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Post00264 HEALTHCARE WASTE MANAGEMENT 4 July 2000 CONTENTS 1. NEW: WORLD BANK HEALTHCARE WASTE MANAGEMENT GUIDANCE NOTE Marcia Rock, WB/PHTG/HDN/HNP, has kindly posted the Banks' recent health care waste management guidelines. The text of the executive summary follows Marcia's introduction. This document compliments the WHO waste management strategy and guidelines posted in Technet Forum Post00259, 20 June 2000. ___________________________________________________________________________ The file is available for download in Adobe acrobat PDF format. The free viewer is available from To get the file go to the website then click on the file name: HealthCareWasteGuidelinesWB-6March2000.PDF or by email: Send an email to: [][/email] With the message: get technet HealthCareWasteGuidelinesWB-6March2000.PDF ___________________________________________________________________________ From: [][/email] Subject: HealthCare Waste Management Guidance Note To: Allan Bass Date: Wed, 28 Jun 2000 Allan, Here is the World Bank draft Health Care Waste Management Guidance Note for posting on the Technet Forum. It is authored by Lars Mikkel Johannessen, Marleen Dijkman and Candace S. Chandra with input from David Hanrahan, Carl Bartone and many others. It intends to complement WHO's waste management note, and is primarily for Bank task managers, but contains information that is useful to a nonBank audience as well. As the author's note states: "This guidance note should be viewed as an internal World Bank working document that attempts to synthesize the currently available knowledge and information in the field of healthcare waste management. There is much interest, but a lack of practical information, in this rapidly developing field. WHO has just released technical guidelines for healthcare facilities and waste management projects. These relatively comprehensive and explicit guidelines (Safe Management of Wastes From Health-care Activities, WHO, 1999) are the technical basis for this guidance note. In the meantime, we hope that this guidance note will help to fill the current information gap on specific issues relative to the World Bank." The Bank's work in this area is in progress. Further material is being developed and will be released in the weeks ahead. Best regards, Marcia Rock Marcia N. Rock Operations Analyst, Public Health Thematic Group Human Development Network, Health Nutrition and Population Room #G3-079 phone 202.473-5425 email [][/email] The World Bank 1818 H St. N.W. Wash., D.C. 20433 ___________________________________________________________________________ Extracts of Healthcare Waste Management Guidance Note ___________________________________________________________________________ HEALTHCARE WASTE MANAGEMENT GUIDANCE NOTE January 12, 2000 Lars Mikkel Johannessen Marleen Dijkman Candace S. Chandra The World Bank Revised March 2000 TWU/ENV/HNP Anchor Teams The World Bank --- Table of Contents Abbreviations Used in This Report Authors' Note and Acknowledgment 1. Scope of the Problem 1.1 Healthcare Waste and its Management 1.2 Definition of Healthcare Waste Types 1.3 How to Use These Guidance Notes 1.4 Policy Options and a Decision Tree for Health Care Waste Management 2. Guidance for Small Healthcare Facilities with Minimal Resources 2.1 Small Facility Assessment Checklist 2.2 Basic Steps in HCW Management at Small Facilities 3. Guidance for Large Healthcare Facilities 3.1 Large Facility Assessment Checklist 3.2 Basic Steps in HCW Management at Large Facilities 4. Guidance for Municipal, Metropolitan and Regional Healthcare Waste Projects 4.1 Regional Healthcare Waste Sector Assessment 4.2 Planning New Regional Waste Management Projects 5.Guidance for National Healthcare Waste Projects 5.1 National Sector Assessment 5.2 A National Strategy and Action Plan for HCW Management 6. Information Sources and Bibliography Annexes Annex A.Healthcare Waste Terms Used in this Report A.1 Types of Healthcare Waste A.2 Types of Healthcare Facilities Annex B. Management Issues B.1 Authorities Involved in Healthcare Waste Management B.2 Role of the Private Sector Annex C. National and International Healthcare Waste Regulations Annex D. Technology Considerations for Special HCW Treatment and Disposal D.1 Technology Options D.2 Dioxins and Related Compounds Annex E. Cost Considerations for Waste Treatment and Disposal Annex F. Conducting Environmental Assessments Annex G. Packaging Options Annex H. Sample Terms of Reference: Feasibility Study for Regional HCW Management M.1 Emergency Situations M.2 Long Term Care Annex Tables A1:Types of Healthcare Waste D1:Technical Requirements for Treatment and Disposal of Special HCW D2:Treatment and Final Disposal Technologies for Special HCW D3:Comparisons with Technical Requirements E1:Estimates of Capital Costs per Ton of Treatment Capacity/Various Treatment Options E2:Treatment and Disposal Costs per Ton of Special HCW/Selected Countries E3:Average Treatment and Disposal costs for Special HCW/ Selected Cities G1:Packaging Requirements for HCW and for Different Types of Treatment --- 1. SCOPE OF THE PROBLEM Healthcare Waste and its Management Healthcare waste typically derives from two sources in developing countries: emergency relief donations (leftover from international donor response to either a humanitarian crisis or a natural disaster) and long term healthcare services. Healthcare services aim to reduce health problems and to prevent potential health risks. In doing so, however, waste is often generated that is potentially harmful to public health and the environment. Leftover emergency relief donations normally create a one-time healthcare waste issue, and can be dealt with in much the same way as long term healthcare services waste. In several countries, where many health concerns often compete for very limited resources, the management of healthcare waste may not get the priority it deserves. The goal of this guidance note is to raise awareness of the importance of proper healthcare waste (HCW) management, help define the various types of healthcare waste, and offer practical guidance on ways to assess and improve HCW management in a variety of settings. This note intends to serve an internal World Bank audience. Definition of Healthcare Waste Types Most waste generated in healthcare establishments can be treated as regular solid municipal waste. But a varying proportion of HCW requires special attention, including sharps (e.g. needles, razors, scalpels), pathological waste, other potentially infectious waste, pharmaceutical waste, biological waste, and hazardous chemical waste. Collectively, these wastes are known as "special healthcare waste". In addition, all waste generated under certain circumstances, such as in isolation wards and microbiological laboratories, requires special attention. (See Annex A for the WHO definition of special healthcare waste and its components.) Other waste streams generated by HCW could include packaging, reusable medical equipment, and secondary waste created through disposal technologies. The mismanagement of healthcare waste poses risks to people and the environment. Healthcare workers, patients, waste handlers, waste pickers, and the general public are exposed to health risks from infectious waste (particularly sharps), chemicals, and other special HCW. Improper disposal of special HCW, including open dumping and uncontrolled burning, increases the risk of spreading infections and of exposure to toxic emissions from incomplete combustion. For these reasons, occupational health and safety should be a component of HCW management plans. Transmission of disease generally occurs through injuries from contaminated sharps. Infections of particular concern are Hepatitis B (HBV), Hepatitis C (HCV), and the human immunodeficiency virus (HIV). HBV, for example, can remain infectious for a week, even dried at room temperature, and the probability that a single needle stick will result in sero-conversion is approximately 30 percent. For HIV and HCV, the probability that a single needle stick will result in sero-conversion is 0.3-0.5 percent and 2-5 percent, respectively (WHO, 1997). In the healthcare sector alone, the World Health Organization estimates that unsafe injections cause approximately 30,000 new HIV infections, 8 million HBV infections, and 1.2 million HCV infections worldwide every year. Toxic risks arise among others from reagents (particularly laboratory reagents), drugs, and mercury thermometers (CEC, 1993). Furthermore, sensitivity is needed in the management of special HCW when dealing with biological waste. Many cultures have definite views on the disposal and burial of body parts. It is important to consider cultural factors in the disposition plans of special HCW. Additionally, appropriate consideration of local community perception in the proposed waste management plan for all HCW is integral to a sustainable disposition plan. This includes proper consideration of a reliable waste management plan for the community (Essential Waste Management Plan). Quite often, rural health care facilities will utilize different methods of waste management from urban health facilities. -- Proper management of HCW can minimize the risks both within and outside healthcare facilities. The first priority is to segregate wastes, preferably at the point of generation, into reusable and non-reusable, hazardous and non-hazardous components. Other important steps are the institution of a sharps management system, waste reduction, avoidance of hazardous substances whenever possible (e.g. PVC-containing products, mercury thermometers), ensuring worker safety, providing secure methods of waste collection and transportation, and installing safe treatment and disposal mechanisms. Generally, there are four key steps to HCW management: 1) segregation into various components, including reusable and safe storage in appropriate containers; 2) transportation to waste treatment and disposal sites (see Annex B2); 3) treatment (see Annex D2); and 4) final disposition.

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