


Provide waste segregation bins and liners (and training)


Provide assistance to organize transport system


Provide assistance to repair and maintain the means of treatment used (and training)


Where national guidance does not exist, conduct model programs to determine best practices and
find best practical options

15
STEP 6. CALCULATE AND COMMUNICATE NEEDS TO HEALTH
AUTHORITIES

ESTIMATE INVESTMENTS NEEDED

Assess material needed for each facility to implement the adequate waste management
Needle removers
Bins for segregation
Trolleys to transport waste
Centralized incineration or autoclave
Cement and tube for sharp pits
Cement and fences for landfill
Protective clothing : gloves, boots, apron, goggles, etc
Training
See table next page.

ESTIMATE FINANCIAL RESOURCES NEEDED TO COVER RECURRENT COSTS

Transport costs

Human resources

Supplies and operational costs
Syringes
Plastic bags
Cement, clay, or plastic foam for encapsulation
Chlorine, bleach, buckets, gloves, masks
Safety boxes
Needle remover (hub cutter)
Needle remover can
Operation and maintenance costs of incinerator or autoclave (fuel etc.)
See table next page.

WHERE RELEVANT, ORGANIZE A CENTRALIZED HEALTH-CARE WASTE TREATMENT SYSTEM

Set up waste transportation plan

Prepare a clear investment plan including setting, material, vehicles and operational costs also
land and processing facility and operation and maintenance

Contact local suppliers for information on material price and shipping procedures if needed.

WRITE A REPORT OUTLINING RESULTS , RECOMMENDATIONS AND A PLAN OF ACTION

Results and conclusions from initial district assessment of each health-care facility's needs

Recommended actions

Identification of potential local partners

Financial estimation of investments and daily supplies

Needs for local capacity building

Operational plan of action and timeframe.

This document should be the basis for discussion and validation of options with local/national
health representatives, managers of health-care facilities and campaign partners (e.g., non-
governmental organizations).

16
ORGANIZE PURCHASING OF MATERIAL AND TRANSPORT


Keep records of purchasing and organize stock monitoring.

In order to evaluate investments costs you can use the following table:

Price per Sub-

Category Quantity unit Total
Needle remover Q = Number of sites in which injections are P QxP
given in facility
Bins Depends on daily kgs of waste P QxP
Trolleys Depends on daily kgs of waste P QxP
Cement and tube for
Investments Depends on local conditions P QxP
sharp pits
Cement and fences for
Depends on local conditions P QxP
landfill
Protective clothing :
gloves, boots, apron Q = Number of workers operating waste at P QxP
etc the same time during the day

Total SUM

In order to evaluate monthly Operational and Maintenance costs you can use the following table:
Price Sub-
Category Quantity
per unit Total
Transport costs Depends on monthly kgs of waste and P QxP
segregation practices
Electricity Depends on electric material use on-site P QxP
Q = Number of working days per month P = Daily
Operational Salary (per worker)* Salary
QxP
Costs Depends on monthly kgs of waste
Fuel P QxP
incinerated
Maintenance costs Depends on monthly kgs of waste P QxP
incinerated
Other Q P QxP
Q = Daily number of persons who will QxPx
Auto-disable syringes P
benefit from injection + 10% 30
Q = Number of syringes used every QxPx
Safety boxes P
day /100 30
Puncture resistant Q = Number of syringes used every day / QxPx
P
plastic boxes maximal capacity of the box when full 30
Needle removers (hub Q = Number of syringes used every day / QxPx
P
Waste cutter) 500 30
handling Q = Number of syringes used every QxPx
costs Needle remover cans P
day /100 30
Colored plastic liner
Number of bags per point of collection P QxP
bags (black, red)
Cement, clay, or plastic
Depends on needle containers used P QxP
foam for encapsulation
Bleach Depends on kgs of waste to be disinfected P QxP
(plastic syringes)
Other Q P QxP
TOTAL SUM

* Additional lines will be necessary to reflect each category of workers involved

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STEP 7. SET UP A MONITORING AND EVALUATION SYSTEM

ORGANIZE THE SUPERVISION OF HEALTH-CARE WASTE MANAGEMENT

Identify who will monitor and frequency of monitoring

Set up registering and reporting procedures

Provide monitoring forms for the follow up of daily activities and explain how to use them

Collect monitoring forms and consignment notes regularly

Keep a clear record of purchases and stock positions.

Report discrepancies between estimated waste load, subsequent need of supplies and factual
ordering of supplies from health-care facilities.

Carry out regular missions to the field and discuss possible areas of improvement with the
designated health-care waste management officer.

Collect feedback from injection providers, waste handlers, patients and community

EVALUATE THE WASTE MANAGEMENT STRATEGY

Evaluate during field missions compliance and sustainability of recommended practices

Write a final report and make recommendations for the next planning stage

Send this report to relevant health authority representatives and associated bodies.

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SUMMARY STEPS TO IMPLEMENT A SAFE WASTE
MANAGEMENT PLAN

MONTHS

1 2 3 4 5 6 1 2 3 4 5 6 7 8 9 10 11 12

ACTIVITIES
DISTRICT ASSESSMENT
& ESTIMATION OF
VOLUME OF WASTE &
SEE NATIONAL POLICY
MAKE INITIAL
RECOMMENDATIONS
WITH HANDLING,
TREATMENT AND
DISPOSAL OPTIONS
ESTIMATE INVESTMENT
& RECURRENT COSTS
CALCULATE EXTERNAL
SUPPORT REQUIREMENT

ISSUE PLAN OF ACTION

AND TIMEFRAME

FINAL SELECTION OF
STRATEGYAND
PURCHASE OF
EQUIPMENT
SENSITISATION
TRAINING
IMPLEMENTATION

MONITORING
(AS SOON AS
IMPLEMENTATION
BEGINS)
EVALUATION
(AFTER 6 MONTHS AND
AGAIN AT ONE YEAR)

The grey line represents the period of time during which funds will be allocated.

Note: This table is just an example and should be adapted according to context

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References:

1. Diaz, Luis F., George M. Savage, Linda L. Eggerth, and Clarence G. Golueke, Solid Waste Management
for Economically Developing Countries, International Solid Waste Association (ISWA), 1996.

2. Gonzales, O. and L.F. Diaz, Waste Characterisation Program of Health Care Wastes in Guayaquil,
Ecuador, unpublished, 2000.

3. Kane A et al., Bulletin of the World Health Organization, 1999, 77 (10) : 801-807.

4. Prss, A, E. Giroult, P. Rushbrook, editors, Safe management of wastes from health-care activities,
World Health Organization, Geneva, Switzerland, 1999.

5. Savage, G.M., L.F. Diaz, C.G. Golueke, C. Martone, and R.K. Ham, Guidance for Landfilling Waste in
Economically Developing Countries, in association with the U.S. Environmental Protection Agency, the
International Solid Waste Association (ISWA), and U.S. Technology for International Environmental
Solutions, 1998.

6. World Health Organization (WHO), Wastes from Health-care Activities, Fact Sheet No. 253, October
2000.

7. World Health Organization (WHO), Findings on the assessment of small-scale incinerators for health
care waste, WHO 2004.

8. World Health Organization (WHO), Health-care Waste Management, policy paper, August 2004.

9. Rushbrook, P.; R, Zghondi, Better health care waste management: an integral component of health
investment, the World Bank Middle East and North Africa, The World Health Organization, Office for
the Eastern Mediterranean and Regional Centre for Environmental Health Activities, 2004, ISBN 92-
9021-389-2.52

10. World Health Organization (WHO), Management of waste from immunization activities, September
2004.

11. World Health Organization (WHO), Rapid Assessment Tool, September 2004.

12. World Health Organization (WHO), Health-care Waste Management, Fact Sheet No. 281, October
2004.

13. World Health Organization (WHO), United Nations Environmental Programmes (UNEP) and the Basel
Convention, Preparation of National Health Care Waste Management Plans in Sub-Saharan countries -
Guidance Manual, September 2004.

14. World Health Organization (WHO), "Management of Solid Health-Care Waste at Primary Health-Care
Centres, A Decision-Making Guide, 2005.

http://www.who.int/water_sanitation_health

http://www.healthcarewaste.org

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