Safe Handling of Health Care Waste
Contents
1. This section shows how to disinfect waste so that it can be safely buried Apart from re usable syringes this chapter does not show how to sterilize surgical tools or other materials that will be re used What is sterilizing and what is disinfecting Some manuals about treating health care equipment and waste use the word sterilizing rather than disinfecting Sterilizing and disinfecting are not the same and many people confuse them Sterilizing means killing all of the germs on something It is very difficult to do Disinfecting means killing enough of the germs on something that so it will not transmit infection Many people use the word sterilization for proper treatment of health care equipment and the word disinfection when talking about cleaning floors and other surfaces with disinfecting cleaners But there are different levels of disinfection The treatments described in this book are high level disinfection which means killing almost all the germs on something For this reason we use the word disinfection for all of the methods in this book Any materials in a health center that are contaminated with blood body fluids or feces or that have been in close contact with a person with a contagious disease will need to be disinfected to prevent the spread of infection and disease See pages 13 to 22 for ways to disinfect and dispose of wastes What wastes need to be disinfected Wastes that need disinfection2. never in hallways bathrooms wash basins or other places where people might spill them or fill them with mixed waste Seal waste bins and bags when they are only full as a safety measure The full bins and bags are less likely to spill or break reducing the chances of injury to a worker picking up waste If a bag breaks or leaks put it inside another bag before moving it through the health center Store the sealed bags in a closed room until they can be removed from the site The room should be secure from scavenging and from animals Health care waste can only be stored safely for specific amounts of time before it begins to smell bad and risk spreading infection as it decomposes Moderate climate 3 days in winter and 2 days in summer Warm climates 2 days during cool season and 1 day during hot season After these times waste must be treated or transported away from the center Carts or trolleys which are easy to clean after each use and have no sharp edges that could damage bags or containers during loading or unloading are safest for transporting waste Protect yourself and others when handling waste Workers in health centers people Safety glasses can protect PEESI who collect garbage people who res fon ay a ecnne plotaction taf operate incinerators and recyclers things that may fy up breathing in germs and scavengers are at the most risk of harm from health care waste To prevent harm when handling waste
3. Wastes that do not need disinfection Used sharps Body parts Blood and body fluids Wastewater from disinfection and Bandages swabs and other cleaning wastes that carry body fluids Chemicals from disinfection cleaning Other items contaminated with and laboratory tests blood body fluids or feces Food waste Feces from people with infectious Feces from healthy people disease such as cholera Any materials not contaminated with Bedding from all people blood or body fluids cardboard paper plastics glass metal YE c ol ae St R ere Safe Handling of Health Care Waste 13 Disinfecting with chemicals All chemicals used for disinfection can be harmful and need to be used with great care Some chemicals commonly used for disinfection include hydrogen peroxide 6 chlorine bleach ethanol 70 and isopropyl alcohol 70 to 90 Many common cleaning and disinfecting products such as Lysol contain glutaraldehyde or formaldehyde Regular exposure to glutaraldehyde and formaldehyde can cause cancer and death These chemicals should not be used if possible See pages 14 and 15 for safer ways to disinfect with chemicals and page 23 for safe disposal of chemicals No matter what chemicals you use in your health center use them carefully Wear gloves safety glasses a mask and protective clothing to protect your skin eyes and breathing when handling or disposing of chemicals Keep disinfecting chemicals in
4. GAIA 1442A Walnut Street 20 Berkeley CA 94709 USA Tel 1 510 524 4000 E mail gaia essential org Website http www no burn org Health Care Without Harm The Campaign for Environmentally Responsible Health Care 1901 N Moore Street 509 Arlington VA 22209 USA Tel 1 703 243 0056 Fax 1 703 243 4008 http www noharm org International Solid Waste Association ISWA General Secretariat Vesterbrogade 74 3rd floor DK 1620 Copenhagen V Denmark Telephone 45 32 96 15 88 Fax 45 32 96 15 84 E mail iswa iswa dk The Mumbai Medwaste Action Group 5th Floor CVOD Jain School 84 Samuel Street Dongri Mumbai 400 009 India Tel 91 22 370 2592 379 0699 E mail huright giasbm01 vsnl net in Multinationals Resource Center P O Box 19405 Washington D C 20036 USA Tel 1 202 387 8030 Fax 1 202 234 5176 E mail mrc essential org Website http resourcesfirst org Program for Appropriate Technology in Health PATH 1455 NW Leary Way Seattle WA 98107 5136 USA Telephone 206 285 3500 Fax 206 285 6619 Email info path org Protection of the Human Environment PHE Regional Adviser WHO AFRO B P 6 Brazzaville CONGO Telephone 242 241 39271 Fax 242 241 39512 E mail regafro afro who int The Safe Injection Global Network SIGN World Health Organization Department of Blood Safety and Clinical Technology Avenue Appia 20 Geneva CH 1122 Switzerland Tele
5. any other way By using safe alternatives to incineration the health workers oath do no harm can be applied even to the difficult task of waste disposal A Community Guide to Environmental Health Sangu s story When Sangu was young she lived in a small village After years of drought she and her mother and baby brother moved to the city in search of a better life They lived with her mother s family on a steep hill over a dump site Other children showed Sangu how to beat off stray dogs and pick out things to sell at the dump site Before school every morning she went to the dump site to collect scraps of tin glass bottles plastic bags and other things She used the money she made to buy lunch and hot tea after school But life was hard in the city and Sangu s mother was soon working away from the house all day Sangu had to take care of her baby brother and could no longer go to school Every day she spent many hours sorting through garbage at the dump with her brother ina sling on her back Sometimes Sangu found bloody bandages needles and other hospital waste all mixed in with the rest of the trash Sangu s thin sandals did not protect her from getting hurt by sharps buried in the trash Broken glass and rusted metal would sometimes cut her ankles One day a syringe needle pierced her sandal and went right into her foot Soon after the needle pierced her foot Sangu got very sick with fever sore throat
6. contaminated with blood or body fluids that may carry harmful germs and spread disease Used needles and other sharp tools can cause injury as well as spread disease And some health care waste contains dangerous chemicals that can poison the water soil and air If these chemicals get into our bodies they can poison us or cause cancer Most waste from health care is ordinary waste like paper cardboard and food scraps But when waste that carries harmful germs or dangerous chemicals is mixed with ordinary waste the mixed waste becomes a threat to all who handle it both inside and outside of the health center This chapter includes information about how to assess the health care waste problems in your center or community It also offers some ideas about how to reduce the amount of dangerous waste created by health care Since it is impossible to completely eliminate health care waste it is important to know how to separate different kinds of waste how to disinfect waste that carries germs how to safely dispose of small amounts of chemicals how to protect yourself and others from sharps how to safely bury waste that cannot be treated any other way This chapter does not include information about waste from x rays chemotherapy and medical laboratories because these wastes need treatment that is more complicated than we can describe here Please see the resources listed at the end of the chapter for more information 4 A Communit
7. their power you should use care when disinfecting with this method Many hospitals use large high powered microwaves to disinfect tools and waste To ensure high level disinfection 1 Wear gloves and a mask to cut up plastic and cloth items such as catheters IV bags tubing large bandages and so on 2 Put the waste in a non metal container with enough water to cover the waste 3 Put a light cover over the top of the container to reduce the loss of water during heating 4 Microwave waste materials for at least 20 minutes 5 Let the container cool Dispose of liquid waste in a leaching pit see page 22 or down the drain since it is disinfected See Right after disinfection No matter what kind of disinfection you use chemical or heat disinfection disinfected waste should be safely stored in bags or disposed of right after disinfection Keep waste away from patients and make sure that infected waste does not get mixed with disinfected waste 18 A Community Guide to Environmental Health Sharps treatment and disposal rat Many health problems from health care waste are caused m a by sharps Needles blades lancets and other sharp E objects can cause wounds and infections so they ARE 3 need to be handled with great care Outside the 1 health center sharps may put the people who collect and recycle waste in danger Using injections only when they are needed will reduce sharps waste For inf
8. them only when necessary Use pills instead of injections Use non plastic items when possible Use the least toxic products to clean and disinfect whenever possible covers Separating waste The key to safe handling of waste in the health center is to separate waste at the place where it is created Harmful waste can then be safely treated stored and transported to where it can be treated buried or recycled Uncontaminated waste can be separated recycled and reused Discarded food can be made into compost and used to improve soil and create a garden near the health center Harmful waste can be safely disinfected and disposed of see pages 12 to 20 This will greatly reduce risks to health center workers and people who collect sell and recycle waste Separation also reduces the amount of waste that must be treated or buried later It also reduces the cost of waste management Compost from food waste can be used to fertilize a clinic garden and provide food for the clinic kitchen 10 A Community Guide to Environmental Health Separating with colored containers To make it easier for each kind of waste to get the right treatment many health centers separate wastes into different colored containers at the places where waste is created For this to work everyone in the health center needs to understand how different kinds of waste are treated and disposed of and what wastes go in what color containers Di
9. tiredness and swollen lymph glands Sangu felt better after some weeks but a few months later she began to feel sick again She was tired all the time had fevers and lost her appetite She had loose stool and grew very thin Her mother and family worried about her but they had no money to take her to a doctor Her mother borrowed money from a cousin and took Sangu to the health center The doctor listened to Sangu s story examined her and then took a blood test A few weeks later they returned to the clinic and the doctor told Sangu s mother that Sangu had HIV AIDS Her illness was very grave but her family had no money to take her to the hospital for treatment In despair Sangu s mother took her home Sangu rested in bed but everyone knew she would not recover A few months later Sangu died Safe Handling of Health Care Waste 7 Why did Sangu die Sangu died from HIV AIDS after she was infected by stepping on a contaminated syringe needle in a pile of trash Her illness and death were caused by an environmental problem poor disposal of health care waste and a social problem poverty What could have prevented Sangu s death Questioning the social problem Why wasn t Sangu in school Why did Sangu need to collect waste from the dump site Why didn t Sangu have good shoes to protect her feet Why wasn t she able to get health care and medicine when she needed it These questions are e
10. trench or landfill Disposing of liquid waste Many health centers pour bleach contaminated water or other liquids from the health center down the drain This can be safe if the drain does not enter a stream or other water source Dilute the liquid with a lot of water before dumping it But to protect water sources it is better to dump used bleach and other liquids into a safe leaching pit Chemicals such as glutaraldehyde and formaldehyde should be treated before disposal see page 23 To build a safe leaching pit Ina place where the ground does not flood and far from waterways and wells dig a pit meter to 1 meter deep In the bottom put a layer of sand a few centimeters deep Then put a layer of gravel a few centimeters deep and a layer of larger stones on top Put a cover on the pit to prevent rainwater from getting in Safe Handling of Health Care Waste 23 Vaccination Immunization programs and their waste Large numbers of people around the world are protected from diseases such as measles tetanus and yellow fever by receiving special injections through vaccination immunization programs Vaccination immunization programs are often run by international health organizations like World Health Organization WHO and UNICEF together with national and local governments and with the companies that make and sell vaccines These programs often do not include good plans for disposing of waste In many cases they leave
11. waste Protect yourself and others when handling waste Disinfecting waste What wastes need to be disinfected Disinfecting with chemicals Disinfecting with bleach How to use a bleach bucket Disinfecting with safe chemicals Disinfecting with heat Boiling Steaming Pressure steaming Autoclave Microwave Sharps treatment and disposal Guide to infectious waste treatment and disposal Burying health care waste Safe waste pits Disposing of liquid waste Vaccination programs and their waste Safe disposal of chemical wastes Disposing of chemicals used to clean and disinfect Mercury Antibiotics and other medicines Education for Action Organizing a health care waste assessment Community based solutions Health care waste and the law List of difficult words Safe handling of health care waste HEALTH CARE WASTE CAN CAUSE HEALTH PROBLEMS Health workers in every clinic hospital and home do their best to help people heal But if waste from health care is not handled and treated safely it can create health problems for the health workers and the surrounding community Health care waste includes waste from clinics hospitals laboratories blood banks dental clinics birth centers and animal hospitals It also includes waste from vaccination programs and medical aid missions and waste produced when caring for the ill at home Some health care waste is
12. waste behind to be handled by the communities administering and receiving the vaccinations And too often this leads to incinerating or burning the wastes in the open creating health problems for people and the environment Vaccination programs can take responsibility for waste by Using the trucks that deliver vaccine supplies to carry away waste for treatment and disposal If it is a regional program a central waste treatment center might set up an autoclave and safe burial pits Helping communities set up health care waste disposal systems that will remain in place long after the vaccination program is gone Using new technologies such as vaccination guns or jet injectors that produce less waste because they do not use needles or syringes These were widely used until it was learned that they could pass disease from person to person through the vaccination gun New designs to prevent this problem are almost completed This will be a safer and less costly way to give vaccines 24 A Community Guide to Environmental Health SAFE DISPOSAL OF CHEMICAL WASTES These chemical wastes from small hospitals and health centers can be dangerous chemicals used to clean and disinfect mercury from thermometers batteries and other medical devices waste from basic lab tests expired antibiotics and other drugs Larger health centers may create waste from x rays chemotherapy and laboratories but we do not cover these h
13. Mercury is the silver liquid inside a thermometer It is also used in batteries lamps and other medical equipment such as blood pressure cuffs Mercury is very dangerous Breathing in even a very small amount of mercury can cause nerve damage reproductive damage harm to the kidneys lungs brain and birth defects Mercury is not destroyed by incineration In fact burning mercury causes it to turn to vapor and enter the environment in a form that is even more harmful The best way to reduce harm from mercury is to use as few mercury containing items as possible If possible keep equipment with mercury on metal trays so if it breaks the mercury will not soak into wood surfaces tables floors Try to use non mercury thermometers if they are available in your area Mercury spills A When mercury thermometers break the mercury inside breaks into small particles Keep people and animals away from the spill area Turn off any heaters fans or air conditioners and open windows to let air in To clean up the spill you will need gloves an eyedropper 2 pieces of stiff paper or cardboard 2 plastic bags sticky tape a flashlight and a glass container with water in it To collect the mercury safely 1 Do not touch the mercury 6 Pick up any mercury that is Open windows or doors left using sticky tape 2 Remove watches and jewelry 7 Place sticky tape eyedropper Mercury sticks to other gloves and cardboard in a metal
14. Safe Handling of Health Care Waste A selection from Hesperian Foundation s forthcoming Community Guide to Environmental Health The Hesperian Foundation is a non profit organization committed to building a more just world by producing health education materials that enable communities and individuals to take the lead in their own health care As co conveners of the U S Circle of the People s Health Movement we demand Health for All NOW Contact us at Hesperian Foundation 1919 Addison St 304 Berkeley California 94704 USA tel 510 845 4507 fax 510 845 0539 email bookorders hesperian org website www hesperian org titadi Copyright 2005 by Hesperian Foundation The Hesperian Foundation encourages others to copy reproduce or adapt to meet local needs any or all of this pamphlet provided that what is reproduced is distributed free or at cost not for profit Please contact the Hesperian Foundation before beginning any reproduction adaptation or translation to avoid duplication of efforts and to make sure you are working with the most recent updated version of these materials Safe handling of health care waste Health care waste can cause health problems The most common health problems caused by health care waste The problem of incineration Sangu s story Preventing harm from health care waste Reducing waste Separating waste Separating with colored containers Storing and transporting
15. and should be handled carefully if used at all Incineration burning things in a closed furnace in order to destroy them Jet injector injection gun a tool for giving injections that forces medicines through the skin without needles Mercury a dangerous liquid metal that is used in thermometers and other medical supplies Mercury is poisonous to the touch It is even more poisonous when it turns to vapor and is breathed in or gets in water and combines with other elements Microwave an oven that uses waves of energy to heat and disinfect things Sharps needles blades lancets and other sharp tools or instruments Broken glass can also be considered a sharp Sharps can cause wounds and infections so health workers need to handle them with great care Staph infection an infection of the blood that causes a reaction all over the body Sterilize to kill of the germs on something Vaccination injections that prevent disease Vaccinations are commonly given for diseases such as measles tetanus and yellow fever Vaccination programs Programs that vaccinate large numbers of people Vaccination programs are often run by international health organizations like World Health Organization WHO and UNICEF together with national and local governments and with the companies that make and sell vaccines Safe Handling of Health Care Waste 33 WHERE TO GET MORE INFORMATION Global Alliance for Incinerator Alternatives
16. arps waste Safe Handling of Health Care Waste 19 Reusable syringes disposable syringes Reusable syringes can be used again and again Reusable syringes make less waste and can save money but they must be washed very carefully and disinfected after every use NEVER reuse a syringe without washing and disinfecting it first HIV AIDS hepatitis and other diseases can be spread if needles and syringes are not carefully disinfected between uses Disposable syringes are made to be thrown out with the CE needle attached after one use Some disposable syringes can be taken apart boiled or steamed and reused several times But we do not recommend this because if the syringe or needle are not completely disinfected they can spread disease Auto disabled syringes become locked or cover Wt the needle after the syringe is used so that it cannot be reused However auto disabled syringes still have a needle inside so they still have the danger of needle stick accidents inside or outside of the health center For safe disposal methods see pages 18 20 and 22 Many communities do not have enough syringes and needles to afford to dispose of them after a single use For this reason we include information on how to wash and disinfect a syringe and needle for reuse How to wash and disinfect a syringe and needle for reuse 1 Put ona pair of heavy gloves to protect your hands from germs 2 Draw 5 bleac
17. asy to answer but the social problems related to poverty are very difficult to solve Poor shoes no money for medicine and collecting harmful waste combined with the malnutrition and other problems that accompany poverty made Sangu s chance to live a healthy life very slim Questioning the environmental problem Why was harmful health care waste mixed in with other trash that could be recycled and used Why was so much harmful waste dumped in the open rather than safely buried The environmental questions may be harder to answer at first but they are easier to solve Responsible management of waste can make living conditions better for everyone especially those forced by poverty to live on scraps The rest of this chapter explains how to manage health care waste in a way that will protect people who work in health centers as well as people like Sangu who collect and recycle waste beyond the walls of health centers Health care waste affects many people even those too poor to go to a health center Whether in a small health post a larger clinic or when doing health care in the home medical tools and health care a A Community Guide to Environmental Health PREVENTING HARM FROM HEALTH CARE WASTE waste must be handled safely to prevent harm Preventing harm from health care waste includes choosing medical supplies carefully to reduce the quantity and harmfulness of the waste separating wastes where they ar
18. at will be reused Cut all gloves syringes IV bottles tubing and other things that are not intended to be reused before dropping them in the bleach bucket The bucket should always contain enough bleach to completely cover the materials Materials should stay in bleach for at least 10 minutes Keep a tight fitting cover on the bleach bucket This will prevent spills and will also ensure that the bleach solution does not lose strength How to make a disinfecting solution of 5 bleach Chlorine bleach from the store comes in different strengths The strength of the bleach is shown by the amount of available chlorine it has For this reason you may have to mix it with water to make a disinfecting solution If your bleach says Use 5 available chlorine just bleach 10 available chlorine Add 1 part bleach to 1 part water 15 available chlorine Add 1 part bleach to parts water ad at ar Mix just enough solution for one day Do not use it again the next day It will not be strong enough to kill germs any more To dispose of used bleach see page 22 Bleach should never be mixed with other chemicals especially ammonia This mixture will produce a toxic gas that can cause death if breathed in and enough heat to cause an explosion Always wash carefully after handling bleach Laundry In the past many hospitals used carbolic acid to sterilize sheets Now it is known that this is not necessary exc
19. cal and national laws on health care waste disposal Safe Handling of Health Care Waste 21 BURYING HEALTH CARE WASTE Burial pits are most useful for disposing of sharps body parts and expired medicines Try not to fill waste pits with materials that can be composted foods reused some glass and plastic materials or sent to the landfill after disinfection plastics cloth bandages If there is local waste collection and a local landfill disinfected waste can be collected and sent there for safe burial If there is not health centers may consider building small waste pits on site in order to ensure the safe burial of their waste Because sharps are the most dangerous wastes you may want to bury sharps in a safe pit at the health center and send other trash to a landfill Any waste disposal method can be dangerous if it is not done well What makes burial safe is the active involvement of everyone that handles waste You might also consider putting a simple lock on the gate to keep children or other people from opening the pit and being harmed Safe waste pits For a waste pit to be safe it should be located in an area where the ground water is not near the surface downhill from nearby wells and at least 50 meters away from rivers streams springs and other water sources Pit sides and bottoms should be lined with clay to prevent dangerous liquids from passing into the soil and ground water The pit should be well marked and have a f
20. does not completely destroy the waste Health care waste incinerators release chemicals into the air as smoke and into the soil and ground water as ashes When health care waste containing mercury lead and other metals is burned poisonous forms of these are released into the environment When plastics such as blood bags syringes and tubes are burned they produce very dangerous chemicals called dioxins and furans These chemicals have no color and no odor and cause cancer reproductive harm and other serious health problems Incinerating health care waste releases toxic chemicals into the air soil and groundwater Often incinerators do not burn hot enough or long enough to burn waste completely Some incinerators are built to handle specific wastes such as vaccination wastes but end up being used for other wastes as well In some cases health care waste incinerators are used to burn medicines pesticides and other dangerous chemicals Burning waste creates more problems than it solves The rest of this chapter describes ways to deal with waste so that it does not have to be burned We recommend separating out waste that is not harmful such as paper cardboard and uninfected plastic and metal so that it can be recycled or reused and disinfecting waste that carries harmful germs Recycling waste materials can bring money to the centers We recommend burying waste safely if it cannot be treated
21. e created disinfecting wastes that carry germs treating chemical wastes to make them less harmful by diluting them with water or adding other chemicals disposing of health care wastes in the least harmful way possible safely transporting storing and removing waste training everyone who handles health care waste about safe methods Preventing harm from health care waste depends on people No matter which method your clinic center or hospital decides to use make sure that everyone who handles health care waste especially new people understands what needs to be done and why Often people will bring up new ideas that can make work easier and safer for everyone Some clinics have a team of people who together are responsible for training and monitoring safe practices Safe Handling of Health Care Waste 9 Reducing waste Many materials used in health care become waste Using fewer materials and less harmful materials will reduce the amount of harmful waste When choosing health care materials think about what kind of waste will be produced and how harmful it will be Try our new ERE isposable ees To reduce the amount of harmful waste plastic sheet clinic really need this Avoid using disposable items if gt ae a reusable version is available Some items such as syringes and needles should not be reused if possible See page 19 Use non mercury thermometers if they are available Do not over buy antibiotics and use
22. ence around it to keep people and animals away Use the 50 meter rule when you dig a hole to bury wastes 22 A Community Guide to Environmental Health Waste pit with concrete cover 1 Diga pit 1 to 2 meters wide and 2 to 5 meters deep The bottom of the pit should be at least 1 meters above the water table 2 Line the bottom of the pit with a layer of clay at least 30 centimeters thick 3 Build up a ridge of earth around the top of the pit to prevent surface water from running in 4 Build a fence around the area where the pit is located to keep animals out Each time waste is put in the pit cover the waste with 10 centimeters of soil or a mix of soil and lime Lime helps disinfect the waste and will also keep animals away while the pit is in use When the waste rises to amp meter from the surface cover it with meter of soil and seal it with a layer of concrete at least 10 to 30 centimeters thick If the pit is used only for infectious waste and not for regular garbage it will not fill up too quickly Sealing sharps waste in containers with concrete Place disinfected sharps and sharps containers in a hard container such as a metal drum When the container is mostly full 3 4 add a mixture of 1 part cement 1 part lime 4 parts sand and 1 3 to part water Lime works as a disinfectant and it also helps the cement flow into empty spaces to completely surround the waste Seal the container and bury it in a
23. ept for burn victims To disinfect bed linens and clothes soak them in a bleach bucket for 10 minutes before washing with hot water and soap 16 A Community Guide to Environmental Health Disinfecting with heat Many health centers use autoclaves or microwaves to disinfect syringes tools and some waste If you have no autoclave or microwave then boiling steaming or pressure steaming materials for at least 20 minutes will disinfect them Waste should not be disinfected together with tools that will be reused because it will be difficult to separate the reusable tools from the waste in a way that keeps the tools clean To ensure disinfection For boiling steaming and pressure steaming start to count the 20 minutes after the water is fully boiling Do not add anything new to the pot once you begin to count After 20 minutes turn off the heat and let it cool Materials that will be reused after they are boiled or steamed must be removed using sterile gloves or tongs and placed right away inside a disinfected container and then sealed The used water can be safely poured down a drain because it has been disinfected Boiling You can use boiling to disinfect metal rubber or plastic tools and cloth After you wash and rinse the tools put them in the pot cover the tools with water and boil for 20 minutes Steaming You can use steaming to disinfect gloves masks and things made of metal and plastic The water does no
24. ere because these wastes need special treatment Disposing of chemicals used to clean and disinfect Bleach can be dumped into a leaching pit See page 22 Hydrogen peroxide solutions can be disposed of with no special treatment Glutaraldehyde and formaldehyde can cause cancer and death If your center must use these chemicals for disinfecting and cleaning there are ways to dispose of them to reduce harm To treat glutaraldehyde or formaldehyde for disposal add caustic soda sodium hydroxide solution while measuring the level of acidity pH with litmus paper or a pH meter The pH should be brought to 12 and stay at that pH for no less than 8 hours After 8 hours bring the pH to a neutral level pH 7 by adding hydrochloric acid HC If you do not have the proper material to make these chemicals safe for disposal it is best not to use them In the past carbolic acid was commonly used to sterilize sheets But it causes respiratory and skin problems and its disposal adds to environmental health risks If a clinic chooses to clothing including eye protection and a mask The wastewater should be added to a buffering solution of sodium hydroxide then poured into a leaching pit Today most clinics and hospitals disinfect sheets with bleach and avoid the use of carbolic acid When preparing chemical liquid waste for disposal wear protective gear and be careful not to splash Safe Handling of Health Care Waste 25 Mercury e
25. fferent countries use different colors for each type of waste For example in some countries the color red is used to indicate danger So containers for sharps and other harmful or dangerous wastes are marked with red paint marker or tape More than half of all waste from health centers is just like household waste paper cardboard bottles cans and kitchen scraps If regular waste is separated out it is much easier to deal with the harmful waste Harmful waste should be Regular waste should be put ineo baga und bins snd tudi separated and treated carefully composted or reused if possible see chart on page 20 Containers should be strong enough that they do not leak or break big enough to hold a full day s waste when only full placed close to where waste is created easy to seal and transport without risk of spills leaks or breaks clearly marked with colors and symbols It is best to use containers and bags that are the same color for the same kind of waste If this is not possible mark them with colored tape or paint This way workers who do not read will understand which color container is for regular waste and which color is for harmful waste and so on Safe Handling of Health Care Waste 11 Storing and transporting waste Health care waste needs careful storage until it can be transported safely to its final disposal site Waste containers should be placed where waste is created and disinfected
26. h solution see page 15 up through the needle into the syringe barrel 3 Squirt out the bleach solution 4 Repeat several times Rinse everything several times with clean water 5 Take the syringe apart and boil or steam the syringe See page 16 Never reuse syringe and needle without cleaning and disinfecting first 20 A Community Guide to Environmental Health Guide to infectious waste treatment and disposal The chart on this page shows when and how to disinfect and dispose of infectious wastes in small health centers Some health centers may not be able to use all of these methods or may have their own better ways to treat wastes The important thing is to have a system that everyone in the health center can follow to prevent infection Sharps jems contaminated Blood body Body parts Needles with blood or body fluids fluids and amputated Separate blades Blood bags dialysis kits feces limbs by type gt lancets syringe barrels gloves Liquid blood tissues skin broken glass masks bandages cotton flulds from 888 other sharp swabs other wastes isto spee canisters feces and other contaminated body wastes g Ry Seperate Sages using colored containers RN put in carefully cut or putin colored put in colored container colored bag shred waste bag or bag or or container and put in container container with bleach bucket tight fitting cove
27. hat contain harmful chemicals such as glutaraldehyde to disinfect and clean see pages 13 and 23 But surfaces in health centers can be kept clean and germ free by using less dangerous and less costly materials You can buy hydrogen peroxide solutions that contain orange oil and other natural oils that are strong and effective for disinfecting floors and surfaces They do not cause health When choosing a product ask these questions problems and do not have to be treated _s it harmful Is it difficult to dispose of safely before disposal Or you can make a safe disinfecting solution by mixing together equal parts of white vinegar and hydrogen peroxide This is how to use it Disinfecting with safe chemicals ies including usi 1 Mix together only enough hydrogen peroxide and vinegar needed for one day Keep it in a closed container A 3 peroxide solution is common but 6 is better 2 Pour a small amount of the mixture on a wiping cloth and scrub the surface to be disinfected with strong rubbing motion This mixture is best for use on tabletops bed railings and other surfaces Using hot water and soap to clean surfaces such as floors walls and furniture is often a good first step in making your center germ free But in areas where people with infectious diseases wait or are treated it is important to use a stronger disinfectant to prevent the spread of disease Disinfecting with bleach Many health cente
28. ics see Where There is No Doctor pages 55 to 58 and Helping Health Workers Learn Chapter 19 When your health center buys only the amount of antibiotics it needs then fewer drugs will pass their expiration date and need to be dumped When antibiotics expire return them to the manufacturer The manufacturer has the responsibility and means to dispose of them If they cannot be returned to the company they can be disposed of safely Disposing of antibiotics safely 1 Wearing gloves safety glasses and a dust mask grind up pills 2 Mix powder from the ground up pills with cement 3 Add water and form cement into solid balls 4 Bury these cement balls in a sealed waste pit Safe Handling of Health Care Waste 27 EDUCATION FOR ACTION ORGANIZING A HEALTH CARE WASTE ASSESSMENT A health care waste assessment can help everyone in a health center understand how waste is handled and decide the best ways to improve or create your system An assessment can identify the problems in how waste is created and handled and help find solutions Steps in organizing a health care waste assessment ji Meet and discuss problems with all health center staff List what is in the pharmacy and supply room Make a map of the center Walk through the health center and note problems 5 Learn about different choices for treating and disposing of waste Pe UE Find out how waste is handled and disp
29. ons have guidelines for the handling and disposal of medical waste Find out what the laws are in your country and if your health center follows national guidelines Sometimes these guidelines can be helpful especially when working together with other health centers in a region to set up a shared disposal site Sometimes national laws do not take into account ways to treat and dispose of health care waste that best protect community health and the environment For example many countries promote incineration though it is known to be harmful Many of the methods in this book are not yet included in national laws International conventions Rich countries often send their waste to poorer countries for disposal Companies in rich countries also sell polluting technologies like certain kinds of incinerators to poorer countries even though these technologies may be banned in the country that makes them International laws and guidelines can help protect poorer countries from the dumping of waste and dangerous technologies One international convention that most affects health care waste is the Stockholm Convention on Persistent Organic Pollutants POPS Stockholm Convention The Stockholm Convention on Persistent Organic Pollutants POPS makes it illegal to produce certain chemical pollutants known as POPS Dioxins and furans that come from both large and small health care waste incinerators are POPS Countries that sign and ratify this agreement m
30. ord to run their own system of waste collection treatment transportation and disposal But if centers in your region join together they may decide to share resources and create a safe waste handling system that benefits the health of all in the community If your health center does not have an autoclave and a safe waste pit wastes can be disinfected separated into safe bags and transported to a center that has a safe waste pit or sanitary landfill A system of sharps collection transport and disposal can be organized to serve many health posts in both urban and rural areas If there is municipal garbage collection in the area disinfected waste can be collected and sent to the landfill and hazardous wastes sent to the hazardous waste site if there is one If there is no garbage collection in the area consider working towards a community based solid waste system see Chapter xx Solid Waste to learn more This chapter has presented different methods for reducing the amount of waste created and for separating storing transporting and disposing of health care waste in ways that are safer and least toxic for health care workers waste handlers and scavengers and the environment Which methods your center uses depends on what your resources are and what works best for you What happens in the health center eventually touches everyone in the community Safe Handling of Health Care Waste 31 HEALTH CARE WASTE AND THE LAW Many nati
31. ormation about when to inject and when not to see Where There is No Doctor pages 65 to 67 Safe disposal of syringes and needles After injections needles should be removed from syringes and put in a sharps container right away Putting caps back on needles is dangerous and best avoided Unless you are using reusable syringes always dispose of needles at the place where they are used There are many ways of removing needles from syringes Any method should use only one hand to prevent accidents keep needles in a hard container that they cannot poke through be easy and comfortable for health workers to use be kept at the place the needle is used Make a key hole box to dispose of needles and sharps safely A key hole box is a metal box with a long slot in the top that is wide on one end and gets narrower on the other You can buy them or have a metal worker make them They can also be made using coffee cans or other rigid metal containers What is important is that they let you remove needles from syringes without touching the needles When you have finished using a disposable syringe put the needle into the slot and slide it down to the narrowest point Now pull up on the syringe and the needle will fall off into the box Put the syringe in a waste container When the sharps container is full seal it with tape and put the box into a sharps pit or a sharps drum See page 22 for safe burial of sh
32. osed Take action 8 Regular education and training for all workers wA It is important to have everyone at the center help with the assessment Doctors nurses waste handlers and janitors may have different ideas about where waste is coming from and what the waste problems are id 2 List what is in the pharmacy and supply room Since most materials are ordered through the pharmacy or supply room start your assessment by making a list of what you find in those places As you look at each product ask what kind of waste will be produced and how harmful will it be Can disposables be replaced with non disposables Can fewer or safer chemicals be used Can the center use less plastic less items that contain mercury or make any other changes to reduce the amount of harmful waste 1 Meet and discuss problems with all health center staff 28 A Community Guide to Environmental Health 3 Make a map of the health center Show all rooms doors and windows and note what each room is used for Use different colors to mark places where waste is created where waste containers are kept and where waste is stored as it is collected and transported from its source to its final storage or disposal This map can be changed as the group walks through the health center After the assessment make a new map to show any changes that have been made especially noting where containers are kept for collecting was
33. paves Vek e Wear protective clothing to reduce Seme and risks from sharps germs or off hands splashes from blood other bloody fluids or chemicals An apron g Sotes mat e Never put needles or other sharps Saotes f body keep in bags with other waste San a Wash hands after handling waste and before and after working With passer boots protect every patient against accidents from Never carry open needles sharps and spills Do not let waste touch your body Protective clothing only works if it s clean After each use or at the end of each shift wash gear such as gloves aprons glasses and masks This will prevent the next person that uses it from being contaminated If your center does not have protective clothing people can use available materials for protection For example many people use plastic garbage bags to make protective aprons pants masks and hats It is better to have some protection than none at all 12 A Community Guide to Environmental Health DISINFECTING WASTE Disinfection means destroying germs that cause infection As much as possible health care waste should be disinfected in the place where it is produced The most common methods of waste disinfection used in health centers or in home health care practice are disinfection with chemicals using chlorine bleach hydrogen peroxide or other chemicals and disinfection with heat using boiling steaming pressure steaming autoclave or microwave
34. phone 41 22 791 1275 Fax 41 22 791 4836 E mail sign who int Website www injectionsafety org Srishti H2 Jungpura Extension New Delhi 110014 India Tel 91 11 4328006 Fax 91 11 4320711 Email ravig unv ernet in The Sustainable Hospitals Clearinghouse Lowell Center for Sustainable Production One University Avenue University of Massachusetts Lowell Lowell MA 01854 USA Tel 1 978 934 2980 Fax 1 978 452 5711 Website http www sustainablehospitals org WASTE Advisors on Urban Environment and Development Nieuwehaven 201 2801 CW Gouda The Netherlands Telephone 31 10 182 522625 Fax 31 10 182 550313 e mail office waste nl website www waste nl World Health Organization Water and Sanitation Avenue Appia 20 1211 Geneva 27 Switzerland Telephone 41 22 791 2111 Fax 41 22 791 3111 Website www healthcarewaste org E mail info wsp org
35. r Seal When full when full amp OR keep tight seal bagor when full containers seal container seal bag or fitting cover on cover container seal bag or with tape container bleach bucket with tight fitting container cover we Ry eR wearing put in safe protective burial pit clothing add lime Disinfection arop put disinfect leave in carefully add and cover or safe burial into a container using bleach bucket bleach to with soil sharps intoa 1 heat for at least container and pit drum method 10 minutes let stand for then drain 10 minutes PER KRG when when put in safe dry and reuse put liquid when pit is almost full burial pit cover or recycle glass waste into almost fun full seal drum with with soil When metals and safe leaching cover with Final disposal the pit concrete pit is almost plastics pit or into soll and seal with and bury ful cover with or sanitary sewer With concrete concrete drum in a soll and seal discard with or septic tank tana with concrete other solid waste see pages 18 to 19 see pages 14 to 17 on see page 13 see page 13 For more 0n handling sharps ways to disinfect with on handling on handling Damore n and page 22 on heat and chemicals feces and body body parts burying sharps fluids and and page page 22 for 22 for safe safe burial and waste burial leaching pits Note Follow all lo
36. rs use bleach to disinfect surfaces such as walls floors and tables But care must be taken when disinfecting with bleach because it can cause harm to your skin and eyes when splashed and the fumes are dangerous to breath One way to more safely disinfect with bleach is to use a bleach bucket A bleach bucket has an outer container that holds the bleach solution and a smaller inner container or basket with many small holes that will hold the wastes Any metal or plastic bucket or container with a strainer or even a wicker basket placed inside will make a good bleach bucket A bleach bucket must have a tight fitting cover To prepare a bleach bucket 1 Make a 5 bleach solution see the box on page 15 The outer bucket should be at least full of the bleach solution 2 Place the smaller container or basket inside the outer bucket so the bleach solution passes through the holes Make sure the inner container does not float on top of the solution but that the bleach solution passes though the holes so it will soak into the waste materials Safe Handling of Health Care Waste 15 How to use a bleach bucket If possible keep a bleach bucket wherever there is infectious waste such as used bandages cotton swabs gloves and blood bags Prepare the bleach bucket every day or before each shift if you use a lot of materials You may want to use one bleach bucket for disposable waste and a different one for disinfecting tools and equipment th
37. s plastic bag 3 Shine a flashlight on the area 8 Label the bag mercury to make the mercury easier to waste and put the bag in the see container 4 Wear chemical resistant 9 Seal and mark the container gloves if possible If you have Put it inside another plastic only latex gloves wear at least bag 2 pairs for protection Use 10 Dispose of it as hazardous stiff paper or cardboard to waste see Chapter xx Solid gather up the mercury into a Waste small pile 5 Use an eyedropper to suction up the mercury beads and place the mercury in a glass container with water 26 A Community Guide to Environmental Health Some medicines can be used after their expiration date But other medicines lose their strength and are no longer usable Many health centers pharmacies and drug companies discard old medicines dumping them in open dump sites or waterways When antibiotics are released into the environment by dumping this can cause antibiotic resistance in people animals and even germs that come into contact with them This means that when people take antibiotics to fight infections the drugs will be less effective because fewer germs will be killed by them Antibiotics and other medicines must be disposed of in a way that keeps them out of the water and away from people who handle waste Buy and use fewer antibiotics Do not use antibiotics for health problems they cannot cure For more information about how to use antibiot
38. t need to cover everything in the pot but you must use enough water to keep steam coming for 20 minutes The pot should have a lid that fits tightly Pressure steaming You can use pressure steaming to disinfect metal rubber plastic and cloth Wash and rinse the materials to be disinfected and put them in the pressure cooker with enough water to make steam for 20 minutes Close the lid and heat it on the stove After it comes to a boil cook at 15 to 20 pounds of pressure for 20 minutes Safe Handling of Health Care Waste 7 Autoclave An autoclave disinfects things using steam heat and pressure Autoclaves have been used for many years to disinfect medical instruments They are used more and more to treat waste as well If your health center uses autoclaves to disinfect both instruments and waste it is safest use 2 separate machines one for reusable instruments and one for waste For health centers with very small amounts of waste to be disinfected a pressure steamer is less expensive and works as well as an autoclave Most autoclaves need electricity to operate but it is possible to build gas fired kerosene fired or solar powered autoclaves for areas with no electricity Microwave Microwaves create heat by contact with moisture in the objects placed inside them It is the heat together with the amount of time an object is microwaved which leads to disinfection Because microwave ovens vary greatly in
39. te 4 Walk through the health center and note problems Visit all areas where waste is produced Look in the trash bins and note what kinds of waste are there Do this walk through several times over the course of a few weeks and try to do it at different times of day Then you can see how waste is handled throughout the day and in different conditions Do the walk through with different workers Janitors will see things differently than doctors and nurses and each may have important ideas about how to best handle waste Safe Handling of Health Care Waste 29 5 Learn about different choices for treating and disposing of waste After several walks though the health center have a group discussion about the problems and possible solutions Solutions need not be expensive or technical and most require only organization cooperation and commitment Try to make a plan that starts with the most harmful waste sharps and then blood and other body fluids and so on The goal is to improve your entire system not just 1 part of it The safest way The safest way to to protect myself rotect myself from from dirty needles jirty needles is to toss is to let the nurse them straight into the The safest N ive inje rubbish pail way to protect myself from dirty needles is to have them put in puncture proof boxes 6 Find out how waste is handled and disposed Follow waste from where it is made to where it is stored
40. their proper containers Label the containers Do not use those containers for anything else Keep chemical containers tightly closed and stored upright Check them for breaks leaks and weak spots Chemical fumes can be harmful Do not put chemicals in drink bottles water buckets or containers that may be used for food Wastes best treated with chemicals Blood other body fluids and feces require chemical disinfection to prevent the spread of disease These wastes can be separated in colored bags or containers disinfected with bleach and then safely buried Bedpans and bedding used by people with infectious diseases should also be disinfected with bleach and then washed with hot water and soap The used bleach can be diluted in water and then poured in a leaching pit sanitary sewer or septic tank It is often thought that body parts need to be disinfected with chemicals But body parts including placentas afterbirths and umbilical cords are most simply disposed of by putting them in a latrine or burying them deep in the ground But in many communities burying placentas is an important ritual If it is done safely burial is also a good way to protect the community from germs that may grow in the placenta or other body parts See pages 21 and 22 for safe methods of waste burial and leaching pits 14 A Community Guide to Environmental Health great It kills everything a Some health centers use products t
41. to where it leaves the health center Is there a regular pick up schedule for waste How is it collected Do waste handlers wear gloves shoes or other protective clothing Is it transported in safe containers Health center workers and waste handlers often sell whatever they can to junk dealers This can be safe or it can be dangerous depending on how waste is separated and disinfected When are reusable and recyclable materials pulled out of the waste Is there a way to make a safer system for those who make a living handling or selling waste Is the waste brought to a dump site or incinerator If possible visit the place where waste is dumped Does it remain separated or is it mixed together Does the waste put poison into the environment Does it lead to health risks for the community such as sharps waste in an open dump site 30 A Community Guide to Environmental Health 7 Take action Which solutions are possible for the health center to do now How can the health center influence what happens to waste once it is taken away to a landfill or incinerator Should other health centers in the area be involved to share resources and develop a solution that will improve health in the region 8 Regular education and training for all workers The success of any safety plan relies on regular education and training for everyone who handles and creates health care waste Community based solutions Many health centers cannot aff
42. ust look for cleaner ways to dispose of health care waste Communities that campaign to shut down polluting incinerators and replace them with cleaner alternatives can use the Stockholm Convention as the basis for their legal arguments To find out if your country has signed the Stockholm Convention and to learn more about how to use it in local campaigns look at the POPS website http www pops int 32 A Community Guide to Environmental Health LIST OF DIFFICULT WORDS Antibiotics drugs that prevent or treat infections by killing germs in our bodies Antibiotic resistance when germs become immune and are not killed by antibiotics When people take antibiotics that are not needed or dump antibiotics into the environment this can lead to antibiotic resistance Autoclave a machine that disinfects things using steam heat and pressure Disinfect means killing enough of the germs on something that so it will not transfer infection Disinfection can be done using heat boiling autoclave microwave or using chemicals such as bleach or hydrogen peroxide Disposables items meant to be used once and then thrown out Dioxins and furans very dangerous chemicals that are released by burning plastic Formaldehyde a chemical used for sterilizing and cleaning Formaldehyde is very dangerous and should be handled carefully if used at all Glutaraldehyde a chemical used for sterilizing and cleaning Glutaraldehyde is very dangerous
43. y Guide to Environmental Health The most common health problems caused by health care waste Wounds from dirty needles sharp instruments and other sharps can cause many illnesses including Hepatitis B and C tetanus HIV AIDS staph infections and other infections Frequent contact with disinfectants detergents medicines and laboratory chemicals can cause allergies skin rashes eye irritations asthma and other breathing difficulties and other reactions Frequent contact with discarded antibiotics can cause antibiotic resistance making these drugs less useful in fighting infections Burning health care waste can release dangerous metals such as mercury lead and cadmium as well as toxic chemicals such as dioxins into the environment These can cause cancers and many health problems People most at risk of harm from health care waste are e workers and patients in health people who collect recycle centers especially workers who or sell trash from dump collect and move the trash sites and landfills people who live near where health care waste is dumped or burned Safe Handling of Health Care Waste 5 The problem of incineration In order to destroy health care waste and the germs it carries many clinics and hospitals burn it in furnaces called incinerators It is easy to burn health care waste because different kinds of waste can be collected and simply thrown in the incinerator But incineration
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