MANAGING WASTE FROM HEALTH CARE ACTIVITIES

1. 1 MANAGING WASTE FROM HEALTH CARE ACTIVITIES General Directorate of Infection Prevention and Control 1432-2011

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3. 3 DEFINITIONS Healthcare Waste Waste from all health care activities (biological and non-biological) which is generated as a result of patient diagnosis, immunization or treatment, and discarded and not intended for use Hazardous health-care waste Waste materials that come from sources that could be potentially contaminated with an infectious, chemical and/or radioactive agents wich is about 10 - 25% of healthcare waste.

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5. 5 Major sources of health-care waste Hospitals Private clinics Laboratories Immunization campaigns Animal Research Blood banks Nursing Homes Autopsy centers Are their other important sites where care is given? Are their other important sites where care is given?

6. 6 Physician’s clinics Psychiatric clinics Dental clinics Home health-care Midwives offices Cosmetic piercing Tattooing Institutions for the disabled Minor sources of health-care waste

7. 7 Why does this waste matter? Impacts on patients, workers, and community Volume and permanence of waste Health care institutions generate about 3.5 kg of waste per bed per day (range 0.2 kg to 10 kg) May contain infectious organisms, including drug resistant ones May place cancer causing agents into air or ground water May cause radiation-related illnesses May cause injury (sharps, explosion) May cause congenital defects or stillbirth, prematurity, infertility

8. 8 Risks depend on: Severity of acute or chronic exposure Duration of exposure Frequency of exposure Concentration agent Individual vulnerability (pregnancy, weight, …ect) Route of exposure (skin, respiratory, oral, …etc) Mitigating circumstances (PPE, …etc)

9. 9 Who is at risk? Doctors: anesthesia, pathologists, Nurses: OR, ER, and oncology department Hospital support staff, X-ray assistants, pharmacy, morgue, and lab staff Cleaning staff General public

10. 10 Hazardous health-care waste Infectious waste e.g. sharps, laboratory waste, and pathology waste Chemical waste e.g. heavy metals, left over chemicals, and pesticides Pharmaceutical waste e.g. live viruses, and expired drugs Radioactive waste Can you give examples? Are there other types of hazards? Can you give examples? Are there other types of hazards?

11. 11 Communicate about the Work-place Hazards Job description Posters on doors Labels on hazards Give feedback on use of PPE and disposal in eval. Role model safe use and disposal

12. 12 Recycle Products When Possible Examples of labels for plastic: Type 1 and 2 are commonly recycleable. Other symbols: nickel cadmium batteries, paper, food and organic waste for gardening, CFC labels for refrigerant gas. Type 1 - PETE Polyethylene Terephthalate (PET) Soda & water containers, some waterproof packaging. * Type 2 - HDPE High-Density Polyethylene Milk, detergent & oil bottles. Toys and plastic bags. * Type 3 - V Vinyl/Polyvinyl Chloride (PVC) Food wrap, vegetable oil bottles, blister packages. * Type 4 - LDPE Low-Density Polyethylene Many plastic bags. Shrink wrap, garment bags. * Type 5 - PP Polypropylene Refrigerated containers, some bags, most bottle tops, some carpets, some food wrap. * Type 6 - PS Polystyrene Throwaway utensils, meat packing, protective packing. * Type 7 - OTHER Usually layered or mixed plastic. No recycling potential - must be landfilled. Examples of labels for plastic: Type 1 and 2 are commonly recycleable. Other symbols: nickel cadmium batteries, paper, food and organic waste for gardening, CFC labels for refrigerant gas. Type 1 - PETE Polyethylene Terephthalate (PET) Soda & water containers, some waterproof packaging. * Type 2 - HDPE High-Density Polyethylene Milk, detergent & oil bottles. Toys and plastic bags. * Type 3 - V Vinyl/Polyvinyl Chloride (PVC) Food wrap, vegetable oil bottles, blister packages. * Type 4 - LDPE Low-Density Polyethylene Many plastic bags. Shrink wrap, garment bags. * Type 5 - PP Polypropylene Refrigerated containers, some bags, most bottle tops, some carpets, some food wrap. * Type 6 - PS Polystyrene Throwaway utensils, meat packing, protective packing. * Type 7 - OTHER Usually layered or mixed plastic. No recycling potential - must be landfilled.

13. 13 Provide References and Resources Let your hospital know you can help find the answer,even if you are not an expert today. Identify people, agencies, societies and books that can give information about the hazards of certain chemicals, answer legal and technical waste disposal questions.

14. 14 Have written policies on waste disposal Sharps and infectious waste Chemotherapy (cancer) Heavy metals Chemicals

15. 15 Track exposures (incident reporting) Critical event analysis is a method of objectively looking at an accident to identify preventable causes. It looks for systematic causes and not to blame individuals. Discuss exposures confidentially in Infection Control Committee meetings

16. 16 12. Conduct walk-around interviews Ask about the hazardous substances they work with, how they think they should dispose of them, and what they need to be able to dispose of them properly, problem solve. Janitors can be key reinforcers of sharps waste disposal by reporting sharps in garbage.

17. 17 It does not pose a special handling problem or hazard to human or the environment (e.g. domestic type waste, packing materials, …ect) It can safely be dealt with in the same way as general municipal waste. Large containers used to store ordinary waste should be leak-proof and protected against scavengers (e.g. rodents, dogs, cats, …ect). Recycling should be practiced where feasible (e.g. paper, glass, plastics, ...ect) Ordinary Waste

18. 18 Infectious Waste Portion of waste that could potentially transmit an infectious disease (materials contaminated with infectious agents) It pose a significant hazard to human, general public, or the environment when improperly stored, transported, treated, or disposed

19. 19 Categories of Infectious Waste Contaminated Sharps Discarded sharps (e.g., needles, scalpels) pose the greatest risk for injuries & should be considered as infectious waste It represent a significant occupational hazard to those responsible for handling and disposing However, once contaminated sharps are properly placed into appropriate sharp containers, their environmental risk is negligible The risk of infection is related to: Dose of pathogenic organisms (e.g. HBV, HCV, or HIV) Provision of a portal of entry into a susceptible (e.g. puncture or cut).

20. 20 Categories of Infectious Waste Microbiologic Cultures & stocks Of all of categories of infectious waste, they pose the greatest potential for infectious disease transmission (as they contain high concentrations of pathogenic organisms) if cultures and stocks stored in glass containers (e.g., tubes) are broken, they are considered as contaminated sharps On-site treatment is needed by autoclaving with subsequent disposal as non hazardous solid waste

21. 21 Animal Wastes Discarded material originating from animals inoculated with infectious agents considered as infectious waste. As they may contain high concentrations of pathogenic organisms (are similar to microbiologic cultures and stocks and handled in the same manner) Categories of Infectious Waste

22. 22 Categories of Infectious Waste Blood and Blood Products Include serum, plasma, and components known or suspected to be contaminated with a transmissible agent Small dried amounts of these materials represent an insignificant hazard once they are properly contained (e.g. contaminated dressings or disposable items) Bulk blood, blood-tinged fluids, excretions, and secretions represent a significant hazard (they may be splashed onto mucous membranes and/or the container may break and become a contaminated sharps)

23. 23 Categories of Infectious Waste Blood and Blood Products Methods of Treatment : Contaminated fluids (e.g. suctioned blood, blood-tinged fluids, …ect ) can be poured down into sanitary sewer designed for the disposal of human waste

24. 24 Pathology Wastes Include human tissues and body parts that are collected at autopsy or during surgery Most of these materials do not fit the definition of infectious waste (as they are usually soaked in alcohol or formaldehyde and seldom contain pathogens). Methods of Treatment : Pathology wastes are collected in red bags for burial Incineration or grinding and discharging into a sanitary sewer are also available methods of treatment Categories of Infectious Waste

25. 25 Non-included Wastes Suggested categories without scientific justification for their inclusion. You must keep in mind that the waste discharged from healthcare facilities differs a little from that in normal households and most persons with infectious diseases are not hospitalized Categories of Infectious Waste

26. 26 Includes solids, liquids and gaseous waste contaminated with radionuclide It can be generated from: - In vitro : Analysis of body fluids and tissues - In vivo : Body organ imaging and tumor localization Therapeutic procedures Radioactive Waste

27. 27 Chemical waste may be hazardous or non-hazardous. Chemical waste Includes: discard solid, liquid, and gaseous chemicals used for diagnostic and experimental work, cleaning, housekeeping Left over or expired chemical substances and drugs discard medical or laboratory chemicals Chemical Waste

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29. 29 Hazardous chemical waste: Toxic. Corrosive (pH <2 or >12). Flammable. Reactive (explosive, water reactive, or shock sensitive). Genotoxic (carcinogenic, mutagenic) e.g. cytotoxic drugs. Non-hazardous chemical waste: other than those described above (e.g. sugars, amino acids, and some organic and inorganic salts) Chemical Waste

30. 30 Components of infectious waste management plan Designation Segregation Packaging Storage Transport Infectious Waste Management

31. 31 Designation Development of definitions for infectious and non-infectious wastes to sort the discarded materials into the proper waste stream Definitions for sorting of waste must accord to safety, and cost-reduction regulations Development of a list of infectious wastes generated in the facility with identification of the generating areas is recommended (e.g. blood/blood products known or suspected to be contaminated with infectious agents are generated in out-patient clinics, surgery departments, and emergency rooms). Infectious Waste Management

32. 32 Segregation Segregation must be started by the user directly at the point of origin into appropriate designated containers: Infectious Waste Management

33. 33 Segregation Approved infectious waste containers that is lined with suitable standard infectious waste plastic bags are appropriate for bulk solid or semisolid infectious wastes, or disposables containing residual liquids Approved sharps containers are appropriate for Sharps (e.g. syringes, needles, and broken glass) Infectious Waste Management

34. 34 Infectious Waste Management Segregation Sharps must be discarded intact and needles must never be recapped, bent, or broken by hand before being discarded Sharps container should not be overfilled (no more than 2/3 or 3/4 full) to be sealed securely before transportation Plastic bags should not be overfilled (waste should not exceed 2/3 or 3/4 of the bag capacity before being closed securely with plastic tape)

35. 35 Infectious Waste Management Segregation If a member of staff is injured by sharp waste, he or she should directly seek medical attention. Staff involved in waste handling should be vaccinated for Hepatitis B and Tetanus. Waste spillage should be regarded as a potential hazard and dealt with immediately.

36. 36 Packaging Safe proper containment of infectious waste that: Protect patients, staff, visitors, and the public from potential exposure to infectious materials Facilitate safe handling, storage, treatment, and/or disposal of the waste (integrity must be maintained during collection, transport, storage, and disposal) Infectious Waste Management

37. 37 Requirements of infectious waste plastic bag : Made of material that is environmentally acceptable Impervious, leak proof, and tear resistant (according to standards of American Society for Testing and Materials ) color-coded (e.g. yellow) & labeled with a biohazard label Infectious Waste Management

38. 38 Requirements of infectious waste container : Rigid (made of metal or strong plastic) Impervious and leak proof color-coded & labeled with a biohazard label equipped with lid that can be opened and closed easily by foot Infectious Waste Management

39. 39 Requirements of sharps container : Rigid (made of rigid cardboard or strong plastic that is environmentally acceptable) Puncture resistant Impervious, leak proof on the sides and bottom Its opening can be used easily with restriction of removal of discarded sharp items, and securely closable. Labeled with a biohazard warning label Easily accessible Infectious Waste Management

40. 40 Storage Waste can be transported to final treatment daily or stored in approved suitable cold storage area for a maximum of 2 to 3 days after collection date Requirements for storage area Limited access & away from people traffic (secured against unauthorized people, scavengers, and insects) Well ventilated, and kept cool Has biohazard symbol Walls and floor are easily cleaned and disinfected Provided with water source and floors slope to drain into sanitary sewer Infectious Waste Management

41. 41 Infectious Waste Management Requirements for storage area The organs or any part of human body should be kept in refrigeration until handled according to Islamic Fatwa No. 8099 dated 21 safer 1405H.

42. 42 Transport Integrity of the packaging containers of infectious waste must be maintained during transportation Internal (on-site) Transport Approved carts are used for on-site transportation of infectious waste Requirements of on-site transportation carts Made of metal or strong plastic Equipped with lid that can be tightly closed, and used only for that purpose. Suitable capacity (about 5 waste bags) & Leak-proof Easily cleanable or can be lined with plastic Infectious Waste Management

43. Stainless Steel or any material resists thermo chemical disinfection ; Sealed Doors Trolley with Castors and protective features Trolley must be washed and disinfected before recirculation again.

44. Carts and Containers Washing ; Disinfecting and Drying High Level disinfection; Thermal Disinfection is recommended Drying is a must before re use. Automatic system for bulk items Manual steam water detergent Gun

45. 45 External (off-site) Transport Licensed vehicles should be employed for off-site transportation of infectious waste Requirements of off-site transportation trucks Suitable capacity & Leak-proof Easily cleanable or can be lined with plastic Displaying biohazard symbol, and registered in accordance with municipal and national regulations (Appropriately licensed commercial companies may be contracted for off-site transport and treatment of healthcare wastes) Infectious Waste Management

46. Special Cars with Internal Stainless steel walls Doors are fully sealed Cabinet with Low Temperature Temperature alarms Car Washing Area Distance/Temperature Tracking of service

47. 47 Infectious Waste Management Treatment Method is determined by amount of infectious waste generated, the capabilities of the facility, and the cost effectiveness of on-site treatment versus contracting the service to a licensed commercial facility Incineration Steam/gas sterilization Chemical disinfection Modern alternative technologies (e.g. microwave, infrared, and laser technologies) Efficacy of the method selected should be monitored

48. 48 Infectious Waste Management Training For all personnel involved in the generation, handling, transporting, treatment or disposal of infectious waste Should be included in hospital continuous training program, and given to all new personnel Training program must be suitable for personnel who may not be fluent in Arabic and English languages, or who may be semi-literate, and periodically updated Records for waste handling training must be maintained All personnel who have been trained and designated to handle waste should not be replaced by the contracted company without reporting IC team

49. 49 Infectious Waste Management Training Training program should fulfill the following items: Hazards of healthcare waste Definition of infectious waste and methods of prevention of related HAIs Safe handling of infectious waste; appropriate PPE, hand hygiene, …ect Labeling or coding of infectious waste Safety procedures for management of chemical, pharmaceutical, and radioactive waste Post exposure management

50. 50 THANK YOU