## *Chapter 8*

## *Healthcare waste: Generation, handling, treatment and disposal*

### Brief Description of the Sector  {#brief-description-of-the-sector .unnumbered}

Small-scale healthcare activities, such as rural health posts,
immunization posts, reproductive health posts, mobile and emergency
healthcare programs, and urban clinics and small hospitals, provide
important and often critical healthcare services to individuals and
communities that would otherwise have little or no access to such
services. They are the front line of defense against epidemics such as
AIDS, malaria, and cholera and a key component of any comprehensive
development program. The medical and health services they provide
improve family planning, nurture child and adult health, prevent
disease, cure debilitating illnesses, and alleviate the suffering of the
dying.

### Potential Environmental Impacts of Development Programs in the Sector and Their Causes  {#potential-environmental-impacts-of-development-programs-in-the-sector-and-their-causes .unnumbered}

Although small-scale healthcare activities provide many important
benefits to communities, they can also unintentionally do great harm
through poor design and management of waste management systems.

Healthcare waste is dangerous. If handled, treated or disposed of
incorrectly it can spread disease, poisoning people, livestock, wild
animals, plants and whole ecosystems.

**Types of waste.** These wastes generally fall into three categories:

-   ***General*** healthcare waste, similar or identical to domestic
    waste, including materials such as packaging or unwanted paper. This
    waste is generally harmless and needs no special handling; 75--90%
    of waste generated by healthcare facilities falls into this
    category.

-   ***Hazardous*** healthcare wastes including infectious waste (except
    sharps and waste from patients with highly infectious diseases),
    small quantities of chemicals and pharmaceuticals, and
    non-recyclable pressurized containers.

-   ***Highly hazardous*** healthcare wastes including sharps, highly
    infectious non-sharp waste, stools from cholera patients, and bodily
    fluids of patients with highly infectious diseases. They also
    include large quantities of expired or unwanted pharmaceuticals and
    hazardous chemicals, as well as all radioactive or genotoxic wastes.

Table 3.1: Types of hazardous and highly hazardous medical wastes\
relevant to small-scale facilities

+---------+----------------------+---------+--------------------------+
| Ha      |                      | Highly  |                          |
| zardous |                      | Ha      |                          |
| Waste   |                      | zardous |                          |
|         |                      | Waste   |                          |
+---------+----------------------+---------+--------------------------+
| Inf     | Wastes thought to    | Sharps  | Sharp objects that can   |
| ectious | contain low          |         | easily cut or injure a   |
|         | concentrations of    |         | handler. Used hypodermic |
|         | infectious agents,   |         | needles are the most     |
|         | such as              |         | common and dangerous, as |
|         | disease-causing      |         | they are often           |
|         | bacteria, viruses,   |         | contaminated with highly |
|         | parasites, and       |         | infectious blood         |
|         | fungi, that could    |         |                          |
|         | spread the disease   |         | *Examples*: syringe      |
|         |                      |         | needles, scalpels,       |
|         | *Examples*:          |         | knives, infusion sets,   |
|         | tissues/swabs;       |         | broken glass             |
|         | materials or         |         |                          |
|         | equipment that have  |         |                          |
|         | been in contact with |         |                          |
|         | infected patients;   |         |                          |
|         | human excretions     |         |                          |
|         | such as pus, feces   |         |                          |
|         | and vomit from       |         |                          |
|         | patients without     |         |                          |
|         | highly infectious    |         |                          |
|         | diseases; wash water |         |                          |
+---------+----------------------+---------+--------------------------+
| Patho   | Tissue or body       | Highly  | Contain high             |
| logical | fluids from humans   | infe    | concentrations of highly |
|         | or animals without   | ctious\ | infectious agents and    |
|         | highly infectious    | (non-   | pose an extreme health   |
|         | diseases             | sharps) | hazard                   |
|         |                      |         |                          |
|         | *Examples*: blood,   |         | *Examples*: body fluids, |
|         | body parts, organs,  |         | such as blood, from      |
|         | animal carcasses     |         | patients with highly     |
|         |                      |         | infectious diseases;     |
|         |                      |         | microbial cultures; and  |
|         |                      |         | carcasses of inoculated  |
|         |                      |         | laboratory animals       |
+---------+----------------------+---------+--------------------------+
| C       | Waste containing     | C       | The same pharmaceuticals |
| hemical | purified chem- ical  | hemical | and chemicals that are   |
| (in     | substances that are  | and     | only hazardous in small  |
| small   | toxic, corrosive,    | ph      | quantities may be highly |
| quan    | flammable, reactive, | ar-mace | hazardous in large       |
| tities) | and/or explosive     | utical\ | quantities               |
|         |                      | (in     |                          |
|         | *Examples*: unwanted | large   |                          |
|         | disinfectants,       | quan    |                          |
|         | solvents, film       | tities) |                          |
|         | developer,           |         |                          |
|         | laboratory reagents  |         |                          |
+---------+----------------------+---------+--------------------------+
|         |                      | Heavy   | *Examples*: Some         |
|         |                      | metal   | rechargeable batteries,  |
|         |                      |         | mercury from broken      |
|         |                      |         | thermometers or          |
|         |                      |         | blood-pressure gauges,   |
|         |                      |         | some medical equipment   |
|         |                      |         | batteries                |
+---------+----------------------+---------+--------------------------+
| Ph      | Waste containing     | Ge      | Wastes containing        |
| arma-ce | pharmaceuticals      | notoxic | substances which can     |
| utical\ |                      |         | cause mutations, birth   |
| (small  | *Examples*:          |         | defects and cancer.      |
| quan    | bottles/boxes of     |         | Facilities with          |
| tities) | expired or unwanted  |         | laboratory facilities    |
|         | medications          |         | might stock some         |
|         |                      |         | genotoxic chemicals      |
|         |                      |         |                          |
|         |                      |         | *Examples*: chemotherapy |
|         |                      |         | drugs                    |
+---------+----------------------+---------+--------------------------+
| Pres    | Gas cylinders, gas   | Radi    | Waste containing         |
| surized | cartridges, aerosol  | oactive | radioactive substances   |
| con     | cans                 |         |                          |
| tainers |                      |         | *Examples*: Some         |
|         |                      |         | laboratory wastes,       |
|         |                      |         | wastes associated with   |
|         |                      |         | radiation therapy. Not   |
|         |                      |         | likely to be used by     |
|         |                      |         | small-scale healthcare   |
|         |                      |         | facilities.              |
+---------+----------------------+---------+--------------------------+
|         |                      |         |                          |
+---------+----------------------+---------+--------------------------+

**Disease transmission.** Transmission of disease through infectious
waste is the greatest and most immediate threat from healthcare waste.
If waste is not treated in a way that destroys the pathogenic organisms,
dangerous quantities of microscopic disease-causing agents---viruses,
bacteria, parasites or fungi---will be present in the waste. These
agents can enter the body through punctures and other breaks in the
skin, mucous membranes in the mouth, by being inhaled into the lungs,
being swallowed, or being transmitted by a vector organism.

People who come in direct contact with the waste are at greatest risk.
Examples include healthcare workers, cleaning staff, patients, visitors,
waste collectors, disposal site staff, waste pickers, drug addicts and
those who knowingly or unknowingly use "recycled" contaminated syringes
and needles.

Although sharps pose an inherent physical hazard of cuts and punctures,
the much greater threat comes from sharps that are also infectious
waste. Again, healthcare workers, waste handlers, waste-pickers, drug
addicts and others who handle sharps can, and have, become infected with
HIV/AIDS and hepatitis B and C viruses through pricks or reuse of
syringes/needles. These infections may be fatal.

![](media/image1.png){width="3.002083333333333in"
height="2.251388888888889in"}Contamination of water supply from
untreated healthcare waste can also have devastating effects. If
infectious stools or bodily fluids are not treated before being disposed
of, they can create and extend epidemics.

**Chemical and toxic threats.** Chemical and pharmaceutical wastes,
especially large quantities, can be health and environmental threats.
Since hazardous chemical wastes may be toxic, corrosive, flammable,
reactive, and/or explosive, they can poison, burn or damage the skin and
flesh of people who touch, inhale or are in close proximity to them. If
burned, they may explode or produce toxic fumes. Some pharmaceuticals
are toxic as well.

When chemical and pharmaceutical waste is disposed of in unlined
landfills, especially unlined pits, these wastes may contaminate ground
and surface water---particularly when large quantities are disposed of.
This can threaten people who use the water for drinking, bathing and
cooking, and damaging plants and animals in the local ecosystem.

Burning or incinerating healthcare waste, while often a better option
than disposal in an unlined pit, may create additional problems.
![](media/image2.wmf){width="2.125in"
height="2.8333333333333335in"}~x~), particulates, dioxins and heavy
metals and distribute them over a wide area. Dioxins and heavy metals
are of particular concern. Dioxins believed to be potent cancer-causing
agents, do not biodegrade, and accumulate in progressively higher
concentrations as they move up the food chain. Heavy metals such as
mercury and cadmium are toxic and/or cause birth defects in small
quantities and can also concentrate in the food chain.

Finally, disposable pressurized containers pose another hazard for
incineration, as they can explode if burned.

In short, disposal of large quantities of hazardous chemicals and
pharmaceuticals is a serious problem.

### Environmental Mitigation and Monitoring Issues  {#environmental-mitigation-and-monitoring-issues .unnumbered}

This guideline recommends that designers and managers of small-scale
healthcare facilities take an incremental approach to improving waste
management practices. The first priority are actions and procedures that
will reduce risk the most at the least cost. The ultimate goal is to
develop a complete, if minimal, program.

The two subsections that follow outline the minimum elements of a
complete healthcare waste management program for a small-scale facility.
They indicate:

-   which elements will result in the most significant improvements at
    least cost---and should therefore be introduced first; and

-   what questions to ask when developing a healthcare waste management
    program for a small-scale facility.

Two tables are also included that should be useful to planners and
managers. Table 3.2 covers treatment and disposal options appropriate
for small-scale healthcare activities; table 3.3 covers best management
options by waste category. These do not cover every option, but
highlight those that are realistic for small facilities.

Table 3.2: Treatment and disposal options appropriate\
for small-scale healthcare facilities

+--------+------------------+-------+------------+--------------------+
| Treat  | Description      | Effe  | Advantages | Disadvantages      |
| ment/\ |                  | ctive |            |                    |
| di     |                  | for   |            |                    |
| sposal |                  |       |            |                    |
| method |                  |       |            |                    |
+========+==================+=======+============+====================+
| Si     | A permanent      | Infec | Disinfects | Emits pollutants   |
| ngle-c | simple furnace   | tious | ef         | such as fly ash,   |
| hamber | of solid         | waste | fectively. | acid gases, and    |
| incine | construction,    |       |            | some toxins. May   |
| ration | e.g., concrete.  | S     | Reduces    | produce odors (can |
|        | Waste is placed  | harps | waste      | be limited by not  |
|        | on a fixed       | waste | volume by  | burning PVC        |
|        | grate. Burning   |       | \~80%;     | plastics).         |
|        | is maintained by | Pa    | burning    |                    |
|        | the natural flow | tholo | efficiency | Sharps in ashes    |
|        | of air.          | gical | of         | will still pose    |
|        | Operating        | waste | 90--95%.   | physical hazard.   |
|        | temperature      |       |            |                    |
|        | reaches \<300°C. |       | Low        | Not good for most  |
|        | May need to add  |       | investment | pharmaceutical or  |
|        | kerosene or      |       | and        | chemical waste.    |
|        | similar fuel to  |       | operating  |                    |
|        | maintain         |       | costs.     |                    |
|        | combustion.      |       |            |                    |
|        |                  |       |            |                    |
|        | Pictured in      |       |            |                    |
|        | Prüss et al.     |       |            |                    |
|        | 1999, chapter 8, |       |            |                    |
|        | figures 8.3 and  |       |            |                    |
|        | 8.4.             |       |            |                    |
+--------+------------------+-------+------------+--------------------+
| Drum   | A simple furnace | Infec | Disinfects | Emits black smoke, |
| or     | with less mass   | tious | reasonably | fly ash, acid      |
| brick  | and insulating   | waste | well,      | gases, and some    |
| incin  | value than a     |       | destroying | toxins. May        |
| erator | single chamber   | S     | 99% of     | produce odors (can |
|        | incinerator.     | harps | micro      | be limited by not  |
|        | Constructed out  | waste | organisms. | burning PVC).      |
|        | of an empty oil  |       |            |                    |
|        | drum or a short  | Pa    | 80--90%    | Sharps in ashes    |
|        | chimney of       | tholo | burning    | will still pose    |
|        | bricks placed    | gical | e          | physical hazard.   |
|        | over a metal     | waste | fficiency. |                    |
|        | grate and        |       |            | Not good for most  |
|        | covered with a   |       |            | pharmaceutical or  |
|        | fine screen.     |       |            | chemical waste.    |
|        | Operating        |       |            |                    |
|        | temperature \<   |       |            |                    |
|        | 200°C. May need  |       |            |                    |
|        | to add kerosene  |       |            |                    |
|        | or similar fuel  |       |            |                    |
|        | to maintain      |       |            |                    |
|        | combustion.      |       |            |                    |
|        |                  |       |            |                    |
|        | Pictured in      |       |            |                    |
|        | Prüss et al.     |       |            |                    |
|        | 1999, chapter 8, |       |            |                    |
|        | figures 8.5 and  |       |            |                    |
|        | 8.6.             |       |            |                    |
+--------+------------------+-------+------------+--------------------+
| Op     | Burning of       | Infec | Similar to | Burning may be     |
| en-air | wastes in or     | tious | drum or    | incomplete and     |
| b      | next to pit      | waste | brick      | residues still     |
| urning | where they will  |       | in         | infectious. More   |
|        | be buried. May   | S     | cinerator. | hazardous to staff |
|        | need to add      | harps |            | involved. Greater  |
|        | kerosene or      | waste |            | risk of scavenging |
|        | similar fuel to  |       |            | by waste-pickers   |
|        | maintain         |       |            | or of transfer of  |
|        | combustion. Not  |       |            | pathogens by       |
|        | recommended as a |       |            | vectors including  |
|        | permanent        |       |            | insects, animals   |
|        | solution, but    |       |            | or birds.          |
|        | better than      |       |            |                    |
|        | burying          |       |            | Not effective for  |
|        | untreated on     |       |            | pathological       |
|        | site.            |       |            | waste.             |
|        |                  |       |            |                    |
|        |                  |       |            | Even if            |
|        |                  |       |            | disinfected,       |
|        |                  |       |            | sharps in ashes    |
|        |                  |       |            | will still pose    |
|        |                  |       |            | physical hazard.   |
|        |                  |       |            |                    |
|        |                  |       |            | Not good for most  |
|        |                  |       |            | pharmaceutical or  |
|        |                  |       |            | chemical waste.    |
+--------+------------------+-------+------------+--------------------+
| Autoc  | Steam treatment  | H     | Efficient  | Requires qualified |
| laving | of waste at high | ighly | at         | operators.         |
|        | temperature and  | infec | dis        |                    |
|        | pressure for a   | tious | infecting. | Cannot be used on  |
|        | sufficient       | w     |            | pathological,      |
|        | amount of time   | astes | Has no     | pharmaceutical,    |
|        | for              |       | s          | and chemical       |
|        | sterilization.   |       | ignificant | waste.             |
|        | Usually used for |       | env        |                    |
|        | sterilizing      |       | ironmental | Autoclaves         |
|        | reusable medical |       | adverse    | designed to        |
|        | equipment. Steam |       | impacts.   | sterilize          |
|        | must be able to  |       |            | equipment have a   |
|        | penetrate the    |       | Relatively | limited capacity.  |
|        | waste.           |       | low        |                    |
|        |                  |       | investment |                    |
|        |                  |       | and        |                    |
|        |                  |       | operating  |                    |
|        |                  |       | costs.     |                    |
+--------+------------------+-------+------------+--------------------+
| En     | Containers are   | S     | Simple and | Not effective for  |
| capsul | filled three-    | harps | safe.      | non-sharps         |
| a-tion | quarters full    | waste |            | infectious waste.  |
|        | with hazardous   |       | Low cost.  |                    |
|        | waste. Material  | Small |            |                    |
|        | such as cement   | am    |            |                    |
|        | mortar, clay,    | ounts |            |                    |
|        | bituminous sand, | of    |            |                    |
|        | or plastic foam  | chem. |            |                    |
|        | is used to fill  | and   |            |                    |
|        | the container.   | p     |            |                    |
|        | When capping     | harm. |            |                    |
|        | material is dry  | waste |            |                    |
|        | the container is |       |            |                    |
|        | buried or        |       |            |                    |
|        | landfilled.      |       |            |                    |
+--------+------------------+-------+------------+--------------------+
| Safe   | Burial of waste  | Infec | Provides   | Soil can become    |
| b      | in a pit on      | tious | some       | polluted if        |
| urying | site. Access to  | waste | measure of | permeable.         |
|        | site should be   |       | human      |                    |
|        | limited. Pit     | S     | health and | Difficult to       |
|        | lined with clay, | harps | env        | prevent            |
|        | if available.    | waste | ironmental | scavenging.        |
|        |                  |       | protection |                    |
|        | To extend useful | Small | by making  |                    |
|        | life of pit,     | am    | waste      |                    |
|        | should be used   | ounts | ina        |                    |
|        | only for         | of    | ccessible. |                    |
|        | hazardous waste  | chem. |            |                    |
|        |                  | and   | Organic    |                    |
|        | Less than 1 kg   | p     | materials  |                    |
|        | buried at one    | harm. | will       |                    |
|        | time. Each layer | waste | eventually |                    |
|        | of waste is      |       | b          |                    |
|        | covered with a   |       | iodegrade. |                    |
|        | layer of earth.  |       |            |                    |
|        | Illustrated in   |       |            |                    |
|        | Prüss et al.     |       |            |                    |
|        | 1999, chapter 8, |       |            |                    |
|        | figure 8.12.     |       |            |                    |
+--------+------------------+-------+------------+--------------------+
| ***The |                  |       |            |                    |
| m      |                  |       |            |                    |
| ethods |                  |       |            |                    |
| below  |                  |       |            |                    |
| are    |                  |       |            |                    |
| in     |                  |       |            |                    |
| cluded |                  |       |            |                    |
| for    |                  |       |            |                    |
| c      |                  |       |            |                    |
| omplet |                  |       |            |                    |
| eness. |                  |       |            |                    |
| Ho     |                  |       |            |                    |
| wever, |                  |       |            |                    |
| they   |                  |       |            |                    |
| are    |                  |       |            |                    |
| un     |                  |       |            |                    |
| likely |                  |       |            |                    |
| to be\ |                  |       |            |                    |
| ava    |                  |       |            |                    |
| ilable |                  |       |            |                    |
| to     |                  |       |            |                    |
| most   |                  |       |            |                    |
| small  |                  |       |            |                    |
| -scale |                  |       |            |                    |
| faci   |                  |       |            |                    |
| lities |                  |       |            |                    |
| in     |                  |       |            |                    |
| most   |                  |       |            |                    |
| deve   |                  |       |            |                    |
| loping |                  |       |            |                    |
| c      |                  |       |            |                    |
| ountri |                  |       |            |                    |
| es.*** |                  |       |            |                    |
+--------+------------------+-------+------------+--------------------+
| Wet    | Similar to       | Infec | Efficient  | Shedder liable to  |
| T      | autoclaving.     | tious | at         | mechanical         |
| hermal | Waste is         | w     | dis        | failure.           |
| Tre    | shredded and     | astes | infecting. |                    |
| atment | exposed to       |       |            | May require        |
|        | high-pressure,   |       | Has no     | off-site           |
|        | high-temperature |       | s          | transport.         |
|        | steam.           |       | ignificant |                    |
|        |                  |       | env        | Cannot be used on  |
|        |                  |       | ironmental | pathological,      |
|        |                  |       | adverse    | pharmaceutical,    |
|        |                  |       | impacts.   | and chemical       |
|        |                  |       |            | waste.             |
|        |                  |       | High       |                    |
|        |                  |       | capacity.  | Requires qualified |
|        |                  |       | Relatively | operators.         |
|        |                  |       | low        |                    |
|        |                  |       | investment |                    |
|        |                  |       | and        |                    |
|        |                  |       | operating  |                    |
|        |                  |       | costs.     |                    |
+--------+------------------+-------+------------+--------------------+
| Mic    | Waste is         | Infec | Efficient  | Relatively high    |
| rowave | shredded,        | tious | dis        | capital and        |
| irrad  | humidified and   | w     | infection. | operating costs.   |
| iation | irradiated with  | astes |            |                    |
|        | microwaves. Heat |       | Envir      | Shedder liable to  |
|        | destroys         |       | onmentally | mechanical         |
|        | micro-organisms. |       | sound.     | failure.           |
|        |                  |       |            |                    |
|        |                  |       | Shredding  | May require        |
|        |                  |       | reduces    | off-site           |
|        |                  |       | waste      | transport.         |
|        |                  |       | volume.    |                    |
|        |                  |       |            | Cannot be used on  |
|        |                  |       |            | pathological,      |
|        |                  |       |            | pharmaceutical,    |
|        |                  |       |            | and chemical       |
|        |                  |       |            | waste.             |
|        |                  |       |            |                    |
|        |                  |       |            | Requires qualified |
|        |                  |       |            | operators.         |
+--------+------------------+-------+------------+--------------------+
| Sa     | Waste is         | Infec | Low-cost   | Requires access to |
| nitary | packaged to      | tious | option.    | sanitary landfill. |
| La     | minimize         | waste |            |                    |
| ndfill | exposure and     |       | Organic    | Transportation to  |
|        | placed in a      | S     | materials  | site creates many  |
|        | shallow hollow   | harps | may        | opportunities for  |
|        | dug below the    | waste | eventually | exposure.          |
|        | working face.    |       | b          |                    |
|        | Waste is then    | Small | iodegrade. | Improper handling  |
|        | immediately      | a     |            | of leachate        |
|        | covered with 2 m | mount |            | (liquid that       |
|        | of mature waste. | of    |            | filters through    |
|        |                  | chem. |            | the waste) can     |
|        | Alternatively,   | and   |            | cause water        |
|        | packaged waste   | p     |            | pollution and      |
|        | is placed in a 2 | harm. |            | potential public   |
|        | m-deep pit in    | waste |            | health risks.      |
|        | mature waste and |       |            |                    |
|        | covered          |       |            | May be difficult   |
|        | immediately.     |       |            | to prevent         |
|        |                  |       |            | scavenging.        |
|        | > Waste-picking  |       |            |                    |
|        | > must be        |       |            |                    |
|        | > prevented.     |       |            |                    |
+--------+------------------+-------+------------+--------------------+
| In all |                  |       |            |                    |
| cases  |                  |       |            |                    |
| where  |                  |       |            |                    |
| waste  |                  |       |            |                    |
| is     |                  |       |            |                    |
| tr     |                  |       |            |                    |
| eated, |                  |       |            |                    |
| the    |                  |       |            |                    |
| t      |                  |       |            |                    |
| reated |                  |       |            |                    |
| waste  |                  |       |            |                    |
| should |                  |       |            |                    |
| be     |                  |       |            |                    |
| buried |                  |       |            |                    |
| using  |                  |       |            |                    |
| safe   |                  |       |            |                    |
| burial |                  |       |            |                    |
| m      |                  |       |            |                    |
| ethods |                  |       |            |                    |
| or     |                  |       |            |                    |
| di     |                  |       |            |                    |
| sposal |                  |       |            |                    |
| in a   |                  |       |            |                    |
| sa     |                  |       |            |                    |
| nitary |                  |       |            |                    |
| lan    |                  |       |            |                    |
| dfill. |                  |       |            |                    |
+--------+------------------+-------+------------+--------------------+

Table 3.3 : Best management options by waste category\
for small-scale activities

+----------+-------------------------------------+--------------------+
| Type of  | Management Options                  | Comments           |
| waste    |                                     |                    |
+==========+=====================================+====================+
| Solid    | Autoclave, incinerate/burn, or bury | Autoclaving is     |
| in       |                                     | ineffective for    |
| fectious |                                     | pathological waste |
| waste    |                                     | such as body       |
|          |                                     | parts.             |
+----------+-------------------------------------+--------------------+
| Stools   | Isolate patients if possible and    |                    |
| from     | capture stool/excreta in a bucket.  |                    |
| patients |                                     |                    |
| with     | Disinfect this excreta by adding    |                    |
| cholera  | chlorine oxide powder, dehydrated   |                    |
| or other | lime oxide (CaO), bleach (sodium    |                    |
| forms of | hypochlorite) or other              |                    |
| diarrhea | disinfectant.                       |                    |
|          |                                     |                    |
|          | In case of epidemic, disinfect all  |                    |
|          | hospital sewage.                    |                    |
|          |                                     |                    |
|          | Pour treated stools into a pit      |                    |
|          | where they will be filtered by the  |                    |
|          | soil, but will not contaminate      |                    |
|          | drinking water.                     |                    |
+----------+-------------------------------------+--------------------+
| Blood    | Disinfect by adding chlorine oxide  |                    |
| and      | powder, dehydrated lime oxide       |                    |
| other    | (CaO), bleach (sodium hypochlorite) |                    |
| in       | or other disinfectant.              |                    |
| fectious |                                     |                    |
| bodily   | Pour treated fluids into a pit      |                    |
| fluids   | where they will be filtered by the  |                    |
|          | soil, but will not contaminate      |                    |
|          | drinking water.                     |                    |
+----------+-------------------------------------+--------------------+
| Sharps   | Separate from other waste.          |                    |
|          | Immediately after use put in        |                    |
|          | plastic, metal, or cardboard        |                    |
|          | container that will keep liquid     |                    |
|          | from leaking; cardboard containers  |                    |
|          | should be lined with plastic bags.  |                    |
|          |                                     |                    |
|          | If possible, containers should be   |                    |
|          | colored yellow and marked "SHARPS," |                    |
|          | "Infectious waste," "Dangerous," or |                    |
|          | something similar, in all relevant  |                    |
|          | languages.                          |                    |
|          |                                     |                    |
|          | Burn or encapsulate the sharps when |                    |
|          | containers reach ¾ full.            |                    |
|          |                                     |                    |
|          | If container is to be reused,       |                    |
|          | sterilize with bleach or other      |                    |
|          | disinfectant.                       |                    |
+----------+-------------------------------------+--------------------+
| Pharma   | In general, bury.                   | For more           |
| ceutical |                                     | information see:   |
| waste,   | -   If collected together with      | *Guidelines for    |
| small    |     infectious waste, small         | safe disposal of   |
| qu       |     quantities of pharmaceutical    | unwanted           |
| antities |     waste can be treated as         | pharmaceuticals in |
|          |     infectious waste. (I.e., follow | and after          |
|          |     the same procedures of          | emergencies*.      |
|          |     incineration/burning and safe   | World Health       |
|          |     burial.) Note: crush ampoules   | Organization,      |
|          |     and bury; these can explode if  | Geneva, 1999,      |
|          |     burned.                         | Chapter 4.         |
|          |                                     | http://whqlibdoc.  |
|          | ```{=html}                          | who.int/hq/1999/WH |
|          | <!-- -->                            | O_EDM_PAR_99.2.pdf |
|          | ```                                 |                    |
|          | -   If collected separately,        |                    |
|          |     encapsulate semi-solids.        |                    |
+----------+-------------------------------------+--------------------+
| Pharma   | Return to supplier.                 | Acceptable options |
| ceutical |                                     | are neither cheap  |
| waste,   | Subcontract for incineration in a   | nor easy and are   |
| large    | double-chamber incinerator that     | not likely to be   |
| qu       | operates at \>900°C, if available.  | readily available  |
| antities |                                     | to small-scale     |
|          | Water-soluble, mild                 | facilities, i.e.,  |
|          | pharmaceuticals, such as vitamin    | there is no safe   |
|          | solutions, cough syrups,            | way to dispose of  |
|          | intravenous solutions, eye drops,   | these materials.   |
|          | etc., may be diluted with large     | It is therefore    |
|          | amounts of water and discharged to  | critical to        |
|          | fast-flowing watercourses.          | minimize the       |
|          |                                     | amount of          |
|          | Other options are available for     | pharmaceutical     |
|          | some subcategories.                 | waste generated.   |
|          |                                     |                    |
|          | If no other option is available,    |                    |
|          | waste can be encapsulated.          |                    |
+----------+-------------------------------------+--------------------+
| Chemical | In general, bury.                   |                    |
| waste,   |                                     |                    |
| small    | If collected together with          |                    |
| qua      | infectious waste, small quantities  |                    |
| ntities. | of chemical waste can be treated as |                    |
|          | infectious waste (i.e., follow the  |                    |
|          | same procedures of                  |                    |
|          | incineration/burning and safe       |                    |
|          | burial).                            |                    |
+----------+-------------------------------------+--------------------+
| Chemical | Return to supplier.                 | Acceptable options |
| waste,   |                                     | are neither cheap  |
| large    | Subcontract for incineration in a   | nor easy and are   |
| qu       | double-chamber incinerator that     | not likely to be   |
| antities | operates at \>900°C, if available.  | readily available  |
|          |                                     | to small-scale     |
|          | Export to a location with adequate  | facilities, i.e.,  |
|          | facilities for safe disposal.       | there is no safe   |
|          |                                     | way to dispose of  |
|          | Other options are available for     | these materials.   |
|          | some subcategories.                 | It is therefore    |
|          |                                     | critical to        |
|          |                                     | minimize the       |
|          |                                     | amount of chemical |
|          |                                     | waste generated.   |
+----------+-------------------------------------+--------------------+
| PVC      | Bury.                               | DO NOT BURN. Doing |
| plastic  |                                     | so will create     |
| and      |                                     | highly toxic       |
| other    |                                     | pollutants and     |
| hal      |                                     | spread them over a |
| ogenated |                                     | wide area.         |
| m        |                                     |                    |
| aterials |                                     |                    |
+----------+-------------------------------------+--------------------+
| M        | E.g., broken thermometers,          | DO NOT BURN. Doing |
| aterials | manometers, rechargeable batteries. | so will spread     |
| co       |                                     | highly toxic       |
| ntaining | Capture mercury and reuse or        | pollutants over a  |
| heavy    | recycle via local cottage industry, | wide area.         |
| metals   | if available. Batteries may also be |                    |
|          | locally recyclable via cottage      |                    |
|          | industry.                           |                    |
+----------+-------------------------------------+--------------------+
| Pre      | Return undamaged containers to      | Do not             |
| ssurized | supplier.                           | burn/incinerate    |
| co       |                                     | because of high    |
| ntainers | Empty damaged containers completely | risk of explosion. |
|          | and recycle via local cottage       |                    |
|          | industries.                         |                    |
|          |                                     |                    |
|          | Small cans can be buried with ash,  |                    |
|          | residues and other waste on site.   |                    |
+----------+-------------------------------------+--------------------+
| Wa       | Treat using best available          |                    |
| sh-water | treatment system (see *Water Supply |                    |
| and      | and Sanitation* guideline in this   |                    |
| sewage   | volume for more information).       |                    |
|          |                                     |                    |
|          | If sewage will not be treated,      |                    |
|          | disinfect wash water by adding      |                    |
|          | chlorine oxide powder, dehydrated   |                    |
|          | lime oxide (CaO), bleach (sodium    |                    |
|          | hypochlorite) or other              |                    |
|          | disinfectant.                       |                    |
|          |                                     |                    |
|          | Pour treated liquid in a pit where  |                    |
|          | it will be filtered by the soil,    |                    |
|          | but will not contaminate drinking   |                    |
|          | water.                              |                    |
+----------+-------------------------------------+--------------------+
| Inc      | Bury in pit on site.                |                    |
| inerator |                                     |                    |
| ash/     |                                     |                    |
| residues |                                     |                    |
| from     |                                     |                    |
| burning  |                                     |                    |
+----------+-------------------------------------+--------------------+
| In all   |                                     |                    |
| cases    |                                     |                    |
| where    |                                     |                    |
| waste is |                                     |                    |
| treated, |                                     |                    |
| the      |                                     |                    |
| treated  |                                     |                    |
| waste    |                                     |                    |
| should   |                                     |                    |
| be       |                                     |                    |
| buried   |                                     |                    |
| using    |                                     |                    |
| safe     |                                     |                    |
| burial   |                                     |                    |
| methods  |                                     |                    |
| or       |                                     |                    |
| disposal |                                     |                    |
| in a     |                                     |                    |
| sanitary |                                     |                    |
| l        |                                     |                    |
| andfill. |                                     |                    |
+----------+-------------------------------------+--------------------+

### Minimum elements of a complete waste management program {#minimum-elements-of-a-complete-waste-management-program .unnumbered}

Small-scale facilities require a sound healthcare waste management
system to minimize damage to health and the environment caused by their
wastes. A comprehensive minimal program includes the following
practices:

1.  *A written waste management plan*. The plan describes all the
    practices for handling, storing, treating, and disposing of
    hazardous and non-hazardous waste, as well as types of worker
    training required. Usually drawn up after doing a comprehensive
    assessment of waste handling at the facility.

2.  *Clearly assigned staff responsibilities.* Make responsibilities
    clear so that workers feel accountable for how well tasks are
    completed and so that no step in the process is overlooked.

3.  *Written internal rules for generation, handling, storage,
    treatment, and disposal.* Formalize desired practices, as written
    rules may be better maintained.

4.  *Staff trained in safe handling, storage, treatment, and disposal.*
    Training is necessary to ensure that staff are aware of all hazards
    they might meet and that they are practicing good hygiene, safe
    sharps handling, proper use of protective clothing, proper packaging
    and labeling of waste, and safe storage of waste. Training helps
    ensure correct response to spills, injury, and exposure. Untrained
    workers handle wastes in ways that endanger themselves and the local
    community.

5.  *Protective clothing available.* Workers need specific types of
    clothing, such as surgical masks and gloves, aprons, and boots, to
    protect themselves when moving and treating various types of
    collected infectious waste.

6.  *Good hygiene practices.* Many infectious agents must enter the
    mouth or be swallowed to cause disease. Even if protective clothing
    is worn, some organisms will get on workers' hands and faces. Thus,
    workers need to wash their hands and faces regularly with soap and
    warm water. They get sick more often when they do not observe good
    hygiene practices.

7.  *Vaccinated workers.* Workers should be vaccinated against
    potentially deadly viral hepatitis B and tetanus infections.

8.  *Temporary storage containers in designated locations.* Hazardous
    healthcare wastes should be stored only for short periods---less
    than 24 hrs in the warm season in warm climates. Also, they should
    be put in a labeled, covered container in a fixed location---for
    example, a specific corner of the room. They should not be stored
    near patients or food.

9.  *Minimization, reuse, and recycling procedures.* The less waste
    generated, the less there is to manage. Unnecessary disposal of
    valuable chemicals and pharmaceuticals can be avoided through good
    inventory practices: for example, by using the oldest batch first;
    by never opening a new container before the last one is finished; by
    preventing products from being thrown out during routine cleaning;
    and by checking on delivery to make sure materials are not about to
    expire. Where possible and safe, using reusable syringes and needles
    generates approximately 0.5--2% of the waste of using disposables,
    and costs 5 to 15 times less. Minimize use of products containing
    PVC plastics. Competitively priced substitutes for PVC plastic are
    available that perform equally well.

10. *A waste segregation system.* Segregating (sorting and separating)
    waste both reduces the volume of waste and enables different kinds
    of materials to be handled appropriately. Approximately two-thirds
    of waste from small-scale facilities is general waste. Separating
    hazardous from general waste reduces the amount that must be treated
    by 75--90%. The dangers of sharp waste can be minimized when sharps
    are collected in separate puncture-proof containers. Other elements
    that can be segregated for separate handling, treatment, and/or
    disposal include hazardous liquids, chemicals and pharmaceuticals,
    PVC plastic, and materials containing heavy metals.

11. *Treatment methods for hazardous and highly hazardous waste.*
    Treatment options available to small-scale facilities for hazardous
    and highly hazardous waste are limited (see table 3.2 for details).
    **The most important function of treatment is disinfection.** It is
    the high concentration of infectious agents that makes infectious
    waste dangerous. Risks associated with current methods for managing
    healthcare waste exist because little is being done to reduce these
    concentrations prior to disposal. For rural facilities, burning in
    the open air in a drum or brick incinerator, or a single-chamber
    incinerator, preferably combined with good waste segregation
    practices, is the recommended option.

> Because the air pollution produced by burning poses a much greater
> hazard in urban areas, autoclaving of infectious waste combined with
> encapsulation of sharps may be the best option for urban facilities.
> If a larger nearby hospital with more advanced treatment and disposal
> systems is located nearby, small facilities could investigate
> piggy-backing on those systems, although precautions will need to be
> taken to reduce risks associated with transporting the waste.

12. *A final disposal site.* Facilities must have a place to dispose of
    waste that cannot be treated, and the residues from treated waste.
    **It is recom-mended that small-scale facilities bury waste on
    site,** ideally in a pit lined with clay or a similarly impermeable
    material to prevent contamination of ground water. Most urban
    facilities lack adequate space for on-site burial, and disposal in a
    public landfill may be the only option. However, many precautions
    must be taken under this option, to protect handlers and
    waste-pickers from infection. Sharps should be encapsulated to
    prevent accidental sticks and recovery for intentional reuse.

13. *A schedule for periodic review of adherence to the plan and
    effectiveness of the plan.* Maintaining good waste management
    practices is a process of continuous improvement. A program schedule
    must be established for regular follow-up to ensure planned
    practices are in place, are being carried out correctly, and are
    actually minimizing risk, damage and disease.

### First steps {#first-steps .unnumbered}

A facility does not need to do everything at once. Implementing just a
few key practices can dramatically reduce risk and improve the health
and safety of facility personnel, patients, and the surrounding
community. **If a facility does nothing else, AT A MINIMUM IT SHOULD
take the following four steps**:

1.  *Burn or incinerate the healthcare waste on site* (rural
    facilities)*.* Ideally, burning should be conducted in a
    single-chamber incinerator. Second in desirability is burning in a
    drum or brick incinerator. If no other option is available, burning
    may be conducted in open pits. (See table 3.2 for a description of
    the various treatment options) Alternatively, bury in small pits
    (e.g., 2 meters in depth and 2 meters on each side), but above the
    water table or lined with clay or plastic, and protected by a fence
    or other effective barrier (e.g., rows of thorny brush).

    *Autoclave infectious waste and encapsulate sharps* (urban and
    peri-urban facilities) and bury on site or

2.  *Segregate the waste*. Begin with sharps. Separate hazardous and
    general waste, if possible.

3.  *Motivate managers and other staff to follow new practices.*

4.  *Give workers minimal training in how to safely handle hazardous
    waste, including:*

-   personal hygiene---make soap and water readily available.

-   sharps handling, especially how to avoid being pricked with
    hypodermic needles that could transmit HIV/AIDS, viral Hepatitis B
    or C, or other blood-borne diseases.

-   use of protective clothing---provide thick gloves and aprons for
    staff handling healthcare waste.

Starting with these four steps is probably the best way for facilities
with limited resources to begin working towards a complete minimal
healthcare waste management program.

An outline of such an approach can be found in *Safe Management of
Healthcare Waste at Health Posts and other Small-Scale Facilities* in
Annex\_\_\_. This guide is designed as a supplement to *Safe management
of wastes from health-care activities*, edited by A. Prüss, E. Giroult
and P. Rushbrook (see reference list). Available at
<http://www.who.int/water_sanitation_health/Environmental_sani/MHCWHanbook.htm>.

##### Note on facility siting and design: {#note-on-facility-siting-and-design .unnumbered}

To minimize the potential spread of disease and environmental impact
when planning a new facility, healthcare planners should:

1.  Select a location with easy access to safe drinking water. The
    drinking water source should be dedicated exclusively to the
    facility, if possible, to reduce the risk of spreading disease.

2.  Install adequate sanitation facilities to prevent the spread of
    disease from infected patients.

3.  Avoid locations adjacent to schools to minimize children's risk of
    exposure.

4.  Pick a location where waste can be safely buried (e.g., above the
    water table and protected from scavenging) or easily shipped off
    site off safe disposal in a sanitary landfill.

### Sector Program Design---Questions to help guide development of a healthcare waste management program {#sector-program-designquestions-to-help-guide-development-of-a-healthcare-waste-management-program .unnumbered}

The following is a list of questions to help guide development of a
healthcare waste management program:

#### General facility information {#general-facility-information .unnumbered}

1.  How many employees will the facility/facilities have?

2.  How many patients will the facility serve on a daily basis? How many
    beds will the facility have, and what is the expected bed occupancy
    rate?

3.  How broad a range of health services will the facility conduct?
    Family planning or HIV testing services only? Mother and infant
    health support? General primary care? What kinds of resources will
    these services require: Distribution of pharmaceuticals? Laboratory
    facilities for testing? Food preparation? Bathing? Laundry?

#### Handling of healthcare waste  {#handling-of-healthcare-waste .unnumbered}

4.  How much and what types of healthcare waste will be generated
    routinely, e.g., infectious sharps? What materials are used and
    stored that could at some point become waste, e.g., (expired)
    pharmaceuticals?

5.  How much of this will be hazardous or highly hazardous waste?

6.  How and where will the facility's healthcare waste be stored before
    collection and/or treatment?

7.  How much segregation (separation) of waste is feasible? Sharps from
    other? Sharps and hazardous from general waste? Separate collection
    of sharps, hazardous and highly hazardous wastes?

8.  What will happen to bath water? Water from laundry operations?

9.  Where will patient urine and excreta be disposed of?

#### Treatment and disposal of healthcare waste {#treatment-and-disposal-of-healthcare-waste .unnumbered}

10. How will waste be treated? If it will be burned, how will the
    remaining ash and materials be handled and disposed of?

11. If waste is to be transported off site, how will this be done? How
    will the waste be packaged? What types of vehicles will be used to
    transport the waste? What precautions will be taken to protect
    handlers and bystanders?

12. Will any of the waste be taken to a dump or landfill site? If so,
    how will it be handled at this facility? Will it be buried
    immediately after arriving at the landfill/dump? Will it be burned
    on site? Is it likely to be left unattended at any time after being
    unloaded?

13. If there is open access to the landfill/dump, will waste-pickers,
    children, others be at risk?

14. Is there potential danger of well or ground water contamination from
    wastewater, or patient excreta or urine? How can these potential
    effects be mitigated?

#### Management issues {#management-issues .unnumbered}

15. Who will be responsible for healthcare waste management at the
    healthcare facility?

16. What are the current operational standards for healthcare waste, and
    what are the applicable national, regional, and local policies?

### Minimal Program Checklist and Action Plan {#minimal-program-checklist-and-action-plan .unnumbered}

Small-scale facilities require a sound healthcare waste management
system to minimize adverse health and environmental impacts caused by
their wastes. The following elements of a complete minimal healthcare
waste management program should be in place in all facilities. Adapted
from "Healthcare waste: Generation, handling, treatment and disposal,"
in Environmental Guidelines for Small Scale Activities in Africa, 2nd
Edition (Working Draft). Washington, D.C., USAID AFR/SD. 2002.
[http://www.encapafrica.org/EGSSAAsectionsfrom18Jun01draft/EGSSAA3-13medwastedraft.pdf]{.underline}

+---------------------------------------------+----+-----+----+------+
| > **Elements/Actions**                      | ** | *   | ** | *    |
|                                             | In | *By | By | *Out |
|                                             | Pl | Who | Wh | come |
|                                             | ac | m** | en | Ex   |
|                                             | e? |     | ** | pect |
|                                             | ** |     |    | ed** |
+=============================================+====+=====+====+======+
| > **Written Plans and Procedures**          |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 1.  A written waste management plan\        |    |     |    |      |
|     Describing all the practices for        |    |     |    |      |
|     handling, storing, treating, and        |    |     |    |      |
|     disposing of hazardous and              |    |     |    |      |
|     non-hazardous waste, as well as types   |    |     |    |      |
|     of worker training required.            |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 2.  Internal rules for generation,          |    |     |    |      |
|     handling, storage, treatment, and       |    |     |    |      |
|     disposal of healthcare waste.           |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 3.  Clearly assigned staff responsibilities |    |     |    |      |
|     that cover all steps in the waste       |    |     |    |      |
|     management process.                     |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 4.  Staff waste handling training curricula |    |     |    |      |
|     or a list of topics covered.            |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 5.  Waste minimization, reuse, and          |    |     |    |      |
|     recycling procedures.                   |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| > **Staff Training, Practices, and          |    |     |    |      |
| > Protection**                              |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 6.  Staff trained in safe handling,         |    |     |    |      |
|     storage, treatment, and disposal.       |    |     |    |      |
|                                             |    |     |    |      |
| -   Do staff exhibit good hygiene, safe     |    |     |    |      |
|     sharps handling, proper use of          |    |     |    |      |
|     protective clothing, proper             |    |     |    |      |
|                                             |    |     |    |      |
| -   packaging and labeling of waste, and    |    |     |    |      |
|     safe storage of waste?                  |    |     |    |      |
|                                             |    |     |    |      |
| -   Do staff know the correct responses for |    |     |    |      |
|     spills, injury, and exposure?           |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 7.  Protective clothing available for       |    |     |    |      |
|     workers who move and treat collected    |    |     |    |      |
|     infections waste such as surgical masks |    |     |    |      |
|     and gloves, aprons, and boots.          |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| > **Staff Training, Practices, and          |    |     |    |      |
| > Protection cont'd.**                      |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 8.  Good hygiene practices. Are soap and,   |    |     |    |      |
|     ideally, warm water readily available   |    |     |    |      |
|     workers to use and can workers be       |    |     |    |      |
|     observed regularly washing.             |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 9.  Workers vaccinated for against viral    |    |     |    |      |
|     hepatitis B, tetanus infections, and    |    |     |    |      |
|     other endemic infections for which      |    |     |    |      |
|     vaccines are available.                 |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| > **Handling and Storage Practices**        |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 10. Temporary storage containers and        |    |     |    |      |
|     designated storage locations.           |    |     |    |      |
|                                             |    |     |    |      |
| 11. Are there labeled, covered, leak-proof, |    |     |    |      |
|     puncture-resistant temporary storage    |    |     |    |      |
|     containers for hazardous healthcare     |    |     |    |      |
|     wastes?                                 |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 12. Minimization, reuse, and recycling      |    |     |    |      |
|     procedures.                             |    |     |    |      |
|                                             |    |     |    |      |
| -   Does the facility have good inventory   |    |     |    |      |
|     practices for chemicals and             |    |     |    |      |
|     pharmaceuticals, i.e.:                  |    |     |    |      |
|                                             |    |     |    |      |
| ```{=html}                                  |    |     |    |      |
| <!-- -->                                    |    |     |    |      |
| ```                                         |    |     |    |      |
| -   use the oldest batch first;             |    |     |    |      |
|                                             |    |     |    |      |
| -   open new containers only after the last |    |     |    |      |
|     one is empty; procedures to prevent     |    |     |    |      |
|     products from being thrown out during   |    |     |    |      |
|     routine cleaning; and                   |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 13. A waste segregation system.             |    |     |    |      |
|                                             |    |     |    |      |
|     -   Is general waste separated from     |    |     |    |      |
|         infectious/hazardous waste?         |    |     |    |      |
|                                             |    |     |    |      |
|     -   Is sharp waste (needles, broken     |    |     |    |      |
|         glass, etc.) collected in separate  |    |     |    |      |
|         puncture-proof containers?          |    |     |    |      |
|                                             |    |     |    |      |
|     -   Are other levels of segregation     |    |     |    |      |
|         being applied e.g. hazardous        |    |     |    |      |
|         liquids, chemicals and              |    |     |    |      |
|         pharmaceuticals, PVC plastic, and   |    |     |    |      |
|         materials containing heavy metals   |    |     |    |      |
|         ((these are valuable, but less      |    |     |    |      |
|         essential)?                         |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| > **Handling and Storage Practices          |    |     |    |      |
| > cont'd.**                                 |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 14. Temporary storage containers and        |    |     |    |      |
|     designated storage locations.           |    |     |    |      |
|                                             |    |     |    |      |
| -   Are there labeled, covered, leak-proof, |    |     |    |      |
|     puncture-resistant temporary storage    |    |     |    |      |
|     containers for hazardous healthcare     |    |     |    |      |
|     wastes?                                 |    |     |    |      |
|                                             |    |     |    |      |
| -   Is the location distant from patients   |    |     |    |      |
|     or food?                                |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| > **Treatment Practices**                   |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 15. Frequent removal and treatment of waste |    |     |    |      |
|                                             |    |     |    |      |
| -   Are wastes collected daily?             |    |     |    |      |
|                                             |    |     |    |      |
| -   Are wastes treated with a frequency     |    |     |    |      |
|     appropriate to the climate and season?  |    |     |    |      |
|                                             |    |     |    |      |
| ```{=html}                                  |    |     |    |      |
| <!-- -->                                    |    |     |    |      |
| ```                                         |    |     |    |      |
| -   Warm season in warm climates within     |    |     |    |      |
|     **24 hrs**                              |    |     |    |      |
|                                             |    |     |    |      |
| -   In the cool season in warm climates     |    |     |    |      |
|     within **48 hrs**                       |    |     |    |      |
|                                             |    |     |    |      |
| -   In the warm season in temperate         |    |     |    |      |
|     climates within **48 hrs**              |    |     |    |      |
|                                             |    |     |    |      |
| -   In the cool season in temperate         |    |     |    |      |
|     climates within **72 hrs**              |    |     |    |      |
+---------------------------------------------+----+-----+----+------+
| 16. Treatment mechanisms for hazardous and  |    |     |    |      |
|     highly hazardous waste. [(The most      |    |     |    |      |
|     important function of treatment is      |    |     |    |      |
|     disinfection).]{.underline}             |    |     |    |      |
|                                             |    |     |    |      |
| -   Are wastes being burned in the open     |    |     |    |      |
|     air, in a drum or brick incinerator, or |    |     |    |      |
|     a single-chamber incinerator?           |    |     |    |      |
|                                             |    |     |    |      |
| -   If not are they being buried safely (in |    |     |    |      |
|     a pit with an impermeable plastic or    |    |     |    |      |
|     clay lining)?                           |    |     |    |      |
|                                             |    |     |    |      |
| -   Is the final disposal site (usually a   |    |     |    |      |
|     pit) surrounded by fencing or other     |    |     |    |      |
|     materials and in view of the facility   |    |     |    |      |
|     to prevent accidental injury or         |    |     |    |      |
|     scavenging of syringes and other        |    |     |    |      |
|     medical supplies?                       |    |     |    |      |
|                                             |    |     |    |      |
| -   If the waste is transported off-site,   |    |     |    |      |
|     are precautions taken to ensure that it |    |     |    |      |
|     is transported and disposed of safely?  |    |     |    |      |
+---------------------------------------------+----+-----+----+------+

**For more detailed checklists and guidance consult**: Safe management
of wastes from health-care activities, edited by A. Prüss, E. Giroult
and P. Rushbrook. Geneva, WHO, 1999, 228 pages. Available at:
[http://www.who.int/water_sanitation_health/Environmental_sanit/MHCWHanbook.htm.
English]{.underline} (French and Spanish in preparation).

### References and Useful Resources {#references-and-useful-resources .unnumbered}

-   ***Safe management of wastes from health-care activities*,** edited
    by A. Prüss, E. Giroult and P. Rushbrook. Geneva, WHO, 1999, 228
    pages. Available at:
    http://www.who.int/water_sanitation_health/Environmental_sanit/MHCWHanbook.htm.
    English (French and Spanish in preparation). Can be ordered from
    WHO, MDI, CH-1211 Geneva 27 (e-mail: publications@who.ch). Price:
    SwF 72, SwF 50.40 for developing countries.

    This comprehensive handbook recommends safe, efficient and
    sustainable methods for the handling, treatment and disposal of
    wastes from healthcare activities. It addresses a variety of
    technical options, as well as organizational and policy issues
    essential in managing healthcare wastes. The handbook is targeted at
    public health professionals, regulators, and hospital managers and
    administrators.

-   ***Teacher's Guide -- Management of wastes from health-care
    activities***, A. Prüss & W.K. Townend, World Health Organization,
    Geneva, 1998, 227 pages. Available at:
    http://www.who.int/environmental_information/Information_resources/worddocs/HCteachguid/health_care_wastes_teacher.htm
    . English (French and Spanish in preparation). Can be ordered from
    WHO, MDI, CH-1211 Geneva 27 (e-mail: publications@who.ch) Price: SwF
    35.-, SwF 24.50 for developing countries.

    The Teacher's Guide accompanies the WHO handbook on management of
    wastes from healthcare activities described above. It provides
    teaching materials (ready-to-copy texts for overhead transparencies,
    lecture notes, handouts, exercises and course evaluation forms) and
    recommendations for a three-day training course. It is designed
    mainly for managers of healthcare establishments, public health
    professionals and policy-makers.

-   ***Guidelines for safe disposal of unwanted pharmaceuticals in and
    after emergencies**.* World Health Organization, Geneva, 1999, 31
    pages. Available at:\
    http://whqlibdoc.who.int/hq/1999/WHO_EDM_PAR_99.2.pdf. Can be
    ordered from WHO, MDI, CH-1211 Geneva 27 (e-mail:
    publications@who.ch). Price: CHF 8.-, CHF 5.60 for developing
    countries.

    Practical guidance on the disposal of drugs in difficult situations
    in or after emergencies, in relation to armed conflicts, natural
    disasters or others. In such situations, large quantities of
    unwanted drugs may accumulate due to difficulties, mismanagement of
    stocks and inappropriate donations. The guidance provided consists
    of relatively simple and low-cost measures and is addressed to local
    authorities, healthcare personnel or other professionals confronted
    with these kinds of problems.

-   ***Vital to Health? Briefing Document for Senior Decision-Makers,
    1998.*** World Health Organization/US Agency for International
    Development (USAID). Contact: WHO Headquarters, attention Mario
    Conde, CH 1211, Geneva 27, Switzerland. Tel 41-22-791-4374 or US
    Agency for International Development, Children's Vaccine Programme,
    Office of Health and Nutrition, 3.07-037 Ronald Reagan Building,
    Washington DC 20523. Tel 1-202-712-4808, Fax 1-202-216-3702.

    This document provides information on unsafe injections. It
    illustrates misuse of medical sharps, and circumstances that lead to
    misuse. The document provides detailed information about safety
    standards for disinfecting sharps and their disposal. It also
    addresses the choice of different kinds of injection equipment and
    the issue of waste management.

-   ***Healthcare Waste Management Guidance Note.*** Johannessen**,**
    Lars M. et al.*,* Waste Management HNP Anchor Team. The World Bank,
    2000, 68 pages. Available at:\
    <http://wbln0018.worldbank.org/hdnet/hddocs.nsf/c0d65c5ea6fcb4688525670c004d14c2/0d87e869807f2f69852568d20054e66b>.

    A working document that attempts to synthesize currently available
    knowledge and information in healthcare waste management. It is
    meant to complement WHO's guidelines and provide particular
    information necessary for World Bank projects. Gives attention to
    management and policy issues and technical background on particular
    issues in greater detail than the WHO guidelines.

-   ***Managing medical wastes in developing countries: report of a
    Consultation on Medical Wastes Management in Developing
    Countries***, Geneva, September 1992. World Health Organization,
    Geneva, 1994. Available at:
    http://whqlibdoc.who.int/hq/1994/WHO_PEP_RUD_94.1.pdf.
    WHO/PEP/RUD/94.1. Unpublished document.

    This report is concerned with waste management practices in
    hospitals and other facilities which are associated with health
    care. It promotes procedures and facilities to reduce the risk of
    disease transmission and the occurrence of accidents associated with
    such wastes. The main focus is on countries in tropical areas and
    those which are seriously constrained by the lack of financial
    resources and trained manpower.

-   **Safe Management of Healthcare Waste at Health Posts and other
    Small-Scale Facilities** (Draft). 2000. USAID AFR/SD and REDSO/ESA.
    Available at:
    <http://www.encapafrica.org/resource_docs/USAID_Healthcare_Wastemanagement_Guide.pdf>

    A quick but thorough introduction to healthcare waste hazards and
    practices to minimize those hazards. Designed to be used in
    conjunction with. *Safe management of wastes from health-care
    activities*, Prüss et al., 1999, World Health Organization.
    Emphasizes an incremental approach to healthcare waste management at
    small-scale facilities. Designed to address the practices most
    predominant in Africa.

-   **Healthcare or Health Risks? Risks from Healthcare Waste to the
    Poor**, Jenny Appleton and Mansoor Ali, WELL, Loughborough
    University 2000

> Study considers relative risk of various potential adverse
> environmental impacts of healthcare waste and considers these in
> relation to people most likely to be exposed to risk focusing
> particularly on the poor. The report provides examples of good
> practice and suggests an overall strategy for healthcare waste
> management that stresses an incremental approach with attention to
> areas of highest risk.