Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697707746487.pdf (Zimbabwe)
1 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP)Cordaid Zimbabwe15 Connaught RoadAvondale, Harare P.O.
Box A430, Avondale Harare, ZimbabweTel: +263 772 161 806/7Twitter: @rbfhealthzimwebsite: www.cordaid.orge­mail: commzim@cordaid.orgBUILDING FLOURISHING COMMUNITIESwww.healthprojectzim.orgRD­GRAPHIXInfection Control and Waste Management Plan (ICWMP)November 2022Zimbabwe Health Sector Development Support Project Additional Financing V (HSDSP AF V) Prepared for Ministry of Health and Child Care November 2022 2 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID TABLE OF CONTENTS Foreword................................................................................................................................................................................................................ 9 1.
Introduction............................................................................................................................................................... 11 1.1 Project Context and Components................................................................................................................................................... 11 1.1.1 Project Components....................................................................................................................................................................... 12 1.1.2 COVID-19 Intervention.................................................................................................................................................................... 12 1.1.3 Rationale for the ICWMP................................................................................................................................................................ 13 1.2 Laws and Policies................................................................................................................................................................................ 13 1.2.1 International Conventions............................................................................................................................................................ 13 1.2.2 The Constitution of Zimbabwe.................................................................................................................................................... 14 1.2.3 Environmental Management Act (Chapter 20:27)................................................................................................................... 14 1.2.4 SI.
10 of 2007.................................................................................................................................................................................... 15 1.2.5 Rural and Urban Council Act (Chapter 29:13)........................................................................................................................... 17 1.2.6 Public Health Act (Chapter 15:17)................................................................................................................................................ 17 1.2.7 Infection Prevention and Control Guidelines............................................................................................................................ 18 1.2.8 National Infection Prevention and Control Policy, Strategic and M&E Plans (2014)....................................................... 18 1.2.9 Zimbabwe Guidelines for Management of COVID-19 (2020)............................................................................................... 18 1.2.10 Permits and Licences................................................................................................................................................................... 18 1.2.11 Bank Policies Triggered................................................................................................................................................................ 19 1.3 Health Care Structure........................................................................................................................................................................ 22 1.3.1 The Targeted Health Care Facilities (HCF)................................................................................................................................. 23 1.3.2 Cumulative Impacts......................................................................................................................................................................... 23 1.4 The Design Requirements of the Health Care Facilities............................................................................................................ 25 1.4.1 Administrative Controls are Operational Controls.................................................................................................................. 25 1.4.2 IPC Considerations when designing isolation and Treatment centres.............................................................................. 25 1.4.3 Staff and Patient Flow.................................................................................................................................................................... 25 1.5.
Zimbabwe Healthcare Waste Management Status................................................................................................................... 26 1.5.1 Situation Analysis............................................................................................................................................................................. 26 1.5.2 National Institutional, Organizational and Technical Capacity of Zimbabwe.................................................................... 27 1.5.3 Institutional and Technical Capacity........................................................................................................................................... 27 2.
Infection Prevention and Control and Waste Management............................................................................... 27 2.1 Overview............................................................................................................................................................................................... 27 2.1.1 What is Infection Prevention and Control?...............................................................................................................................
27 2.1.2 Importance of Infection Prevention and Control (IPC).......................................................................................................... 27 2.1.3 Infection Prevention and Control Programmes...................................................................................................................... 27 2.1.4 Management and Organisation.................................................................................................................................................. 27 2.1.5 Components of an Infection Prevention and Control Programme.................................................................................... 27 2.1.6 Principles and Practices of Infection Prevention and Control.............................................................................................. 28 3 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.1.7 Main Functions of an IPC Program.............................................................................................................................................. 30 2.1.8 Role of IPC Focal Person................................................................................................................................................................ 31 2.1.9 Essential IPC Structures................................................................................................................................................................. 31 2.1.10 Link Nurses/Persons.................................................................................................................................................................... 31 2.1.11 IPC Committee/Team................................................................................................................................................................... 31 2.1.12 IPC Guidelines................................................................................................................................................................................ 31 2.1.13 Example of a Clinic IPC Committee/Team............................................................................................................................... 31 2.1.14 The Infectious Disease Transmission Cycle............................................................................................................................ 32 2.1.15 Standard Precautions................................................................................................................................................................... 33 2.1.16 Objectives of Standard Precautions......................................................................................................................................... 33 2.1.17 Healthcare Associated Infections.............................................................................................................................................. 33 2.1.18 Components of Standard Precautions.................................................................................................................................... 34 2.1.19 Standard Precaution Practices.................................................................................................................................................. 34 2.1.20 Common Challenges to Implementing Standard Precautions.......................................................................................... 34 2.1.21 Transmission Based Precautions.............................................................................................................................................. 35 2.1.22 Health Care Waste Management............................................................................................................................................. 35 2.1.23 Classification of Healthcare Waste........................................................................................................................................... 36 2.1.24 Definitions...................................................................................................................................................................................... 39 2.1.25 Wastewater.................................................................................................................................................................................... 41 2.1.26 Water Pollution Prevention Measures..................................................................................................................................... 41 2.1.27 Other Wastewater Streams & Water Consumption............................................................................................................. 42 2.1.28 Why is Health Care Waste a Concern?.....................................................................................................................................
43 2.1.29 Who is responsible for healthcare waste management in healthcare facilities?..........................................................
43 2.1.30 Healthcare Waste Streams.......................................................................................................................................................... 44 2.1.31 Waste Segregation........................................................................................................................................................................ 46 2.1.32 Minimization of Waste................................................................................................................................................................. 48 2.1.33 Handling, Transportation, Storage and Treatment of Waste............................................................................................. 48 2.1.34 Health Care Waste Treatment................................................................................................................................................... 49 2.1.35 Sharps Management................................................................................................................................................................... 53 2.1.36 Types of Incinerators................................................................................................................................................................... 54 2.1.37 Emissions........................................................................................................................................................................................ 54 2.1.38 Pollution Prevention and Control............................................................................................................................................. 54 2.1.39 Emissions Standards.................................................................................................................................................................... 55 2.1.40 Management of Air Pollution and Incinerator Residue....................................................................................................... 56 2.1.41 Water Quality and Pollution....................................................................................................................................................... 57 2.2 Management Measures................................................................................................................................................................... 57 2.2.1 Roles and Responsibilities for ICWMP...................................................................................................................................... 57 4 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 3.
Emergency Preparedness and Response............................................................................................................... 60 3.1 What is an Emergency....................................................................................................................................................................... 60 3.2 Management of Spills......................................................................................................................................................................... 60 3.3 Management of Needle Pricks........................................................................................................................................................ 61 3.4 Management of Fire........................................................................................................................................................................... 63 3.5 Septic Tanks and Communities....................................................................................................................................................... 63 4.
Institutional Arrangements and Capacity Building............................................................................................. 65 4.1 Levels of Capacity Building and Institutional Arrangements.................................................................................................... 65 4.1.1 Zimbabwe Health Sector Development Support Project (HSDSP) Level........................................................................... 65 4.1.2 National (Central) Level.................................................................................................................................................................. 65 4.1.3 Provincial Level................................................................................................................................................................................ 66 4.1.4 District Level..................................................................................................................................................................................... 66 4.1.5 Facility Level (Urban and Rural Clinics)....................................................................................................................................... 66 4.2 Trainings................................................................................................................................................................................................ 67 5.
Monitoring and Reporting....................................................................................................................................... 70 5.1 Indicators to be Monitored ............................................................................................................................................................. 70 5.2 Records.................................................................................................................................................................................................. 71 5.3 Estimating Amount of Health Care Waste Generated Per Facility.......................................................................................... 71 5.4 Reporting............................................................................................................................................................................................... 71 5.5 Implementation of Infection Control and Waste Management Plan (ICWMP).................................................................... 71 6.
Consultations............................................................................................................................................................. 75 6.1 Field Visits.............................................................................................................................................................................................. 75 6.2 Sampling................................................................................................................................................................................................ 75 6.3 Data Collection..................................................................................................................................................................................... 75 6.4 Composition of the PDC.................................................................................................................................................................... 76 6.5 Composition of the DDC................................................................................................................................................................... 76 6.6 Validation Workshop for the ESMF and ICWMP.......................................................................................................................... 76 6.7 Risk Communication........................................................................................................................................................................... 76 6.8 Consultations During Project Implementation............................................................................................................................ 77 7.
Disclosure.................................................................................................................................................................. 79 8.
Conclusion and Recommendations....................................................................................................................... 81 8.1 Recommendations and Lessons Learnt........................................................................................................................................ 81 5 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 9.
References.................................................................................................................................................................... 84 10.
Appendices................................................................................................................................................................ 86 Appendix 1: Standard Operating Procedure for Waste Management....................................................................................... 86 Appendix 2: Infection Control and Waste Management Plan Timeline and Reporting for MOHCC................................... 91 Appendix 3: Facility Medical Waste Management Plan Template............................................................................................... 92 Appendix 4: Infection Control and Waste Management Checklist.............................................................................................. 95 Appendix 5: Incinerator Operation Checklist And Safety Guidelines.......................................................................................... 98 Appendix 6: Establishing a New Healthcare Waste Incinerator in Zimbabwe: Authorization and Licensing Required.. 102 Appendix 7: Validation of ICWMP Comments And Responses..................................................................................................... 106 Appendix 8: Programme of Activity -ESMF and ICWMP Validation Workshop......................................................................... 113 Appendix 9: List of Validation Workshop Participants.................................................................................................................... 116 Appendix 10: PPE Requirements......................................................................................................................................................... 118 Appendix 11: Consultations.................................................................................................................................................................. 120 6 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID LIST OF TABLES Table 1-1: Licences and
 Costs......................................................................................................................................................................... 19 Table 1-2: Bank Policies Triggered................................................................................................................................................................. 20 Table 1-3: Health Facilities targeted by the project HSDSP AF-(V)........................................................................................................ 24 Table 2-1: Comparison of EHS and Zimbabwean Waste Treatment Categories............................................................................... 36 Table 2-2: Recommendations for Management of Healthcare Waste................................................................................................. 42 Table 2-3: Sites Generating Waste................................................................................................................................................................ 44 Table 2-4: Recommended Waste Segregation and Collection Scheme.............................................................................................. 46 Table 2-5: Colour Coding for Waste Segregation...................................................................................................................................... 47 Table 2-6: Responsibility and Requirements for Waste Management................................................................................................. 47 Table 2-7: Definitions used in treatment and disposal of waste............................................................................................................ 49 Table 2-8: Comparison of EHS Guidelines and Zimbabwean Emission Standards........................................................................... 56 Table 3-1: Sodium Hypochlorite
 Dilutions.................................................................................................................................................... 61 Table 3-2: Management of Health Care Worker Following Blood/Body Fluid Exposure................................................................. 61 Table 4-1: ICWMP Suggested Training Topics............................................................................................................................................ 68 Table 5-1: Infection Control and Waste Management Plan Timing....................................................................................................... 72 Table 5-2: Estimated Implementation Budget............................................................................................................................................ 73 LIST OF FIGURES Figure 2-1: Diverse Roles in Infection Prevention and Control for Health Care Delivery................................................................. 30 Figure 2-2: The chain of infection.................................................................................................................................................................. 32 Figure 2-3: Standard Precautions.................................................................................................................................................................. 34 Figure 2-4 Summary for HCW Stream.......................................................................................................................................................... 45 Figure 3-1: Flow charts for HIV & HBV post exposure prophylaxis....................................................................................................... 62 7 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) LIST OF ABBREVIATIONS AF DDC DEHO DMO PC PCFP Additional Financing District Development Committee District Environmental Health Officer District Medical Officer Infection
 Prevention and Control Infection Prevention and Control Focal Person ICWMP Infection Control and Waste Management Plan EMA EHSD EHO EHT GOZ Environmental Management Agency Environmental Health Services Department Environmental Health Officer Environmental Health Technician Government of Zimbabwe HSDSP Health Sector Development Support Project MOHCC Ministry of Health and Child Care NIPCC PDC PEHO PIE POP RBF National Infection Prevention and Control Committee Provincial Development Committee Provincial Environmental Health Officer Project Implementing Entity Persistent Organic Pollutant Results Based Financing RMNCAH-N Reproductive, Maternal, Neonatal, Child, Adolescent Health and Nutrition SOP ZCERP Standard Operating Procedure Zimbabwe COVID-19 Emergency Response Project 8 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Foreword Infection prevention and control (IPC) is a scientific approach categories and levels of staff.
Such compliance is obligatory with practical solutions designed to prevent harm, caused to the prevention and control of hospital acquired and other by infections, to patients and health care workers grounded infections in the health care facilities and settings, as well in principles of infectious disease, epidemiology, social as in the community.
This ICWMP is very comprehensive science, health system strengthening, and rooted in patient but simple to follow and appropriate for use by all safety and health service quality.

The COVID-19 pandemic disciplines.


It is designed with sections, which outline the has completely changed the healthcare landscape, among different aspects of infection prevention and control that which includes the healthcare infrastructure, increased may be adapted/adopted to meet specific institutional or use of Personal Protective Equipment (PPE) in healthcare community requirements.

facilities and the community.
Infection control and waste management is of paramount importance, and this has I am confident that this document will be valuable for prompted the development of the Infection Control and improving the quality of services, not only because it was Waste Management Plan (ICWMP) for the Health Sector developed after extensive review of relevant literature Development Support Project Additional Financing V and consultation with experts, professional groupings, (HSDSP AF V) being financed by the World Bank Global and other stakeholders, but also because its contents are Financing Facility.
realistic, practical, and designed to meet local needs.

This ICWMP of the Ministry of Health and Child Care I recommend that it be used as a reference document for (MoHCC), responds to the heightened concerns about the planning and establishment of infection control and inappropriate infection control and waste management waste management systems to promote good and safe practices in health care settings in the country.

This practices.
This practices.

document outlines processes and procedures required for the practice of an internationally acceptable standard of infection control and waste management in this project’s health care settings.
Infection prevention and control practices are a Air Commodore (Dr) J. Chimedza multidisciplinary endeavour and require compliance by all Secretary for Health and Child Care ………………………………………………………………………… 9 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) CHAPTER 01 10 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 1.
Introduction Infection Control and Waste Management Plan (ICWMP) is a World Bank Operational Policy (OP 4.01) requirement for all healthcare facilities in the Zimbabwe Health Sector Development Support Project (HSDSP).

The management of healthcare waste faces many challenges and requires strengthening as will be elaborated in the document.

For example, some facilities have resorted to dumping instead of incinerating medical waste.
This Infection Control and Waste Management (ICWMP) will give an overview of required Infection Prevention and Control (IPC) and detailed steps for proper health care waste management for the Zimbabwe Health Sector Development Support Project (HSDSP) under the Result Based Financing (RBF) programme through an Additional Financing (AF) V. This section describes the projects components of the HSDSP AF V, rationale, and purpose of this ICWMP, the legal framework underpinning waste management and infection control.
Additionally, World Bank policies which are going to be triggered by the implementation of the HSDSP AF V are outlined and analysed in this section.

The national health care structure and design requirements for health facilities is also presented in this section.

1.1 Project Context and Components supply side of community RBF through community based health workers, scale-up the pilot urban RBF to additional The Government of Zimbabwe has received funding facilities in the two urban cities i.e.
Harare and Bulawayo for the Zimbabwe Health Sector Development Support and provide technical assistance in assessing feasibility Project (HSDSP) funded by World Bank-Global Financing of introducing health equity card given fiscal context and Facility under the Result Based financing (RBF) programme available resources.
through an Additional Financing (AF) V. The objective of the programme is to improve coverage and quality of an The project will also support the Government’s COVID-19 integrated package of Reproductive Maternity, Neonatal emergency response and further strengthen institutional Child, Adolescent, Health and Nutrition (RMNCAH-N) capacity through implementation of selected health services, as well as strengthen COVID-19 response and financing reforms.
To assess and manage potential institutional capacity to manage performance-based environmental and social risks and impacts, CORDAID contracts consistent with the Recipients’ ongoing health has prepared an Environmental and Social Management initiatives.

CORDAID is the Programme Implementing Entity Framework (ESMF).

Previous versions of the project used (PIE).

the national Health Care Waste Management Plan.


AF V has drafted this Infection Control and Waste Management The project will expand the RBF package of services to Plan (ICWMP) to take its place for this project.

Site-specific cover prioritized RMNCAH-N and other related services ESMPs or checklists will be prepared as needed during to respond to Zimbabwe’s burden of disease while also implementation.
The ESMF and ICWMP will guide on the reconfiguring the RBF approach to appropriately respond best practices for waste management, IPC and other to the COVID-19 pandemic.

In addition to continuing to safeguards concerns that may be identified including any support institutionalization of the Rural RBF programme, necessary labour management measures.
The ICWMP the project will support central hospitals and provincial presents mitigation measures that consider the limited hospitals through quality focused RBF, pilot extended capacity level of the health sector 11 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 1.1.1 Project Components Component 1: Results-Based Financing in Delivery of Packages of Key Maternal, Child and Other Related Health Services (RMNCAH-N) Component 3.
Documentation, Monitoring and Verification of Results This component will support monitoring, evaluation, and external verification including the Health Professions Authority (HPA) in performing its counter-verification role.

It also proposes to finance: (i) operational research This component will continue to support rural RBF in the in collaboration with the National Institute of Health 18 districts where RBF incentives are being financed by Research (NIHR) to generate evidence and lessons from the GOZ.
The GOZ will increase funding on an incremental AF implementation and (ii) joint review missions with other basis to an additional 42 rural districts that are currently development partners as part of the Country Coordination financed by the HDF.

This component proposes to pilot Platform’s 11 role in monitoring HSIC implementation.
In and implement an Extended Supply Side Community addition, this component will strengthen project-related (ESSC) RBF through community health workers to promote mechanisms for grievance redress (GRM) and stakeholder community participation as part of the overall rural RBF in engagement through provision of technical assistance (TA), four districts and pilot quality focused RBF in two central equipment, and tools to improve current systems within and four provincial hospitals; scale-up the UV scheme to 24 the MOHCC and the PIE.
It will also support documentation health facilities and expand its package to include vitamin and dissemination of most significant changes and lessons.

A supplementation for 6-59 months old children of UV beneficiaries and PEP to poor urban pregnant women who Component 4.

COVID-19 Response are UV beneficiaries and their children who are affected by sexual and gender based violence.

Component 2.
Component 2.

Management and Capacity Building This component will provide immediate support to prevent COVID-19 from spreading and limit local transmission through containment strategies.

It will prioritize infection prevention and control, contact tracing and surveillance.

It will support enhancing disease detection capacities This component will support overall program and project through provision of training for technical staff, laboratory management and capacity building.
This will include equipment and systems to ensure prompt case finding and technical and operational support to (i) equip additional contact tracing, consistent with WHO guidelines.

It will also facilities participating in RBF (provincial and central enable the country to mobilize surge response capacity hospitals, urban facilities); and (ii) design and implement through trained and well-equipped frontline health some health financing reforms.
It will also support the workers and better equipped facilities.

The component will GOZ to (i) reconfigure the RBF approach for essential also finance provisions for emergency response activities RMNACH-N services to mitigate COVID-19-related risks targeted at migrant and displaced populations in fragile, and (ii) incorporate COVID response interventions.

This conflict or humanitarian emergency settings compounded component will continue to support RBF institutionalization by COVID-19.
and selected innovative approaches to the delivery of RMNCAH-N services at all levels of the health system, in 1.1.2 COVID-19 Intervention line with the draft Zimbabwe HSIC, NHS towards Universal Health Coverage and the National COVID-19 Emergency On 31 December 2019, the World Health Organisation Response Plan.
Finally, this component will finance project (WHO) received a report of a cluster of pneumonia patients supervision including staff and consultants and incremental in Wuhan City, Hubei Province of China.

One week later, operating costs.

It will also continue to support technical on 7 January 2020, Chinese authorities confirmed that staff seconded to MOHCC Program Coordination Unit they had identified a novel (new) coronavirus as the cause (PCU).
12 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID of the pneumonia.

The virus was named 2019-nCoV, later This ICWMP presents Standard Operating Procedures renamed COVID-19.1 and a Waste Management Plan for project HCF based on a rapid situation assessment.
This ICWMP is a safeguard WHO Director General convened meetings of the instrument that is part of the AF V’s Environmental and International Health Regulations (2005) Emergency Social Management Framework (ESMF).

Committee on the outbreak of novel coronavirus (n-CoV) on the 23rd and 30th January 2020.

Following 1.2 Laws and Policies the recommendation of the IHR (2005) Emergency Committee, WHO Declared the outbreak a Public Health Emergency of International Concern on the 30th January 20202.
In line with recommendations issued by the IHR (2005) Emergency Committee, all countries were urged to prepare for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of further human-to-human transmission of the virus.

The disease has spread rapidly, with reports of the disease now in all continents of the world.
Zimbabwe recorded its first COVID-19 on March 20, 2020, and as of 9 December 2021 there were 155 817 cases and 4 723 deaths.

A total of 3 924 108 and 2 946 357 people have received 1st and 2nd doses of the COVID-19 vaccine respectively.
Zimbabwe developed a national preparedness and response plan to minimize morbidity and mortality resulting from COVID-19 and associated adverse socio-economic impact in the country while strengthening national core capacities under IHR (2005).3 1.1.3 Rationale for the ICWMP Given that project interventions will contribute to the generation of health care waste, and also given that some of the waste generated will be from COVID-19 treatment activities, this Infection Control and Waste Management Plan (ICWMP) has been drafted to manage the related waste.
Past versions of this project adhered to the 2011 Zimbabwe Health Care Waste Management Plan.

AF V’s COVID-19 related activities necessitated an update of the HCWMP to an Infection Control and Waste Management Plan.

1.2.1 International Conventions Zimbabwe is a signatory and party to more than twenty- one international, conventions, treaties and protocols.

Zimbabwe has signed the Basel Convention (2012), the Rotterdam Convention, and the Stockholm Convention.
Zimbabwe is also a signatory of the Minamata Convention (2013).

The legal framework for HCW management in Zimbabwe is based on the Environmental Management Act [Chapter 20:27] of 2002.

This act provides for the establishment of the National Environmental Council, the Environmental.
Management Agency, the Environment Management Board, the Standards and Enforcement Committee, and the Environment Fund; the formulation of environmental quality standards and environmental plans; environmental impact assessments, audit and monitoring of projects; and other matters related to management and conservation of the environment.

The Public Health Act [Chapter 15:17] forms the basis for healthcare and environmental health service.
Of the many treaties, the following may be broadly relevant to the Infection Control and Waste Management Plan (ICWMP).

The Basel Convention Technical Guidelines focus on reducing the impacts on health and the environment of biomedical and healthcare wastes that is based on the major classification in Annexes I, II, VII of the Basel Convention, but specified for practical use in the healthcare sector.
This guideline focuses on, (i) a strict definition and classification of the relevant waste streams, (ii) the segregation at source 1Ministry of Health and Child Care, 2020 2WHO (2020), WHO Director-General’s statement on IHR Emergency Committee on Novel Coronavirus (2019-nCoV) on 30 January 2020.
3Zimbabwe Preparedness and Response Plan, Corona Virus Disease 2019- COVID -19, Ministry of Health and Child Care 13 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) of the waste and (iii) the access to the best available and use of natural resources while promoting information for the identification of waste.

The Basel justifiable economic and social development.
Convention also was designed to minimize the movement of hazardous waste between nations, specifically to prevent 1.2.3 Environmental Management Act movement of hazardous waste from developed to less developed countries.
It also emphases the minimization of generation of waste at source, minimization of waste to be transported and treatment and disposal of waste as close as possible to the place of generation of waste to be transported and treatment and disposal of waste as close as possible to the place of generation.

The Stockholm Convention on Persistent Organic Pollutants (POPs) is a multilateral international environmental agreement to protect human health and the environment from chemicals, known as POPs.
POPs have harmful impacts on human health or on the environment at large.

The Stockholm Convention on Persistent Organic Pollutants is a global treaty to protect human health and the environment from chemicals that remain intact in the environment for long periods, become widely distributed geographically, accumulate in the fatty tissue of humans and wildlife, and have harmful impacts on human health or on the environment.

This is relevant to this ICWMP because of the emissions from the incinerators.
1.2.2 The Constitution of Zimbabwe (Chapter 20:27) The Environmental Management Act is the primary law with regards to matters of the environment and has the provision for the prevention of pollution and environmental degradation.
Under this Act the general functions of the Minister responsible for environment include regulating the management of the environment to promote, coordinate and monitor the protection of the environment and the control of pollution; imposing penalties on any persons who cause harm to the environment; and to ensure persons or institutions that are responsible for causing environmental harm will meet the cost of remedying that harm.
The Act provides for the establishment of an Environmental Management Agency (EMA) whose functions and powers include formulating quality standards for waste management.
The EMA functions also include ensuring through monitoring that actions, situations, and circumstances that include pollution and degradation of land, air and water are avoided, minimized, managed, or regulated, so far as is practicable and permissible to do so under any law and that waste is reused and recycled where possible and otherwise disposed of in a responsible Stipulates that Zimbabwe will adopt policies designed to manner.
protect and enhance the natural and cultural environment of Zimbabwe for the benefit of both present and future generations and shall endeavour to ensure all citizens a sound and safe environment adequate for their health and well-being.
Section 73 of the Constitution outlines the Environmental rights and stipulates that everyone has the right to: (a) an environment that is not harmful to their health or well-being; and (b) have the environment protected for the benefit of The Act prohibits the discharge of waste in such a manner as to cause pollution to the environment and prescribes that every person whose activities generate waste shall employ measures essential to minimize wastes through treatment, reclamation, and recycling.
According to the Act any person who intends to transport waste within Zimbabwe or to operate a wastes disposal site or plant or to generate hazardous waste of a prescribed type or quantity, shall prior to doing so apply to the EMA Board for the grant of an appropriate waste license.

present and future generations, through reasonable The Environmental Management Act also empowers legislative and other measures that— (i) prevent pollution and ecological degradation.
(ii) promote conservation; and the Minister responsible for environment, by statutory instrument, to assign to any local authority some of the functions in the Act for the purpose of managing the (iii) secure ecologically sustainable development environment within its area of jurisdiction.
14 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID The management of health care waste and other It further requires that if the waste disposal facility disposes hazardous wastes was administered by the MoHCC under both ordinary waste and hazardous waste, the disposal the Hazardous Substances and Articles Act [Chapter 15:05] facility shall be deemed as a hazardous waste disposal until 2002 when this Act was repealed by the Environmental facility unless the streams of the discharge are separated.
Management Act [Chapter 20:27].
This transfer of the administration of health care waste (as part of hazardous EMA may, upon receiving an application for a license and waste) to the Environmental Sector has tended to shift after an inspection, deem it fit to issue the relevant license: the emphasis of the impacts of these wastes on the environment rather than on public health while within the a) A blue license in respect of a disposal, which is health sector, health care waste management is considered environmentally safe, as an infection prevention and control measure.
b) A green license in respect of a disposal that is considered to present a low environmental hazard, Sections 72-73 of the Environmental Management c) A yellow license in respect of a disposal which is Act deal with Hazardous Wastes.
According to Section considered to present a medium environmental 72 hazardous waste is defined as any waste that can hazard; and cause harm to humans and the environment, corrosive, d) A red license in respect of a disposal that is considered flammable, toxic, radio-active and any other category of to present a high environmental hazard.

waste the Board may consider necessary and does not specifically refer to infectious waste.
Statutory Instrument Healthcare waste falls under the red license; as it presents (SI) 10 of 2007 Environmental Management (Hazardous high risk to the humans and the environment, this is the Waste Management) Regulations 2007 is the implementing licence which all healthcare facilities public or private vehicle for Sections 72-73 of the Act.

1.2.4 SI.

10 of 2007 should have as they generate and dispose of hazardous waste.
However, only private facilities pay for the license; the government facilities supported by this project are exempt from paying for red licenses.

In this SI 10 of 2007, health care waste (clinical waste) is classified as hazardous waste and is listed under the Fourth Some of the general conditions attached to the license Schedule Table 1.

It is defined under A4 as hazardous waste include that: which may contain either inorganic or organic constituents.
Such clinical and related wastes are defined as wastes arising from medical, nursing, dental, veterinary, or similar practices, and waste generated in hospitals or other facilities during the investigation of treatment of patients or research projects.

Health care waste is not considered in the Statutory Instruments unlike other wastes like waste oils which have four dedicated Parts (iv-vii) in SI 10 of 2007.

Statutory Instrument 10 addresses hazardous waste management.
The regulations require that no person shall generate, store, sell, transport, use, discharge or dispose of hazardous waste to the environment, except under a license.

A person wishing to generate, store, sell, transport, use, recycle, discharge, or dispose of hazardous waste is required to apply for a license.

a) A license shall be valid for a period of twelve months from the date of its issue or renewal unless otherwise specified in the license.
b) The EMA may, at any time while a license is in force, review it and amend or cancel it where there has been any material change in the circumstances in respect of which it was originally issued or any failure on the part of the license holder to comply with any of its terms or condition.

c) Officers of EMA shall monitor compliance with the terms of the licence, for which purpose the licence holder shall pay the appropriate monitoring fee to EMA.
d) There shall be charged to the licence holder and payable to EMA the appropriate environmental fee 15 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) for the discharge or disposal of hazardous waste to Part III of SI 10 deals with waste management plans and the environment; that is per kilogram of total mass of targets.
For the purposes of the regulation every generator solid hazardous waste discharged or disposed of by of wastes (except at household level), is required to by no the license holder, later than 31 December of each year prepare, implement, and adhere to a waste management plan which shall Within every period of three months ending on the consist of: 31st March 30th June, 30th September and 31st December in each year, the licence holder shall render a) An inventory of the waste management situation to EMA a quarterly return of the total volume or mass specifying the- of hazardous waste and of the quality and nature of (i) quantity of waste produced; and waste disposed of by the licence holder no later than (ii) the components of such waste.
fourteen days before the quarter to which the return relates.

specific goals for- e) In the case of a holder of a red licence, an additional (i) the adoption of cleaner production methods.

penalty fee of fifty per centum of the total appropriate (ii) the reduction of the quantities and pollutant fees payable shall be payable to EMA for every quarter discharges of wastes.

during which the license is to be held.


(iii) the recycling and sorting, wherever practicable, of f) Every license holder shall maintain records of all waste in an environmentally safe form and manner.

relevant information, pertaining to management of the (iv) the safe transportation and disposal of the wastes licensed waste or effluent, including flow or disposal that can be neither prevented nor recycled.
records, waste analysis, receiving environment analysis, (v) generally, the adoption of environmentally sound accidental discharges and pertinent correspondence management of wastes.

with the EMA, and these records shall be retained and available for inspection at the request of any officer of Part IV of SI 10 which describes waste collection and EMA for a period of three years.

management by the local authorities and by any enterprise collecting hazardous waste.
This requires SI 10 also stipulates requirements for hazardous waste notification of EMA or the local authority having jurisdiction landfills where: over the area.

a) No hazardous waste shall be disposed of at any other Other Sections of the Environmental Management Act place except in a licensed hazardous waste disposal which are of relevance to the management of health care site or landfill.
waste are Sections 69-71 which relate to general waste, b) Any person who disposes hazardous waste shall and which are implemented through Statutory Instrument ensure that the hazardous waste disposal site or 6 of 2007 Environmental Management (Effluent and Solid landfill has the following facilities- Waste Disposal) Regulation 2007.

This SI governs the (i) lining that is resistant to corrosion by the hazardous general waste generated at health institutions.
substance in question as approved by EMA, (ii) mechanism for the collection, quantification, Sections 57-62 of the Environmental Management Act treatment, and disposal of any leachate, relate to water pollution and are also implemented (iii) mechanism to protect the site from surface runoff, through Statutory Instrument 6 of 2007.
The regulations (iv) devices to test and monitor the quality and quantity of apply to water pollution and the Act prohibits discharge any waste finally discharged to the environment, of poison, toxic, noxious, or obstructing matter, radio- (v) devices to monitor impact of the site on the active wastes and any other pollutants; hence, they apply environment e.g.

groundwater and surface water to some of the health care wastes.
Like hazardous solid contamination, air pollution, waste, the health institution discharges liquid waste (vi) access points for sampling by EMA inspectorate.

(effluent) into a public stream or into any other surface separation and isolation of the hazardous waste from water, whether directly or indirectly through drainage or any other general waste.

seepage under license.


The law also requires that every 16 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID generator of waste, including project health care facilities, addition to the Statutory Instruments of the Environmental produce a waste management plan specifying the quantity Management Act.

of waste produced and the components of such waste.

EMA visits facilities to verify these and other matters.
Thus waste management is legislated in three Government Ministries: The Ministry of Environment, Climate, Tourism Sections 63-68 relate to Air Quality and are enforced through and Hospitality Industry (MECTHI)the Ministry of Health and Statutory Instrument 72 of 2009 (Air Pollution control) Child Care (MoHCC) and the Ministry of Local Government Regulations 2009.
The Standards Association of Zimbabwe and Public Works The Acts governing these ministries has also published a standard on Air Quality and Emission overlap in terms of mandates and sometimes contradict Zimbabwe Standard Number 977:2015 which gives each other in relation to waste management; therefore requirements for specified processes and activities and there is need for Government to review these laws and classifies the classes for licenses by process.
For example, to rationalize the mandates of the three ministries with those for waste incineration are given for particulates, acid regards to solid and liquid waste management particularly mist, Sulphur dioxide, nitrogen oxides and carbon dioxide to health care waste.

for the blue, green, yellow, and red categories.

These limit values are being considered for incorporation into SI 72 1.2.6 Public Health Act (Chapter 15:17) which is currently under review.
This statutory instrument is key to the construction and operation of incinerators in health institutions.

On the ground although the EMA implements the Environmental Management Act which has subsumed protecting the environment and human health against pollution; management of health care waste still resides in the MoHCC which supervises the management of healthcare waste in all health institutions in Zimbabwe.
The MoHCC is obliged to put systems in place in all healthcare facilities on management of hazardous waste such that it will not harm the healthcare workers, patients, and the community.

1.2.5 Rural and Urban Council Act (Chapter 29:13) The Public Health Act (Chapter 15:17) which falls under the MoHCC provides for health care waste management through section 113 of the Act.
The Act provides for the development of health care waste management plans and regulations relating to health care waste management, hazardous substances and articles of public health importance.

MoHCC remains the implementer of healthcare waste management using the 2011 Healthcare Waste Management Plan and EMA is the monitor.
The Public Health Act refers to waste as a nuisance whereby a nuisance is defined as an accumulation or deposit of refuse, offal, manure, or other matter which is offensive, or which is injurious or dangerous to health.
The thrust of the Act is targeted more to the public and local authorities and similar its execution is similar to the Environmental Management Act as personnel from the MoHCC can also The local authorities are also responsible for waste fine or take to court persons and local authorities who do management in Zimbabwe and are governed by the not dispose of waste properly.
With respect to regulations, Urban Councils Act [Chapter 29:15] (and the Rural District the Minister responsible for health may make regulations, Councils Act [Chapter 29:13].

The Urban Councils Act and may confer powers and impose duties in connection governs urban areas such as cities and towns while the with the carrying out and enforcement thereof on local Rural District Councils Act governs the growth points.
Both authorities, district administrators and district officers in Acts govern effluent or refuse removal and treatment terms of waste removal and disposal of rubbish, refuse, and give powers to the Councils to provide and operate a manure and waste matters.

service for removing and treating trade or other effluent, refuse and human waste for the Council area and to make The Public Health Act addresses waste generated in the the use of the service compulsory.
The Councils implement health care institutions as health care waste.

However, the Acts through by-laws, therefore health care facilities the MoHCC developed a five-year national health strategy must comply with the by-laws of their local authorities in and had the National Health Strategy for Zimbabwe 17 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) (2009-2013) which has been reviewed and updated to the 1.2.9 Zimbabwe Guidelines for National Health Strategy for Zimbabwe (2016-2020).
Goal 1 of the 2016-2020 objective 14 specifically is improve management of waste (solid, liquid, chemical, radiation and noise) and reduce pollution.

One of the strategies is to strengthen waste management systems.

1.2.7 Infection Prevention and Control Guidelines Management of COVID-19 (2020) The Zimbabwe Guidelines for Management of COVID-19 (2020) were adapted from the World Health Organisation (WHO) COVID-19 Guidelines (2020).
The section on infection prevention and control also emphasises waste segregation at source, using colour coded bins and job aides, provision of PPE for waste handlers and timely disposal.

In addition, since the development of the HCWMP in 2011, 1.2.10 Permits and Licences the MoHCC also developed the National Infection, Prevention and Control Guidelines, May 2013 which were reviewed and updated in 2019.
The Guidelines outline procedures for the classification, segregation, safe handling and packaging (containment), labelling, storage, transportation and disposal of clinical (health care and related waste) at health institutions.

The procedures also include education and training; management responsibilities; development of waste management policies and of a health care waste plan at facility level.
The guidelines outline steps for developing the facility level waste management plans that include advocating for the development of the plan, assessing of duties, responsibilities and practices as well as costs and development of the health care facility waste management policy and allocation of responsibilities.
1.2.8 National Infection Prevention and Control Policy, Strategic and M&E Plans (2014) This policy was formulated to provide guidance to health facilities in development and implementation of infection prevention and control programs.

The policy emphasizes that implementation of infection prevention and control programs be done at various levels of health care delivery system within the public and private sectors.
The policy stipulates that all health care facilities (public and private) in Zimbabwe should have an active IPC program in place, aimed at promoting IPC practices and M&E plans to monitor IPC practices.

All healthcare facilities public and private, with or without an incinerator are required to register with EMA as waste generators and must submit reports on waste management to EMA on an annual basis as required by Statutory Instruments 6 and 10 both of 2007.
The following permits and licences are issued to waste management enterprises: 1.

Waste Management Enterprise License This is issued by local authority for the purpose of processing or treatment of hazardous waste for profit, this includes: a) operation of a plant in which thermal processing (i.e., incineration) of hazardous waste takes place.
Upon receiving a waste management enterprise license application, EMA issues the relevant licence from among the following choices: a) a blue licence in respect of a disposal, which is environmentally safe, b) a green license in respect of a disposal that is considered to present a low environmental hazard, c) a yellow license in respect of a disposal which is considered to present a medium environmental hazard, and d) a red license in respect of a disposal that is considered to present a high environmental hazard and is regarded as hazardous waste.
Healthcare facilities generate hazardous waste and must arrange appropriate disposal, therefore when the facility has 18 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID an on-site incinerator it applies for a red licence.

All by EMA and their cost is $30 annually for the emission fee project facilities with on-site incinerators are required and $134.65 for healthcare waste management enterprise.

to obtain a red licence.


However, the project will not pay for these licences since the participating health care facilities are public and the The red licence permits disposal of hazardous waste and government is exempted from paying such fees.

emissions required for incinerators.

These are authorized Hazardous Waste Transportation Licence The Hazardous Waste Transportation licences are issued by EMA, as per the Environmental Management (Control of Hazardous Substances) (General) Regulations, 2018.
The licences are issued according to the same classification system as the incinerator emission licences.

No operator can transport any type of a hazardous substance consignment whether by air, road, water, pipeline, or rail without a licence issued to the operator by the Agency.

The permits can be obtained from the Environmental Management Authority upon submission of facility details, quantity and quality of waste being handled.
Drivers and handlers of infectious waste should be informed of what their cargo is and receive any necessary training.

Cost of the licences is shown in Table 1-1 below.

Table 1-1: Licences and Costs Name of license Waste management enterprise license Blue license Green license Yellow license Red license Hazardous waste transportation license More information on permits is in Appendix 6.
1.2.11 Bank Policies Triggered Cost of the license annually $134.65 $62.00 $108.75 $240.50 $718.00 $322.89 The World Bank has eleven environmental and social to avoid, mitigate or minimise adverse environmental and safeguard policies that outline environmental and social social impacts of projects supported by the Bank.

The matters associated with Bank lending operations.
The following is a summary of the Safeguard Policies that will be environmental and social safeguard policies are designed triggered by the HSDSP AF-V: 19 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Table 1-2: Bank Policies Triggered No.

1.

SAFEGUARD POLICIES TRIGGERED?


EXPLANATION (OPTIONAL) Environmental Assessment Yes The ICWMP will guide on the best practices for waste OP/BP 4.01 management and any other safeguards concern that may be identified including any necessary labour management measures.

The ICWMP will present mitigation measures that consider the limited capacity level of the health sector.

ICWMP template and checklists will be prepared and used during implementation.
The proposed AF will continue to support mostly activities that are aligned with the parent project and current AF.

There will be some modifications based on lessons learnt during implementation and new activities on COVID-19 emergency preparedness and response.

The project will cover more and new areas (with some possibly nationwide interventions) and include some new activities such as water and sanitation installation.
The project will have positive impacts as it will improve COVID-19 surveillance, monitoring and containment.
OP 4.01 is triggered due to the potential environmental impacts related to the minor civil works activities such as minor sanitation structures (such as septic tanks or pit latrines, ventilated improved pit latrines, composting toilets or pit latrines with slabs), and the installation of water tanks in selected isolation centres, supplies for handwashing facilities and basic sanitation facilities in critical areas will be supported.
These minor activities will be site-specific and will not have any significant environmental impacts on the ground.

.

2.

3.
.

2.

3.

Performance Standards for No The AF will not finance any private sector activities Private Sector Activities OP/ BP 4.03 Natural Habitats4 OP/BP No The policy is not triggered as the AF will be restricted to 4.04 already existing health facilities unless facilities are already located in a protected area or natural habitat; however there are no facilities located in protected areas.
4Natural habitats are land and water areas where (i) the ecosystems’ bio-logical communities are formed largely by native plant and animal species, and (ii) human activity has not essentially modified the area’s primary ecological functions.

(see OP 4.04, Annex 1 for full definition).


Critical natural habitats are (i) existing protected areas and (ii) areas officially proposed by governments as protected areas, (iii) areas initially recognized as protected by traditional local communities (e.g., sacred groves) (of known high conservation value) and (iv) sites that maintain conditions vital for the viability of these protected areas (See OP 4.04, Annex A Para.I.

[b] for full definition.)


20 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID No.

4.

5.

6.

SAFEGUARD POLICIES TRIGGERED?

EXPLANATION (OPTIONAL) Forests OP/BP 4.36 No The AF will not involve any forests unless facilities are already located in a forest; any such activities will be identified in screening and appropriate measures taken as directed in the ESMF.
Pest Management OP 4.09 No The policy is not triggered as the AF will not finance the use of pesticides.

Physical Cultural Resources No The project activities will only finance minor improvements OP/BP 4.11 for already existing structures which do not have PCR.

The ESMF will include chance-find procedures as a precautionary measure.

7.

Indigenous Peoples OP/BP No There is a possibility that indigenous communities could be 4.10 present in or near several areas targeted by Component 4 (COVID response).
If their presence is confirmed, the project will address any risks posed to them and measures put in place to ensure that they receive culturally appropriate benefits.

This will be done through the specific targeting of stakeholder engagement activities relevant to Indigenous Peoples (IPs) that meet the requirements of OP4.10 and that a Social Assessment (SA) is carried out prior to any activities that would impact them.
Following the SA, and as appropriate: (i) a stand-alone Idigenous Peoples Plan, (IPP) or Indegenous Peoples Planning Framework (IPPF) may be developed; (ii) or key elements of risk mitigation and culturally appropriate benefits will be included in theICWMP and ESMF.

In case where indigenous communities will be affected by quarantine provisions or other targeted 8.

Involuntary Resettlement No No project activities require land acquisition or adversely OP/BP 4.12 impact livelihoods.
Financing may support rehabilitation and 9.

10.

11.

Safety of Dams OP/BP 4.37 Projects on International Waterways OP/BP 7.50 No No minor upgrades at existing facilities.

The AF will not involve the construction of dams.

The AF will not involve international waterways.

Projects in Disputed Areas No The AF will not involve disputed areas.
OP/BP 7.60 In addition to the Safeguards Policies, the project will follow and industry-specific examples of Good International the World Bank Group Environment, Health and Safety Industry Practice (GIIP).5 They define acceptable pollution Guidelines which are the basis for preparing site-specific prevention and abatement measures and emission levels EHS Plans.

in World Bank financed projects.


World Bank Group Environment, Health and Safety (EHS) guidelines are technical reference documents with general 5A complete list of industry-sector guidelines can be found at: www.ifc.org/ifcext/enviro.nsf/Content/ EnvironmentalGuidelines.

21 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Box.

1.

General EHS Guidelines General EHS Guidelines 1.


Environmental The EHS Guidelines contain the performance levels and measures that are generally considered to be achievable in new facilities by existing technology at reasonable costs.

Application of the EHS 1.1 Air Emissions and Ambient Air Quality Guidelines to existing facilities may involve the establishment of 1.2 Energy Conservation site-specific targets, with an appropriate timetable for achieving 1.3 Wastewater and Ambient Water Quality them.
The application of the Guidelines to existing facilities 1.4 Water Conservation may involve the establishment of site-specific targets with an 1.5 Hazardous Materials Management appropriate timetable for achieving them.

The environmental 1.6 Waste Management 1.7 Noise 1.8 Contaminated Land assessment process may recommend alternative (higher or lower) levels or measures, which, if acceptable to the World Bank, become project- or site-specific requirements.

2.
2.

Occupational Health and Safety If less stringent levels or measures than those provided in 2.1 General Facility Design and Operation the EHS Guidelines are appropriate, in view of specific project 2.2 Communication and Training circumstances, a full and detailed justification for any proposed 2.3 Physical Hazards 2.4 Chemical Hazards 2.5 Biological Hazards 2.6 Radiological Hazards alternatives is needed as part of the site-specific environmental assessment.
This justification should demonstrate that the choice for any alternate performance levels is protective of human health and the environment.

When host country 2.7 Personal Protective Equipment (PPE) regulations differ from the levels and measures presented in the 2.8 Special Hazard Environments EHS Guidelines, projects are expected to achieve whichever is 2.9 Monitoring more stringent.

3.
3.

Community Health and Safety 3.1 Water Quality and Availability The Project will apply the General Guidelines, including 3.2 Structural Safety of Project Infrastructure (i) Environmental, 3.3 Life and Fire Safety (L&FS) 3.4 Traffic Safety 3.5 Transport of Hazardous Materials 3.6 Disease Prevention (ii) Occupational Health and Safety, (iii) Community Health and Safety and (iv) Construction and Decommissioning.
3.7 Emergency Preparedness and Response The (2007) Health Care Facilities EHS Guidelines are also applicable to this project.

The project will ensure that hazardous 4.

Construction and Decommissioning materials and wastes will be handled according to occupational health and safety guidance provided in the EHS Guidelines.
4.1 Environment 4.2 Occupational Health and Safety 4.3 Community Health and Safety 1.3 Health Care Structure At Independence in 1980, Zimbabwe adopted the Primary Health Care (PHC) Approach in line with the Alma Ata Declaration of 1978.

The implementation of the PHC approach resulted in decentralization of health service provision from central level (cities and towns) to administrative wards at district level in the rural communities.
Four tiers for health service delivery were established as follows: 22 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID l Quaternary Level: Central Teaching Hospitals with facilities where those who have been exposed to the specialist medical services in the capital city Harare, infection are kept whilst being monitored for signs the second largest city Bulawayo and in Chitungwiza.

and symptoms of the disease.


These isolation and l Tertiary Level: Provincial Hospitals with ambulatory quarantine centres are in every province and district.

and inpatient specialist services in the eight rural Isolation centres keep patients for 14 days whereas provinces of Zimbabwe.

quarantine centres keep patients mostly 7 days (up l Secondary Level: District Hospitals with emergency, to the time they have COVID-19 results).
All these ambulatory and inpatient services in the sixty-two healthcare facilities should be easily accessible with districts of Zimbabwe.

good infrastructure such as road network, water and l Primary Level: Rural Health Centres with primary care power supply.

In response to COVID-19 planned bed services in the 220 wards of Zimbabwe.
capacity for isolation and treatment centres were 1.3.1 The Targeted Health Care Facilities (HCF) The targeted health care facilities which are being supported by Health Sector Development Support Project AF-V(HSDSP) are as follows: 1.

Rural RBF: 424 facilities in 18 districts (the districts are found in the 8 rural provinces -2 districts per province in the 6 provinces and 3 districts per province in the remaining 2 provinces).

2.
2.

Urban Voucher: 34 health facilities in the two big cities (Harare and Bulawayo) and 2 central hospitals.

3.

Community RBF: in 4 districts which will be selected from the 18 districts.

4.

Hospital quality focused RBF: 2 central hospitals (which are already under the urban voucher) and 4 provincial hospitals which are among the 424 facilities in the rural RBF.
The average bed capacity for the Rural Health Centres/ Clinics in supported facilities is 7 beds per facility, average bed capacity for the district hospitals is 130 beds per district hospital and the average bed capacity for provincial hospitals is 170 beds per provincial hospital.

For COVID-19, 5 isolation/treatment facilities are to be supported with installation of water tanks and some minor works, PPE and ventilators.
Under the project, 104 hospitals are to be provided with PPE, 26 laboratories also to be supported with Gene Expert cartridges for PCR tests to diagnose COVID-19.

Isolation centres are where those people with COVID -19 infection are being separated from those without the infection to prevent transmission of the disease.

Quarantine centres are 2269, but only 70% of these are available.

However, 44.3% of these need piped oxygen and equipment.
Isolation and treatment centres are wards which were repurposed existing facilities, therefore amount of waste generated may increase due to menstrual hygiene kits and PPE.

From the laboratories, waste will be increased from the cartridges and PPE as well.

Traditionally 10-25% of healthcare waste is infectious waste and with isolation centres at these healthcare facilities, infectious waste will increase to up to 25-45% of total waste.
Since waste generated from quarantine and isolation centres newly set up under the project will be sent to facilities with an incinerator in that province or district for disposal, emission levels are likely to increase from the manufacturer estimated emission level of 150mg/Nm3.

Gases emitted by the incinerator are carbon dioxide, nitrous oxide, and sulphur dioxide.

Emission levels will be higher if the incinerator is not reaching the required temperatures to completely burn the waste e.g.

600-800oC.
600-800oC.

Many Zimbabwe HCF incinerators do not reach the required temperatures leaving waste not completely neutralized.

1.3.2 Cumulative Impacts The increase of waste generation from project activities will increase the cost of waste management supplies for example bin liners, exposure of healthcare workers to needle prick injuries, and increased gaseous emissions.
With the COVID-19 pandemic, poor management of waste especially tissue used from sneezing and used PPE could increase disease transmission.

None of these are new impacts introduced by the project, rather the project may just increase the amount of waste exposure and other impacts.

Cumulative impacts are impacts that may be insignificant on an individual basis but have significant impacts when combined with other generators and activities.
Examples 23 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) of cumulative impacts include incremental contribution of gaseous emissions to an airshed; reduction of water flows in a watershed due to multiple withdrawals; increases in sediment loads to a watershed; interference with migratory routes or wildlife movement; or more traffic congestions and accidents due to increases in vehicular traffic on community roadways.

The project will monitor for any cumulative impacts as it is being implemented.
In any case, project impacts will be managed and minimized through use of the ESMF, this ICWMP, the individual facility Medical Waste Management Plans and any site- specific or general Environmental Management Plans so there should not be much concern of the project significantly contributing to cumulative impacts.
Table 1-3: Health Facilities targeted by the project HSDSP AF-(V) ACTIVITY Rural RBF Urban Voucher Community RBF LOCATION 424 facilities in 18 districts (the districts are found in the 8 rural provinces-2 districts per provinces in the 6 provinces and 3 districts per province in the remaining 2 provinces) 34 health facilities in the two big cities (Harare and Bulawayo) and 2 central hospitals in 4 districts which will be selected from the 18 districts Hospital quality focused RBF 2 central hospital (which are already under urban voucher) COVID-19 and 4 provincial hospitals (which are among the 424 facilities in the rural RBF).
5 isolation/treatment facilities (for installation of water tank and some minor works, PPE, Ventilators), 104 hospitals (only for provision of PPE), 26 laboratories (Gene Xpert Cartridges for PCR test to diagnose COVID-19).

Central hospitals in Zimbabwe were not built for infectious Ministerial Committee which provides oversight to the diseases but in every city, there is an infectious disease response.

hospital for treatment and care for those with infectious diseases.
Zimbabwe had its first COVID-19 cases on the In response to COVID –19, central, provincial and district 20th of March and from then cases increased.

However, hospital were repurposed to compliment infectious disease the government of Zimbabwe has put up in place a national hospitals as the cases increased.

Infectious hospitals were rapid response team for COVID-19 consisting of 9 pillars as upgraded to cater for critically ill patients who might need follows: assisted ventilation.

1.
1.

Coordination and planning When repurposing or constructing healthcare facilities, 2.

Risk communication and community engagement infection prevention and control measures must be put in 3.

Surveillance 4.

Point of entry 5.

National laboratory systems 6.

Infection prevention and control place to reduce transmission of infections.

Measures to reduce the transmission of COVID-19 health facilities need to be actively implemented.

Some of the 7.
Some of the 7.

Case management and continuity of essential services recommended IPC measures include: 8.

Logistic procurement and supply management 9.

Socio-economic pillar (outside the MOHCC) l Hand hygiene l Respiratory hygiene An additional pillar on Social –economic which also includes l Maintaining physical distance of >1m security was introduced to bring all to 9 pillars.
To oversee all these pillars, the President established a National Inter- l l Rational use of PPE including universal use of masks Screening and triage 24 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID However, engineering/environmental, and administrative on the policies, guidelines, and adherence to SOPs.

controls need to be well established to have effective l Human, financial resources and supplies to be availed.

implementation of IPC measure.


l Nurse patient ratios to be adhered to.

l Capacitating all healthcare workers in current health 1.4 The Design Requirements of the issues e.g.

COVID-19.

Health Care Facilities l Provision of adequate and easy access to PPE.
(See Appendix 10) When healthcare facilities are being designed engineering or environmental controls focus on the infrastructure as follows: 1.4.2 IPC Considerations when Designing Isolation and Treatment Centres l Layout of the different departments/units/wards in When building or renovating consider space for the relation to each other and this will determine how following: staff and patients move within the facility, number of patients and type of equipment that can be l Clinical practice accommodated l Hand hygiene facilities in the patient care areas l Availability of sufficient hand hygiene stations both for hand washing or sanitizing by staff, patients and l l Reprocessing of medical devices Staff areas (e.g.
tea, rest, conference rooms) including visitors.

separate space for ancillary staff l Availability and proper positioning of donning and l Clean and dirty areas (e.g.
medicine preparation, doffing l Ventilation systems whether mechanical or natural l During this COVID-19 pandemic existing facilities have been repurposed to become isolation facilities and new structures (temporary or permanent) have been established to facilitate triaging of suspect and sluice, waste holding areas) l Good ventilation (12 - 15 air changes per hour) l l l l Type of floors, lighting and smooth walls Patient comfort Separate toilets for staff and patients Isolation areas (single rooms or cohort facilities) with confirmed cases of COVID-19 in-suite facilities l It is important to actively involve IPC practitioners/ l Storage for PPE, sterile items, drugs, etc.
experts when constructing, repurposing or renovating healthcare facilities in order to make sure that the infrastructure will support good IPC practices.

l Procurement of quality and correct size PPEs This project is unlikely to support any new (i.e.

to be built) HCF; however, it is important to note that for any new HCFs financed by the project, waste disposal facilities should be integrated into the overall design and an ESIA developed.
1.4.1 Administrative Controls are Operational Controls Are as follows: 1.4.3 Staff and Patient Flow The movement of staff and patients in isolation and treatment facilities should be controlled and unidirectional hence there should be demarcated as 1.

2.

Low risk (green zone) Intermediate risk (yellow zone) 3.

High risk (red zone) Staff areas are considered to be low risk areas and direct movement from high-risk areas is prohibited.
Intermediate l Infection control policies, guidelines, and standard risk is the nurse’s stations and duty rooms where one can operating procedures (SOPs, to be availed and enter coming from the red zone.

Red zone area is the understood by all levels of staff.

All staff to be trained highest risk where the confirmed cases are taken care of and this is considered the highly infectious zone.

25 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 1.5.
Zimbabwe Healthcare Waste Management Status The general situation and capacity on healthcare waste management in Zimbabwe is very low since it has partially collapsed.

There is no proper infrastructure for healthcare waste management in most facilities.

At the central hospitals, the old incinerators have broken down and are now irreparable.

Some of the rural healthcare facilities have waste management facilities with Otto way pits, bottle crushers, ash pit and incinerator.
Some of the waste management areas are secured.

The incinerators have very low temperatures which do not completely burn the waste such as sharps and bottles.

The main source of fuel for incinerators is coal, but in rural healthcare facilities, they also have challenges with accessing coal to use for combustion and they end up resorting to firewood which is not always available and is not environmentally sustainable.
In the ten provinces one or two provincial hospitals have an incinerator but they are no longer maintaining the required temperatures of 600-800℃ to completely burn all the waste, due to shortages of fuel for combustion.

However, in Harare there is a seasoned private waste management company, Bromo and Bytes.
used by most private healthcare facilities in the Harare province, for final disposal of their waste This private company has an incinerator with temperatures of 1200 to 1400℃ which can even incinerate expired drugs.

It assists in final disposal of waste from private healthcare facilities.

Public health care facilities can also contract with the private operator for the disposal of their waste for a fee.
There are some private companies who also collect waste and sent it to these private incinerators for final disposal.

Private companies collecting waste are required by law to register with EMA, and they are registered.

MoHCC are the implementors of the Healthcare Waste Management Plan 2011 and EMA regulates and monitors all the activities related to waste management including health care waste.
Besides the above-mentioned operator, there is also company now in the country, FENCRAFT, which is locally manufacturing incinerators.

It manufactures incinerators of all sizes including standard and advanced models.

The incinerators use coal or diesel for combustion.

MoHCC can partner with this manufacturer so that they can get the incinerators at a low cost.

Generally, the cost of an incinerator is 25000 united states dollars (USD 25,000).
In addition, there are challenges related to inadequate resources for waste management in the public healthcare facilities.

There are no colour coded bins and pedal operated bins therefore segregation of waste using colour coded bins is not being practiced.

Some facilities do not have the bins and they end up improvising with cardboard boxes.

Furthermore, there are no well-trained incinerator operators to operate the incinerators, to diagnose and conduct minor repairs when an incinerator breaks down.
There is also a challenge with the maintenance and servicing of the incinerators which is generally not conducted once the incinerator is installed.

The unit is usually used until it breaks down.

Most of the functional incinerators in the country are failing to reach the 850oC that is required to treat or destroy sharps.

Most of the incinerators that are in the system do not have wet scrubbers which are used for emissions pollution control.
The Department of Public Works under the Ministry of Local Government and Public Works is responsible for the operation and maintenance of waste management facilities including incinerators, at government institutions.

The Department has skilled technicians and workers who monitor and maintain these facilities.

Through the Results Based Financing (RBF) approach, the PIE will continue to support health facilities to plan and invest in health care waste management facilities and equipment.
There is need for the country to revamp and improve service delivery on healthcare waste management in the country and develop appropriate legislation for healthcare waste management.

1.5.1 Situation Analysis A situational analysis was conducted to assess the national status with respect to infection control and waste management by visiting select health care facilities.
Consultations including face-to-face focus group discussion and online interviews were completed from the 10-30th of September 2020 (Appendix 11).

Also, some online interviews with other non-governmental organizations like OXFAM and a service provider who manufactures incinerators, FENCRAFT, were completed and they gave their input to the development of this ICWMP.
26 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Healthcare facilities of different categories were selected the country’s infrastructural decay and that has resulted for assessment of infection control and health care in the accumulation of waste and outbreaks of diseases.

management practices.


The healthcare facilities selected Service delivery has collapsed in municipalities since they were those which are being supported by the Results Based fail to collect the refuse regularly.

One of the causes of lack Funding under the HSDSP AF-V.

These were as follows: of collection is inadequate machinery which frequently breakdown.
The typical waste management service l l 2 central hospitals one in Harare and one in Bulawayo continues to fall way below accepted standards with town 2 provinces Mashonaland East and Matabeleland councils failing to collect waste around their areas of South (provincial, district hospitals, and rural health jurisdiction regularly as scheduled.
Like other businesses, centre healthcare facilities pay council/ municipal rates(taxes) to l 2 metropolitan cities Harare and Bulawayo isolation municipalities that handle the collection and disposal of facilities and urban clinics.

general non-infectious waste.


Local authorities in Zimbabwe need to embrace the 3R (Reduce, Recover and Recycle) A March 2016 independent assessment, Review of the concept of solid waste management as part of sustainable Implementation of the Health Care Waste Management development aimed at increasing the life span of the landfills Plan in 18 Rural Districts under the Results Based Financing as only 10% of waste generated is recovered and recycled.
Programme in Zimbabwe found that HSDSP brought about Encourage recycling through provision of adequate waste an improvement in participating facility waste management, receptacles, public campaigns and involving communities However, this ICWMP review of project facilities in 2020 in planning and collection of waste as well as pursuing revealed that there has been a deterioration in the sustainable financing mechanisms from government and management of health care waste in facilities as evidenced the private sector to invest in other subsystems of waste by broken down incinerators and an inadequate supply management.
In accordance with their individual ICWMPs, of bins and bin liners.

During the assessment it was that health facilities participating in the project will ensure that 90% of the facilities visited had no functional incinerators their waste is disposed of in an appropriate acceptable and segregation of waste is not being achieved due to manner.

inadequate supply of bins and bin liners.


There are no waste storage areas in 75% of facilities visited, and those 1.5.3 Institutional and technical capacity that have the storage area it is inadequate.

It was also observed that there is shortage of vehicles to transport The Environmental Management Agency (EMA), which waste to its final disposal.

Findings are discussed more in was established under the Environmental Management Consultations.
1.5.2 National institutional, organizational and technical capacity of Zimbabwe to manage non-hazardous and non-infectious waste The technical and administrative capacity of Zimbabwe to properly implement sound mechanisms for non- infectious and non-hazardous waste management is low.

The responsibility of managing this waste lies with the local authorities which have insufficient financial, human, and material resources.
Zimbabwe lacks appropriate and effective technologies in waste management, due to Act, is a statutory body responsible for ensuring the sustainable management of natural resources and the protection of the environment; the prevention of pollution and environmental degradation; and the preparation of national environmental plans for the management and protection of the environment.
In each district EMA has an Environmental Officer and an Environmental Technician or Assistant to support the implementation of the Environmental Management Act.

Approximately there are 120 Environmental Officers deployed by the Agency countrywide.

They actively provide guidance on pollution prevention and monitor adherence to environmental and pollution standards to project facilities.

Legal frameworks (See section 1.2.5. and 1.2.6.)


27 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) CHAPTER 02 28 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 2.

Infection Prevention and Control and Waste Management 2.1 Overview 2.1.1 What is Infection Prevention and Control?
Infection prevention and control is a scientific approach with practical solutions designed to prevent harm, caused by infections, to patients and health care workers grounded in principles of infectious disease, epidemiology, social science, and health system strengthening, and rooted in patient safety and health service quality.
2.1.2 Importance of Infection Prevention l Ministry of Health and Child Care- National Infection and Control (IPC) Infection prevention and control protects: l Patients from hospital acquired infections which are costly to deal with as they increase length of stay in the hospital, require treatment with expensive broad-spectrum antibiotics and increase use of other interventions like laboratory and surgery.
Prevention and Control Committee (NIPCC) - Central Hospitals - Province & City Health Directorate levels - District Level - Health Facility level - Community Representatives l Other sectors to be involved in IPC service development (Local Government, Housing & Public Works) l Healthcare workers from occupational exposures 2.1.5 Components of an Infection bloody borne infections like HIV and Hepatitis B and C. Prevention and Control Programme l Communities and the environment from pollution 2.1.3 Infection Prevention and Control Programmes According to the National infection prevention and control guidelines and policy each healthcare facility should have infection prevention and control programme.
2.1.4 Management and Organisation Organisational Structures for effective implementation of IPC activities at the various levels of health care delivery include: l l l l A focal IPC Coordinator Infection Control Team Plus Infection Prevention and Control Committee An IPC Plan with timelines Infection Prevention and Control Guidelines, Policies and Standard Operating Procedures (SOPs).
l Standard Precautions and Transmission Based Precautions l System of Monitoring of IPC practice includes risk assessment l Surveillance of Healthcare Associated Infections (HAI) and Multi-drug resistant organisms l Training 29 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.1.6 Principles and Practices of Infection healthcare is being delivered.
It is an active, on-going quality Prevention and Control IPC is the responsibility of all health care providers as part of duty of care aimed at prevention of the transmission of pathogens (microorganisms that can cause disease) where assurance process that develops, implements, supports and monitors IPC standards also involves all aspects of healthcare delivery.

Figure 2-1 below shows that infection control is everyone’s responsibility in healthcare delivery.
Figure 2-1: Diverse Roles in Infection Prevention and Control for Health Care Delivery Domestic Cleaning Pest Control Waste Maintenance Autoclaves Bedpan washers Pharmacy Disinfection policy Dressings Laundry Monitoring Policies Patients Education Counselling Isolation Theatre cssd disinfection Wards Advice Monitoring Education Policies Catering Food Hygiene IPC Occupational Health Infected staff Sharp injuries Outbreaks Hepatitis B vaccinations Procurement Problems with equipment Evaluating new equipment Provincial/District Health Team members: Advice Management Advice Report Public Health Outbreaks Committees Community Staff Advice Education Policies Morning College Teaching policies Microbiology Infection Control Doctor Lab Reports Waste Monitoring Policies 2.1.7 Main Functions of an IPC Program -Other relevant data, e.g.
staff exposure to blood and body fluids 1.

Develop and maintain IPC policies and procedures 4.

Implement isolation precautions and monitor based on best practice standards clinical practice -Policies must be appropriate for the healthcare 5.

Identify and manage outbreaks context (level of care and cost-effective) 6.

Conduct IPC risk assessments (audits) and risk 2.

Educate and train healthcare workers, patients, and management support staff in IPC 3.

Obtain and manage IPC data: 7.


Advise and support procurement of capital equipment and supplies 8.

Active participation in healthcare facility design and -Surveillance data of healthcare-associated infection reconstruction to improve workflow (HAI) 30 9.
Research in IPC – collect, interpret, and share data and experiences ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 2.1.8 Role of IPC Focal Person Each healthcare facility generally has an IPC Focal Person formal link to specialist team members’ (MacArthur,1998), for the following tasks: in this case, the IPC team.

These nurses/persons connect diverse ward/unit/clinic/departments and IPC team.
They - Conducting surveillance activities such as investigating are the “eyes and ears” of IPC, they are an advocacy for outbreaks of hospital infections.

good IPC practices Their role is to increase awareness of - Monitoring infection prevention and control practices infection control issues in their ward or departments and - - Collecting, recording, storing, and reporting relevant motivate staff to improve IPC practice.

infection control data.


Advising on the management of ‘at risk’ patients 2.1.11 IPC Committee/Team relating to isolation categories and prevention and control measures Should be a multidisciplinary team with the following - Conducting learning needs assessment on infection prevention and control for all categories and levels of responsibilities health workers.

- Planning, conducting training and/or participating in orientation and education programs on infection prevention and control.
- The Infection Prevention Control Focal Person (IPCFP) also keeps a record of all staff that has completed such trainings and programs.

l l l Link with hospital management Set standards and establish IPC policies Identify and deal with IPC priorities l Monitor antibiotic usage l l l Initiate IPC policies Surveillance and monitoring of IPC practice Training & development of local IEC material - - Serving as the secretary of the Infection Prevention l Management of outbreaks and Control Committee.
Facilitating availability of vaccines e.g Hepatitis B vaccines for all HCW including waste handlers.

2.1.12 IPC Guidelines The IPC Focal Person should be a healthcare worker trained in basic IPC or holding a Postgraduate diploma in IPC and her/his terms of employment is generally on a full-time basis.
2.1.9 Essential IPC Structures Central, provincial and district hospitals should have multidisciplinary IPC committee and at rural healthcare centres, urban and rural clinics there should be IPC teams which report all their IPC issues to the district and the district reports to the province.

IPC teams for hospitals to include link nurses/person who will be coordinating IPC issues within their departments.
2.1.10 Link Nurses/Persons Link Nurses (LNs)/ persons are defined as ‘practicing nurses or persons with an expressed interest in a specialty and a Policies and guidelines should easily be accessible to all healthcare workers, and to be user-friendly, and these are: l IPC policies, standard operating procedures l National and other IPC guidelines 2.1.13 Example of a Clinic IPC Committee/Team l Nurse in charge of the clinic l Environmental health technician l Nurse aid l General hand l Health Centre Committee (HCC) representative l Community based organizations representative The above is a multidisciplinary team which handles IPC and waste management issues at facility level and these issues include water and sanitation, waste collection and disposal and also environmental cleanliness.
31 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.1.14 The Infectious Disease Transmission Cycle Transmission of infectious agents within a healthcare setting requires three elements: a source (or reservoir) of infectious agents, a susceptible host with a portal of entry receptive to the agent, and mode of transmission for the agent as shown in Figure 2-2.
Figure 2-2: The chain of infection Causative Agent Susceptible host Reservoir Portal of Entry Portal of exit Mode of Transmission 32 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID For infection to develop the following are needed: with body fluids is potentially infectious was developed.

In 1987 universal precautions were updated when body 1.
An infectious agent (the disease causing or pathogenic substance isolation was added to include the use of microorganism) gloves when coming in contact with all body fluids, mucus 2.

A susceptible host (a human with poor immune membranes and moist skin.

However, in 1995 a synthesis defences against the micro-organisms) of universal precautions and body substance isolation 3.
The right environment (the ideal conditions under was carried out which established the now standard which infection can be spread).

precautions.

The sequence of infection transmission is sometimes called 2.1.16 Objectives of Standard the “chain of infection”.

It is the step-wise manner in which a micro-organism can be transmitted to a susceptible host.

The following steps are required to spread an infectious agent or micro-organism 1.

It leaves its reservoir.


A reservoir is the environment where the micro-organism is usually found, e.g., Staphylococcus aureus is commonly found in the nose; Mycobacterium tuberculosis (TB) is commonly found in the lungs.

Precautions Objectives of Standard Precautions are the following: l Employee protection against occupational exposure and infection from blood borne pathogens or other body fluids.
l Reduction of the risk of transmission of micro- organisms from both recognized and unrecognized sources of infection in a health facility.

2.

It leaves through a portal of exit.

For example, l Creation of a safe environment for both patients and SARS-COV-2 viruses are coughed up from the lungs personnel.

(respiratory tract) into the air.

3. .

It is transmitted by a route of infection.

For example, SARS-COV-2 virus droplets in the air).

4.

It gets into another person through a portal of entry.
For example, SARS-COV-2 droplets may be breathed into the lungs of a person closer to the COVID-19 patient.

Transmission: For infection transmission to occur there must be enough of the pathogen and the pathogen must be virulent enough to cause disease.

The pathogen moves through a route of transmission and reaches a “portal of entry” to enter the susceptible host.

Common portals of entry include respiratory tract, gastrointestinal tract, mucosa (e.g.
nose, conjunctiva, and mouth), genitourinary tract, breach of skin integrity.

Chain of infection can be prevented by breaking one or more of the links in the chain of infection transmission between the source or reservoir of infecting organisms which cause the infection and the susceptible host.

Standard precautions when adhered to breaks the chain of infection transmission.
2.1.15 Standard Precautions The number of patients colonized or infected with pathogens that we know about may only be a small portion of the true picture.

Also, the patients not identified or not suspected of being colonized or infected with pathogens represent a substantial risk to other patients; therefore, we must treat all patients as if they have a potential infection.
Body fluids classified as infectious are blood, amniotic fluid, vaginal secretions, seminal fluid, peritoneal fluid, pericardial fluid, pleural fluid, and synovial fluid.

2.1.17 Healthcare Associated Infections Delivery of healthcare is associated with a risk of transmission of infectious agents through other patients, healthcare workers and in association with medical devices.
Risk of transmission of infectious agents is determined by susceptibility, route of transmission, duration and intensity of exposure, and availability and behaviour of healthcare workers with hands-on patient contact.

Every year large numbers of patients acquire healthcare associated infections due to poor adherence to standard In 1985 Universal Precautions, a system of Infection precautions.
Some of these infections are directly related Prevention and Control which assumed that every contact to surgical and other invasive procedures.

However, 33 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.1.18 Components of Standard Precautions standard precautions are the basic level of infection control l Hand hygiene precautions which are to be used, as a minimum, in the care of all patients.
These are also routine precautions that l l Appropriate use of PPE Safe injection practices apply to all patients, health workers and visitors in all health l Health care waste management care settings.

The aim of standard precautions is to reduce the risk of l l l Sharps management Spillage management Environmental cleanliness transmission of infections in all healthcare settings.
Use of l Handling of linen one or a combination depends on the anticipated contact l Decontamination and sterilization with the patient.
l l Patient’s placement Cough etiquette l Occupational health Figure 2-3: Standard Precautions Occupational Health Handle linen correctly Safe injection practices Safe sharps’ disposal Hand Hygiene Protective Clothing STANDARD PRECAUTIONS Patient Placement Decontamination of equipment Cough Etiquette Handle waste correctly Keep environment clean 2.1.19 Standard Precaution Practices l Consider every person (patient or staff) as potentially infectious and susceptible to infection l Wash hands before and after using gloves, or after accidentally touching blood, body fluids and between patient contacts, or use alcohol hand rub when hands are not visibly soiled.
l Wear gloves (both hands) before touching anything wet—broken skin, mucous membranes, blood, or body fluids, soiled 34 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID instruments, or contaminated waste materials and 2.

Lack of supervision and monitoring of IPC practices to before performing invasive procedures ensure compliance l Use physical barriers PPEs (protective goggles, face 3.
Broken down facilities e.g., hand washing basins, masks and aprons) if splashes and spills of blood or incinerators and window latches body fluids (secretions and excretions) are likely.

4.

Delays in repairs due to limited funding.


l Use antiseptic agents for cleansing the skin or mucous membrane prior to surgery, cleaning wounds, or doing Despite the challenges where resources are limited hand rubs or surgical hand scrubs with an alcohol- recommendations will need to be modified according to based antiseptic product.

what is possible, practical, and affordable.


l Use safe work practices such as not recapping or bending needles, safely passing sharp instruments 2.1.21 Transmission Based Precautions and suturing, when appropriate, with blunt needles.
l Safely dispose of infectious waste materials to protect those who handle them and prevent injury or spread of infection to the community l Process instruments and other items after use by thoroughly cleaning first and then either sterilizing or high-level disinfecting them using recommended procedures.

2.1.20 Common Challenges to Implementing Standard Precautions Implementation and adherence to standard precautions are a global challenge resulting in Healthcare Associated Infections (HAIs).
Some of the common challenges faced worldwide are: 1.

Standard precautions are not being applied all the times for all patients by healthcare providers due to complacence.

2.

Health institutions do not routinely train staff in IPC to provide an understanding in the rationale application of standard precautions.
However, these challenges in implementation and adherence to standard precautions are more pronounced to Zimbabwe because of lack of human capital with the necessary expertise and worsened by brain drain as they look for greener pastures, constrained resources and inadequate supplies for IPC activities and poor economic structures.
In addition, these are challenges peculiar to Zimbabwe: These are required to contain highly infectious and/or epidemiologically important pathogens; they are used in addition to Standard Precautions.

Transmission based precautions are based on the mode of transmission of the specific pathogen hence Contact Precautions Droplet Precautions Airborne Precautions a.

Application of Transmission-Based Precautions While mostly used for diagnosed infection they are useful when a specific diagnosis is suspected.
Goal of this 2-tier system is to minimise risk of infection and maximise safety levels within the healthcare facility environment.

Transmission based precautions must be applied by all health workers or visitors into the COVID-19 care areas.

2.1.22 Health Care Waste Management Healthcare waste management is one of the components of infection prevention and control.

When this intervention is carried out appropriately, it breaks the chain of transmission of infection.
In a pandemic like COVID-19, health care waste generation grows due to the increase in the amount of PPE being used and (from the laboratories) the number of specimens being processed.

Meticulous waste segregation is of paramount importance and use of the 3-bin system is to be maintained and monitored.

1.

Shortages of supplies for IPC activities e.g.


PPEs, colour coded bins, colour coded bin liners, detergents and disinfectants Health Care Waste (HCW) includes all the waste generated within health-care facilities, research centres and 35 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) laboratories for medical procedures; and includes sharps, 2.1.23 Classification of Health Care non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices, and radio-active materials (WHO, 2014).
Healthcare waste carries greater potential for causing infection and injury than any other form of waste due to its contamination state and this necessitates its proper handling and management (WHO, 2004).

Between 75% and 90% of the waste produced by health care providers is equivalent to domestic waste which is usually called ‘non-hazardous’ or general health care waste, and about 10-25% is hazardous waste.

Generally, there are two major classifications of waste: hazardous and non-hazardous waste.
Hazardous waste includes cytotoxic drugs, chemical and clinical waste (e.g.

sharps and non-sharps) while non- hazardous waste includes biodegradable waste (e.g.

kitchen waste or generally domestic waste) and inorganic waste (i.e.

waste that is recyclable and can be sold at the market).

Waste Health care waste falls into the following categories: i.

Domestic or general waste ii.

iii.

Sharps Infectious waste iv.

Pathological tissues v. Pharmaceutical waste vi.

Radioactive waste vii.


Genotoxic/Cytotoxic waste viii.

Chemical waste ix.
Heavy metal waste x. Pressurized containers Table 2-1: Comparison of EHS and Zimbabwean Waste Treatment Categories EHS TERMS and TREATMENT ZIMBABWE TERMS and TREATMENT COMMENTS Infectious waste: Include waste Infectious waste: Any waste that is This is the same type of waste suspected to contain pathogens (e.g., generated in the diagnosis, treatment, identified in the EHS, and the bacteria, viruses, parasites, or fungi) or immunization of human beings treatment is the same in sufficient concentration or quantity e.g., dressings, bandages, gauze, to cause disease in susceptible hosts.
and cotton contaminated with blood Includes pathological and anatomical or body fluids gloves and masks material (e.g., tissues, organs, body contaminated with blood or body parts, human foetuses, animal fluids and other waste contaminated carcasses, blood, and other body with blood and body fluids.
It also fluids), clothes, dressings, equipment / refers to that portion of Clinical Waste instruments, and other items that may which may transmit viral, bacterial or have come into contact with infectious parasitic diseases, if concentration and materials.

virulence of pathogenic organisms is Treatment: incineration sufficiently high.
Treatment: incineration 36 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID EHS TERMS and TREATMENT ZIMBABWE TERMS and TREATMENT COMMENTS Sharps: Include needles, scalpels, Sharps: includes both used and Same term and same treatment blades, knives, infusion sets, saws, unused sharps that may cause cuts broken glass, and nails, etc.
and punctures, and usually refers to the sharps’ tins in which needles, Treatment: incineration intravenous, sets, scalpels, blades, saws, broken vials and ampoules, are placed and sealed when three quarters full.

Treatment: incineration Pharmaceutical waste: Include expired, Pharmaceutical waste: Expired Same term and same treatment unused, spoiled, and contaminated drugs; spilled drugs disinfectants pharmaceutical products, drugs, (glutaraldehyde, phenols, etc.
), vaccines, and sera that are no longer cleaners, spilled mercury, pesticides.

needed, including containers and other potentially contaminated Treatment: Incineration materials (e.g., drug bottles vials, tubing etc.)

Treatment: incineration Genotoxic / cytotoxic waste: Genotoxic Wastes: Genotoxic waste Same terms and treatment Genotoxic waste may have mutagenic, is highly hazardous and may have teratogenic, or carcinogenic mutagenic or carcinogenic properties.
properties, and typically arises It may include certain cytostatic drugs, from the faeces, urine, and vomit of vomit, urine, or faeces from patients patients receiving cytostatic drugs, treated with cytostatic drugs, chemical and from treatment with chemicals and radioactive material.

and radioactive materials.

Cytotoxic Treatment: incineration drugs are commonly used in oncology and radiology departments as part of cancer treatments.
Treatment: incineration 37 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) EHS TERMS and TREATMENT ZIMBABWE TERMS and TREATMENT COMMENTS Chemical waste: Waste may be Chemical waste Same terms and treatment hazardous depending on the toxic, Waste may be hazardous depending corrosive, flammable, reactive, and on the toxic, corrosive, flammable, genotoxic properties.

Chemical reactive, and genotoxic properties.


waste may be in solid, liquid, or Chemical waste may be in solid, liquid, gaseous form and is generated or gaseous form and is generated through use of chemicals during through use of chemicals during diagnostic / experimental work (such diagnostic / experimental work (such as reagents), cleaning, housekeeping, as reagents), cleaning, housekeeping, and disinfection.

Chemicals typically and disinfection.


Chemicals typically include formaldehyde, photographic include formaldehyde, photographic chemicals, halogenated and chemicals, halogenated and nonhalogenated solvents, organic nonhalogenated solvents, organic chemicals for cleaning / disinfecting, chemicals for cleaning / disinfecting, and various inorganic chemicals (e.g., and various inorganic chemicals (e.g., acids and alkalis).
acids and alkalis) Treatment: incineration or sewer system Treatment: incineration or sewer system Radioactive waste: Include solid, liquid, Radioactive waste Terms are the same and treatment is and gaseous materials that have been Waste containing radioactive guided by some authority.

contaminated with radionuclides.


substances, Contaminated glassware, Radioactive waste originates from packages, or absorbent paper, activities such as organ imaging, sealed sources, Unused liquids tumour localization, radiotherapy, from, radiotherapy departments or and research / clinical laboratory laboratory research, Urine and excreta procedures, among others, and may from patients treated or tested with include glassware, syringes, solutions, unsealed radio nuclides.

and excreta from treated patient.


Treatment: guided by the International Treatment: Atomic Energy Agency IAEA (2003) guided by the Radiation Authority of Zimbabwe Pressurized containers: Include Pressurized containers Same terms and same treatment containers / cartridges / cylinders for Includes containers / cartridges / nitrous oxide, ethylene oxide, oxygen, cylinders for nitrous oxide, ethylene nitrogen, carbon dioxide, compressed oxide, oxygen, nitrogen, carbon air and other gases.
dioxide, compressed air and other Treatment: crushing and landfill gases.
Treatment: crushing and landfill 38 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID EHS TERMS and TREATMENT ZIMBABWE TERMS and TREATMENT COMMENTS General health care waste (including General domestic type waste from Same terms and same treatment food waste and paper, plastics, offices, public areas, stores, catering cardboard): areas, comprising of newspapers, Treatment: Disposal as part of letters, documents, cardboard domestic waste.
Food waste should containers, metal cans, plastics, be segregated and composted.

bottles, floor sweepings, flowers, Component wastes (e.g., paper, empty saline bottles, non-bloody, cardboard, recyclable plastics [PET, PE, diapers; non-bloody intravenous PP], glass) should be segregated and tubing and bags, office papers, sent for recycling.

packaging, newspapers, magazines, uncontaminated gloves and masks, and includes kitchen waste.
Waste with high content of Waste containing heavy metals should Same term and same treatment heavy metals: Batteries, broken be separated from general health care thermometers, blood pressure waste gauges, (e.g., mercury and cadmium content.

Treatment: Safe storage site designed for final disposal of hazardous waste.

Waste should not be burned, incinerated, or landfilled.

Transport to specialized facilities for metal recovery.
The Health Care EHS Table 2-1 categories were compared with the Zimbabwean categories, no difference was noted.

Whichever required measures, whether they be WB EHS or national law/guideline, are more stringent, will be followed.

2.1.24 Definitions a) Domestic or General Healthcare Waste Waste that does not pose a biological, chemical, radioactive, or physical hazard.
Includes general domestic type waste from offices, public areas, stores, catering areas, comprising of newspapers, letters, documents, cardboard containers, metal cans, plastics, bottles, floor sweepings, flowers, empty saline bottles, non-bloody, diapers; non-bloody intravenous tubing and bags, office papers, packaging, newspapers, magazines, uncontaminated gloves, and masks, and includes kitchen waste.

b) Infectious Waste6 Waste suspected to contain pathogens e.g.
cultures and stocks of infectious agents from diagnostic and research laboratories and items contaminated with such agents; 6 Infectious waste includes clinical waste.

Clinical waste is any waste that is generated in the clinical area that is diagnosis, treatment or immunization of human beings e.g.

dressings, bandages, gauze, and cotton contaminated with blood or body fluids gloves and masks contaminated with blood or body fluids and other waste contaminated with blood and body fluids.
The terms are used in Zimbabwe interchangeably.

39 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) wastes from infectious patients (excreta, dressings from d) Sharps infected or surgical wounds, clothes and bedding heavily soiled with human blood or other body fluids, and other contaminated waste infected with human pathogens e.g.

food residues); discarded live and attenuated vaccines; contaminated waste that has been in contact with infected patients undergoing haemodialysis (e.g.
dialysis equipment such as tubing and filters, disposable towels, gowns, aprons, gloves, and laboratory coats); infected animals from laboratories.

c) Laboratory Waste Laboratory waste can also be classified as infectious/clinical waste this includes: all microbiological cultures in which a multiplication of pathogens of any kind has occurred.

This waste is generated in medical laboratories, microbiology, virology, and other similar medical establishments.
Laboratory waste (cultures and stocks with any viable biological agents artificially cultivated to significantly elevated numbers, including dishes and devices used to transfer, inoculate, and mix cultures of infectious agents and infected animals from laboratories).
In view of This includes both used and unused sharps that may cause cuts and punctures, and usually refers to the sharp tins in which needles, intravenous, sets, scalpels, blades, saws, broken vials and ampoules, are placed and sealed when three quarters full.

e) Pathological Waste This is waste removed during surgery/autopsy or other medical procedures including human tissues, organ, body parts, body fluids and specimens along with their containers, placentas, and foetuses.
f) Pharmaceutical Waste Expired drugs; spilled drugs Disinfectants (glutaraldehyde, phenols, etc.

), cleaners, spilled mercury, pesticides.

g) Radioactive Waste COVID-19, the amount of highly infectious waste generated Waste containing radioactive substances, contaminated has increased along with the number of cartridges, glassware, packages, or absorbent paper, sealed sources, reagents7 and the specimens.
One of the project activities unused liquids from, radiotherapy departments or is to procure cartridges and reagents for COVID-19 laboratory research, Urine and excreta from patients testing.

Some reagents are considered hazardous or treated or tested with unsealed radio nuclides, non-risk toxic because of their catalytic and reactive nature.

They general waste.
They general waste.

may be flammable, corrosive, irritating, and thus damaging or dangerous to human health and the environment if h) Chemical Waste not carefully stored and disposed of.

Therefore, proper disposal of these to be adhered to as mentioned above.

The PCR cartridges are also hazardous as they contain cyanide which is very toxic and the COVID -19 virus which is also highly infectious.
Proper disposal of the cartridges is of paramount importance, and these must be incinerated in a functioning incinerator with temperatures ranging between 1000-1200℃ for them to be completely burnt.

Waste may be hazardous depending on the toxic, corrosive, flammable, reactive, and genotoxic properties.

Chemical waste may be in solid, liquid, or gaseous form and is generated through use of chemicals during diagnostic / experimental work, cleaning, housekeeping, and disinfection.
Chemicals typically include formaldehyde, photographic chemicals, halogenated and nonhalogenated solvents, organic chemicals for cleaning / disinfecting, and various inorganic chemicals (e.g.

acids and alkalis) 7 Reagents are substances that are used to detect, measure or prepare a product because of their chemical or biological properties.

For example, in a PCR test run, there are reagents that are nucleotides that expand a reaction.
40 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID i) Pressurized Containers Includes containers / cartridges / cylinders for nitrous oxide, ethylene oxide, oxygen, nitrogen, carbon dioxide, compressed air and other gases.

2.1.25 Wastewater Process wastewater from HCFs generally has a quality similar to urban wastewater.
Contaminated wastewater may result from discharges from medical wards and operating theatres (e.g., body fluids and excreta, anatomical waste), laboratories (e.g.

microbiological cultures, stocks of infectious agents), pharmaceutical and chemical stores; cleaning activities (e.g.

waste storage rooms), and x-ray development facilities.
Wastewater may also result from treatment disposal technologies and techniques, including autoclaving, microwave irradiation, chemical disinfection, and incineration (e.g., treatment of flue gas using wet scrubbers which may contain suspended solids, mercury, other heavy metals, chlorides, and sulphates).
Depending on the effectiveness of hazardous waste management practices, hazardous health care wastes may enter the wastewater stream, including microbiological pathogens (wastewater with a high content of enteric pathogens, including bacteria, viruses, and helminthes / parasitic worms), hazardous chemicals, pharmaceuticals, and radioactive isotopes.

The contaminated wastewater will be disposed of in a septic tank as it cannot go through the local drainage.
Hazardous wastewater can only be discharged into the public sewer system only after it has been treated.

If it cannot be treated, then septic tanks must be used for disposal.

However, in most facilities especially in rural areas where they have no access to reticulated sewer systems, they rely on septic tanks.
2.1.26 Water Pollution Prevention Measures l Procedures and mechanisms for separate collection of urine, faeces, blood, and vomit from patients treated with genotoxic drugs to avoid their entry into the wastewater stream.

l Collection of large quantities of pharmaceuticals for separate treatment or return to manufacturer.

Small quantities of mild, liquid pharmaceuticals, excluding antibiotics or cytotoxic drugs, may be discharged to sewer systems with a large water flow.
However, this wastewater cannot be discharged into the municipal sanitary sewage treatment system as it is hazardous to the environment and humans.

Therefore, facilities should ensure that they have on-site treatment of wastewater to include primary and secondary treatment, in addition to chlorine disinfection.

Currently most facilities discharge wastewater into an onsite septic tank.

HCF participating in the project will need to adopt specified wastewater treatment practices as per the 2007 EHS for HCF.
Techniques for treating wastewater in this sector include source segregation and pre-treatment for removal / recovery of specific contaminants such as radio isotopes, mercury, etc.
; skimmers or oil water separators for separation of floatable solids; filtration for separation of filterable solids; flow and load equalization; sedimentation for suspended solids reduction using clarifiers; biological treatment, typically aerobic treatment, for reduction of soluble organic matter (BOD); biological or chemical nutrient removal for reduction in nitrogen and phosphorus; chlorination of effluent when disinfection is required; dewatering and disposal of residuals as hazardous medical / infectious waste.
Additional engineering controls may be required for (i) removal of active ingredients (antibiotics and miscellaneous pharmaceutical products, among other hazardous constituents), and (ii) containment and treatment of volatile constituents and aerosols stripped from various unit operations in the wastewater treatment system.

Wastewater generated from use of wet scrubbers to treat air emissions should be treated through chemical neutralization, flocculation, and sludge settling.
Sludge Pollution prevention measures to minimize the generation should be considered hazardous and may be treated off- of wastewater include the following: site in a hazardous waste facility or encapsulated in drums with mortar and landfilled.

Sludge treatment should include Waste segregation measures should be employed to anaerobic digestion to ensure destruction of helminths minimize entry of solid waste into the wastewater stream, and pathogens.
Alternatively, it can be dried in drying beds including: before incineration with solid infectious wastes.

41 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.1.27 Other Wastewater Streams & Water Consumption Guidance on the management of non-contaminated wastewater from utility operations, non-contaminated stormwater, and sanitary sewage is provided in the General EHS Guidelines.

Contaminated streams should be routed to the treatment system for industrial process wastewater.
Recommendations to reduce water consumption, especially where it may be a limited natural resource, are provided in the General EHS Guidelines.8 Table 2-2: Recommendations for Management of Healthcare Waste Waste Category Examples Types of Handling Special Containers to be Disposal** Considerations used* Infectious wastewater Blood, products, body Impervious container Disinfect with 3-3.5% Bags should be ¾ fluids, dialysis water with lid chlorine-based full, sealed, marked Pathological waste/ Tissues, organs body Suitable impervious Incineration, burn Bags should be ¾ compound prior to with site of origin and discharging in sewer removed.
anatomical waste parts, foetus, placenta, containers or waste surgical waste etc.

storage bags placed in rigid containers with lids Isolation waste Viral haemorrhagic National approved Incineration fever sealed, impervious containers with lid full, sealed, marked with site of origin and removed.
Mark container with biohazard label Follow national guidelines for VHF Animal waste From research Impervious container Incineration, burn Bag sealed and laboratory with lid marked with site of origin Laboratory waste Culture plates and Impervious container Autoclave if possible Bags should be ¾ (highly infectious) bottles.

Diagnostic with lid lined with a before disposal then full, sealed, marked specimens, vaccines plastic disposal bag incinerate or burn with site of origin and and reagents.
Double red bags Incineration Cartridges labelled biohazard waste removed.

Bags to be ¾ full double bagged and labelled biohazard.

To be sent to an incinerator of temperatures 1200- 1600℃ for complete combustion.

8 EHS: HCF (2007).
42 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Waste Category Examples Types of Handling Special Containers to be Disposal** Considerations used* Sharps Needles, scalpels, Special puncture Incineration, burn Empty ash pit blades, razors, other resistant sharps sharps, clinical glass container or disposal site Container ¾ full for disposal Medical waste Gloves, sponges, Impervious waste Incineration, burn or Empty ash in ash pit dressings, holding bag or landfill or disposal site sanitary pads, surgical double plastic bag drapes soiled or soaked with blood, body fluids, secretions Container ¾ full for disposal Food waste Milk, Meat, fish chicken, Lined plastic bins Incineration, burn or When ¾ full seal bag vegetables etc.
covered with tight lid landfill and take to disposal site Other kitchen waste Empty bulk cartons, Lined bins with lid Incineration or landfill Place separately from Food containers, Food wrappers food.

When ¾ full seal and dispose 2.1.28 Why is Health Care Waste a 2.1.29 Who is responsible for healthcare Concern?

waste management in healthcare facilities?


Health care waste is a concern because it contains infectious, radiological and chemical waste that can pose Healthcare waste management is the responsibility of all dangers to human health, pollute water bodies, land and health care workers including: the environment as a whole Additionally, if not managed well, health care waste can harbour disease-causing vectors Chief Executive Officers, hospital managers, doctors, e.g.
flies and finally cause smell and sight nuisances.

nurses, administrators, pharmacists, laboratory scientists, accountants, and environmental health officers.
For practical purposes, the following table depicts wastes generated at a health care facility and it is further categorised according to method of final disposal: 43 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Table 2-3: Sites Generating Waste Waste Type Site of Generation Type of disposal Domestic/general waste Office, Kitchen/Cafeteria, Billing, Municipal dump site Sharps Infectious waste Pathological Administration, Cashier, Rest rooms Wards, etc.
Clinics both urban and rural Wards Operation theatres, Intensive Care Units Blood Bank Pharmacy and Medical Stores, laboratories, Casualty Scan rooms Clinics both urban and rural Incineration 44 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 2.1.30 Healthcare Waste Streams According to WHO (2014), thorough steps in health-care waste management include: waste generation; segregation/ separation; collection; transportation, treatment and disposal.
Figure 2-4 presents healthcare waste streams.

Figure 2-4 Summary for HCW Stream (Source: Secretariat for Basel Convention & WHO, National Health-Care Waste Management Plan: Guidance Manual.
Can also be accessed at www.who.int website) 45 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP)StepLocationHealth Care Waste StreamKey Points0Waste MinimizationPurchasing policy, stockmanagement andrecycling of certain typesof waste1Medical Unit, Wardor DepartmentPurchasing policy, stockmanagement andrecycling of certain typesof waste2Purchasing policy, stockmanagement andrecycling of certain typesof waste3Protective equipment,sealed containers andspeciﬁc easy to washtrolleys4Inside Health FacilityAdequate and lockable,easy to clean storageroom.
Storage timelimited to 24-48 hours5Overall time in storageroom limited to amaximum of 48 hours6Outside Health FacilityAppropriate vehicle andconsignment note, HCF isinformed about ﬁnaldestination7Appropriate vehicle andconsignment note toensure proper handlingand transportGenerationSegregation, Colour-coded Packaging/ContainerizationCollectionStorageTreatment DisposalOﬀ-site TransportationOﬀ-site Treatment Disposal 2.1.31 Waste Segregation Waste should be segregated at the point of generation using appropriately colour-coded bags and labelled containers.
Segregation is the responsibility of the one who generates the waste.

There is a need to be vigilant to avoid intermixing of different categories of waste by patients, attendants, or visitors.

The three-bin system to be instituted in all healthcare settings and the containers for collection should be strategically located at all points of generation.
Given the fact that only about 10-25% of the HCW is hazardous, treatment and disposal costs could be greatly reduced if thorough segregation is to be performed.

Segregating hazardous from non-hazardous waste also significantly reduces risks of infecting workers handling HCW.

Generally, the part of the HCW that is hazardous and requires special treatment could be reduced to about 2-5% if the hazardous part was immediately separated from the other waste.
Table 2-4: Recommended Waste Segregation and Collection Scheme Waste Categories Colour of Container and Type of Container Collection Frequency Markings Infectious waste Yellow with biohazard Leak-proof strong plastic When three-quarters filled symbol and Red (highly bag placed in a container or at least once a day.
infectious waste should be (bags for highly infectious additionally marked HIGHLY waste should be capable of INFECTIOUS being autoclaved) Sharp waste Yellow, marked SHARPS with Puncture-proof container.

When three-quarters filled.

biohazard symbol.

Pathological waste Yellow with biohazard Yellow with biohazard When three-quarters filled symbol.

symbol.

or at least once a day.

Chemical and Brown, labelled with Plastic bag or rigid On demand.

pharmaceutical waste appropriate hazard symbol.

container.
container.

Radioactive waste Labelled with radiation Lead box.

On demand.

symbol.

General health-care waste Black.

Plastic bag inside a When three-quarters filled container or container or at least once a day.

which is disinfected after use.
Adopted from Safe management of Wastes from Healthcare Activities, WHO (2017) 46 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Table 2-5: Colour Coding for Waste Segregation Colour code Category Examples Black Red/Yellow Red/Yellow Red/Yellow Red/Yellow Domestic or general waste Food scraps, paper Clinical waste Sharps Used bandages, gloves Needles Pathological/infectious waste Placentas, amputations Pharmaceutical waste Uncompleted medication from wards, expired drugs Red with ‘’radioactive” label Radioactive waste Body fluids from patient on radiotherapy Adapted from National Infection Prevention and Control Guidelines, Zimbabwe, March (2020) If either the red or yellow bag is not available in stock, the yellow or red bags can be used for both clinical and pathological/ infectious waste.
However, if pathological waste is placed in yellow bag, it must be labelled ‘Pathological or Infectious waste’.

The color-coded bags must be strong and leak-proof.

Pedal operated bins must be used in all departments as an infection prevention and control practice.

Table 2-6: Responsibility and Requirements for Waste Management Site Container Responsibilities Wards Sluice room Patient bins Nurse station Pedal bins for patients with black Doctors, charge nurse, nurses, nurse liners.
aides and general hands Two large bins with yellow/red and black color-coded liners Casualty and treatment rooms Pedal bins with yellow liners Doctors, charge nurse, nurses, nurse Doctor’s consulting rooms Two large black bins with yellow /red aides and general hands and black color-coded liners in sluice room for collection of waste from the different rooms Theatres and ICUs Two bins with yellow/red and black Doctors, charge nurse, nurses, or color-coded liners nurse aide to segregate the waste upon generation Office/ administration Pedal operated bins lined with black Housekeeper liners Kitchen Large bins lined with black bin liners Housekeeper 47 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.1.32 Minimization of Waste must not be used for other procedures such as carrying clean linen, medications, and other items.
To avoid waste Effective waste reduction programs require commitment accumulation, collection must be on a regular basis and of top management and effective communication among waste transportation to a central storage area or temporal hospital staff.

Physicians, managers and other medical holding area within the health care facility.

Collection must staff must be made aware of waste generation and follow specific routes through the HCF, to reduce the associated hazards.
Source reduction requires involvement passage of loaded wheelie bins or trolley through wards of purchasing staff and periodic reassessment.

These and other clean areas.

If there are no wheelie bins the programs require staff and moderate infrastructure trolleys used to transport waste to the temporal holding support, planning and organization, assessment, feasibility area should be easy to load, have no sharp edges that can analysis, implementation, training, and periodic evaluation.
damage waste bags or containers and should be easy to All waste bins red or black and sharp tins should be labelled clean.

with the ward where they are coming from to identify those wards that will be mixing waste and inform accordingly.

Great care should be taken when handling healthcare Place information at each waste separation point to waste as most serious risks are associated with injuries reinforce and quickly illustrate the separation procedure.

from sharps.
from sharps.

When handling healthcare waste, sanitary Waste bags and sharp tins when ¾ full, should be tied, staff and cleaners should always wear protective clothing labelled and tins sealed appropriately.

including (as a minimum) overalls or industrial aprons, boots and heavy-duty gloves.

2.1.33 Handling, Transportation, Storage and Treatment of Waste Health care facility staff must handle medical waste as little as possible before storage and disposal.
The more often waste is handled, the greater the chance for accidents.

Special attention must be paid when handling used needles and other sharps which pose the greater risk of accidental injuries and infections.

a) Transportation and Storage of Waste in Clinical Areas In the health-care facilities, health care waste is temporarily stored before being treated or disposed of on-site or transported to a disposal facility off-site.
Non-risk health care waste should always be stored in a separate location from the infectious/ hazardous healthcare waste to avoid cross-contamination.
b) Transport to External Facilities Transportation of waste destined for off-site facilities will proceed according to the guidelines for transport of hazardous wastes / dangerous goods in the General EHS Guidelines as they are more stringent than national The house keeping staff will be responsible for transporting the different coloured polythene bags of waste from the guidance.

sluice room, nursing station and treatment room of each ward on garbage trolleys to the waste designated collection points.
Waste is stored temporarily in the sluice room within the clinical areas.

When bags are three-quarters full they should be tied securely, removed from the large bin and kept in ward sluice room.

Waste can only be kept in the sluice room overnight and removed twice daily according to schedule.

All waste generated the previous day and during the night must be removed from the sluice room and placed at designated waste collection point.
Each ward must have a wheelie bin or trolley designated for transportation of waste to designated areas, including waste that must be transported directly to the incinerator.

The trolley l Transport packaging for infectious waste should include an inner, watertight layer of metal or plastic with a leak-proof seal.
Outer packaging should be of adequate strength and capacity for the specific type and volume of waste, l Packaging containers for sharps should be puncture- proof, l Waste should be labelled appropriately, noting the substance class, packaging symbol (e.g.
infectious waste, radioactive waste), waste category, mass / volume, place of origin within hospital, and final destination, 48 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID l Transport vehicles should be dedicated to waste and storage area for disposal within 24 hours.

the vehicle compartments carrying waste sealed.

iv.

Be accessible to authorized employees and lockable to prevent unauthorized access.
The transporter of hazardous waste to get permission from v. All waste containers to have lids to protect from the Environmental Management Agency and to be issued animals and not provide a breeding place or food with a red license which allows transportation of hazardous source for insects and rodents.

waste.

However, EMA will also assess if the incinerator and vi.
Should have a concrete floor which is cleanable and transportation has been approved and will issue Residue to be kept clean and free from any loose debris and and Incineration Certificate.

Drivers and handlers of always standing water.

infectious waste should be informed of what their cargo is vii.

To be fenced right round (completely) and locked so and receive any necessary training.

that no unauthorized or scavengers can enter.

viii.
viii.

It should be disinfected weekly and whenever a spill c) Temporary Waste Holding Area occurs.

Each healthcare facility has a waste holding area where waste is stored after collection from the wards and will be awaiting incineration or to be transported to an off-site incinerator.

Waste temporal storage area should meet the following parameters: i.

Be protected from water, rain, or wind, i.e., placed in a shed.

ii.
ii.

Minimize the impact of odours, or putrescent waste (waste that can decompose and produce odours after several days).

iii.

Do not store for more than three days; putrescent waste should be transported to the incinerator immediately.

However, during COVID-19 outbreak, infectious wastes should be removed from an HCF’s 2.1.34 Health Care Waste Treatment It is illegal to send infectious waste to any dumpsite or landfill in Zimbabwe, therefore health care infectious waste requires treatment.
HCW treatment systems should be efficient, environmentally sound, and have access controls, to protect persons from voluntary or accidental exposure to waste during the treatment process.
Technological choices should be made according to the following criteria: a) Performance and efficiency of treatment b) Environmental viability c) Easiness and simplicity in the setting up, the operating and maintenance d) The spare parts should be available, easy to acquire e) Costs of investments and operating f) Social acceptability Table 2-7: Definitions used in treatment and disposal of waste Treatment Any method, technique, or process (usually thermal or chemical) designed to change the biological character or composition of a health care risk waste to reduce or eliminate its potential for causing disease.
The treatment may/not physically destroy the waste and render it unrecognizable.

Destruction The process whereby wastes are rendered unrecognizable, such as grinding or shredding.

Destruction may be part of the treatment process or follow treatment.

Disposal Final placement of health care facility waste, or its residue, following treatment to eliminate its original risk.

Source: Safe Management of Wastes from Health-care Activities.
Edited Pruss A, Giroult E, Rushbrook P. World Health Organization (1999) 49 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) In addition to this, the waste treatment system should be c. Incineration close to the waste generating point.

The following is an outline of available technologies for treating HCW: Waste incineration is a thermal treatment, which aims at destroying organic waste parts by oxidation.

Various types a.
Various types a.

Microwave Disinfection of equipment are used: This method is used to disinfect bio-medical waste in l Pyrolytic incinerator: This has a treatment capacity stationary or mobile plants.

The waste is heated by means ranging from 500 to 30000 kg wastes daily, at a of microwave energy.

The waste will be safe to handle combustion temperature of 1200° or 1600° C; its after this process and can be sent for incineration or to initial cost is very high.
It also needs highly qualified the landfill.

However, this method has high investment and staff.

The remnants of wastes are sent to lined landfill operating costs.

disposal sites or ash-pits.

b. Autoclaving (sterilization) l Pyrolytic incinerator (Standard /modern This type of treatment is used in health facilities (medical analysis laboratories) for the sterilization of reusable medical equipment.
In this process, a dry heat sterilizer is used, and heat of 180° C is generated for 30 minutes or longer, for deactivating vegetative micro-organisms and most bacterial spores.

This process can handle only limited quantities of waste and therefore is commonly used only for highly infectious waste such as microbial cultures from clinical or research laboratories.
Autoclaving is environmentally sound, requires high investment and moderate operating costs, and ensures good disinfection efficiency under appropriate operating conditions.

However, it cannot be used for all types of waste and generates contaminated wastewater.

The contaminated wastewater will be disposed of in a septic tank as it cannot go through the local drainage.

Hazardous wastewater can only be discharged into the public sewer system only after it has been treated.
If it cannot be treated, then septic tanks must be used for disposal.

However, in most facilities, especially in rural areas where they have no access to reticulated sewer systems, they rely on septic tanks.

One of the project activities permitted are minor civil works, therefore, facilities could use their subsidies for building of septic tanks for proper disposal of contaminated wastewater or use alternatives like chemical disinfection.
In addition, operation of autoclaving machines requires qualified technicians, and its shredders are subject to frequent breakdown.

After receiving this treatment, waste will be safe to handle and can afterwards go for incineration or other purposes.
50 incinerator): its treatment capacity is from 200 to 10,000 kg/daily, with a combustion temperature ranging from 800 to 900° C; its requirements in terms of investment and care taking are somewhat high; it needs qualified staff; the remnants of wastes are sent to the landfill disposal sites or ash-pits.

l Incinerator with combustion room (artisanal construction, with local materials): Its investment and maintenance costs are relatively low; it can work effectively, even with low-qualification staff.
Pyrolytic incinerators, also known as standard/modern incinerators are the kind mainly used in Zimbabwe health care settings because of these properties.

Incineration provides very high disinfection efficiency and drastic reduction of weight and volume of waste.

It is relatively low in cost and does not need highly qualified staff to operate, however it requires qualified maintenance officers to maintain the incinerator.

On the other hand, it generates pollutant emissions.
Due diligence of existing incinerators in facilities participating in the project should be conducted to examine their technical adequacy, process capacity, performance record, and operators’ capacities.
This includes implementation of operational controls including combustion and flue gas outlet temperatures (combustion temperatures should be above 850°C while flue gases need to be quenched very quickly to avoid formation and reformation of Persistent Organic Pollutants (POPs) as well as use of flue gas cleaning devices meeting international standards).9 Persistent Organic Pollutants are hazardous organic compounds that are resistant to ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID environmental degradation through chemical, biological, this red licence and incinerator manufacturers to provide or photolytic processes.
This resistance means that they standard and checklists on how to operate and maintain bioaccumulate in humans and wildlife with potential the incinerator.

Project Implementing Entity to monitor adverse impacts on human health and the environment.

In and evaluate the standards which the incinerator will be case any gaps are discovered, corrective measures should operating biannually for any private facilities (see Appendix be recommended and pursued.

5).
5).

Most project facilities will likely be governmental since the project does not support private facilities.

All rural health centres participating in the project have incinerators which use low-cost single chamber static Given the malfunctioning incinerators, the project will grates.

Their volume of waste is low.

Unfortunately, there examine use of private facilities and specialized companies is not much operation and maintenance of them.
All urban, for collection and treatment of hazardous and medical district and provincial healthcare facilities’ incinerators have waste and other possibilities such as use of hub incinerators broken down and are not working.

Consultations for this to treat waste from multiple HCF.

ICWMP found that there were no working incinerators in the provinces.
Most of the few functioning incinerators in Currently there are 2 main private companies that the country fail to reach the 850°C that is required to treat incinerate waste; one in Harare and one in Bulawayo.

The or destroy sharps.

one in Bulawayo also has intercity operations—transporting health care waste from other cities for incineration in In the 2011 HCWM assessment most of urban, district and Bulawayo.
The second company also has capacity to treat provincial healthcare facilities supported by the project project waste, however further due diligence is required had functional incinerators compared to the assessment before contracting them.

completed in September 2020 for this ICWMP that found that most of them are no longer functional.
Historically HCF Waste disposal facilities should be integrated into the incinerators would use coal but since they usually do not overall design and ESIA developed for any new HCFs to be have the money to buy coal, they use the general waste constructed.

However, the project is not building any new they generate to support combustion leaving some of the health care facilities and so there is no need for ESIAs.

Good infectious waste not totally burnt.


In accordance with the design, operational practices and internationally adopted project’s Exclusionary List, coal and wood for incinerators emission standards for healthcare waste incinerators can will not be extracted from any fragile or sensitive be found in pertaining EHS Guidelines and GIIP (i.e.

the ecosystems, protected areas, forests or other such sources 2007 Health Care Facility EHS).

(consult the Exclusionary List in the ESMF).


In view of this, it is proposed that stand alone funding be made available for i.

On-site Incinerator the repair and maintenance of incinerators.

In terms of emissions control technologies, most of the incinerators in Zimbabwe do not have wet scrubbers which is a device that is used for pollution control.

Incinerators can be fitted with dry gas scrubbers to reduce acidic gasses.
Incinerators should have permits issued by authorized regulatory agencies and be operated and maintained by trained employees.

EMA will issue a red licence according to SI10 of 2007 in respect of disposal of waste that is considered to present a high risk to the environment.

Private healthcare facilities with incinerators are required to have l The incinerator is maintained by the Engineering services department and is operated by a supervisor and workers.
l After the waste (in yellow and red coloured bags) is deposited in the custody of the supervisor, the sanitation staff should obtain a proper receipt, and the entire process should be documented.

l It is the responsibility of the supervisor to ensure that waste-pickers and other unwanted elements do not rummage through the waste for re-using of disposables and plastics.
The functioning of the incinerator and the number of cycles operated per day 9 Refer to Guidelines on BAT/BEP practices relevant to Article 5 and Annex C of the Stockholm Convention on Persistent Organic Pollutants, Section V. 51 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) should be documented and recorded in a logbook.

l Regular monitoring of the process should be carried chlorine and other acids are used to destroy pathogens before wastes are burned or transported to disposal sites.
out by the engineers.

The most frequent chemical disinfectants are: l The ash produced by incineration should be sent for final disposal at the land fill or disposed in an ash pit 1.

Chlorine - This is a universal disinfectant, very active to control air pollution from the ash dust.

l Incinerator operators to be provided with appropriate against micro-organisms.
In case of possible HIV/ AIDS infectious materials, concentration of 5 g/litre PPE which includes a regular air purifying respirator, (5000ppm) of chlorine is recommended and and to be vaccinated against blood-borne disease e.g.

2.

Formaldehyde - which is an active gas against all micro- hepatitis B and tetanus.
ii.Off-site Incinerator If a HCF has no incinerator or their incinerator is not working they will outsource services from other institutions that have functional incinerators or private companies who incinerate waste.

In such case, the Infection Control Team and other relevant parties should visit and assess off-site incinerators and ascertain the following: l If they are licensed by the Environmental Management Agency to operate as a private waste disposal entity.
l If they have covered trucks to collect and transport waste to the incinerator.

l If the area is secured from scavengers If the above is in place, a service level agreement can be signed.

d. Chemical Disinfection Chemical disinfection, frequently used in health facilities to destroy micro-organisms on medical equipment, floors and walls, is now being extended to the treatment of biomedical wastes.

Chemicals are put in the waste to destroy or inactivate the pathogens.
This treatment usually is more efficient for disinfection than for sterilization.

Disinfection is use of chemicals to destroy micro-organisms excluding bacterial spores, while sterilisation is destruction of any form of micro-organisms including bacterial spores.

Chemical disinfection is most suitable for treating liquid waste such as blood, urine, stools, or hospital sewage.
Solid (and even highly hazardous) biomedical wastes, including microbiological cultures, sharps, etc., may also be disinfected chemically.

Chemical products such as hypo- organisms except at low temperature (<20°C); the relative humidity must be near 7 %.

It is also sold in the form of gas dissolved in water at concentrations of 370 g/litre.

This disinfecting product is recommended for Hepatitis and Ebola virus (but not for HIV/AIDS).
The risk associated with formaldehyde is that it can cause cancer in those applying it.

This risk will be avoided by use of proper PPE (i.e.

heat resistant gloves, goggles, face masks, respirator, helmet, heat resistant gum boots and heat resistant work suit, washing facilities) and the fact that hazardous materials and wastes will be handled according to occupational health and safety guidance provided in the General EHS Guidelines.
Challenges of this system is that the disinfected wastes still need other methods of final elimination.

This method gives highly efficient disinfection in good operating conditions, and some chemical disinfectants are relatively inexpensive.

But it requires highly qualified technicians for executing the process However due to lack of qualified personnel, general hands or nurse aides are often trained on the job to perform those processes.
Therefore, thorough training or proper recruiting of qualified personnel is recommended.

e. Burial in Municipal Landfills This practice consists of disposing of healthcare general waste directly in municipal landfills.

In fact, this is not a treatment system: the wastes are stored with household wastes.

This system requires very low investments, but it presents huge health and environmental risks, in view of scavenging practices at public landfills.
However, land filling is better than leaving hazardous wastes accumulated at hospitals or other publicly accessible places.

More suitable treatment methods should immediately be envisaged.
52 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID f. Burial Inside Health Facilities 2.1.35 Sharps Management Burial at the origin of HCW production – the health facility - A sharp object is defined as anything that can puncture the is another form of elimination, mainly used where there is skin.

Examples of sharp objects are hypodermic needles, no treatment system or means of waste transportation to blades, glass ampoules, bone fragments and jagged metal.
public landfills.

The risk in this case is that the destruction of In a clinical environment, a sharp may be contaminated with infected wastes is not guaranteed, depending on the burial blood or other body fluids and expose healthcare workers place.

Also, there is always the risk of the public digging up to blood-borne infections.

wastes, most of all, the sharp objects.

Safe disposal of sharps is the responsibility of the person g. Concrete Lined Pits who has used it.
Disposal at the origin of HCW production in concrete lined pits at the health care facility - is another form of elimination, mainly used where there is no treatment system or means of waste transportation to public landfills.

The risk in this case is reduced by the lining and the pit must be above the water table.

However, the destruction of infected wastes is not guaranteed, according to the burial place.

Also, there is always the risk of accidentally digging up wastes, most of all, the sharp objects.
h. Open Air Burning When done in open air, the burning of HCW constitutes a factor of pollution and harm to the environment.

Since HCW is generally burned in a hole, the destruction is never complete: often the quantity of unburned residue constitutes 70% of the original wastes.

This encourages children and scavengers to look for toys and reusable objects.
i. Encapsulation This method consists of disposing of wastes by filling metal or plastic containers (¾ full) with waste materials and topping the container up with plastic foam, bituminous sand, cement mortar or clay material.

The process is cheap, safe, and very appropriate for health centres that cannot envisage other methods to treat sharps, chemical and pharmaceutical waste.

Encapsulation is not recommended for non-sharps infectious waste.
The main advantage is to prevent the risk of scavengers getting access to these wastes in landfills and to reduce mobilization of toxic substances.

To minimize risk of exposure the following must be adhered to: l Discard sharps, needles and syringe as one unit.

l Discard sharps in a rigid sharps container immediately after use.

l Do not recap needles l Sharps boxes to be located close to point of use.

l Make sure sharps bins are always in stock.


l Do not transfer used sharp from one person to l l another by hand.

Sharps bins to be labelled.

Sharps bins not to be overfilled, to be sealed and sent for incineration when ¾ full.

l Sharps to be disposed of as clinical waste thus requiring incineration.

l When needle prick injury occurs, to be handled in accordance with the healthcare facility post exposure prophylaxis protocols.
l Sharps are not disinfected before incineration therefore production of POPs from chlorinated disinfection solution residues during incineration is avoided.

2.1.36 Types of Incinerators Incineration is controlled burning of solid, liquid, or gaseous combustible wastes to produce gases and residues containing little or no burnable material and will be safe to handle.

Incineration is a high temperature dry oxidation process that reduces the volume and weight of waste.
This process is usually selected to treat waste that cannot be recycled, reused, or disposed of in a landfill, thus healthcare waste.

Health-care waste includes all waste generated by health care facilities, research facilities, laboratories and 53 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) that produced in the course of health care undertaking in l Heavy metals, the home e.g.
dialysis, insulin injections and home based care (needles, syringes, soiled bandages, disposable sheets, l Organics in the flue gas, which can be present in the vapor phase or condensed or absorbed on fine medical gloves, dialysis machine filters, plastic catheters particulates, and drip set, glass waste, urinary bags, expired medicines, medicine containers, pesticide containers, sanitary napkins, liquid waste and placenta) (WHO, 1998).
Pyrolytic incinerator (Standard /modern incinerator): This is a standard incinerator consist of a primary combustion chamber, which has a treatment capacity of 200 to 10,000 kg/daily, with a maximum combustion temperature ranging from 800 to 900° C. Its requirements in terms of investment and maintenance is not very high; it needs trained staff to operate it hence found in most rural healthcare facilities.
This is fuelled by firewood or coal; the residues of wastes are sent to the landfill disposal sites or ash-pits.

l Various organic compounds (e.g.

polychlorinated dibenzo-p-dioxins and furans [PCDD/Fs], chlorobenzenes, chloroethylenes, and polycyclic aromatic hydrocarbons [PAHs]), which are generally present in hospital waste or can be generated during combustion and post-combustion processes, l Hydrogen chloride (HCl) and fluorides, and potentially other halogens-hydrides (e.g.
bromine and iodine); l Typical combustion products such as sulphur oxides (SOX), nitrogen oxides (NOX), volatile organic compounds (including non-methane VOCs) and methane (CH4), carbon monoxide (CO), carbon dioxide (CO2), and nitrous oxide (N2O).10 Pyrolytic incinerator (Advanced): An advanced incinerator 2.1.38 Pollution Prevention and Control with two combustion chambers, primary and secondary combustion chambers.
It has a treatment capacity ranging Pollution prevention and control measures include: from 500 to 30,000 kg wastes daily, at a combustion temperature of 1200° or 1600° C. This incinerates even l Application of waste segregation and selection expired medicines, but its initial cost is very high.

The incinerator is highly controlled with air pollution equipment and operational practice is specifically designed to reduce formation of dioxins.
It needs fuel or electricity to function and highly qualified staff to operate it hence found in central hospitals.

The residues of wastes are sent to landfill disposal sites or ash-pits.

To install and operate an incinerator, a red licence is including removal of the following items from waste destined for incineration: halogenated plastics (e.g.
PVC), pressurized gas containers, large amounts of active chemical waste, silver salts and photographic / radiographic waste, waste with high heavy metal content (e.g.

broken thermometers, batteries), and sealed ampoules or ampoules containing heavy metals; 11 required from the Environmental Management Agency l Incinerators should have permits issued by authorized (EMA).

This is because treatment, disposal of hazardous waste and discharge is a high environmental hazard.
Each facility with an incinerator pays a fee of 16574.58 USD annually which includes environmental monitoring and emission fees.
2.1.37 Emissions Pollutants potentially emitted from health care waste incinerators (HWIs) include: regulatory agencies and be operated and maintained by trained employees to ensure proper combustion temperature, time, and turbulence specifications necessary for adequate combustion of waste.12 This includes implementation of operational controls including combustion and flue gas outlet temperatures (combustion temperatures should be above 850 °C while flue gases need to be quenched very quickly to avoid formation and reformation of POPs) as well as use of flue gas cleaning devices meeting international standards.13,14 10 WB (2007) Health Care Facility EHSG, p6.
54 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Secondary air pollution control measures for hospital waste environment for long periods, become widely distributed incinerators (HWI) include the following: geographically, accumulate in the fatty tissue of humans l Wet scrubbers to control acid gas emissions (e.g.

hydrochloric acid [HCl)], sulphur dioxide [SO2, and fluoride compounds]).
A caustic scrubbing solution will increase the efficiency for SO2 control.

Control of particulate matter may be achieved through l and wildlife, and have harmful impacts on human health or on the environment.

The Convention specifically targets incinerators.


Among other actions, it will require countries to develop and implement actions to address the release of dioxins and furans; Article 5 will require measures to reduce dioxin/furan releases from incinerators with the use of cyclones, fabric filters, and / or electrostatic goal of their “ultimate elimination;” and countries are precipitators (ESP).
Efficiencies depend on the particle required to promote the use of alternatives including the size distribution of the particulate matter from use of the best available techniques/technologies.

Under the combustion chamber.

Particulate matter from the Stockholm Convention, standard incinerators are not hospital incinerators is commonly between 1.0 to 10 a preferred technique due to their potential to emit POPs.

micrometres (µm).
micrometres (µm).

ESPs are generally less efficient Only highly controlled incinerators with air pollution control than baghouses in controlling fine particulates and equipment and operational practice specifically designed to metals from HWI, minimize dioxin formation and release could be considered l Control of volatile heavy metals depends on the the best available technology.

temperature at which the control device operates.


Fabric filters and ESP typically operate at relatively high Zimbabwe emission standards are regulated by the temperatures and may be less effective than those Environmental Management Agency SI.72 of 2009 that operate at lower temperatures.

Venturi quenches (Atmospheric Pollution Control Regulation 2009.

These and venturi scrubbers are also used to control heavy standards are monitored by the Standards Association of metal emissions.
The volatile heavy metals usually condense to form a fume (less than 2 µm) that is only Zimbabwe (SAZ) which test the air to assess the amount of partially collected by pollution control equipment, pollutants.
Table 2-8 shows a comparison of EHS Emission l Management of incineration residues such as fly ash, Guidelines to Zimbabwean Emission Standards, however bottom ash and liquid effluents from flue gas cleaning the EHS Emission Guidelines are generally more stringent as a hazardous waste (see General EHS Guidelines) and therefore will be used for this project.
Zimbabwean as they may contain high concentrations of POPs.15 standards will be used when they are more stringent, such It is important to note that since sharps will not be as for NOx.

disinfected with chlorine solutions, POPs are not expected to be formed during incineration.
2.1.39 Emission Standards The Stockholm Convention on Persistent Organic Pollutants (POPs) is a global treaty to protect human health and the environment from chemicals that remain intact in the 11 WB (2007) Health Care Facility EHSG, p6.

12 Technical information on the proper operation and maintenance of hospital waste incinerators may be obtained from WHO (1999) Chapter 8 and the US EPA Handbook on the Operation and Maintenance of Medical Waste Incinerators (2002).
13 Refer to Guidelines on BAT/BEP practices relevant to Article 5 and Annex C of the Stockholm Convention on Persistent Organic Pollutants, Section V. 14 WB (2007) Health Care Facility EHSG, p9.

15 WB (2007) Health Care Facility EHSG, p9.
55 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Table 2-8: Comparison of EHS Guidelines and Zimbabwean Emission Standards POLLUTANTS UNITS EHS GUIDELINE VALUE ZIMBABWE EMISSION STANDARD Total Particulate matter (PM) Total organic carbon (TOC) Hydrogen Chloride (HCl) Hydrogen Fluoride (HF) Sulphur dioxide (SO2) Carbon Monoxide (CO) NOX Mercury (Hg) Cadmium + Thallium (Cd + Tl) mg/Nm3 mg/Nm3 mg/Nm3 mg/Nm3 mg/Nm3 mg/Nm3 mg/Nm3 mg/Nm3 mg/Nm3 Sb, As, Pb, Cr, Co, Cu, Mn, Ni mg/Nm3 and V Polychlorinated dibenzodioxin and dibenzofuran (PCDD/F) ng/Nm3TEQ 10 10 10 1 50 50 200-400a 0.05 0.05 0.5 0.1 100 30 30 ---- 50 100 150 ---- ---- ---- ---- 2.1.40 Management of Air Pollution and Incinerator Residue Emissions from project facilities are not expected to be significant or deleterious to the health of surrounding and other populations.
Additionally, the general air quality in Zimbabwe is not already considered to be degraded such that the healthcare facilities emissions would be considered a significant additional burden.

Therefore, measures to control such emissions will be undertaken when technically and financially feasible or necessary.
In accordance with the Health Care EHS, secondary air pollution control measures for hospital waste incinerators should include the following where technically and financially feasible: l Wet scrubbers to control acid gas emissions (e.g.

hydrochloric acid [HCl]), sulphur dioxide [SO2, and fluoride compounds]).
A caustic scrubbing solution will increase the efficiency for SO2 control, Control of particulate matter may be achieved through l use of cyclones, fabric filters, and / or electrostatic precipitators (ESP).

Efficiencies depend on the particle size distribution of the particulate matter from the combustion chamber.

Particulate matter from hospital incinerators is commonly between 1.0 to 10 micrometres (µm).
ESPs are generally less efficient than bag houses in controlling fine particulates and metals from HWI.

l Control of volatile heavy metals depends on the temperature at which the control device operates.

Fabric filters and ESP typically operate at relatively high temperatures and may be less effective than those that operate at lower temperatures.

Venturi quenches and venturi scrubbers are also used to control heavy metal emissions.
The volatile heavy metals usually condense to form a fume (less than 2 µm) that is only partially collected by pollution control equipment.

l Management of incineration residues such as fly ash, bottom ash, and liquid effluents from flue gas cleaning as a hazardous waste as they may contain high concentrations of POPs.
l Incineration residues (including those which may contain POPs) will be disposed in an ash pit to control 56 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID emissions to the environment.

Installing new ash pits for individual characteristics will also depend on variability.

is not the goal of the project but refurbishing the ones Sampling and analysis are required most frequently for already in existence is possible.
microbial and less often for chemical constituents.

However ad hoc water samples can be collected for analysis if there However, Zimbabwe is a low-income country and the is need.

Usual practice during water quality monitoring standard incinerators which are used in healthcare facilities is to include the critical parameters for microbial quality generally do not have pollution control devices.
They (normally E. coli, chlorine, turbidity and pH) and for a sanitary adhere to air emission standards prescribed by EMA.

For inspection to be carried out.

Methods for these tests must this project, participating facilities will need to install or use be standardized and approved.

It is recommended that field an air pollution control measure acceptable to the Bank.
test kits be validated for performance against reference or 2.1.41 Water Quality and Pollution In Zimbabwe, health facilities are checked on whether they have adequate supplies of potable water before commissioning and the water supply is required to be maintained during the operation of the facility.

Potable water provided in project health facilities is already required to be monitored to ensure its safety.

Additionally, some health facilities, especially in rural areas, may use septic tanks.
Since surrounding communities may use ground standard methods and approved for use in water quality testing.

Testing and monitoring details must be reflected and detailed in individual facility ICWMPs.

Plans should be developed to respond to results that do not meet water quality targets.

These should include investigation of the cause of non-compliance and, where necessary, corrective action.
2.2 Management Measures water, it is important to ensure communities are safe from 2.2.1 Roles and Responsibilities for contamination of ground water that could come from ground seepage or contamination of surface water from septic system problems.

Septic tanks should have been sited in such a way to avoid contamination of any nearby community water supplies.
Periodic testing and sanitary inspection of health facility and community drinking-water supplies will be undertaken by the by MOHCC and other agencies such as EMA and SAZ to assess microbial hazards and known problem chemicals.

Water quality monitoring is conducted in accordance with the Public Health Act, the Environmental Management Act, the Water Act and WHO Guidelines for Drinking Water.
The quarterly water sampling programme ensures that the MOHCC EHT visits each facility and tests the drinking water at least once every quarter.

Government laboratories analyse the samples for quality assurance.

EMA also conducts water testing as part of their routine surveillance or monitoring for environmental pollution.

Comprehensive analysis of the chemical quality of all sources is recommended prior to commissioning as a minimum and preferably every quarter thereafter.
Sampling frequencies are usually based on the population served or on the volume of water supplied, to reflect the increased population risk.

Frequency of testing ICWMP According to the national HCWMP of 2011, the ICWMP falls directly under the responsibility of the Environmental Health Department of MoHCC.

The Department was given the role to implement and apply the multi-stakeholder approach so that all relevant players take part.
The key targeted stakeholders included Ministry of Environment, Water and Climate and its Environmental Management Agency, local authorities, non-governmental organizations, and the private sector.

The Environmental Health Department was chosen because the responsibility is part of its mission, it has competent staff cascading to ward level and it has capacity to offer health education services, public information and raising awareness.
The department was thus tasked with the responsibility to procure consumables, maintain existing incinerators, build capacity among health care workers, and coordinate the whole HCWMP process.

The Environmental Management Agency had the responsibility of monitoring the implementation of the HCWMP as it was considered to have the overall responsibility of protecting the environment.
Therefore, the Environmental Health Department’s activities would have to conform to the requirements of the Environmental 57 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Management Act.

The EMA had to oversee the whole chain meet this requirement because of the pertaining macro- of the health care waste from generation to final disposal.

economic environment.

It was beyond the scope of this The HCWMP neglects to mention the need for facilities of the visited urban local authorities.
to register with EMA as waste generators, and hence inadvertently misses the need to submit reports on waste Another role of the local authorities noted during the management to EMA on an annual basis as required by visits was that they collected the general health care waste Statutory Instruments 6 and 10 both of 2007. from the hospitals visited.
However, it was clear that they consultancy to check what was happening at the dumpsites sometimes collect mixed hazardous and non-hazardous Local authorities have the responsibility to ensure that their health care waste as there were no mechanisms in place landfills (currently dumpsites) are designed to take in health for them to check the waste designated as non-hazardous care waste.

To this end, the landfills should have separate waste at the health institutions before transportation.
designated sections devoted to the disposal of health Use of color-coded bins, spot checks and audits on waste care waste according to the norms and standards defined segregation is a solution which can be put in place to by the Environmental Management Act to avoid possible minimize mixing of waste as well as training or information environmental pollution.
The coordination of the activities sessions for local authorities to educate them on the logic was to be done by the local authorities’ Environmental of waste segregation and the dangers of mixing.

Health Departments.
Health Departments.

It was suggested that this could be strengthened if the local authorities were to put in place At the healthcare facility level, the Infection Control regulations to refuse any mixed waste from health facilities, Focal Person and the Environmental Health Officer are forbid uncontrolled health care waste disposal and set up responsible for the health care waste management.

They deterrent penalties for offenders.


Most of the legislation to ensure that waste management arrangements are in place, achieve these requirements are in place but are not being and that they meet the national policy, regulations, and implemented.

For example, currently there is no properly standard operating procedures.
Infection Control Focal lined landfill in Zimbabwe although Statutory Instruments 6 Person and Environmental Health Officer are responsible and 10 both required the lining of general and hazardous for the segregation, collection, transportation, and waste landfills, respectively by 2012.

Therefore, project treatment of health care waste.


They ensure that facilities facilities rely on incineration and disposing of the ash in meet the national policy, regulation, and standard operating ash pits while those without an ash pit will take their ashes procedure requirements.

to the unlined landfill.

Local authorities have failed to 58 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID CHAPTER 03 59 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 3.
Emergency Preparedness and Response 3.1 What is an Emergency An emergency event is an unanticipated incident, arising from both natural and man-made hazards, typically in the form of fire, explosions, leaks, spills or injuries from needle pricks.

This may occur for a variety of different reasons, including failure to implement operating procedures that are designed to prevent their occurrence, extreme weather or lack of early warning.
Emergency preparedness and response are measures designed to address the emergency event in a coordinated and expeditious manner, to prevent it from injuring the health and safety of the community, and to minimize, mitigate and compensate for any impacts that may occur.

See the project ESMF for further details on project arrangements for emergencies.
3.2 Management of Spills In-house This is also a standard precaution which should be adhered to at all the time when there are spillages within healthcare facilities.

Spillages can be chemicals, body fluids and any liquids in the facility.

Example of body fluids spillages that can occur in healthcare facility are blood, urine pleural fluid etc.

Sulphuric acid should be diluted before containment as it burns.
When a spill occurs, personnel handling the spillage are to wear appropriate Personal Protective Equipment (PPEs).

- Contain the spill using paper towels, newspapers, or rugs.

Occupational exposure to be in place and adhered to accordingly and post exposure prophylaxis to be known by all staff and to be easily accessed for reference.

3.2.1 Dilution of Sodium Hypochlorite Chlorine in liquid bleach comes in different concentrations.
l You can use any concentration to make a dilute chlorine solution by using the following formula: [% chlorine in liquid bleach] divided by [% chlorine desired] -1 = Total parts of water for each part bleach* Example: To make a 0.5% chlorine solution from 3.5%** bleach: - Dispose the paper towels, newspapers or rugs used for containing the spill as clinical or hazardous waste.
l [ 3.5%/0.5%] – 1 = [7] – 1 = 6 parts water for each part bleach - Mop the area with soap and water and thereafter disinfect using the healthcare facility recommended disinfectants.

Therefore, you must add 1 part bleach to 6 parts water to make a 0.5% chlorine solution.

- Do not mix detergents and disinfections as they can l Parts” can be used for any unit of measure (e.g.
litre, cause a chemical reaction which will be hazardous to or gallon) or any container used for measuring, such as the ones handling the spill.
a measuring jug or a bottle 60 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Table 3-1: Sodium Hypochlorite Dilutions Product Chlorine available How to make How to make How to make How to make 0.1% 0.5% 1% 2% Sodium 3.5% 1 part bleach to 1 part bleach to 6 1 part bleach to 4 parts bleach to hypochlorite liquid 34 parts water parts water.
2.5 parts water 3 parts water (bleach) Sodium hypochlorite liquid (bleach) 5% 1 part bleach to 1 part bleach to 9 1 part bleach to 4 1 part bleach to 49 parts water parts water parts water 1.5 parts water 3.3 Management of Needle Pricks hrs.

and at least within 72 hrs.
l Ascertain HIV/HBV status of patient & HCW after Procedure following blood or body fluid exposure appropriate counselling l Action to be taken depends on results of HIV/HBV l Wash exposed area thoroughly with soap and water test… under running water l Rinse eye or mouth with plenty of saline water if l If it is not possible to determine the HIV status of the source patient, assume positivity and proceed contaminated accordingly l l Report the injury to a senior/supervisor Take recommended PEP immediately – i.e.
within 1-2 l If HCW refuses to be tested for HIV, they should be counselled, and the event documented Table 3-2: Management of Health Care Worker Following Blood/Body Fluid Exposure Source Patient Health care worker Health care worker Management HIV+ve HIV-ve HIV+ve HIV-ve HIV+ve HIV-ve Refuses to be tested assume positivity HIV-ve Starter pack, give ARVs for 28 days then monitor for 6 months.
Repeat HIV test at 4 week, 3 months and at 6 months Stop Starter pack and refer to OI clinic Stop starter pack no further PEP necessary Manage as for (i) HBV+ HBV+ Previously vaccinated Was not vaccinated Give a booster dose of HB vaccine Start Vaccination Course i.e.
3 doses 61 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Antiretroviral medicines to be used in PEP l In line with Guidelines on Antiretroviral Therapy for the Prevention and Treatment of HIV in Zimbabwe l Tenofovir 300mg orally once daily Plus • Lamivudine 300mg orally once daily Plus • Atazanavir 300mg/ritonavir 100mg orally once daily • This regimen is continued until HIV results for HCW and the patient are known or for l one month.
Figure 3-1: Flow charts for HIV &HBV post exposure prophylaxis Flow chart for HIV post exposure prophylaxis Flow chart for HBV post exposure prophylaxis l Exposure to HIV l Percutaneous l Splashes l Broken skin l Human bite PEP Policies Exposure to HBV l Wash exposed area with soap under running water l Report to immediate supervisor l For mucous membranes flush with plenty of water/saline l Initiate PEP within 1-2 hours if possible and not later than 72 hours l Refer both patient and health worker for HIV Counselling and testing Ascertain HIV status of both patient and health worker If patient HIV Negative and health Worker HIV negative If health worker HIV Negative and patient positive or patient refuses testing assume positivity If Patient HIV positive or Negative unknown, health worker HIV positive STOP PEP, offer supportive Counselling and follow-up Complete 4 weeks of PEP and offer supportive Counselling STOP PEP Counsel and refer to specials/ OI Repeat HIV test 6 weeks, 3/12 and 6/12 after initial test if HIV positive provide appropriate care and counselling and refer for expert opinion.
If negative, counsel.
HIV 62 l Wash exposed areas under running water l Refer both patient and health worker for HBV testing Determine HIV status of patient and health worker Patient HBV Negative Health Worker HBV negative and previously vaccinated Patient HBV positive or unknown or patient refuses testing so assume positivity Health Worker HBV negative and not vaccinated Give booster dose of HBV vaccine Start vaccination course Patient HBV positive or HBV status unknown Health Worker HBV positive Counsel and refer for specialist care Repeat HIV course 3 months and 6 months after initial test Offer on- going supportive counselling HBV ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 3.4 Management of Fire the emergency response teams (police, fire brigade Expected fires- electricity faults l respond (use fire-fighting equipment available) etc.)
a) Before c) After l l l l l electricity workmanship should be standard servicing of all installations Serviced fire extinguishers to be available serviced sand buckets to be available l audit (find out what caused the fire, access extend of damage, what did we do good and wrong, were there any causalities) everyone should be taught how to use fire-fighting 3.5 Septic Tanks and Communities equipment, can have drills l establish and label emergency escape routes and fire If a septic tank leakage impacting communities is assemble point confirmed: l have emergency numbers in place and available to every member in the institutions l have an emergency siren/bell l Immediately stop the community from using the water point until further communication.
l Provide water treatment chemicals to affected b) During communities.

l l raise an alarm using the emergency siren/bell water point or evacuate all staff and patients, have body count and l Engage maintenance department or other relevant account for everyone concurrently be in contact with entity to resolve as a matter of emergency.
l Provide alternatives to water access – directing to next 63 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) CHAPTER 04 64 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 4.
Institutional Arrangements and Capacity Building 4.1 Levels of Capacity Building and Institutional Arrangements 4.1.1 Zimbabwe Health Sector Development Support Project (HSDSP) Level HSDSP PIE has a qualified Environmental Specialist who will work with MoHCC at all levels to ensure that this ICWMP and the project ESMF are being implemented.

The Environmental Specialist will also compile relevant performance and compliance data on all participating facilities providing guidance as necessary.
The Environmental Specialist, in coordination with any other necessary parties, will report on ICWMP implementation, compliance and other relevant project performance matters to the PIE as required and to the World Bank on a biannual basis.

All accidents, fatalities and incidents are to be reported to the Bank within 48 hours after learning of them.
Among other duties, the Environmental Specialist will ensures that any risks posed by or to the environment ensure that each participating project HCF will establish are dealt with quickly and properly.
EHT roles include an ICWMP tailored to its needs providing guidance to the among other activities, food quality monitoring, premises facility as necessary before such facility begins project inspections, water quality monitoring, disease prevention funded activities that generate infectious waste, check that and control.
They are appointed upon completion of a required trained, and qualified staff are in place (including three-year course after which they are awarded a diploma those in charge of infection control and biosafety and certificate in environmental health.

The EMA and EHSD waste management), check that IPC measures are funded will lead in developing the health care waste regulations and in place, that there is use of appropriate PPE for waste and technical guidelines at national level.
According handlers, appropriate bins, colour coded bin liners and to the Environmental Management Act, each facility is transportation to the waste disposal area if onsite or off required to develop a waste management plan and report site.

to EMA annually on its waste management activities and these reports will feed into the state of the environment The PIE Environmental and Communications Specialists will report which EMA is required to produce by the same Act.
be available to support the facilities in reporting any risks and Although waste management plans are required, facilities dangers associated with infectious and hazardous wastes usually do not generate them.

to the public appropriately.

Consultations and disclosures will be carried out during project implementation.

Consult Zimbabwe emission standards are regulated by the the ESMF for further details.
4.1.2 National (Central) Level According to the 2011 Healthcare Waste Management Plan (HCWMP), which is being updated, the coordination structure for the national HCWMP would be designed by the MoHCC Environmental Health Services Department (EHSD) ensuring that responsibilities are clearly defined.

An Environmental Health Technician (EHT) from MoHCC SI.72 of 2009, Environmental Management (Atmospheric Pollution Control) Regulation 2009.
These standards are monitored by the Standards Association of Zimbabwe (SAZ) which does the testing of the air to assess amount of pollutants.

The PIE Environmental Specialist will verify if each participating facility has the required licensing (for example incinerator licences) and support the facilities in developing appropriate health care waste management plans.
The PIE Environmental Specialist working in collaboration with MOHCC will check that facilities with 65 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) incinerators are adhering to the emission and pollutants 4.1.5 Facility Level (Urban and Rural standards required by EMA and SAZ.

All participating HCF in the project are required to adhere to national laws and policies maintaining or obtaining mandatory licences as necessary.

SAZ empowers EMA to do regular inspections and monitoring incinerators.
EMA is also responsible for monitoring disposal of both solid and liquid waste.

4.1.3 Provincial Level The Provincial Development Committee will ensure that healthcare waste is being managed properly without causing harm to the community and the environment.

The committee is also responsible for ensuring that healthcare waste treatment infrastructure is available and being maintained well and infection control measures are being followed.

This is done by reviewing facility performance.


Provincial Environmental Health Officer and Provincial IPC Focal Person are also responsible for training all healthcare workers on IPC and waste management and their implementation.

4.1.4 District Level Clinics) All relevant departments in an HCF must be involved in waste and hazardous materials management.
An independent team which is not part of the healthcare facility management the Health Centre Committee (HCC), manages, coordinates, and regularly reviews issues and performance.

In the urban and rural clinics, the clinic management which includes the HCC and Community Based Organizations (CBOs) are responsible for raising public awareness and health by educating the patients and the community on healthcare waste management and infection control measures to prevent spread of disease.
In response to COVID-19, they are responsible for ensuring social distancing, hand hygiene, mandatory masking and respiratory hygiene within healthcare facilities and the community.

Infection Control Focal Person also monitors the incidences of needle pricks, other injuries and ensure that Post Exposure Protocol and appropriate reporting internally and externally has been adhered to.
The District Development Committee headed by the District In any case, the District Medical Officer, District Nursing Development Coordinator is responsible for ensuring Officer or Charge Nurse of a HCF takes overall responsibility that there is appropriate and enough infrastructure for infection control and waste management, leading an in the district for healthcare waste management.
The intra-departmental HCC team which includes doctors, committee provides oversight to government ministries nurses, cleaners, lab personnel including the microscopist including MOHCC.

The committee also ensures infection and EHTs of the facility which regularly reviews issues and control measures for COVID-19, like social distancing, performance of the facility infection control and waste hand hygiene, mandatory masking, respiratory hygiene management practices.
and environmental cleanliness are being adhered to in healthcare facilities and the community.

The committee Each facility generally has an Infection Control Focal with the District Environmental Health Officer (DEHO) and Person who is trained in IPC and waste management.
District IPC Focal Person conduct monthly inspections in Together with the MoHCC EHSD, this Infection Control public areas, raise awareness and educate the community Focal Person is supervised by the Nursing Department and to reinforce these practices.

The DEHO and District IPC is responsible for ensuring any necessary IPC and waste Focal Person are also responsible for implementing IPC management training of health facility workers (including and waste management in all district healthcare facilities.
of waste handlers known as general hands or cleaners).

At The DEHO reports to the PEHO, and the District IPC Focal each health facility, the EHT are responsible for HCWM in Person reports to the Provincial Nursing Officer.

close collaboration with the facility Infection Control Focal Person.
Provincial Health Executives and DHEs under 66 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID the guidance of Environmental Health Department and The IPC and the EH departments will keep the record of Infection Control Focal Persons take responsibility for day- the trainings and feed to the health information systems to-day management of health care waste.
Infection Control on the number of trained healthcare workers in IPC and Focal Person to ensure that facility has appropriate bins, waste management.

IPC and EH departments are also color coded bin liners and PPE for the waste handlers and responsible for writing training reports.

an on–site or another incinerator is available.


If incinerator is off- site to ensure that it meets all the standards and 4.3 Estimated Training Budget regulatory requirements, and the waste handlers are trained to carry out the job.
The facility should establish an information management system to track and record the waste streams in HCFs and monitor and report on performance, budget and other arrangements for environmental and social risk management related to infection control and medical waste management.

4.2 Trainings Trainings are delivered in every province by the Provincial Environmental Health Officer and Provincial IPC Focal Person.
The province will train the districts and the District Environmental Health Officer, (DEHO) and the District IPC Focal Person will cascade the trainings to the Rural Health Centres (RHCs) and Primary Health Centre (PHCs).

Two training sessions will be conducted during the entire project period.
An estimate budget based on some of the following to be drafted: Trainings on implementation of Infection Prevention and Healthcare Waste Management are planned to be provided l Prevailing costs of goods and services to all healthcare workers, that is from the highest level to l An average number of 20 people from a District /local the lowest level of personnel on orientation, refresher level team, RHCs and PHCs, this number depends on annually and as when there is need.
The District Medical the number of facilities the district has.

Training is Officer (DMO) /Medical –Superintendent, IPC Focal Person to be standard across the board for example 2-day or facility manager will be leading in the implementation of Integrated IPC and Case management training for this ICWMP at the facility level.
Each facility EHT and IPC Focal COVID-19 for professional HCW and 1 day training for Person will lead in the development and implementation the ancillary staff which includes the cleaners.

of facility-specific ICWMP which will have many of the basic l The length of training sessions will depend on the elements of the EMA required waste management plan.
course and will vary from 3 days to about 2 weeks, l The estimated costs include training costs/fees, hire of The MOHCC, EHD and Nursing Directorate Infection Control rooms, food for participants, per diems, and transport Department are responsible for training healthcare workers costs.
Training subsistence allowances have been on infection prevention and healthcare waste management estimated at US $10.00 per participant per day while a at provincial level through the Provincial Environmental lump sum of US $6 000.00 has been included for each Health Officer (PEHO) and Provincial IPC Department.

training session to cover the costs of the trainer.
The PEHO and IPC Department are responsible for training Trainings will be conducted on facilities targeted by the districts and the districts will cascade training to urban and project, Physicians, other medical staff and managers rural healthcare facilities.

must be made aware of waste generation and associated hazards.

Estimated budget for trainings are US $25 000.
67 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Table 4-1: ICWMP Suggested Training Topics Awareness of HCFs on ICWMP Segregation of waste Use of color-coded bins and labelling of waste bags Handling and collection of waste Storage of waste Transportation of waste Disposal of waste Management of spills Monitoring and evaluation PPE use, types, donning and doffing Functions of an incinerator 68 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID CHAPTER 05 69 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 5.
Monitoring and Reporting Facilities will be expected to conduct regular testing, monitoring and reporting of required parameters on a regular basis as part of their ICWMPs.

Each HCF generally has an Infection Control Focal Person responsible for monitoring and reporting IPC and waste management practices monthly, quarterly, and annually.
Observation of segregation of waste in all departments within a healthcare facility and recording those who are not complying, and reinforcement of practices are regular parts of a facility’s operation.

Auditing of infection control and waste management practices must be done to improve practices.

Weighing of waste should be done to monitor amount of waste generated per healthcare facility.
HCFs should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities.

HCFs are to be encouraged to develop an information technology (IT)-based information management system should their technical and financial capacity allow.
Zimbabwe emission standards are regulated by the sources is recommended prior to commissioning as a Environmental Management Agency SI.72 of 2009 minimum and preferably every quarter thereafter.

Sampling (Atmospheric Pollution Control) Regulation 2009.

These frequencies are usually based on the population served or standards are monitored by the Standards Association of on the volume of water supplied, to reflect the increased Zimbabwe (SAZ) which test the air to assess the amount of population risk.
Frequency of testing for individual pollutants.

characteristics will also depend on variability.

Sampling and analysis are required most frequently for microbial and Potable water provided in project health facilities is already less often for chemical constituents.

However ad hoc water required to be monitored to ensure its safety.

Additionally, samples can be collected for analysis if there is need.
Usual some health facilities, especially in rural areas, may use practice during water quality monitoring is to include the septic tanks.

Since surrounding communities may use critical parameters for microbial quality (normally E. coli, ground water, it is important to ensure communities are chlorine, turbidity and pH) and for a sanitary inspection safe from contamination of ground water that could come to be carried out.
Methods for these tests must be from ground seepage or contamination of surface water standardized and approved.

It is recommended that field from septic system problems.

Periodic testing and sanitary test kits be validated for performance against reference or inspection of health facility and community drinking-water standard methods and approved for use in water quality supplies will be undertaken by the by MOHCC and other testing.
agencies such as EMA and SAZ to assess microbial hazards and known problem chemicals.

Water quality monitoring 5.1 Indicators to be Monitored is conducted in accordance with the Public Health Act, the Environmental Management Act, the Water Act and WHO Guidelines for Drinking Water.

The quarterly water sampling programme ensures that the MOHCC EHT visits each facility and tests the drinking water at least once every quarter.

Government Analyst laboratories analyse the samples for quality assurance.
EMA also conducts water testing as part of their routine surveillance or monitoring for environmental pollution.

Comprehensive analysis of the chemical quality of all 1.

Agreed upon, functioning ICWMP 2.

Availability of waste management supplies and equipment i.e.

pedal operated bins, color coded bin liners, incinerator otto-way pit, bottle crusher and well fenced waste management area 3.
Availability of color-coded bins, bin liners and foot operated pedal bins with lids or bins with wheels available on the wards and departments 4.

Availability of waste management material resources, appropriate PPE for waste handlers i.e.
helmet, heat 70 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID resistant goggles, heavy duty gloves, heat resistant district hospitals or 0.03 kg/patient per day for health gloves heat resistant apron, N-95 masks and surgical centres and dispensaries.

masks 5.

Availability of wheeled bins or wheeled trolleys Weighing of healthcare waste is key in waste management 6.
Number of HCW trained in Infection Prevention and as the information generated will enable authorities to Control and Waste Management (IPC&WM) assess if waste segregation at source is being implemented 7.

Number of meetings held on IPC&WM and if they want to build an incinerator, the data will assist 8.

Frequency of meetings in IPC &WM on determining the size of incinerator required.

9.
9.

Availability of surveillance systems for Healthcare Associated Infections (HAI) due to healthcare waste 5.4 Reporting management practices 10.

Number of needle stick injuries from healthcare waste management 11.

Air emissions from incinerator (Number of HCF incinerators meeting emission standards) as necessary 12.

Facility incinerator licenced 13.

Safety of water quality for any drinking water provided in facility 14.

Safety of water in nearby communities of healthcare facilities on septic tanks.
5.2 Records The PIE Environmental Specialist will also compile relevant performance and compliance data on all participating facilities providing guidance as necessary to facilities.

The Environmental Specialist, in coordination with any other necessary parties, will report on ICWMP implementation, compliance and other relevant project performance matters to the PIE as required and to the World Bank on a biannual basis.
All accidents, fatalities and incidents are to be reported to the Bank within 48 hours after learning of them.

Facilities must register with EMA as waste generators and i.

Training records on waste management and disposal.

thereafter, submit reports on waste management to EMA ii.

Reports on routine IPC rounds checking on waste on an annual basis as required by Statutory Instruments 6 segregation.

and 10, both of 2007.

EMA will also submit an annual report iii.


Costs for waste disposal materials and for occupational to the Environmental Health Department on facilities health activities such as needle stick injuries and post performance on healthcare waste management.

The exposure treatments.

Environmental Health Department to report biannually on iv.

Registers of waste generated and sent for disposal.
performance of facilities on healthcare waste management v. Summaries (minutes) from any public consultations to the Ministry of Health and Child Care (MOHCC).

held for the projects.
5.3 Estimating Amount of Health Care Waste Generated Per Facility 5.5 Implementation of Infection Control and Waste Management Plan (ICWMP) Assess your facility: l Number of wards, or department or offices l Number of beds per wards l Distance from central storage place l Number of staffs or health workers l Amount of waste generated per day To establish the amount of waste generated per day, At the national level, the HCWMP, which is being updated, is part of the Government’s Environmental Health Strategy, of which this is an important component.
Implementation will be coordinated by the EHD of the MOHCC, in collaboration with other stakeholders (NIPCC, EMA, Ministry of Local Government and Public Works) who will participate in a range of activities – from implementation to supervision.

Trainings and awareness are some of the activities which will be executed, and each facility will come up with its own multiply the generation rate factor (0.41 kg/occupied bed budget.
per day) by the number of beds for referral, regional and 71 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Table 5-1: Infection Control and Waste Management Plan Timing Objective Timing/Period Responsible Party Orientation to institutional and legal At the beginning of the program (first PIE in collaboration with MOHCC/EHD framework year) Planning activities for IPC and waste At the beginning of the program MOHCC in collaboration with PIE management Implementation of Infection Control Continuous and Waste Management plan at health facility Control and follow up of the execution of infection Control and Waste Management Plan activities at healthcare facilities Daily Monthly Yearly Nursing Services Department Environmental Specialist MOHCC in collaboration with PIE Environmental Specialist/ Health Care facilities Health facilities IPC Focal Persons PEHO/Provincial IPC focal Person/ Environmental Specialist MOHCC /PEHO, Provincial IPC focal Person/PIE Environmental Specialist Training At the beginning of the project and MOHCC/EHD/Nursing services every quarter Department /PIE Environmental Awareness Biannually Specialist MOHCCEHD/Nursing Services /PIE Environmental Specialist and NGOs, CBOs Supervision Quarterly MOHCC/EHD/Nursing Services Department Evaluation of the ICWMP After 2 years MOHCC EHD/ Nursing Services in At the end of the 5th year MOHCC/EHD in collaboration with PIE Environmental Specialist collaboration with PIE The PIE will work in collaboration with the MOHCC to implement the ICWMP.
Below is the estimated budget for implementation.

72 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Table 5-2: Estimated Implementation Budget (Thousands of USD) Activity Printing of Documents (ICWMP) Amount $10 Training (i.e.
Venue, Conference Packages for the $25 Participants, Facilitators Fees and Per Diems for Facilitators 6 Participants Per Districts for 20 Districts @US$75 Per 450 Copies @US$10 Each for 450 Facilities Total US$4500 and Participants) IEC Material Development Participants Per Day (Lunch, Supper, Breakfast, Incidental, Conference Facility, Transport, Facilitator Fees,) for 4 days Total US$27000 $5US 30 Participants @US$75 Per Participants Per Day (Lunch Supper, Breakfast, Incidental, Conference Facility, Transport, Facilitator Fees,) for 3 Days IEC Material Printing and Distribution Total Total US$9000 5000 copies @US$0.40 Total US$2000 US$38000 73 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) CHAPTER 06 74 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 6.
Consultations 6.1 Field Visits A situational analysis was conducted to assess the national status with respect to infection control and waste management by visiting select health care facilities.

Stake holder mapping was carried out and a list of key informants was developed to facilitate the extraction of information that would be useful for the development of this ICWMP.

Face- to-face focus group discussion and online interviews were completed from the 10-30th of September 2020.
Also, some online interviews with other non-governmental organisations like OXFAM and a service provider who manufactures incinerators, FENCRAFT, were completed and they gave their input to the development of this ICWMP.
A March 2016 independent assessment, Review of the South (provincial, district hospitals, and rural health Implementation of the Health Care Waste Management centre Plan in 18 Rural Districts under the Results Based Financing l 2 metropolitan cities Harare and Bulawayo isolation Programme in Zimbabwe found that HSDSP brought about facilities and urban clinics.
an improvement in participating facility waste management, However, this ICWMP review of project facilities in 2020 revealed that there has been a deterioration in the management of health care waste in facilities as evidenced by broken down incinerators and an inadequate supply of bins and bin liners.

During the assessment it was that 90% of the facilities visited had no functional incinerators and segregation of waste is not being achieved due to inadequate supply of bins and bin liners.
There are no waste storage areas in 75% of facilities visited, and those that have the storage area it is inadequate.

It was also observed that there is shortage of vehicles to transport waste to its final disposal.

6.2 Sampling 6.3 Data Collection Key informants were met through the Provincial Development Committee (PDC) at provincial level and the District Development Committee (DDC) at district level.
Interviews in all the provinces and districts were held as focus group discussions and the consultants were assessing the following: (see question guide Appendix 1) 1.

Current situation and gaps on infection prevention and control (IPC), waste management and COVID-19 2.

Waste management infrastructure supplies i.e.

functional incinerators, size of the incinerator, provision of waste receptacles and supply of colour Healthcare facilities of different categories were selected coded bin liners.
for assessment on infection control and health care management practices.

The healthcare facilities selected 3.

Availability of PPEs, hand washing facilities, supply of were those which are being supported by the Results Based detergents and disinfectants, waste management Funding under the HSDSP AF-V.

These were as follows: supplies l l 2 central hospitals one in Harare and one in Bulawayo 4.
Capacity building of all healthcare workers on IPC and 2 provinces Mashonaland East and Matabeleland waste management 75 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 5.

Isolation and quarantine facilities in view of COVID-19 the MOHCC and its stakeholders.

During the workshop, the 6.

Management of healthcare waste in view of home ensures that feedback from the initial consultations was draft instruments were reviewed and critiqued.
This also the ESMF and ICWMP are in line with the expectations of isolation incorporated in the documents.

The Programme of activity for the ESMF and ICWMP Validation Workshop (Agenda) 7.

Over and above interviews, site visits were done and the list of participants are appendices 7 and 8.
Thirty to assess the situation on the ground and a participants from MoHCC departments were invited questionnaire on waste management practice was including: Environmental Health, Nursing Services, Quality, administered at facility level (see Appendix 2).
Monitoring and Evaluation, Communication, Ministry of 6.4 Composition of the PDC l Provincial Development Coordinator l Ministry of Local Government, National Housing and Public works l Ministry of Public Services Labour and Social Welfare l l l l l l Environmental Management Agency (EMA) Provincial Pharmacist Provincial Medical Officer Provincial Nursing Officer Provincial IPC Focal Person Provincial Environmental Officer 6.5 Composition of the DDC l District Development Coordinator l District Environmental Officer l District Medical Officer l District Nursing Officer l District IPC Coordinator l District Administrator l Ministry of Local Government and Social Works at district level l Ministry of Labour and Social Welfare at district level The interviews showed that all ministries are working together as a team in the development of their provinces and districts.
6.6 Validation Workshop for the ESMF and ICWMP Local Government and Public Works, EMA, CORDAID and the two consultants to present the ESMF and ICWMP.

On the first day the ESMF was validated and the ICWMP on the second day.

The consultants presented an overview of each instrument.

Then participants were divided into four groups and each group was allocated some chapters to review.

Afterwards, each group presented their findings.


The consultants finally presented a summary of what came out of the review/validation.

For the ICWMP, the proposed changes and comments are in Appendix 7.

The feedback from the consultation process resulted in minor changes to the ICWMP.
However, a significant change was noted under Emergency Preparedness and Response where the group felt that there is need to add a section on Fire Management since fires can be an emergency in health care settings due to electricity, old buildings and incinerators.

the validation process sharpened the document to make it more specific.

The feedback from participants made some sections of the document clearer.
In addition, MOHCC became enlightened about the ICWMP and it requirements and that assisted to get a buy from MOHCC to own the document.

6.7 Risk Communication The infectious nature of healthcare facility waste and hazardous nature of other items such as reagents, means that it is important to keep project implementation staff, communities and any others who come in contact with potentially dangerous materials informed of potential risks.
All waste handlers and transporters will be informed of the nature and risks involved with the waste they will be managing to be part of their training and orientation.
Those A validation workshop for the ESMF and ICWMP was held in laboratories and other places coming into contact with at Mazowe Hotel on 7-8 June 2021 in order to ensure that reagents and radiological materials will also be informed of 76 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID the risks associated with the hazardous items.

The need 6.8 Consultations During Project for proper labelling has been elaborated throughout this ICWMP.
When possible, or in some cases as necessary, appropriate signage indicating the presence and location of dangerous materials should be displayed.

Similarly, project affected peoples (PAPs) should also be advised of risks to their health and well-being during project consultations.

Implementation It will be good practice to continue to hold consultations with stakeholders and any PAPs as needed at key times during project implementation.
This will ensure that PAP concerns are considered and addressed as necessary throughout the project.

77 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) CHAPTER 07 78 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 7.
Disclosure To meet the consultation and disclosure requirements of the Bank, once MOHCC has approved the ICWMP, the Government of Zimbabwe (GoZ) will issue a disclosure letter to inform the Bank of (i) The Government’s approval of the ICWMP; (ii) The completed disclosure of these documents to all relevant stakeholders and potentially affected persons in Zimbabwe, and (iii) The Government’s authorization to the Bank to disclose the ICWMP on its website.
Ordinarily, disclosure of the safeguard documents must be completed prior to appraisal of a Project as per the Bank’s Disclosure Policy OP 17.50 however, since this is an emergency project, the disclosure of this ICWMP was deferred to after project effectiveness.

This ICWMP and other future safeguards instruments for the project will be disclosed both in- country and by the World Bank, in English.
In country, the safeguards instruments will be disclosed both on the MoHCC website (http://mohcc.gov.zw) and CORDAID website as well as the project website.

Project web address will be provided when it is available 79 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) CHAPTER 08 80 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 8.
Conclusion and Recommendations Field visits undertaken for the development of this ICWMP revealed that there is a massive deterioration of healthcare waste management in healthcare facilities as evidenced by broken down incinerators, inadequate supply of bins and bin liners.

Ninety percent of the facilities visited had no functional incinerators and segregation of waste not being achieved due to inadequate supply of bins and bin liners.
There are no waste storage areas in 75% of facilities visited and those that have them are inadequate in terms of size.

It was also observed that there is a lack of vehicles to transport waste to its final disposal.

It is a requirement that each facility have a dedicated vehicle to transport waste to the disposal area.

That dedicated vehicle is not to be used for carrying kitchen supplies, clean linen or pharmacy supplies.
There is critical shortage of water supply in 75-80% 8.1 Recommendations and Lessons healthcare facilities compromising most IPC practices which include hand hygiene, environmental cleanliness and Learnt supply clean linen.

With COVID -19 pandemic there is need for isolation facilities with appropriate equipment and these facilities need proper donning and doffing area to reduce healthcare worker contamination.
It has been noted that refurbishment of the 95% isolation facilities visited were almost completed, but due to lack of funding they have come to a halt.

The 5% left includes piping of oxygen, equipment for room loading e.g.

beds, ventilators, monitors, etc.

PPE is inadequate in all healthcare facilities visited, therefore the project will supply it for project related activities.
Laboratories which are conducting COVID -19 testing have a critical shortage of reagents and cartridges affecting the turnaround times of the results.

The biosafety cabinets need to be refurbished.

On capacity building, 50% of healthcare worker in healthcare facilities visited have been trained on IPC and COVID-19.

There is need for funding to train the remaining 50%.

Almost 95% of facilities visited had dilapidated laundry and mortuaries resulting in overcrowding of fast decomposing bodies.
Despite these challenges, this ICWMP lays out the expected standards and practices for proper IPC and medical waste management.

For the effective Infection Control and Waste Management the following is recommended: 1.

Given the challenges faced by all health care facilities, devise project-wide solutions for proper waste management.

2.
2.

Communities and Health Care Facilities will be encouraged to use their subsidies and any other possible funding from the project to invest in required health care waste management infrastructure.

Some facilities under previous iterations of the project have done this.

3.
3.

Refurbish all the incinerators in the central, provincial and districts hospitals to standard conditions so as to reach temperatures above 800 degrees Celsius, installation of burners in small rural healthcare centres and clinics and assist in procurement of pedal operated bins and color-coded bin liners.

4.

Rehabilitation of boreholes and the infrastructure that supply healthcare facilities with clean water.

5.
5.

Completing the refurbishment of the isolation facilities, procurement of required equipment for these to be functional.

6.

Provision of adequate PPE.

If the project has difficulties with obtaining necessary PPE, World Bank Procurement 81 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) will be consulted for possible solutions.

mortuaries are not project activities, but dirty linens and 7.
Procurement of reagent and cartridges to improve the bodies may results (even inadvertently) from project turnaround times of COVID-19 results.

activities.

Since most of laundries and mortuaries 8.

Assistance with funding for capacity building of consider financing repair, new equipment/facilities or are old and not functioning well, the project should healthcare worker so that they will be well-versed other solutions if possible.
on how to handle traditional waste and waste from COVID-19 isolation and quarantine centres.

It is important to note that each facility will be required to develop an acceptable facility level ICWMP before receiving 9.

Rehabilitation or refurbishment of laundries and funding from HSDSP AF V. 82 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID CHAPTER 09 83 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 9.

References 1.
References 1.

Government of Angola (2019), Environmental and Social Management Framework (ESMF) for Additional Finance, Luanda, Angola.

2.

Government of Angola (2019), Health Care Waste Management Plan (HCWMP) for Additional Finance (2019), Luanda, Angola.

3.

IFC (2007); Environmental, Health, and Safety (EHS) Guidelines, General EHS Guidelines, International Finance Corporation (IFC), World Bank Group, April 30, 2007, Washington DC.
USA.https://www.ifc.org/wps/wcm/connect/topics_ext_content/ ifc_external_corporate_site/sustainability-at-ifc/policies-standards/ehs-guidelines 4.

MOHCC (2019), National Infection Prevention and Control Guidelines, Zimbabwe, November 2019, second edition (pp 40-45).

5.

MOHCC (2011), National Healthcare Waste Management Plan for Zimbabwe 2011 6. WHO (2017), Safe management of wastes from health-care activities: a Summary.

Geneva, Switzerland, (https://apps.


who.int/iris/handle/10665/259491, accessed 3 March (2020).

7.

World Bank (2018), Environmental and Social Framework for IPF Operations, ESS4: Community Health and Safety, World Bank Group, Washington DC 8. WHO (2016), Guidelines on Core Components of Infection Prevention and Control Programmes at National and Acute Health Care Facility Level, Geneva, Switzerland.
84 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID CHAPTER 10 85 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 10.

Appendices Appendix 1: Standard Operating Procedure for Waste Management Procedure No.

SOP: Waste Management Prepared By Date Adopted Version Infection Control specialist Chipo Gwayagwaya Prepared By Date Approved New Procedure Signature Stamp 1.0 Purpose To prevent health and environmental hazards associated with healthcare waste.
The health hazards include injuries from sharps, exposure to hazardous chemicals and healthcare associated infections.

Patients, healthcare workers, visitors and the general public may all be exposed to the effects of poor waste management practices in health care settings.

Environmental risks include air, water and soil contamination resulting from improper treatment and disposal of healthcare waste.
2.0 Scope This procedure applies to all health workers at all public, private or mission health care facilities including COVID-19 designated isolation facilities 3.0 Responsibility Charge-nurses, Nurse Managers, Domestic Services Managers, Heads of Departments and IPC team 4.0 Definitions Infectious waste – Is waste known or suspected to contain pathogens and pose a risk of disease transmission, e.g.
clinical or laboratory waste from COVID-19 isolation units or care areas such as respiratory specimens or excreta of COVID-19 patients, that may contain the COVID-19 virus; Pathological waste – incudes human tissues, organs or fluids e.g.
body parts and foetuses 86 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Sharps –all objects and materials with puncture or cutting properties such as all types of needles, syringes, scalpel blades, razors, broken glass, ampoules, specimen tubes, and other similar material.
Chemical waste – includes solid, liquid, or gaseous chemicals such laboratory reagents; film developer; disinfectants that are expired or no longer needed; solvents; waste with high content of heavy metals such as thermometers and blood pressure gauges.

Pharmaceutical waste – this includes expired or partly used medications of all kinds, as well as residuals of drugs used in chemotherapy that may be toxic, genotoxic, mutagenic teratogenic or carcinogenic.
Items contaminated by pharmaceuticals or empty pharmaceutical bottles or boxes.

Radioactive waste – any solid, liquid, pathological waste contaminated with radioactive isotopes of any kind, urine or excreta from patients treated or tested with unsealed radionuclides.

General waste – all waste that does not contain hazardous (clinical, infectious, chemical or radioactive) waste types e.g.

office paper, boxes and empty food packages.


In COVID-19 management, such waste is considered infectious because the virus can stay on surfaces such as plastic and be transmitted via contact 5.0 REQUIREMENTS i. Bins ii.

Red bin liners iii.

Biohazard labels iv.

Puncture proof sharps containers v. Transport (internal and external): carts, trolleys; truck(s) vi.
PPE for waste handlers (heavy duty gloves and plastic aprons, heat resistant gloves and aprons, boots or safety shoes, goggles or face shield) 6.0 PROCEDURES FOR WASTE MANAGEMENT a.

Waste minimization i.

Plan and prepare adequately for any activities in advance to avoid wastage ii.

Limit the number of personnel working in the Isolation or COVID-19 patient care areas b.
Waste segregation i. Segregate waste at the point of generation (ward bedside, Operation Theatre, Laboratory, or any other room or ward in the hospital where waste is generated) by placing in the appropriate colour coded bag (red bag for infectious waste) or sharps’ container.

Never attempt to sort waste once it has been placed in a waste bag.

c. Waste treatment i.


If autoclave dedicated for waste is available, autoclave laboratory waste (tissues and specimens) that is directly associated with specimen processing before disposal into red bin liners.

If autoclaving is not feasible, double bag before transporting for final disposal.

87 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) d. Waste storage i.

Avoid storing waste in the COVID-19 care areas.

ii.

Seal bags when they are 3/4 full and send immediately for incineration.
If immediate disposal is not feasible, store in a secure room.

Bags of waste to be stored for not more than 48hrs.

iii.

Store clinical and general waste separately iv.

Develop a schedule for waste collection based on waste load generated.

Filled waste bags should not be kept in the COVID-19 care areas for more than 12 hours.

N.B.
N.B.

: All personnel handling health care waste should wear appropriate PPE (boots, apron, long-sleeved gown, thick heavy duty gloves, mask, and goggles or a face shield) and perform hand hygiene after handling the wastes.

Health workers should be conscious of the risk of splashes or sprays whenever handling of waste.
e. Waste transportation Waste should be labeled, whoever receives or collects the waste must ensure that this is done and should be empowered to alert designated parties if it is not completed.

On-site transport i.

Do not carry filled waste bags or sharps containers directly against the body.

Lift waste bags or sharps containers onto a waste designated trolley or cart.

Trollies and carts must be easy to load and unload, have no sharp edges that could damage waste bags or containers and easy to clean ii.
Collection of waste must follow specific routes through the facility to reduce the passage of loaded carts through wards and other clean areas.

iii.

Collect and transport clinical and general waste separately.

iv.

Transport to the incinerator or waste collection holding area on the trolley or cart and clean.

f. External transport i.

Establish the final disposal site for any waste generated if it is to be moved off-site.

Use a registered transporter if not using your own (out-sourcing).

ii.
ii.

The waste collected should be properly documented and the transporter must carry a consignment note iii.

Vehicle must not be used to carry other items.

The vehicle must be free of sharp edges, easy to load and unload by hand, easy to clean / disinfect, and fully enclosed to prevent any spillage in the hospital premises or on the road during transportation iv.

Transport domestic waste separately from the infectious waste.

N.B.
N.B.

The waste should be transported in two bin liners (leak proof 100-micron).

Seal the first bag carrying the waste and place in a second bin liner and seal for transportation to final disposal site.

Perform Hand Hygiene.

g. Final treatment and disposal i. Disinfect body fluids and excreta of infected patients with hazardous communicable diseases before discharging to the sewerage system with 2% Sodium hypochlorite ii.
Prioritize waste incineration from COVID-19 care areas before the other clinical waste.

iii.

Dispose ash from the incinerator into a designated ash pit 88 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 7.0 General Guidance on Waste Handling and Infrastructure a.

Waste Storage Areas i.

Storage Location A HCF should have multiple waste storage areas designed for different types of wastes if possible.

Their functions and sizes are determined at design stage.
The waste management and collection system for COVID-19 response in principle has the designation of at least 2 waste storage locations.

One temporary storage/collection location that is within/or close to the isolation unit (high-risk area) and second one within the general Waste Zone of the Healthcare facility.

All waste storage locations should be always locked and accessible uniquely to authorized personnel: ii.
Waste Storage (1/2): A dedicated space (preferably dry and ventilated) needs to be defined in each area dealing with suspected/confirmed cases to temporarily store waste before collection by waste officer.

Choose a space just outside the isolation unit to avoid the waste collection staff entering isolation area.

Waste Storage (2/2): Dedicated space for holding COVID-19 waste inside the waste zone before final disposal/destruction should be dry and well ventilated.
The space must have enough capacity to store 1 day waste to ensure that programmed separated disposals are possible without mixing with the regular activities ’waste.

8.0 Cleaning and disinfection of storage area All waste collections should be completed with cleaning/disinfecting of the storage area.

Existing reports suggest that during the COVID-19 outbreak, infectious wastes should be removed from an HCF’s storage area for disposal within 24 hours.

Facilities for hand washing should be available.


9.0 Waste collection 9.1 Scheduled collection All waste collected from locations dealing with suspected/confirmed COVID-19 cases should be transferred to the designated waste storage area (2/2) inside the Waste zone.

In order to facilitate the collection, the location should be equipped with designated bins with labels, preferably with wheels for facilitating the transportation.
Medical staff/cleaning staff inside the Isolation unit (high risk zone) is responsible for ensuring the transfer of all bins from the high risk zone to the designated area just outside the isolation for the collection by the waste management team.

9.2 Transportation It is highly recommended to use separate (from the other services) vehicles/trolleys and transportation equipment for the waste collection from the isolation unit and/or any other services related to the suspected/confirmed cases of COVID-19.
Upon the reception of the waste bins from the isolation unit, all contaminated waste should be loaded and transferred immediately to the dedicated location in the waste zone.

Transportation means (trolley, vehicle etc.)

and equipment should be disinfected immediately after every transport (see: SOP on Cleaning and disinfection of equipment).
89 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) If the waste zone is just next to the isolation facility and there is no crossing of other work flows, then no trolley/vehicle is required to transport the waste, as well as no two bin liner system is required for the safe transport of the waste.

9.3 Other protective measures for Health workers and the environment i.

Ensure facilities to enable personal hygiene for waste handlers are available e.g.

change rooms, showers and hand washing facilities.


ii.

Waste handlers must be immunized against Hepatitis B and tetanus.

iii.

Waste handlers must wear the following personal protective clothing: b.
Suitable heavy-duty gloves when handling HCW containers; c. Safety shoes or industrial boots to protect the feet against the risk of containers being accidentally dropped; d. Industrial apron or leg protectors when handling containers which could cause wounds e. visors / face masks and eye protection (especially for cleaning of hazardous spills), f. and respirators (for spills or waste involving toxic dust or incinerator residue) as necessary iv.
All health workers must be trained on their roles and responsibilities regarding health care waste management, trainings to be done annually and on orientation of new staff.

v. Healthcare workers must be aware of procedures to follow should they encounter an injury or body fluid exposure in the process of handling waste.

9.4 Performance indicators i.

Waste Management Policy to be available in wards/departments.

Isolation and quarantine centres.

ii.


Color-coded and foot operated pedal bins with lids or bins with wheels to be available on the wards and departments.

iii.

100% availability of waste management material resources-bin liners, appropriate PPE iv.

Availability of wheeled trolleys, containers or carts that are not used for any other purpose.

v. training sessions vi.

Rate of nosocomial infection vii.

Number of injuries from health care waste management viii.
Number of incinerators constructed properly 9.5 Records i.

Training records on waste management and disposal.

ii.

Reports on routine IPC rounds checking on waste segregation.

iii.

Costs for waste disposal materials and for occupational health activities such as needle stick injuries and post exposure treatments.

iv.

Registers of waste generated and sent for disposal v. Complaints and their resolution vi.
Accidents and fatalities 90 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Appendix 2: Infection Control and Waste Management Plan Timeline and Reporting for MOHCC Infection control and waste management plan and reporting Objective Timing/Period Responsible Parties Awareness of the project ICWMP At the beginning of the program (first MOHCC/EHD in collaboration with PIE year) Planning activities for IPC and waste At the beginning of the program MOHCC, Nursing Services Department management IPC FP Approved Medical Waste Management Before infectious waste generating Each participating facility to generate; Plan for each HCF project activities begin PIE/Environmental Specialist to provide guidance, review and clear Implementation of Infection Control Continuous MOHCC /Healthcare Facility IPC Focal and Waste Management plan at health facility Control and follow up of the execution of infection Control and Waste Management Plan activities at healthcare facilities Daily Monthly Yearly Person Health facilities PEHD/Provincial IPC focal Person/ Environmental Specialist Implementation: PEHD, Provincial IPC focal Person/MOHCC/ Monitoring: PIE Environmental Specialist Training Awareness Supervision Every quarter PEHD/Nursing services Department Biannually Quarterly MOHCC PEHD/Nursing Services MOHCC and NGOs, CBOs PEHD/Nursing Services Department MOHCC Evaluation of facility Medical Waste annually MOHCC/EHD/Nursing Services Management Plan PIE Environmental Specialist 91 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Appendix 3: Facility Medical Waste Management Plan Template An Infection Control Prevention and Health Care Waste Management System adequate for the scale and type of activities and identified hazards will be developed for each project HCF.
Medical Waste Management Plan 1.

Introduction 1.1 Describe the project context and components 1.2 Describe the targeted healthcare facility (HCF): - - - - - Type: E.g.

general hospital, clinics, inpatient/outpatient facility, medical laboratory, quarantine or isolation centers; Special type of HCF in response to COVID-19: E.g.

existing assets may be acquired to hold yet-to-confirm cases for medical observation or isolation; Functions and requirement for the level infection control, e.g.
biosafety levels; Location and associated facilities, including access, water supply, power supply; Capacity: beds 1.3 Describe the design requirements of the HCF, which may include specifications for general design and safety, separation of wards, heating, ventilation and air conditioning (HVAC), autoclave, and waste management facilities.

2.
2.

Infection Control and Waste Management 2.1 Overview of infection control and waste management in the HCF - Type, source and volume of healthcare waste (HCW) generated in the HCF, including solid, liquid and air emissions (if significant) - Classify and quantify the HCW (infectious waste, pathological waste, sharps, liquid and non-hazardous) following WBG EHS Guidelines for Healthcare Facilities and pertaining GIIP.
- Given the infectious nature of the novel coronavirus, some wastes that are traditionally classified as non-hazardous may be considered hazardous.

It’s likely the volume of waste will increase considerably given the number of admitted patients during COVID-19 outbreak.

Special attention should be given to the identification, classification and quantification of the healthcare wastes.
- Describe the healthcare waste management system in the HCF, including material delivery, waste generation, handling, disinfection and sterilization, collection, storage, transport, and disposal and treatment works Provide a flow chart of waste streams in the HCF if available Describe applicable performance levels and/or standards Describe institutional arrangement, roles and responsibilities in the HCF for infection control and waste management - - - 92 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 2.2 Management Measures - Waste minimization, reuse and recycling: HCF should consider practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety considerations.
- Delivery and storage of specimen, samples, reagents, pharmaceuticals and medical supplies: HCF should adopt practice and procedures to minimize risks associated with delivering, receiving and storage of hazardous medical goods.

- Waste segregation, packaging, color coding and labeling: HCF should strictly conduct waste segregation at the point of generation.

Internationally adopted method for packaging, color coding and labeling the wastes should be followed.
- Onsite collection and transport: HCF should adopt practices and procedures to timely remove properly packaged and labelled wastes using designated trolleys/carts and routes.

Disinfection of pertaining tools and spaces should be routinely conducted.

Hygiene and safety of involved supporting medical workers such as cleaners should be ensured.

- Waste storage: A HCF should have multiple waste storage areas designed for different types of wastes.

Their functions and sizes are determined at design stage.
Proper maintenance and disinfection of the storage areas should be carried out.

Existing reports suggest that during the COVID-19 outbreak, infectious wastes should be removed from HCF’s storage area for disposal within 24 hours.

- Onsite waste treatment and disposal (e.g.

an incinerator): Many HCFs have their own waste incineration facilities installed onsite.
Due diligence of an existing incinerator should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity.

Detail the source of the incinerator’s power.

If charcoal or wood, detail where that wood is extracted from or obtained.

This project does not permit wood or charcoal extraction from protected areas, forests, national parks or any fragile or sensitive ecosystems.

In case any gaps are discovered, corrective measures should be recommended.
Although there will not be any new construction of HCF under the project, a new HCF would require waste disposal facilities to be integrated into the overall design and ESIA developed.

Good design, operational practices and internationally adopted emission standards for healthcare waste incinerators can be found in pertaining EHS Guidelines and GIIP.

- Transportation and disposal at offsite waste management facilities: Not all HCF has adequate or well-performed incinerator onsite.
Not all healthcare wastes are suitable for incineration.

An onsite incinerator produces residuals after incineration.

Hence offsite waste disposal facilities provided by local government, or the private sector are probably needed.

These offsite waste management facilities may include incinerators, hazardous wastes landfill.
In the same vein, due diligence of such external waste management facilities should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity.

In case any gaps are discovered, corrective measures should be recommended and agreed with the government or the private sector operators.
- Drinking water: Facilities are required to provide drinking water which must be tested on a quarterly basis for critical parameters such as E. coli, chlorine, turbidity and pH.

Sanitary inspections are also carried out by the MOHCC Environmental Health Technicians.

Facilities are to present the details of their monitoring plan including parameters, frequency and safety levels - Wastewater treatment: HCF infectious wastewater is treated according to hazardous waste management practices.
Proper waste segregation and handling as discussed above should be conducted to minimize entry of solid waste into the wastewater stream.

In case wastewater is discharged into municipal sewer sewerage system, the HCF should ensure that wastewater effluent comply with all applicable permits and standards, and the municipal wastewater treatment plant (WWTP) is capable of handling the type of effluent discharged.
In cases where municipal sewage system is not 93 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) in place, HCF should build and properly operate onsite primary and secondary wastewater treatment works, including disinfection.

Residuals of the onsite wastewater treatment works, such as sludge, should be properly disposed of as well.

There are also cases where HCF wastewater is transported by trucks to a municipal wastewater treatment plant for treatment.
Requirements on safe transportation, due diligence of WWTP in terms of its capacity and performance should be conducted.

If an HCF uses septic tanks for water treatment, and surrounding communities use ground water, that community water should be tested quarterly basis in case the tanks are leaking to detect the possible contamination of community water supplies.
If harmful contamination is detected according to the EHS Guidelines, corrective action must be taken to ensure communities get unpolluted water.

Facilities are to present the details of their monitoring plan to include parameters, frequency and safety levels in this document (that is, the facility-level ICWMP).

3.
3.

Emergency Preparedness and Response Emergency incidents occurring in a HCF may include spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, and fire.

These emergency events are likely to seriously affect medical workers, communities, the HCF’s operation and the environment.
Thus, an Emergency Response Plan (ERP) that is commensurate with the risk levels is recommended to be developed.

The key elements of an ERP are defined in ESS 4 Community Health and Safety (para.

21).

4.

Institutional Arrangements and Capacity Building Clearly defined institutional arrangements, roles and responsibilities should be included.

A training plan with recurring training programs should be developed.
The following aspects are recommended: - - - - - - Define roles and responsibilities along each link of the chain along the cradle-to-crave infection control and waste management process; Ensure adequate and qualified staff are in place, including those in charge of infection control and biosafety and waste management facility operation.
Stress the chief of a HCF takes overall responsibility for infection control and waste management; Involve all relevant departments in a HCF, and build an intra-departmental team to manage, coordinate and regularly review issues and performance; Establish an information management system to track and record the waste streams in HCF; and Capacity building and training should involve medical workers, waste management workers and cleaners.
Third-party waste management service providers should be provided with relevant training as well.

5.

Monitoring and Reporting Many HCFs in developing countries face the challenge of inadequate monitoring and records of healthcare waste streams.

HCF should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities.
The HCF is encouraged to develop an IT based information management system should their technical and financial capacity allow.

As discussed above, the HCF chief takes overall responsibility, leads an intra-departmental team and regularly reviews issues and performance of the infection control and waste management practices in the HCF.

Internal reporting and filing systems should be in place.

Externally, reporting should be conducted per government and World Bank requirements.
94 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Appendix 4: Infection Control and Waste Management Checklist Name of facility.........................................................................................................................................................................................................
Type of facility...........................................................................................................................................................................................................

Bed capacity..............................................................................................................................................................................................................
Categories of waste generated............................................................................................................................................................................

Amount of healthcare waste generated per day.............................................................................................................................................. Standard Yes No Policies and legislation Policies and legislation requirements met Required Licenses/Permits secured?
List here: Minimization of waste Segregation of waste at source Use of color coded bins Bins and sharp tins ¾ full and sealed properly Use of pedal operated bins Labeling of bins Transportation and labeling of waste Designated tools for transportation of labeled waste Use of carts /trolleys/wheelie bins with lids Temporary holding area Biohazard warning sign on the area Secured from scavengers Storage area clean and tidy Cleanable area with concrete Source of water near the temporal holding area Adequate drainage Time waste is kept in the temporal holding area Area well ventilated Disposal of waste On-site incinerator Weighing of waste generated Recording of waste generated 95 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Standard Yes No Off-site incinerator Labeling of waste Weighing of waste Designated vehicle covered Record of waste send for incineration Permit to transport waste (Red Licence) PPE Work suite /scrub suite Heat resistant visor Gown Surgical mask N95 mask Heavy duty heat resistant gloves Heavy duty heat resistant apron Helmet Heat resistant industrial shoes Safety goggles Training Categories of waste Segregation of waste Collection Transport Storage Disposal Personnel Protective Equipment (PPE) Hand Hygiene Incineration and standard temperatures Cleaning of the incineration site and surrounding areas Maintenance of the incinerator Monitoring and evaluation Weighing of waste Recording of waste Designing a waste data base In Facility Drinking Water Results Recorded Community Water Quality Results Recorded 96 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Standard Yes No Occupational health Vaccination Post exposure prophylaxis Reporting of incidence/accident internally and externally Hand Hygiene Basic hand hygiene facility Hand washing Hand sanitizing Budgetary needs Trainings Waste management supplies PPEs Permit and licenses 97 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Appendix 5: Incinerator Operation Checklist And Safety Guidelines Personal protective equipment (PPE) must be selected to protect against risks specific to incinerator operators.
The major risks to these staff are encountered either during direct contact with medical waste or when incinerator operators are exposed to heat or fumes emitted by the incinerator while burning health care waste.

Wearing PPE reduces risk from sharps, germs, exposure to blood and other bodily fluids, splashes from chemicals, inhalation of exhaust, and sparks from the incinerator.
PPE FOR INCINERATOR OPERATORS INCLUDES: Work suit Heat resistant visor Helmet Safety goggles Respirator mask Heavy-duty, heat resistant gloves Heavy duty heat resistant apron Clothes that cover the body Heavy-duty, heat resistant industrial shoes.

INSTRUCTIONS FOR OPERATING THE INCINERATOR The following are key steps that incinerator operators should follow: - Wear personal protective equipment such as helmet, goggles, respirator, overcoat/overalls, heavy-duty gloves, apron, and boots.
Ensure fuel is available for operating the incinerator.

Record the number of safety boxes and bags to be burned.

Clean the incinerator.

Remove the ash and deposit it safely in the ash pit.

The incinerator operator should always: Follow the incinerator operations procedure.

Use protective equipment when handling waste.

Ensure an adequate supply of fuel is available.

Record the weight and type of waste received.

Follow the regular maintenance schedule for incinerator.
- - - - - - - - - - To reduce risk of infection: - Wash hands after working with waste or infected material.

- - - Handle all waste with care to minimize needle stick injury.

Do not sort waste or open waste containers to sort waste.

Know the procedures for treatment of injuries and cleaning of contaminated areas.

SECURITY AT THE WASTE DISPOSAL SITE Entry to the waste disposal site should be restricted.

Keep the incinerator site locked at all times.


- - 98 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID - Do not allow unauthorized persons to enter the incinerator area during periods of incineration.

Immediately report any vandalism, theft, or unauthorized entry to the waste management supervisor.

INCINERATOR MAINTENANCE CHECKLISTS All incineration equipment requires regular service and preventive maintenance.
Unscheduled maintenance is also required in the event of failures.

The provided service schedule should be used and well-trained and qualified technicians are required to regularly visit the incineration sites to inspect and service the equipment.
DAILY MAINTENANCE - - - - - - - The incinerator operator should inspect the incinerator daily and do the following: Check for evidence of cracks on the refractory lining Remove the secondary chamber particulate matter through the ash door Keep the incinerator house floor areas clean and disinfected.

Carefully sweep the area around the incinerator to ensure that all the non-combustible waste is placed in the ash pit.

Clean tools and equipment.


Store safety boxes and other non-infectious health care waste in an orderly manner in the incinerator waste store.

- Maintain fuel stock levels for the incinerator (Coal).

- - Keep tools, records, and protective clothing in the storage room or box provided at the Incinerator.

Immediately report to the waste-management supervisor any damage to the incinerator that affects operation or performance.
WEEKLY MAINTENANCE - - Remove any lumps of melted glass/plastics and clean grates (to improve aeration).

Properly install the grates where required.

- Maintain good housekeeping of the Waste disposal site by clearing the grass around the incinerator house.

- Check the operational responsiveness of all the combustion control equipment - Maintain good house-keeping on the ash pit and its perimeter to comply.
- - Ensure the fencing is intact Check the refractory for evidence of cracking MONTHLY MAINTENANCE - - - - - Ensure the fence of the site is intact.

Check the vertical fixings of the chimney.

Check the refractory and incinerator case for evidence of thermal damage.

Check the ash door for corrosion.

℃ Check the ash door for damaged hinges.

Take an inventory of condition of tools and equipment.

YEARLY MAINTENANCE - - - - Inspect and replace metal parts, refractory and consumable parts where necessary.
Overhaul the incinerator or its components where necessary.

Check the status of the ash pit.

Empty it when full or decommission it.

Perform annual audit/inspection of all the components and equipment.

99 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) - - Report when incinerator is no longer effective and/or the ash pit is full, and take appropriate action Ensure environmental audits and licenses are obtained.
RECORD KEEPING IMPORTANCE OF RECORDS Records help to plan for events and expansion; budgets for the incineration, monitoring, and evaluation of the incineration process; and for organizing waste audits.

RECORDS The following records/tracking documents are: - Waste Incineration Log: This documents the amount of waste incinerated daily and the events (i.e., failure of equipment, accidents/injuries) and records of visitors.

- Supervisor’s checklist.


Responsibility of the operator in recording The operator is responsible for maintaining the records and to ensure that these records are always available for inspection at the site.

Responsibility of the supervisor in recording The supervisor is responsible for ensuring the records are maintained correctly.

The supervisor should also ensure that he/she duly fills in the supervision checklists as required.
100 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID SUPERVISION CHECKLIST Health facility: .........................................................................................

Date: .........................................................................................................
Type of Incinerator:............................................................................... Activity......................................................................................................
Yes No Remarks...................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................
Incinerator licence................................................................................. SAFETY 1.

2.

3.

4.

Is there adequate personal protective equipment (PPE)?

Is the PPE being used?

Is the PPE in good condition?

Is there restricted entry to the waste disposal site?

Is there functional fire safety equipment?

5.

Do the operators know how to use the equipment?

6.

Is there adequate first aid kit?

7.

Are the operators conversant with use of the kit?

8.

9.
8.

9.

Is flammable material stored away from the incinerator?

Is there adequate water at the waste disposal area?

10.

Are warning signs distinctly displayed?
Additional comments on safety: ........................................................................................................................................................................... ....................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................... OPERATION - Is the ash properly disposed into the ash pit?
Are the following tools and equipment available?
- Ash rakes, Shovel, Hand brush/dustpan, hard broom, wheel barrow, weighing scales, fire resistant gloves, eye protection/face mask, overalls or suitable clothing to cover the upper body, including the lower arms and safety first aid kit Additional comments on operation: ...................................................................................................................................................... ............ .......................................................................................................................................... ............................................................................................ ................................................... ................................................................................................................................................................................... Signature of the supervisor 101 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Appendix 6: Establishing a New Healthcare Waste Incinerator in Zimbabwe: Authorization and Licensing Required 1.0.
THE EIA PROCESS According to the EMA Act, it is mandatory for any organization or individual who intends to construct and operate a hazardous waste incinerator to obtain the mandatory environmental authorization’s and licenses that are required to construct and operate the hazardous waste incinerator.

In order to comply with the provisions of the EMA Act as amended, the first stage is for the project proponent to embark on an Environmental impact assessment process as follows: 1.1.
FIRST STAGE: THE PROSPECTUS PHASE The proponent of the project is first required at law to identify potential issues and select the preferred alternatives to focus on in the impact assessment phase.

During this time, interested and affected persons can assist the project proponent by ensuring that all possible impacts of the project are being identified.

The outcome of this phase is the Prospectus Report and Approval from EMA to proceed with the EIA.

1.2.
1.2.

SECOND STAGE: IMPACT ASSESSMENT PHASE At this stage the EMA Act requires that the project proponent engages a registered and EMA approved air quality analysis specialist to carry out detailed studies of potential positive and negative impacts associated with the project.

Findings are then consolidated into the Environmental impact Report and the Environmental Management Report and forwarded to EMA for consideration and approval.

1.3.
1.3.

THIRD STAGE: DECISION MAKING PHASE At this stage, EMA uses the EIA findings to decide if the project should be authorized.

If authorized, EMA will then issue a positive Environmental Authorization with certain conditions covering the incinerator expected performance standards, operation conditions, running test required, waste analysis, monitoring and inspections required.

2.
2.

PERFORMANCE STANDARDS The EMA Act that deals specifically with air pollution control set performance standards which limit the quantity of gaseous emissions an incinerator may release.

Specifically, the regulations set limits on the emission of organics, HCl, and PM.

• ORGANICS To obtain an EMA permit to operate an incinerator, an owner/operator is required to demonstrate that emission levels set for various hazardous organic constituents are not exceeded.
In line with international best practice, the principle measure of incinerator performance is its destruction and removal efficiency (DRE).

A 99.99 percent DRE means that one molecule of an organic compound is released to the air for every 10,000 molecules entering the incinerator.

A 99.9999 percent DRE means that one molecule of an organic compound is released to the air for every one million molecules entering the incinerator.
Since it would be impossible to monitor the DRE results for every organic constituent contained in a waste, certain principal organic hazardous constituents (POHCs) are selected for monitoring and are designated in the permit.

POHCs are selected based on high concentration in the waste feed and difficulty in burning compared to other organic compounds.
For healthcare waste, the main POHCs that are considered are human tissues, sharps, laboratory waste and 102 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID pharmaceutical waste.

If the incinerator achieves the required DRE for the selected POHCs, then it is presumed that the incinerator should achieve the same or better DRE for organic compounds that are easier to incinerate.
In line with best international practice, performance standards require a minimum DRE of 99.99 percent for POHCs designated in the permit and a minimum destruction and removal efficiency of 99.9999 percent for dioxin-bearing wastes.

EMA is yet to mandatorily enforce these provisions.

• HYDROGEN CHLORIDE HCl is an acidic gas that forms when chlorinated organic compounds in hazardous wastes are burned.
In line with international best practice, an incinerator burning hazardous waste is required not to emit more than 1.8 kg of HCl per hour or more than 1 percent of the total HCl in the stack gas prior to entering any pollution control equipment, whichever is larger • PARTICULATE MATTER PM is tiny particles of ash that are carried along with the combustion gases to the incinerator’s stack.
The incinerator regulations control metal emissions through the performance standard for particulates, since metals are often contained in or attached to the particulate matter.

A limit of 180 milligrams of particulate matter per dry standard cubic meter of gas emitted through the stack has been established 3.

OPERATING CONDITIONS The goal of setting operating conditions for hazardous waste incinerators is to ensure compliance with the performance standards discussed above.
(i.e., for organics, HCl, and PM).

Within the permit, the law requires EMA to clearly specify the operating conditions that will have been established in a trial burn to result in the incinerator meeting these performance standards.

A very important aspect of the regulations is that compliance with the operating conditions specified in the permit is deemed to be compliance with the performance standards for organics, HCl, and PM.
The EMA permit for a hazardous waste incinerator will set operating conditions that specify allowable ranges for, and requires continuous monitoring of, certain critical parameters.

Operation within these parameters ensures that combustion is performed in the most protective manner and the performance standards are achieved.
These parameters, or operating conditions, include: l Maximum allowable carbon monoxide levels in stack emissions l Allowable ranges for temperature l Maximum waste feed rates l Combustion gas velocity limits on variations of system design and operating procedures.

At law, the permit requires that, during incinerator the startup and shut down, hazardous waste must not be fed into the unit unless it is operating within the conditions specified in the permit.
The law further stipulates that an incinerator must cease operations when changes in waste feed, incinerator design, or operating conditions exceed limits designated in its permit.

3.1 FUGITIVE EMISSIONS The EMA Act requires incinerator owners to also control fugitive emissions during the operation of the incinerator.
Fugitive emissions are gases that escape from the combustion chamber (for example, gases may escape through the opening where wastes are fed into the combustion chamber) and do not pass through pollution control devices.

Fugitive emission control methods are (1) maintaining negative pressure in the combustion zone so that air will be pulled into the APCD rather than escaping into the ambient air, or (2) totally sealing the combustion chamber so that no emissions can escape to the environment.
103 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 4.

PERMIT PHASES The EMA Act requires an owner/operator wishing to operate a new hazardous waste incinerator to obtain a permit before construction of the unit commences.

The purpose of a hazardous waste incinerator permit is to allow a new hazardous incinerator to establish conditions including, but not limited to, allowable waste feeds and operating conditions that will ensure adequate protection of human health and the environment.
The incinerator permit covers four phases of operation: pre-trial burn, trial burn, post-trial burn, and final operating conditions 4.1.

PRE-TRIAL BURN In line with international best practice, the pre-trial burn phase of the permit allows the incinerator to achieve a state of operational readiness necessary to conduct the trial burn.
The pre-trial burn permit conditions are effective for the minimum time (not to exceed 720 hours) required to bring the incinerator to a point of operational readiness to conduct a trial burn.

This phase is often referred to as the shakedown period.

4.2.

TRIAL BURN The trial burn can be seen as the “test drive” of the incinerator.

It is the time when the owner/operator will bring the unit up to operational readiness, monitor the key operating conditions and measure the emissions.
The trial burn test conditions are based on the operating conditions proposed by the permit applicant in the trial burn plan submitted to EMA for evaluation.

In line with international best practice, EMA is responsible for establishing conditions in the permit necessary to conduct an effective trial burn, meaning that the burn will be representational of the incinerator’s intended day-to-day operation and will yield meaningful data for analysis.
It should be noted that currently in Zimbabwe today, these trial burns are not being mandatorily enforced by EMA although covered in the relevant regulations.

4.3.

POST-TRIAL BURN The post-trial burn period is the time for EMA to evaluate all of the data that was recorded during the incinerators trial burn.
To allow the operation of a hazardous waste incinerator following the completion of the trial burn, EMA is required to establish permit conditions sufficient to ensure that the unit will meet the incinerator performance standards.

This post- trial burn period is limited to the minimum time required to complete the sampling, analysis, data computation of trial burn results, and the submission of these results to EMA.

4.4.
4.4.

FINAL OPERATING CONDITIONS After reviewing the results of the trial burn, EMA will modify the permit conditions again, as necessary, to ensure that the operating conditions of the incinerator are sufficient to ensure compliance with incinerator standards and protection of human health and the environment.

Owners/operators of incinerators are required to comply with the final permit conditions for the duration of the permit, or until the permit is modified.

5.
5.

WASTE ANALYSIS During operation, the owner/operator of an incinerator is required to conduct sufficient waste analyses to verify that the waste feed is within the physical and chemical composition limits specified in the permit.

This analysis may include a determination of a waste’s heat value, viscosity, and content of hazardous constituents, including POHCs.
Waste analysis 104 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID also comprises part of the trial burn permit application.

EMA stresses the importance of proper waste analysis to ensure compliance with emission limits.

6.
MONITORING AND INSPECTIONS The EMA Act requires the owner/operator of an incinerator to perform, at a minimum, the following functions while incinerating hazardous waste: l Monitor the combustion temperature, waste feed rate, and indicator of combustion gas velocity on a continuous basis l Monitor carbon monoxide on a continuous basis at a point downstream of the combustion zone and prior to release into the atmosphere l Sample and analyze the waste and exhaust emissions once every four months to verify that the operating requirements established in the permit achieve the performance standards and submit results to EMA for a review of the permit.
l l Conduct daily visual inspections of the incinerator and associated equipment Record monitoring and inspection data in the operating log.

7.

MANAGEMENT OF RESIDUES According to WHO, if an incinerator burns a listed hazardous waste, the ash is also considered a listed waste.
The derived- from rule states that any solid waste generated from the treatment, storage, or disposal of a listed hazardous waste, including any sludge, spill residue, ash, emission control dust, or leachate, remains a hazardous waste unless and until delisted.

The owner/ operator of a hazardous waste incinerator must manage the residual ash as a hazardous waste.

8.

CLOSURE At closure, the owner/operator must remove all hazardous waste and hazardous.

Residues from the incinerator equipment site.


In addition, as throughout the operating period, if the residue removed from the incinerator is a hazardous waste, the owner or operator becomes a generator of hazardous waste and must manage the residue in accordance with the applicable requirements of the EMA Act.
105 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Appendix 7: Validation of ICWMP Comments And Responses Area/page/section Comments from the group Responses Group 1: Chapter 1 Section 1.0 page 1 Introduction Usage Use words such as “need to strengthen” -Word changed to partially collapsed of totally collapsed or “partially collapsed” Remove to cradle to grave -Cradle to grave removed Section 1.1. page 1-3 The whole section does not speak to -The project components and the Project context and components the introduction on why the document reason for the development of the is being developed.
If the context ICWMP included is relevant to infection, prevention control and waste management in the COVID-19 era this should be brought out with sentences that link to what has been introduced Section 1.1.1 page 3 COVID-19 intervention Statistics should be updated to 2021.

-The group agreed that I add as by as This background information should be statistics are dynamic.
tied to the paragraphs above Section 1.2.1 page 4&5 Need to highlight on international International conversions now moved International Conversions guidelines that are also in support of the from section 1.2.9 to 1.2.1 The Basel selected laws.

and Stockholm Conversions already in • National Health Care Waste the document.
Management Plans In Sub-Saharan Africa- Guidance Manual Source: Secretariat Of The Basel Convention And World Health Organization (2004) • Management of solid health care waste at primary health care centers- decision making guide Source ; WHO 2005 • Management of wastes from immunization campaign activities- Practical guide for planners and managers Source: WHO Section 1.2.2 page 5 Add what the constitution says about Constitution of Zimbabwe section environmental management 73 on environmental management added to the document.
Section 1.2.5 page 10 Rural and Urban Act Ministry of Local gvt and Public works -Corrected to Ministry of Environment, not national housing (2 different Climate, Tourism and hospitality ministries now) industry (MECTHI), Ministry of Health and Child Care (MoHCC) and Ministry of Local government and Public Works.
106 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Area/page/section Comments from the group Responses Section 1.2.6 page 11 Public Health Act Its contradicting what is in the Public -Contradicting sentence deleted and Health Act section 113 subsection 1 and replaced with correct statements.

2 (health care waste management) Shifting of function not true.
EMA remains a monitor and MoHCC the implementer using the HCWM plan GROUP 2 Chapter 2 adequate Information Section 2.1.10 page 31 Note there is need for the link focal Nurse removed and replaced with Roles and responsibilities person for all the departments (remove person nurse and replace with person) Section 2.1.10 page 31 As above (the Departmental IPC link The definition and role of the link There is an omission on page 32, person nurse/person included.
section 2.1.10 definition and role of An advocate for good IPC add the the link person definition and the role of the link person Section 2& 2.1page 28 Should read Infection prevention and Corrected control • check the same throughout the document Section 2.1.8 page 30 To include private-for-profit and private- -It was agreed in the workshop that not-for-profit facilities this should not be included as the project does not include private facilities Section 2.1.6 page 30 Feeling that number 8 (on training/ -Number 8 moved to 2 Section 2.1.10 page 31 Section 2.1.11 page 31 Section 2.1.18 page 36 education)should move up to 2 Spelling of report (delete “s”) -“s” deleted Replace “by” with “to” By replaced with to Add the general hand; replace “clinic” -General hand added and clinic with “facility” replaced with facility Section 2.1.18 page 39 add - color coded bins on number 1, -Color coded bins added.
add - limited funding on number 4 Limited funding added on number 4 Section 2.1.21 page 39 Includes – delete “s”, -“s” deleted on includes and • check the same throughout the throughout the document document Section 2.1.24 page 47 Delete “over and above its unsightly -Over and above its unsightly removed.
107 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Area/page/section Comments from the group Responses Section 2.1.24 page 49 Figure 2-1 delete “below” -Below deleted Section 2.1.25 Table 8 page 51 Change from “color” to “colour” -Color changed to colour in the rest of • check rest of the document the document.

Section 2.1.25 page 51 Change from “responsibility” to Responsibility changed to “responsibilities” responsibilities.
Section 2.1.27 page 51 Change from “to be transported” to -Transported changed to Generally Check spaces between the words in Same done “transportation” transportation.

Group 3 chapters 3&4 general Section 3.1 pg.

67 What is an -The definition of an emergency is not Injuries from needle pricks added to emergency encompassing emergencies under the definition health care waste management, e.g.

injuries (needle pricks Section 3.2 pg.

67 Management of 1.
67 Management of 1.

PPE should be personal protective Corrected Spills equipment, not personnel 2.

-Give examples of spillages that can occur in health settings i.e.

blood, Examples of blood, urine etc.

given urine, mucus etc.

and statement on sulphric acid added -Give measures of containment of to the document.

each spillage e.g.

sulphuric acid needs to be diluted first before containment 3.-Different strengths of detergents or disinfects for each type of spillage e.g.
sodium hypochlorite comes in different concentrations, hence dilution factors should be known (c1 Strengths of sodium hypochlorite, x v1= c2 x v2) where c=concentration dilution of sodium hypochlorite added and v=volume to the document.
Formula of dilutions The work shop group agreed to changed to the one in the IPC use simple formulae in the Infection Guidelines as agreed in the workshop Prevention and Control 2019 guidelines Add a section on needle prick Before the statement that talks about Management of needle pricks and management occupational exposure PEP protocol added to the document -PEP kit and policy to be in place and all now section 3.3 page 67 staff has to know the procedures -documentation of prick accidents 108 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Area/page/section Comments from the group Responses Add a section on management of fire Before Management of fire added to the (Fire can be an emergency in -electricity workmanship should be document.
Now section 3.4 page a healthcare settings from the standard 68-69 incinerator, electricity etc.)
-servicing of all installations The group noted that fire can be an -Serviced fire extinguishers to be emergency in a health care setting available because of electricity, old buildings -serviced sand buckets to be available and from the incinerator etc -everyone should be taught how to use fire fighting equipment, can have drills -establish and label emergency escape routes and fire assemble point -have emergency numbers in place and available to every member in the institutions -have an emergency siren/bell During -raise an alarm using the emergency siren/bell -evacuate all staff and patients, have body count and account for everyone concurrently be in contact with the emergency response teams (police, fire brigade etc.)
-respond (use fire fighting equipment available) After -audit ( find out what caused the fire, access extend of damage, what did we do good and wrong, were there any causalities ) check that required trained, adequate -Corrected and qualified staff are in place (remove the adequate so statement should read: check that required trained and qualified staff are in place) 109 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Area/page/section Comments from the group Responses Facility level pg.
74 Health Care Committee HCC- shouldn’t Corrected it be Health Centre Committee -Why an independent team?

-remove chief or manager as in chair at a health facility , rather use nurse in charge and the EHT -doctor, lab personnel included but not available at clinic level, EHTs have been left out -second from last paragraph should be EHT added under district level - Chief Executive Officer of manager (use Corrected the correct terms) i.e.
DMO/ Med-sup or nurse in charge -Provincial Environmental Health Corrected Department use the Provincial Environmental Health Officer Section 4.1 pg 74 Trainings Section 4.1 pg 75 - Average people to be trained should Corrected Estimated training budget depend on the number of facilities the district has.

-training should be uniform across all Corrected levels.

-handler of waste must be include in Cleaner added training i.e.

cleaner All indicators were corrected as agreed in the workshop.
Group 4 chapter 5&6 Section-M&E page 77 • i-Xii • Adjusted indicators to make them quantitative • Indicators that were aggregated were disaggregated • A few indicators were dropped out 110 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Area/page/section Comments from the group Responses OLD i.

Agreed upon, functioning ICWMP and necessary equipment/facilities for each facility ii.
Waste Management Policy to be available in wards/departments, isolation and quarantine centers.

NEW • Number of Agreed upon, functioning Corrected ICWMP and equipment/facilities for each facility Name the specific equipment • Number of Waste Management Policy documents available in: o wards o departments, o o isolation and Quarantine centers.

OLD • Color-coded and foot operated pedal bins with lids or bins with wheels to be available on the wards and departments.
• 100% availability of waste management material resources-bin liners, appropriate PPE NEW • Number of Color-coded bins, bin liners and foot operated pedal bins with lids or bins with wheels available on the wards and departments.
• Number of available waste Corrected management material resources-, appropriate PPE (name the PPE) 111 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Area/page/section Comments from the group Responses OLD • Availability of wheeled trolleys, containers or carts that are not used for any other purpose.

• vi.

Training sessions NEW • Number of wheeled trolleys, Corrected • vi.
Training sessions Number of Corrected people trained on IC and WM • Number of meetings on IC and WM Corrected • frequency of meetings on IC and Corrected WM OLD • vii.

Rate of healthcare Associated Infections (HAI) • viii.

Number of needle stick injuries from health care waste management NEW • vii.
Number of healthcare Associated Corrected Infections (HAI) due to health care waste management practices Chapter 6 No comments the group agreed that the information was adequate All these comments raised by groups were addressed in the document with some track changes 112 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Appendix 8: Programme of Activity -ESMF and ICWMP Validation Workshop Ministry of Health and Child Care Programme of activity -ESMF and ICWMP Validation Workshop- 7-8 June 2021 - Mazowe Hotel Time 0800-0815 0815-0830 0830-0840 0840-0850 0850-0920 0920-0950 Activity Day 1 Facilitator Chair/ Rapporteur Environmental Health/ Health Promotions Introductions Welcome Remarks Admin Issues All MOHCC Workshop Objectives MOHCC Overview of the HSDSP AF Cordaid Overview of the Safeguards Consultant Instruments -ESMF 0950-1000 Introduction group work on Cordaid 1000-1030 1030-1130 ESMF Tea Break Group Work ( by Thematic All Area in the ESMF Draft document) 1130-1300 Plenary session-Thematic Consultant 1300-1400 1400-1430 1430-1500 1500-1530 1530-1600 Topics 1-3 (introduction, environmental and social methodology, project baseline information) Lunch Plenary session-Thematic Topics 4 (Zimbabwe legal framework and World Bank safeguards policies) Plenary session -thematic topics 5 &6 (Environmental and social impacts of the project; classification, screening, approval and implementation) Tea Break Plenary Session Thematic Topic 7 (Project complaints, conflict and Grievance Redress Mechanisms) Health Promotions/ Env.
Health 113 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Time Activity Day 1 1600-1630 Plenary session- Thematic Facilitator Chair/ Rapporteur Environmental Health/ Health Promotions Topic 8 (Stakeholder consultation, engagement and disclosure) Plenary Session- Thematic Topics 9-11 (Monitoring and supervision, institutional capacity, and implementation budget).

Day 2 Recap 1630-1700 0800-0815 Health Promotions Public Relations/ Env.
Health Overview of ICWMP Consultants 0815-0830 Introduction To Group Work Cordaid on ICWMP All 0830-1000 Group Work ( by Thematic 1000-1030 1030-1100 1100-1130 1130-1200 Area) Tea Break Plenary Session- 1.

Introduction, project context and components, laws and Policies Plenary Session- 2.

Health Care Structure, Infection control and waste management Plenary Session-3.

Emergency preparedness and response 1200-1230 Plenary Session- 4.

Institutional arrangements and capacity building Plenary session- 5.
Stakeholder consultation Lunch Summary key issues ESMF Consultants Summary key issues ICWMP Consultants Tea Break Recommendations Closing Remarks MOHCC MOHCC 1230-1300 1300-1400 1400-1430 1430-1500 1500-1530 1530-1600 1600-1615 114 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Guide to group works: ICWMP AREAS TO CONCENTRATE ON THEMATIC AREAS AREAS TO CONCENTRATE ON Introduction, project context and components, Analysis of the laws and policies, were relevant laws and laws and Policies policies captured.
Are there any gaps?

Health Care Structure, Infection control and Waste Analysis of Health Care Structure, Infection control and management Waste management.

Is the information adequate?

Analyse the roles and responsibilities Are there any gaps?

Emergency preparedness and response Is the information adequate?

Institutional arrangements and capacity building Analysis of the institutional arrangements and capacity building.

Is the capacity building adequate for the ICWMP?


Monitoring and Reporting Is the information adequate?

Are the indicators relevant to the ICWMP?

Stakeholder consultation Analyse the Stakeholder consultation Were the consultations adequate to this ICWMP?

Are the consultations of any value to the ICWMP?
115 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Appendix 9: List of Validation Workshop Participants REGISTRATION FORM FOR ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK (ESMF) AND INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) VALIDATION WORKSHOP: 7-8 JUNE 2021, MAZOWE HOTEL 0774028331 0713188088 0718428119/ 0777551843 NAME ORG/ DEPT/ DESIGNATION EMAIL ADDRESS PROVINCE CONTACT NUMBER VICTOR NYAMANDI MOHCC HQ DIRECTOR EH victornyamande@gmail.com 0772809365 TEMBA MOYO PMD MIDLANDS PEHO timzamoyo@gmail.com 1.
2.

3.

EDINGTON D MOHCC/ ENV/ EHO edsithole58@gmail.com SITHOLE HQ 4.

MUSIWARWA MOHCC DIRECTOR QA/9 chirumemusiwarwo@gmail.com 0774954622 CHIRUME 5.

6.

CHARLES SIACHIMA MOHCC HQ ACTING DD csiachema@gmail.com NTANDOKAMLIMU EMA P.O ntandonondo@ema.co.zw 0771542087 0772990134 NONDO 7.

ADMIRE HARARE CITY DHPO dombojena@gmail.com 0773264800 DOMBOJENA HEALTH 8.

PAUL MATSVIMBO MOHCC - MASH MPMD pfmatsvimbo@gmail.com 0772855029 EAST 9.
KAMBONDO MOHCC - PMD DHPO kambondogeorge@gmail.com 0773476905 GEORGE MASH WEST 10.

CHIFAMBA PAULOS MOHCC HQ/ QUALITY QAQI ASSURANCE OFFICER 11.

RUMBIDZAI MOHCC - HQ HPM rchimu@gmail.com 0773468834 CHIMUKANGARA 12.

DANDA SYDNEY MOHCC EDC NVCO syddanda@gmail.com 0772739624 HEAD OFFICE 13.

MORDESTER MOHCC - HQ NURSE ADMIN mordmuti@gmail.com MUTIMUKULU OFFICER 14.

WELLINGTON MOHCC -HQ PRO wmusakwa@gmail.com 0773922835 MUSAKWA 15.

PAUL CHINAKIDZWA MOHCC - HQ D/ DIR-HP pchinakidzwa@gmail.com 16.
JOYLEEN MOHCC - HQ PRO mohcccomms@gmail.com 0772727046 0775650647 CHIMONYO 17.

BRIAN D CORDAID - PRBRO brianchakawapano@gmail.com 07796605511 CHAKAWAPANO MASHWEST 18.

ABIGAIL MUSARA MOHCC HQ/ WASTE MANAGER musaraabigail@gmail.com 0773621413 ENV/ HQ 116 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID NAME ORG/ DEPT/ DESIGNATION EMAIL ADDRESS 19.

USHE COSMAS MOHCC - HQ/ DRIVER PROVINCE QAQI CONTACT NUMBER 0772774271 20.
CHIPO MAKWEZWA MOHCC ENV PROG ASST makwezwac@gmail.com 0772130609 HEALTH SERVICE 21.

CHIPO S CORDAID CONSULTANT cgwaya@gmail.com 0778086536 GWAYAGWAYA 22.

SIBEKILE MTETWA CORDAID CONSULTANT mikemtetwa@live.com 23.

BLOODWELL CORDAID ENVIRONMENTAL bloodwell.tarume@cordaid.org 0779623850 TARUME SPECIALIST 24.

MUSA M T CORDAID PRBFO 25.

DODZO LILIAN MOHCC - HQ DIRECTOR- dodzolilian@yahoo.com 0712831382 26.

PAIDAMOYO CORDAID MAGAYA NURSING COMM SPECIALIST pai@cordaid,org 0782702274 27.
K NYATHI MOHCC - PCU RRF HEALTH kny@cordaid.org 0776248128 SPECIALIST 28.

TRISH MUKUNYADZI CORDAID RRF URBAN Trish.Mukunyadzi@cordaid.org 0773 508354 VOUCHER EXPERT 29.

ENDRIS SEID CORDAID TEAM LEADER Endris.Mohammed@cordaid.org 0772161805 117 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Appendix 10: PPE Requirements Facility PPE requirements should be calculated based on bed capacity, number of staff (by category of staff) and procedures or services offered.
CDC and WHO have calculators to estimate PPE requirements.

Management and the procurement department should work together to calculate and procure adequate PPE.

Provision for different sizes to fit the different personnel at the facility, estimations for short term (2 weeks) and long term (3 months), necessary arrangements to stock up and considering the imminent surge in cases should be made.

PPE must be of good quality for it to offer the intended protection and to minimize wastage.
Ensure all staff are trained on rational use of PPE and are competent in donning and doffing PPE safely.

The recommended PPE for COVID-19 is outlined in the National PPE guidelines for COVID-19 which have been adapted from the WHO guidelines the Rational Use of Personal Protective Equipment March (2020).
REQUIRED PPE For healthcare workers l Gown l Plastic apron l N95 mask l Surgical mask l Gloves l Head cape l Overshoes l Heavy duty gloves l Face shields l Goggles PPE for incinerator operator l Work suite /scrubs l Helmet l Safety goggles l Heat resistant visor l N95 mask l Heavy duty heat resistant apron l Heat resistant gloves l Heat resistant industrial shoes/boots 118 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Table 1-4 : Extracted from the draft national PPE guidelines adopted from the WHO rationale use of PPE, 2020 Activities & context Gloves Surgical N95/FFP2 Mask respirator Goggles Type of gown Scenario with no known COVID 19 cases within Health-Structure Catchment area Standard IPC NO direct contact with patients BUT WITH their environment e.g.
pre-triage, admission to standard services Confirmed cases in catchment area / Health Structure Direct Contact with Suspect/Confirmed patients with unlikely exposure to bodily fluids e.g.

HPs, psychologists, Imaging, care-givers Direct Contact with Suspect/Confirmed patients with likelihood of getting in contact with body fluids e.g.
consultation of suspect cases, ambulance Direct Contact with Suspect/Confirmed patients, with concerns for short-range aerosols AND with likelihood of getting in contact with body fluids e.g.

cleaner in suspect area, laundry, PCR lab Disposable gown Disposable fkuid resistant coverall / surgical gown + apron 119 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Appendix 11: Consultations This appendix contains the details of the field consultations that were conducted for the development of the ICWMP.
FIELD CONSULTATIONS The following is an outline of the Public Consultation that was carried out in August 2020 for the development of the ICWMP.

Consultations were done in Mashonaland EAST, Harare, Bulawayo, Matabeleland South, and Matabeleland North.

Table below shows the list of the stakeholders who were met during the Field consultation process.

List of Consulted Stakeholders from field visits.

MEETING DATE NAME ORGANIZATION DESIGNATION Contact No.
& Email Address CONSULTING TEAM Chipo Gwayagwaya Cordaid.
Infection Control + 263778086536 Specialist /Consultant cgwaya@gmail.com Sibekile Mtetwa Cordaid /World bank Environmental + 266 5192562 Safeguard Specialist / mikemtetwas@live.com Consultant MASHONALAND EAST Mashonaland east PMD MEETING 21/08/20 Edmore Mutsinze Cordaid Officer 0779660 Edmore.mutsinze@cordaid 21/08/20 Paul Matsvimbo MOHCC Officer 0772855029 pfmatsvimbo@gmail.com 21/08/20 Godwin Chibvuura MOHCC DR 0772406273 gchibvuura@gmail.com 21/08/20 Laizah Chourombo MPSLSW OFFICER 0782118242 T Mapengo Juliet Mavu Dube MC MLGPW EMA MLG.PW Officer Officer Officer ichourombo@gmail.com terrificcee@yahoo.com Juliet.mavu@ema.co.zw Dubecharles36@gmail.com Matsitsiro Alfred Municipal of Director matsitsiroalfred@yahoo.
Marondera com Boniface Machingauta MOHCC Karetu Admire MOHCC 21/08/20 Eunice Takura MOHCC Marondera District Hospital Officer Officer Officer bmachingauta@yahoo.com ndaramukaretu@yahoo.

com Eunicetakura25@gmail.

com 21/08/20 KAMBA MERCY MOHCC DR 0772819364 kambamercy@gmail.com 120 21/08/20 21/08/20 21/08/20 21/08/20 21/08/20 21/08/20 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID MEETING DATE NAME ORGANIZATION DESIGNATION Contact No.
& Email Address 21/08/20 C Dhege MOHCC DR 0772434162 21/08/20 21/08/20 21/08/20 A Mutsinze E Mutsikiwa Juliet Hungwa Mahusekwa District Hospital cordaid MOHCC MOHCC MOHCC MOHCC Alfred Mhlanga P Mutubuki Munodawafa Kudzai MOHCC KuvelaTawanda Madoro Kutema Chikuniwo Virginia Marondeza Mutume Shupikai Mufambi Regina MOHCC MOHCC MOHCC MOHCC MOHCC MOHCC MOHCC 21/08/20 21/08/20 21/08/20 21/08/20 21/08/20 Chiota Clinic 21/08/20 21/08/20 21/08/20 21/08/20 21/08/20 HARARE Wilkins hospital Officer Officer Officer Officer Officer Officer OFFICER DR Sister Sister Sister SISTER cdhege64@gmail.com Amutsinze64@gmail.com emutsikiwa@gmail.com jhungwa@yahoo.com alimhlanga@gmail.com Pmutubuki27@gmail.com kudzaimudavanhu@gmail.
com tkuveya@gmail.com dytief@gmail.com kutemafary@gmail.com gamuchikuniwo@gmail.
com veemurondeza@gmail.com N/A NURSE aid reginamufambi@gmail.com 28/08/20 Andrew Tapera MOHCC Admin 0773392220 28/08/20 Rhoda Dzawara MOHCC Edith Operman Mbare Clinic 28/08/20 Chirau B City of Harare Mbare poly Srn Sic 28/08/20 Mutandwa V City of Harare a/sic Mbare poly 28/08/20 Mkahanana P City of Harare Sic community Mbare community HCC Mbare atapera@yahoo.com 0773286166 rhodadzawie@gmail.com 0774151759 75-282469 v 75 0773836534 63-1064493 Q 38 0772628991 15-058402 c 15 28/08/20 Chackie Makaza Mbare community HCC Chairman 0772415722 64-448011 D 63 BULAWAYO BULAWAYO - PMD 25/08/20 Mlilo W MOHCC a/pmd 0776435501 25/08/20 Hove S City of Byo CNO Welly.mlilo@gmail.com 0712745533 sthove@ citybyo.co.zw 121 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) MEETING DATE NAME ORGANIZATION DESIGNATION Contact No.
& Email Address 25/08/20 Malaba C City of Byo ADE 0773187724 cmalaba@citybyo.co.zw 25/08/20 Siziba S City of Byo SNPO 0772402425 sisiziba@citybyo.co.zw 25/08/20 Dzoma F Social welfare PSWD 0773299563 25/08/20 ‘Ndlovu D EMA Manager dzomafanwell@gmail.com 0712832259 decent.

ndlovu@ema.co.zw 25/08/20 Nyathi K City of Bulawayo ADHS(PH) 0776248128 25/08/20 KAVU C Local Gvt 25/08/20 P Munyaka Local Gvt THORNEGROOVE CLINIC 25/08/20 25/08/20 S V. Ndiweni N Dhodho 25/08/20 25/08/20 V.S.
Ndlovu N Sibanda MPILO CENTRAL HOSPITAL MOHCC MOHCC MOHCC MOHCC PAO PAO Nurse Nurse Nurse Nurse d.knyathi@citybyo.co.zw 0718912611 chipokavu@gmail.com 0772478689 n/a 292266746 thornegroovehospital@ gmail.com N/A 292 66746 27/08/20 Peggie Lungu MOHCC Srn matron 0772903523 lungupeggie@gmail.com 27/08/20 Nkomo Nokuthula MOHCC Srn 0772884171 Nokuthulagobvu16@gmail.

com UBH 27/08/20 Sithembiso Joyce MOHCC Srnipc 0776865866 Baleni MAQHQWE CLINIC sithmbisobaleni@gmail.
com 27/08/20 Stella Nyoni City of Byo NURSE 0712440726 nyonistella05@smail.com 27/08/20 Sithokozile Ncube CITY OF BYO NURSE 0775708937 27/08/20 C Sibanda City of byo 27/08/20 R Dzemaema City of byo 27/08/20 S Sibanda City of byo Srn Srn Srn 122 sithokozilekamombe@ gmail.com 0772362660 sibandac@citybyo.co.zw 0773511455 rdzemaema@city.co.zw 29266420 siksibanda@citybyo.co.zw ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID MEETING DATE NAME ORGANIZATION DESIGNATION Contact No.
& Email CBO and HCC Maqhawe Nkulumane 27/08/20 Nhlanhla K Nkulumane CBO officer 27/08/20 Khumalo B Nkulumane CBO officer 27/08/20 Zulu P Nkulumane 27/08/20 N Kumalo Nkulumane 27/08/20 C Dezidere Nkulumane HCC HCC HCC 27/08/20 C N Zulu Nkulumane CBO officer 27/08/20 S Chiukuse Nkulumane 27/08/20 Guhwa C Nkulumane 27/08/20 S Sithole Nkulumane 27/08/20 M Mase Nkulumane MATABELELAND SOUTH Matabeleland South – PMD Meeting 25/08/20 25/08/20 Gwanda PDC Rudo Chikohore Joyce Sibanda MOHCC MOHCC HCC HCC CBO HCC PMD PMD Address 0779014874 08-2144907 R 21 0771155243 08-2143390 S 21 0777015227 08-109635 V 39 0772681954 08-516771 J73 0775668033 29-011287903 0718979475 08-2053681 H 21 0773577674 08-37635 C 71 0773516794 08-491140 Z 05 0772872957 73-076919 H 73 0773886868 08-118434 J 41 0772650876 0772477890 24/08/20 NYAKUDYA Social Welfare DSW Officer 0772929332 criswellnyakudya@yahoo.
com 24/08/20 24/08/20 Sithembisiwe Ndhlovu EMA PROVINCIAL MANAGER 0779880544/0712832261 Sithandiwe Ncube PDC PAC 0775671235 24/08/20 Ncube S H Mlg.

pw PPWD Ndumosithandisiwe2@ gmail.com 0772407452 siyaysan@gmail.com 24/08/20 24/08/20 Nyathi A Ndlovu Gift Information Officer Min Of Information anyathi04@gmail.com MOHCC EHT 0772960228 Ndlovugift79@gmail.com 123 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) MEETING DATE NAME ORGANIZATION DESIGNATION Contact No.
& Email Address Mangwe DDC Meeting (Plumtree) 26/08/20 Nganunu Joe MOHCC a/dmo 0772756458 26/08/20 Majonga N mlgpw Pao nganunujoe@gmail.com 0775107227 majonga@gmail.com 26/08/20 Magiga R Council Town planner 0772979324 26/08/20 Tshuma K council EHO Gigast2@gmail.com 0776177354 ktshuma91@gmail.com 26/08/20 Ndlovu Nl DDF Water technician 0784171328 inmatwasa@gmail.com 26/08/20 26/08/20 Matshazi C T Chapanduka A MOHCC MOHCC PEHT Accountant 0773724938 0772962857 26/08/20 Bridget Masuka MOHCC 26/08/20 Tsoelopele Dube MOHCC DNSH SICC achapanduka@gmail.com 0772346090 bridgetmasuka@gmail.com 0774667302 tsoedubenove@gmail.com 26/08/20 Sikhumbuzo Nohovu MOHCC VNO 2 0773535008 sikhumbuzo62@gmail.com 26/08/20 Togara O LOCAL GVT A/DDC 0773686740 ozogarah@gmail.com 26/08/20 Sibanda P MOHCC EHO 0772544484 26/08/20 Xaba N MOHCC EHO patricksibandap@yahoo.
com 0777548897 nduexaba@gmail.com 26/08/20 Mlambo P PCU PRBFO 0779660844 26/08/20 Moyo T MOHCC 26/08/20 Hapanyengwi E MOHCC DTLC DMO Pharaoh.mlambo@cordaid.
org 0772365684 Moyotan9@gmail.com 0772907621 drerasmus@gmail.com 26/08/20 Ndlovu P MOHCC Provincial IPC /SNO 3 0772857925 ST ANNES MATRON 26/08/20 Nyathi S Social development DSDO 0774779660 scele2007@gmail.com 124 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID MEETING DATE NAME ORGANIZATION DESIGNATION Contact No.

& Email Address Marula Clinic 28/08/20 ‘Sibanda Sidumisile MOHCC S R NURSE 0775522822 sduesibanda90@gmail.
com 28/08/20 Mnkandla MOHCC SR NURSE 0771907374 28/08/20 Siphunyuziwe Nesia Ncube CBO Marula Mahole Village MOHCC SRNURSE 0777153272 nesiancube@gmail.com 28/08/2020 Dabson Dube Village CBO Chairman Farmer 0775759625/0717655458 125 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Findings Mashonaland East Province 1.

Mashonaland provincial team was met, a focus group discussion was carried out.
The PMD gave an overview of the province, and the challenges affecting the provision of healthcare services which are as follows: Reduced throughput in all healthcare services, operating at below 50% except for maternity which is operating at above 100% 2.

3.

4.

5.
3.

4.

5.

Inadequate personal protective equipment (PPE) Inadequate testing for COVID-19 due to shortages of cartridges Isolation centres not yet completed and no equipment yet Laundry at the provincial hospital not functioning due to broken down machinery 6.

Provincial hospital mortuary not working due to broken down refrigerators 7.

Incinerators in the province broken down only 1 is functional 8.

Nowhere to dispose expired drugs 9.

Inadequate bins and bin liners compromising segregation of waste 10.
No dedicated vehicle to carry waste 11.

Shortages of fuel 12.

Autoclave is small and needs to be upgraded Focus Group Discussion with Provincial Development Committee, Mashonaland East Province 126 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Site visit to Marondera Provincial Hospital was done and questionnaires were administered.
Marondera Provincial Hospital has a bed capacity of 285 and is operating at below 50% in other services expect for maternity which is above 100%.

Despite the job action 90% of their staff is coming to work.

The following are the challenges they are facing as a facility: 1.

2.

3.

Incinerator not working Few bins for waste segregation and erratic supply of bin liners, mostly have one colour at a time.

Laundry not working all machines are broken down except for the 2 driers 4.

PPE not adequate 5.
PPE not adequate 5.

Mortuary not working refrigerators broken down 6.

COVID-19 isolation centre was renovated but no equipment to load the room and for the ICU a reducer to link oxygen tank and the pipes in the ward still to be procured.

7.
7.

Autoclave not functioning well constantly breaking down Marondera Provincial Hospital incinerator chimney broken down 127 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Mahusekwa District Hospital Site visit was done to the district hospital and a focus group interview was held.

An overview of the two documents ICWMP and ESMF were given by the consultants.

The DMO also gave an overview of where they are in terms of IPC and waste management and the following challenges were cited: 1.
Inadequate PPE 2.

No vehicle for hospital errands within the community 3.

No food for patients and staff 4.

No fuel for DMO to go and see COVID-19 patients in the community 5.

Operating at 95% on medical services as patients are coming from Harare to seek cheaper medical treatment hence not coping with the allocated resources 6.

Water a challenge as the boreholes at the facility need frequent maintenance 7.

Liquid waste bio nutrient removal system not efficient needs to be repaired 8.
No swabs for COVID-19 testing 9.

Isolation centre under renovation but renovations are at a halt due to lack of funding 10.
Incinerator very small operates as a burner, chimney very short so to be upgrade to standard incinerator Temporary Waste Storage Area at Marondera Hospital Incinerator 128 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Group Interview with Mahusekwa District Hospital Management Small Incinerator with a Short Chimney at Mahusekwa District Hospital 129 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Incomplete Biodigester Plant at Mahusekwa District Hospital 130 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Group Interview with Chiota Rural Hospital staff Chiota Rural Health Centre was once repurposed to be an isolation centre, but the decision was reversed.
At this facility waste which was generated 3 months ago when facility was being used as isolation centre is not collected for final disposal due to unavailability of transport in the province.

It was also noted that there is no incinerator at the facility and waste is being burnt in open pit.

The volume of waste is huge at this facility as some of it was generated during the period when it was being used as an isolation centre.

The facility is also having challenges with PPE.
131 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Waste Awaiting Collection 132 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Waste Disposal Area at Chiota Health Centre 133 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Matabeleland South A focus group discussion was done with the provincial development committee the Provincial development coordinator gave an overview of challenges they are facing as a province as follows 1.
Waste management infrastructure 40-50% of incinerators are functional and the ones not working needs some refurbishment to standard incinerators as they are small.

Most of the rural hospitals have Otto way pits and bottle crushers.

2.

No sanitary landfill in the province except for the Gwanda one which awaits commissioning.

3.

Challenges on collection and transportation of waste as they do not have no proper trucks and adequate fuel.

4.
4.

Poor disposal of surgical masks by the community making it a hazard as scavengers do recycle the masks 5.

In terms of COVID-19 pandemic people are not adhering to mandatory masking, hand hygiene and social distancing despite the Provincial Development Committee awareness.

6.

Behavioural change and attitude of the community also a challenge.

7.

The committee need resources to constantly visit people to reinforce IPC and waste management issues but no fuel.

8.
8.

Isolation centre at Phakame almost complete but no equipment to put in the isolation 9.

Water supply a problem within the healthcare facilities.

10.

Isolation centres not meeting IPC requirements as they are very small and overcrowded, no single rooms and few ablution facilities compared to the number of people.

11.

In adequate PPE in healthcare facilities Isolation and quarantine centre.

12.
12.

Use of latrines in other healthcare facilities Focus Group Discussion with PDC Matabeleland South Gwanda 134 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Focus Group Discussion with DDC in Plumtree Matabeleland South.
135 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Waste Management Facilities at Plumtree District Hospital Waste management facilities such as otto-way pit and the old burner are secured in a fence, but some such the bottle crusher and incinerator are not secured and this can provide access uncontrolled access to people and animal posing a health risk.
Also observed is uncut grass within the waste management area attracting animals as cattle were seen grazing around the area The road to the waste disposal area not paved hence destroying the wheels of the trolleys used to transport the waste.

136 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Laboratory at Plumtree Hospital Waste not being segregated due to no colour- coded bin; only black bin liners are the ones available.
137 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Waste Disposal Area at Marula Clinic in Matabeleland South 138 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Marula Clinic Water Storage Facilities Marula Clinic has critical shortage of water as there is no borehole at the clinic.

The 3 reservoir tanks which are at the clinic are filled by ZINWA occasionally due to transport problems.
However, the community will mobilize a tractor from the farmers and fill the water bowser to provide water at the clinic.

139 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Mpilo Hospital Covid-19 Designated Isolation Ward 140 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Mpilo Central Hospital incinerator Incinerator not working and they are using the burner on the side picture.
141 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) (Left) Mpilo Hospital Open Dumping of Waste (Right) General pulling a wheelie bin Medical waste ash being disposed on open land as the hospital does not have an ash pit.

This is an illegal practice and poses an environmental and health risk since the ash will be blown into the air and hence can potentially cause respiratory infections for those in the vicinity.
Open burning of solid wastes, whether hazardous or non-hazardous, is not good practice and should be avoided, as the generation of polluting emissions from this type of source cannot be controlled effectively.

All ash should be disposed of in an ash pit and the general hand pulling the wheelie bin (on the right) instead of pushing it because the path to the waste disposal area is not well-defined.
Mpilo Hospital Undisposed Obsolete Equipment 142 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Mpilo Central Hospital mortuary with a capacity of 27 bodies key informants advised that they were currently holding 400 bodies.

The unfinished structures are a mortuary and a chapel left 10yrs ago.
Mpilo Central Hospital Mortuary 143 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Bulawayo National TB Reference Laboratory at Mpilo Central Hospital Bulawayo National TB Reference Laboratory at Mpilo Central Hospital where COVID-19 specimens are being processed.

Biosafety level 3 currently not meeting requirements.

Inadequate PPE was noted by non-disposal of used PPE and reuse of the PPE causing contamination of the health care worker.
144 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID -Inadequate autoclaves some not functioning and need refurbishing Focus Group Discussion with Bulawayo PDC Challenges of Bulawayo City 1.

No collection of waste from the healthcare facilities and the community 2.

No functional incinerator on one burner working 3.

No temporary storage areas for waste 4.

5.

Inadequate bins and bin liners Landfill not fenced and not under lock and key 6.
Autoclave machines not working 7.

Erratic water supply and inadequate boreholes 8.

Thorn groove isolation centre not yet completed and no equipment 9.

Inadequate laundry facilities 145 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Focus Group Discussion with Bulawayo PDC Thorngroove Infectious Hospital The hospital was built in 1941 but is the one admitting infectious diseases including COVID-19 whilst waiting for completion of the new COVID-19 Isolation Centre.
Segregation of waste at source not being practiced at this hospital.

146 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID New Thorngroove Isolation Facility Awaiting Completion and Uncollected Waste City of Harare challenges 1.

Inadequate PPE 2.

No standard incinerators 3.

No dedicated vehicles to carry waste to disposal area 4.

No fuel for the vehicle 5.

Autoclave constantly breaking down 6.


Inadequate bins and bin liners (one colour of bin liners available at a time) 7.

No secured waste holding area 8.

9.

Isolation facilities refurbishment to be completed Laundry very small needs expansion 10.

Erratic supply of water boreholes constantly breaking down 11.

No power backup in small clinics 12.
Fencing around clinics needs rehabilitation 147 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Harare Wilkins Hospital Refurbishment in progress 148 Waste Storage Areas Not Secured at Wilkins Hospital ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Waste not being segregated at Wilkins Hospital Septic Tank at Wilkins Hospital for Liquid Waste Disposal 149 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Focus Group Discussion at Mbare Poly Clinic Unsecured Temporary Waste Storage area at Mbare Poly Clinic 150 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Waste Transportation for Final Disposal by City of Harare Clinics Broken Down Incinerators at Sally Mugabe Central Hospital 151 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Dump Site Area within Sally Mugabe Central Hospital Sally Mugabe Central Hospital Illegal Dump Site 152 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Incomplete Buildings of the Mortuary and a Chapel at Sally Mugabe Central Hospital 153 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Malfunctioning Laundry Equipment at Sally Mugabe Central Hospital 154 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID 155 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 156 ZIMBABWE HEALTH SECTOR DEVELOPMENT SUPPORT PROJECT ADDITIONAL FINANCING V (HSDSP AF V)CORDAID Cordaid Zimbabwe15 Connaught RoadAvondale, Harare P.O.
Box A430, Avondale Harare, ZimbabweTel: +263 772 161 806/7Twitter: @rbfhealthzimwebsite: www.cordaid.orge­mail: commzim@cordaid.orgBUILDING FLOURISHING COMMUNITIESwww.healthprojectzim.orgRD­GRAPHIXInfection Control and Waste Management Plan (ICWMP)May 2022Zimbabwe Health Sector Development Support Project Additional Financing V (HSDSP AF V)