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Post00237 WASTE MANAGEMENT + INJECTION SAFETY 30 March 2000 CONTENTS 1. DECREASING THE PUBLIC HEALTH BURDEN OF HEALTHCARE WASTE 2. DRAFT KEY ELEMENTS:A NATIONAL STRATEGY:SAFE HEALTH-CARE WASTE MANAGEMENT 3. DRAFT KEY ELEMENTS: AIDE MEMOIRE 4. BD WORLD WIDE IMMUNIZATION CONTACT LIST 5. SAFETY OF VINYL MEDICAL PRODUCTS? ___________________________________________________________________________ TECHNET Forum has more than 400 subscribers in 59 countries! 1. DECREASING THE PUBLIC HEALTH BURDEN OF HEALTHCARE WASTE Hala Azzam, USAID/W and Annette Pruess, WHO/Protection of the Human Environment [PHE], have kindly posted the material that follows. Mixed medical waste management at primary care levels is an old Technet issue - with some action at long last being promoted. This material will also appear in SIGNpost on April 5 2000. Action, comments and additions please: [][/email] or use your reply button ___________________________________________________________________________ Dear Allan, Please find attached a summary of Annette Pruess's presentation on injection safety and healthcare waste management at a meeting held 13 March 2000 at USAID. Also included is the policy analysis handout. Sincerely, Hala Hala Azzam, PhD AAAS Fellow USAID/E&E/EEUD/HRHA tel 202- 712 1585 fax 202- 216 3409 email: [][/email] ___________________________________________________________________________ SUMMARY OF ANNETTE'S PRUESS PRESENTATION AND THE ENSUING DISCUSSION by Hala Azam The purpose of the presentation was to raise awareness with regards to injection safety and the role of improper healthcare waste management and disposal in injection safety and public health. The WHO strategy was presented. INJECTION SAFETY, A SERIOUS PUBLIC HEALTH BURDEN: Diseases acquired through unsafe injection safety practices range from infections with blood borne pathogens (HBV, HCV and HIV), to viral hemorrhagic fever and bacterial infections resulting in abscesses and septicemia, to traumas resulting in paralysis. The major focus is on blood borne pathogens. Conservative estimates indicate that 8 - 16 million HBV, 2.3 - 4.7 million HCV and 80,000 -160,000 HIV infections are due to unsafe injections. These figures do not take into account needle-stick injuries nor injuries due to improper medical waste disposal. WHO publications can be found at Unsafe injection practices are not just about syringe re-use, although that may be a big portion of it. Unsafe injection practices are also about using a clean work space, hand washing, using a sterile syringe and needle, sterile medication, skin cleaning and appropriate sharps and waste collection to minimize needle-stick injuries and re-use. There is a difference between disinfecting and sterilizing equipment. The former is good enough for disposal purposes, the latter is essential for re- use of re-usable equipment and requires an involved rigorous scientific process with indicators of sterility. Often developing nations replace needles but reuse the syringe body. The latter will contain blood or body fluids and therefore may have pathogens. Alternatively they may squirt some water or even disinfectant washing the syringe and needle, and then re-use them without sterilization contaminating both medical vials as well as causing disease transmission. Indeed blood clots form in the needles and despite washing can still be present and infect another patient. In many countries HBV transmission through unsafe injections is about 50%. In Romania, syringe re-use accounted for 50% of HBV transmission (CDC/USAID). Raising public awareness about sterile syringes reduced the disease burden to 20%. The remaining 20% of HBV transmission was found to be due to unsterile techniques of injections whereby shared drug vials are contaminated (CDC / USAID). WHY MEDICAL WASTE? Role Vis-a-Vis Injection Safety and Public Health Medical waste management is about infection control in and outside healthcare settings, along with safe drinking water supply, sanitation and hygiene. The basic aim is to prevent the healthcare setting to cause additional disease burden, either through spreading disease through improper disposal of wastewater excreta or healthcare wastes, or through hospital- acquired infections. It is also about minimizing environmental degradation and contamination through reducing the volume of hazardous waste and disposing of it in an environmentally sound manner. From a healthcare perspective, dealing with medical waste disseminates the concept of infection control by promoting hygiene and sterile conditions. It significantly minimizes occupational health hazards including needle-stick injuries, which are a significant cause of disease burden among healthcare workers and other healthcare personnel including visitors. Finally, specific to many developing nations such as India, Kazakhstan, Philippines, Egypt, Tunisia etc., it targets the existing black market of medical waste which involves resale of used unsterile disposable syringes, IV-bags, bandages and gloves. Children are often paid to dig such wastes from municipal waste. Why isn't medical waste management part of every health programmatic activity? Four main reasons come to mind: 1. Resistance of host country healthcare facilities to deal with the issue citing financial burden as the reason, and/or lack of awareness with regards to route of disease transmission and burden. 2. Resistance on the part of many donors due to lack of awareness of host country practices including unsterile technique practices. 3. Resistance from western healthcare workers and consultants who view medical through the western culture lens. Medical waste in the U.S. for instance was dealt with to appease the public, but is not considered a significant public health burden outside healthcare facilities. 4. Tendency to focus on patient needs and health and to ignore healthcare provider's needs, health and occupational safety. Other causes and further details are cited in the attached WHO policy analysis. DATA COLLECTION Apart form the recent data on syringe re-use and lack of injection safety, there has been very little data collection of the impact of improper medical waste disposal on public health or the environment. It is easier to assess the public health burden within healthcare facilities by looking at infection control practices and occupational hazards. The issue is more complicated within the community at large. It is complicated by the fact that the public health hazard in the community is mainly in the poor population which also suffer from unsafe drinking water and poor sanitary conditions. As a result, it is hard to establish a direct link between medical waste and disease burden in these instances. However, examining the process and asking the question "what happens to medical waste" needs to be part of every health activity assessment. There is even less data on the impact of healthcare waste on the environment, but radioactive wastes, mercury and genotoxic drugs are few examples of harmful materials to the environment. WHO STRATEGY ON HEALTHCARE WASTE Due to the lack of awareness of the public disease burden of healthcare waste, WHO main strategy is to collect data and disseminate information as well as practical solutions to deal with medical waste management. WHO is preparing a policy analysis on management of healthcare waste (draft attached) in addition to the safe management of healthcare waste management guideline book. WHO is close to producing a review of the evidence base available on health impacts of healthcare wastes on various population groups, a decision making guide for primary healthcare facilities and a blood disposal guide. WHO is currently mobilizing partners and funds to initiate and compile a database that would collect field data and give practical guidelines to those wishing to improve their waste management system. Many of these activities require funding and WHO is looking to collaborate and to partner with other donors or actors from the field. WHAT ARE OTHER DONORS DOING? In addition to the public disease burden, and environmental degradation caused by hazardous medical waste such as mercury and genotoxic drugs, many donors, including USAID, have to comply with their government environmental regulations which state that technology transfer should not result in host country environmental degradation. USAID has some programmatic activities in healthcare waste, namely in India and Thailand through USAEP ( looking at management of healthcare waste and providing training in existing technologies and options; and Egypt through the Egypt USAID mission. Currently there is some effort to raise awareness of medical waste issues in the Former Soviet Union countries. The WB is working on medical waste issue in India and other countries by providing money for medical waste disposal in WB-funded healthcare activities. The WB is also trying to approach the medical waste issue from a different angle than the public disease burden, by trying to provide incentives for governments and healthcare facilities to deal with medical waste. These incentives include creating a market value to medical waste through recycling. SUGGESTIONS FROM THE ATTENDEES: There needs to be data on costs of medical waste per patient. ___________________________________________________________________________ Presentation Notes by Annette Pruess ___________________________________________________________________________ POLICY ANALYSIS: MANAGEMENT OF HEALTH CARE WASTES (intended to provide a quick overview of the topic at policy-maker level, in particular at national level) PROBLEM STATEMENT Improper management of wastes generated in health care facilities can have direct health impacts on the community, the personnel working in health- care facilities, and on the environment. In addition, environment polluted by inadequate treatment of waste can cause indirect health effects to the community. Wastes produced in health facilities include sharps (syringes, disposable scalpels, blades etc.), non-sharps (swabs, bandages, disposable medical devices etc.), blood and anatomic waste (blood bags, diagnostic samples, body parts etc.), chemicals (solvents, disinfectants etc.), pharmaceuticals, and may be infectious, toxic, create injuries or radioactive. The risk to the community includes intentional and unintentional exposure in the absence of a safe waste management system. Intentional exposure occurs through the widespread reuse of disposable materials (especially syringes) in developing countries and results in the main disease burden caused by inadequate health-care waste management. Main disease outcomes of concern include HBV, HCV and HIV transmission. Unintentional injuries may occur when the community is exposed to inadequately disposed waste, for example through scavenging on waste sites. The risks to waste workers and hospital personnel who handle health-care wastes are currently being investigated. If adequate measures are taken, the risks to this segment of the population should be low. Most cultures are sensitive to the aesthetics of health-care wastes or perceive the risk as being high to the point that waste workers sometimes refuse to handle the wastes. To date no low-cost, environmentally friendly and safe disposal option for health-care waste are available. Low-cost options are often polluting and are therefore indirectly potentially harmful to human health. The absence of management however also puts human health at risk. ANALYSIS OF CAUSES There are a number of reasons leading to improper exposure to health-care wastes. Some of the most common reasons are listed below: * Lack of awareness about the inherent hazards caused by improper management of health care wastes; * Insufficient allocation of resources (financial and human) for the safe management of the wastes; * Improper control of the waste management system; * Absence of a national policy for the management of health care wastes; * Lack of or inadequate regulatory framework, and * Insufficient evidence on the negative impact of health-care wastes on certain professional groups. In addition, the lack of political will to develop and implement a proper management system plays an important role on the management of health care wastes. The main relations between causes and effects are outlined in Figure 1. [Figure 1: Interference of causes and effects of inadequate waste management] There may also be other reasons that are specific to a given geographical region. Remark: Additional health effects may be caused, but have not been sufficiently documented. AVAILABLE GUIDANCE Guidance on various aspects of health-care waste management is available. Additional guidance for specific types of settings currently is under preparation. Case studies in developing countries are being documented and compiled. Training material is available for policy makers and hospital managers on the management of health care wastes. Training materials for personnel of health-care establishments should be prepared at national or local level taking into consideration the specific conditions of the country. AVAILABLE TECHNOLOGIES A variety of technologies have been developed for the storage, collection, treatment and disposal of health-care wastes particularly for those wastes generated in industrialized countries. Several types of treatment and disposal processes have been applied (incineration, micro waving, chemical treatment, melting etc.), with varying degrees of safety, cost and impact on the environment. None of the available low-cost treatment devices (i.e. below US$ 500) are however safe and environmentally friendly. In developing countries, a trade-off has to be made between direct health risks from absence of waste management leading to reuse of syringes, and indirect health risks created by environmental pollution (e.g. by production of dioxins from inadequate incineration). Progress could be made in waste minimization practices, in particular in the development of materials and products leading to less waste, or less harmful waste when disposed of. IMPLEMENTATION Safe waste management systems are lacking in many health care establishments and countries; reuse of disposable syringes is widespread in developing countries; workers often are insufficiently protected: Implementation of safe systems is far from satisfactory in many countries, and in particular in developing countries. BASIC REQUIREMENTS FOR IMPLEMENTATION AT NATIONAL LEVEL Basic requirements for improvement include the following: * Assessment of the situation * Training/behavioural change * Availability of equipment A checklist of the main activities/structures which are required is summarized as follows: * Commitment/national policy * Designated authority * Assessment of the situation * Regulatory framework * Regional or national treatment policies * National guidelines * Training system * Equipment of health-care facilities * Periodic review of the system * Monitoring of implementation ____________________________________*______________________________________ 3. DRAFT KEY ELEMENTS: AIDE MEMOIRE Annette Pruess has kindly posted this Draft Aide Memoire for national decision makers which follows below. It is in ths same format as the Safe Injection Aide Memoire in SIGNpost0006 on 6 January 2000. The file is available for download: AideMemoire-HealthCWaste-3.PDF Go to the website go to the folder "Waste" and click on the file: AideMemoire-HealthCWaste-3.PDF or Send an email to: [][/email] To get the file - send the message: get technet AideMemoire-HealthCWaste-3.PDF * Comments to: Annette Pruess , [][/email] Contributions, comments and additions please: [][/email] or use your reply button ___________________________________________________________________________ From: [][/email] Date: Wed, 22 Mar 2000 19:30:14 +0100 To: Technet Moderator Subject: Key elements Dear Allan, As promised, I'm sending you a draft entitled 'Key elements', which you may post on SIGNpost and TECHNET forum. It is targeted at national policy makers, but is also useful for others generating, handling, regulating or planning for health-care waste management. It is based on the model of aide-mé­¯ire, like the one on injection safety. I would appreciate receiving comments to [][/email]. Thank you, Annette Pruess Protection of the Human Environment WHO ___________________________________________________________________________ DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT ___________________________________________________________________________ KEY ELEMENTS for a national strategy for safe health-care waste management Health-care waste is a by-product of healthcare that includes sharps, non- sharps, blood, body parts, chemicals, pharmaceuticals, and radioactive materials. Poorly managed health-care waste exposes health-care workers, waste handlers, and the community to infections, intoxication, and injuries, and may damage the environment. In addition, it creates opportunities for collection, re-sale and potential re-use without sterilisation of disposable medical equipment (particularly syringes). Worldwide, 8-16 million hepatitis B, 2.3 to 4.7 million hepatitis C and 80'000 to 160'000 HIV infections are estimated to occur yearly from re-use of syringe needles without sterilization. Many of these infections could be avoided if syringes were disposed of safely. The most relevant principles underlying waste management include (1) the assignment of the legal and financial responsibility for safe management to the waste producer ("Polluter pays" principle); and (2) the responsibility of handling waste with care ("Duty of care" principle). Precaution should be applied when risks are uncertain. Everyone concerned by health-care waste should be engaged to understand that health-care waste management is an integral part of health care, and that creating harm through inadequate waste management reduces the overall benefits of healthcare. Policies and plans for safe management of health- care waste should address three elements: * A comprehensive system, from generation of health-care waste to disposal? * Training of all those involved to increase awareness * Selection of safe and environment-friendly management options. ___________________________________________________________________________ WORDS OF ADVICE * Secure government commitment and support for safe healthcare waste management * Conduct initial assessment of the situation of potential harms from health-care waste * Manage waste comprehensively, addressing responsibilities, resources, minimization, handling and disposal * Raise awareness among those regulating, generating and handling waste, and train on safe practices * Select safe, environment-friendly and sustainable waste management options * Monitor waste management activities and their impact ___________________________________________________________________________ CHECKLIST for actions at national and local level National policy for safe health-care waste management [ ] Designation of responsible authority [ ] National policy on the basis of the "Polluter pays" and "duty of care" principles [ ] Regulatory framework and guidelines [ ] Initial assessment [ ] Three element approach [ ] Monitoring and evaluation Comprehensive system [ ] Assigned waste management responsibilities to personnel [ ] Allocation of resources [ ] Initial assessment of waste generation and practices [ ] Waste minimization [ ] Waste segregation [ ] Safe handling and storage [ ] Safe treatment [ ] Safe disposal Awareness & training [ ] Waste management in health curricula of healthcare personnel [ ] National training package [ ] Train the trainers programme [ ] Education on health risks [ ] Education on safe practices Selection of management options [ ] Review available options [ ] Check safety and environment-friendliness [ ] Ensure workers' safety [ ] Evaluate Sustainability [ ] Assess acceptability [ ] Monitor safety and efficiency ? see back page for details ___________________________________________________________________________ KEY ELEMENTS National policy for safe healthcare waste management It is the responsibility of governments to create a framework for safe health-care management and to ensure that healthcare facility managers take their share of responsibility to manage wastes safely. This goal requires a national multi-disciplinary action involving the Ministry of Health and several other stakeholders. It is important that a designated authority coordinates these efforts and receives sufficient political support, funding, and trained staff.Important activities for a national strategy to achieve safe health-care waste management include: * Identifying the key partners that should be involved, which include but are not necessarily limited to: Ministry of Health, Environment Agency, waste producers and waste disposal companies or services * Designating the responsible authority for policy setting, implementation and evaluation * Conducting an initial assessment of the situation and analysing problems leading to unsafe handling or disposal * Developing a national policy stating that management is part of the health-care system and that health-care services should manage their waste according to the "polluter pays" and the "duty of care" principle * Developing a regulatory framework and national guidelines, based on a comprehensive approach, including training and sound choices of management options according to local circumstances * Setting practical targets or objectives over a time period * Setting up a national or regional infrastructure for health-care waste disposal * Integrate waste minimization into national purchase policies * Monitoring impact through process indicators (number of health-care establishments with safe waste management systems) and outcome indicators (number of accidents involving health-care waste, estimated re-use rate of disposable syringes) ___________________________________________________________________________ COMPREHENSIVE SYSTEM Facilities generating healthcare waste need to set up a comprehensive waste management system based upon the best overall solution that leads to safe, environment-friendly management of waste.Important activities include: * Assign waste management responsibilities * Allocation of sufficient human and financial resources * Initial situation assessment * Investigate waste minimization opportunities, including the better purchasing and stock management practices * Segregation of waste into harmful and non-harmful categories * Implementation of safe handling, storage, treatment, and disposal options * Monitoring of waste production and waste destination AWARENESS & TRAINING Awareness of the risks related to health-care waste and training on safe practices is key to obtain the commitment and behaviour change of all those concerned by issues related to health-care waste management. Important activities include: * Advocacy targeting policy makers and health-care facility managers regarding risks and responsibilities related to health-care wastes * Inclusion of health-care waste management into training curricula of nurses, doctors and health-care managers * National training package adapted to various professional categories * Development of a 'train-the-trainer' programme * Education of health-care and waste workers regarding the risks associated with healthcare waste and safe disposal practices SELECTION OF OPTIONS Waste management options need to be efficient, safe, and environment-friendly to protect people from voluntary and accidental exposure to waste when collecting, handling, storing, transporting, treating or disposing of waste.Important activities include: * Identification of centralized waste management and disposal resources available * Choice of a management and disposal options according to > Affordability > Sustainability > Environment-friendliness > Efficiency > Worker's safety and > Prevention of re-use of disposable medical equipment (in particular syringes) * Identification of appropriate options for all levels of healthcare facilities Department of Protection of the Human Environment, World Health Organization 20 Avenue Appia, CH-1211, Geneva 27, Switzerland. Fax: +41 22 791 4159. Email: [][/email] _________________________________*_________________________________________ 4. BD WORLD WIDE IMMUNIZATION CONTACT LIST Maureen Knaur, BD, posts the list of BD contacts at the request of Technet members. Becton, Dickinson and Company is a manufacturer of injection and medical equipment. The MS Excel file is available for download: BDI-contact.technet.xls Go to the website go to the folder "Organizations" and click on the file: BDI-contact.technet.xls or Send an email to: [][/email] To get the file - send the message: get technet BDI-contact.technet.xls ___________________________________________________________________________ From: [][/email] To: [][/email] Date: Tue, 29 Feb 2000 14:23:39 -0500 Subject: BD Immunization Contact List Allan, The attached file is in response to the request at the TECHNET meeting in Harare for World Wide Immunization Contact list , so that Technet members in Africa, Asia, etc. could directly contact the local BD people. Regards, Maureen ____________________________________*______________________________________ 5. SAFETY OF VINYL MEDICAL PRODUCTS? Earlier TECHNET Forum postings were concerned about the use of medical devices and equipment containing polyvinyl chloride. PVC in mixed medical waste contributes to the production of hazardous dioxins in incineration. Dioxin exposure has been linked to serious illness in humans. This vinyl manufacturers industry statement argues that vinyl is safe in medical products. It does not address the problem of disposal. Contributions, comments and additions please: [][/email] or use your reply button ___________________________________________________________________________ This story appeared on March 9, 2000 Evidence Supporting Safety of Vinyl Medical Products Continues to Mount, Contradicting Activists' Claims WASHINGTON, March 8 /PRNewswire/ via NewsEdge Corporation - The following statement was issued today by Timothy F. Burns, Executive Director, The Vinyl Institute: The decision by the International Agency for Research on Cancer (IARC) to remove the probable-human-carcinogen rating for di(2-ethylhexyl) phthalate (DEHP), the plasticizer used to soften vinyl medical products, deals another blow to Greenpeace's highly emotional campaign against these lifesaving substances. Previously, DEHP was classified as a "probable human carcinogen," but IARC, part of the World Health Organization (WHO), decided that it was "not classifiable as a human carcinogen" based on existing scientific evidence that supports the safety of DEHP as a component of vinyl medical products. For too long, Greenpeace and its affiliate Health Care Without Harm have been waging a highly visible, fear-based campaign alleging that DEHP in vinyl medical products represents a risk to human health. The IARC working group's recent decision confirmed -- yet again -- DEHP's safety. DEHP has been used in medical devices for more than 40 years without any evidence of harm. It is one of the most thoroughly reviewed compounds with hundreds of studies and billions of real-world patient exposures testifying to its track record of safe use. Other recent, prominent evaluations of DEHP help to underscore its safety in vinyl medical products: - In 1996, the most comprehensive DEHP exposure study to date reviewed more than 450 previous studies and concluded that "an additional cancer risk by DEHP in the maximally exposed hemodialysis patients appears unlikely." (W.W. Huber, B. Grasl-Kraupp and R.Schulte-Hermann, "Hepatocarcinogenic Potential of Di(2-Ethylhexyl) Phthalate in Rodents and Its Impact on Human Risk," Critical Reviews in Toxicology, no. 26 (4), (1996). -In 1999, a blue-ribbon scientific panel of health experts chaired by former Surgeon General C. Everett Koop under the auspices of the American Council on Science and Health found that "DEHP, as used in medical devices, is not harmful to humans even under chronic or higher-than-average conditions of exposure." Vinyl is a material of choice for countless life-saving and life-enhancing medical products, including blood and I.V. bags and anesthesia and dialysis tubing. Furthermore, vinyl-containing medical products have been thoroughly tested and have passed the U.S. Food and Drug Administration's (FDA) rigorous and complex approval process for safety and effectiveness. IARC's decision should help reassure doctors and patients that they can continue to rely on vinyl medical products as trusted tools of health care. SOURCE The Vinyl Institute CONTACT: Allen Blakey of The Vinyl Institute, 703-253-0666; or Antoinette Forbes of Goddard Claussen, 202-955-6200, for The Vinyl Institute

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