One month ago, the LANCET (ScienceDirectRef: “Expanding safe waste management to public health systems” https://doi.org/10.1016/S0140-6736(18)32622-9), January 2019, Elsevier Ltd.) published a letter to the editor (see also attached). The letter points to the failure to sustain or expand immunization waste management infra-structure to all public health programmes. To stimulate an exchange of views the letter includes a text-box proposing four key milestones towards a single vision.   I would like to open the discussion also on Technet. The four milestones are quite general at first glance but they are based on specific experiences of the PATH/WHO Children’s Vaccine Programme that I will introduce as we discuss your own experience and areas of interest. John Lloyd

This is the fifth and last topic in my six-part Vaccine Supply Chain Futures series focused on the potential to address safety issues related to the management of sharps waste including syringe and needles. Progress of efforts to achieve safe infectious sharps disposal in many low to middle income countries is impeded by the lack of funding to establish an infrastructure of medical waste handling in the countries. Immunization generates a small fraction of the sharps waste in public health services but the clients for immunization are not ill at the time they make contact with the service. Rejection of the service is provoked by perceived risks to a healthy child from a preventive intervention. As tolerance of the public to perceived risks reduces towards zero, immunization should be a leading champion of safe disposal of injection materials. Immunization services have introduced safe collection boxes for use syringes and needles. Many countries use on-site incinerators as an alternative to burial to dispose of filled safety boxes. In-spite of some progress in immunization services, disposal facilities remain far below acceptable standards, especially in health centers. Strategic options do exist and are described briefly in the attached paper. They depend on a new or stronger link between the financing and infrastructure of medical supplies together with disposak of infectious sharps. A successful outcome of efforts to establish safe medical waste disposal in a country should include: National policy for system of disposal of infectious sharps, centralized or localized National plan for the introduction of waste management infrastructure country-wide including disposal ‘hubs’ and transport integrated with supply Integration of disposal and supply via regulation of packing volumes and materials, and establishment of annual budget built on the workload/medical supplies anticipated SOPs in health facilities aligned with hospital waste management practices and adjustments made to in-service and basic training of health personnel Please open attached file for full text. Please reply to this post with your views. Thank you!

Immunization programs in low-income countries are facing the most ambitious targets of the last four decades: reach every child with existing and many new vaccines. The original immunization supply chains (iSCs) design, put in place in the 1970’s, is struggling to exceed an 80% coverage rate and is unable to support the increasing volume, complexity, bulk, and cost of vaccines. In recent years, the iSC community has recognized the need to encourage more comprehensive iSC redesigns to address the changing requirements of immunization programs. These “next-generation” immunization supply chains represent a fundamental shift in how iSCs are designed and managed in low- and middle-income countries. Next-generation supply chains are not defined by a specific design, but instead share a set of characteristics that represent a fundamental change in how EPI supply chains have historically operated. The purpose of a next-generation iSC is to improve product availability and ensure all children are reached with a full set of immunizations in a cost-effective manner. They are designed to embrace the five fundamentals of system design, data, people, cold chain equipment and continuous improvement to deliver immunization services reliably, efficiently and safely. For those leading the change-management process in countries, evidence related to next-generation iSC is limited and not easily accessible. VillageReach compiled a list of critical questions regarding the impact of shifting to next-generation iSC from stakeholders at the country and global levels and used these questions to develop a research and evidence framework. Three broad themes were identified and these cover the “what”, “why” and “how” of next-generation iSCs. VillageReach conducted a review guided by these key themes and found little evidence in the peer-reviewed literature linking holistic supply chain design or even individual supply chain improvements to improved outcomes. While the grey literature includes more evidence from LMICs, it is primarily related to the effect of supply chain improvements on commodity availability. However, a challenge is there is no single repository for these works, hence it is not easily accessible to advocates or key stakeholders.

Several themes arose from the literature review. First, documentation of the problem is strong. We found substantial evidence in the literature documenting the challenges experienced or anticipated with new vaccine introductions on the supply chain including; increase in cost, waste, reduced availability and the creation of bottlenecks. There is similar documentation around challenges with keeping the cold chain maintained at the right temperature, and the impact of vial size on storage and transport. Second, modeling is an important source of data. Modeling studies in peer-reviewed literature demonstrate the anticipated outcomes of supply chain improvements including improvements in availability and efficiency. Third, costing of existing systems is useful, but limited costing of improved systems exists. The EPI Costing (EPIC) studies are a rich source of information that identify cost drivers of EPI programs, including supply chain components; provide new insights into total cost and efficiency metrics; and help answer questions related to the cost of existing systems. Additional work is expected through the Immunization Delivery Cost (IDC) evidence project. Limited work has been done however, to evaluate the cost difference between current iSC and next-generation iSC systems. Fourth, grey literature does include evidence, particularly on availability of commodities. Case studies, supply chain partner reports, impact briefs, and blogs provide evidence of supply chain improvements for vaccines and other commodities. In particular, repositories are available from USAID|DELIVER and Project Optimize. The grey literature also provides more examples of holistic next-generation iSC impact. Some of the powerful examples we have found were from Nigeria, Senegal, Zambia, Mozambique and Benin (see detailed report attached). While there is much discussion regarding the importance of evidence-based decision making, our work to date has highlighted that the existing literature does not answer many of the priority questions decision-makers are currently asking regarding the move to next-generation immunization supply chains. Moreover, some of the existing evidence is not easily accessed or interpreted by decision-makers. Finally, significant gaps exist regarding the process for move to a next-generation iSC and the resources required. Join the discussion:
If you are interested in discussing how we can gather, develop and share evidence regarding iSC improvement, please contact:melissa.west@villagereach.orgorbvudzai.magadzire@villagereach.org

This posting is one of four, each discussing a different indicator. This post discusses vaccine utilisation efficiency. Another efficiency indicator measures the level of vaccine administered expressed as a percentage of the vaccine consumed (Doses ‘Consumed’ = ‘Doses ‘administered’ to clients + ‘Doses wasted’). This is the inverse of vaccine wastage. Overall vaccine wastage is the sum of: Doses in closed/sealed vials, condemned by expiry or exposure   Doses in opened vials, abandoned for administrative reasons and due to be destroyed. But opened vial wastage is mainly caused by small immunization sessions where the number of clients is much less than the number of doses per vial. So high levels of opened vial wastage can be a normal consequence of small sessions, for example in areas of low population density and may not be changed by management. Closed vial wastage on the other hand is due to expiring vaccine or vaccine with VVMs at stage 3 or 4 and should be manageable. Overall wastage should not exceed national policy ‘targets’ that are expressed as % doses wasted (both types) of total doses consumed. Wastage or utilization efficiency may be tracked in a number of ways that are summarized in the Table below. Table: Alternative Vaccine Wastage Indicators *Recommended SC indicator for District Supervisors to monitor Health Center performance. As part of the health worker’s Standard Operating Procedure he/she checks on a daily basis that vaccine has not been exposed to freezing temperatures and that the expiry date has not been passed. If vaccine in closed vials is no longer useable the affected vials are set aside for disposal and they become one part of the overall vaccine wastage. This wastage is avoidable in most cases by improving vaccine handling or practicing stock turnover or rejecting attempts to supply vaccine near expiry. Indicator a) is therefore the best indicator of wastage to track compliance with best practices but the data has to be measured in the health centre and passed monthly to the district. The indicator at the district would therefore be: “The number of doses of vaccine in closed vials that have been discarded due to expiry or cold chain failure as a percentage of doses consumed within the last supply period” The second indicator b) is a measure of overall wastage, including both the closed vial wastage and all vaccines discarded in opened but unfinished vials. This ‘administrative’ wastage is influenced heavily by the size of immunization sessions, the extent of outreach and several factors that are only partly able to be managed. As an aggregate record of wastage or utilization it can be calculated at any level of the system but is most useful to the District Supervisor. The trend of this level of wastage (monthly for >3 months) is a more valid measure than direct comparison area to area because it is so dependent on the local situation.

I hope that you will disagree with me and tell me that medical waste disposal systems in low-to-middle income countries have advanced dramatically in the last ten years. But I have the impression is that the interest that existed in the first five years of the millennium has declined and that the national plans that were drawn up a decade ago were neither funded nor updated. It is surprising that, at this crucial moment in the struggle against the spread of Ebola, there has hardly been a mention of the infrastructure needed to collect and destroy infected clothing and materials. The focus remains entirely on supply. In the world of Immunization, disposal of used needles is no longer treated as a priority and seems excluded from external funding opportunities. Please prove me wrong by posting your description or links to any source of news reporting positive developments in low or middle-income countries. Perhaps you can include innovative country experiments, financing schemes, public/private outsourcing or technological ideas that have reached national scale-up in the last decade? In other words – any progress in the infrastructure of sharps waste management in urban and/or rural areas would be welcome news? I hope to devote my next two postings respectively to urban and rural medical waste systems innovations that remain under-used.

by Yves Chartier, WHO, and Olga Popova, Crucell Worldwide immunization programs have had an enormously positive impact on health and health care since 1974 when the World Health Assembly launched the Expanded Programme on Immunization. However, like all great achievements the effort has unveiled new challenges. One of the most serious has been the re-use of syringes without adequate sterilization. As this issue came to light in the 1950s, disposable syringes were developed to resolve the problem. Unfortunately, they did not, and the rise of HIV/AIDS and hepatitis B and C transmission raised the issue into an even greater sphere of concern. The late 1980s brought the successful development and deployment of autodisable syringes, which are now in widespread use in immunization programs. And while autodisable syringes have considerably reduced re-use and contamination issues—at least within the relatively narrow confines of immunization programs—their use has given rise to an associated concern, how to manage injection-related waste. Improper management of injection-related waste can have both direct and indirect health consequences for health personnel, community members, and the environment. Direct consequences of improper waste management arise when disposable materials (especially syringes) are intentionally re-used. The transmission of hepatitis B and C and HIV represent the main disease burden caused by inadequate management of injection-related waste. Unintentional injuries may also occur when people mishandle or are exposed to inadequately disposed waste, for example through scavenging on waste sites. Indirect health effects can arise from environmental pollution in the form of toxic emissions from inadequate burning of medical waste or in the sheer volume of waste generated in a short period of time. For instance, a countrywide mass immunization campaign will produce millions of used syringes in a period of three to four weeks. This requires appropriate options and a well-prepared strategy defined months before the campaign starts. A variety of technologies have been developed to aid in the safe storage, collection, treatment, and disposal of health care wastes. Several types of treatment and disposal processes, such as incineration, microwave or chemical treatment, and melting have been applied in health care settings with varying degrees of safety, cost, and impact on the environment. However most are geared toward industrialized country settings. None of the available low-cost treatment devices (i.e., below US$500) on the market are both safe and environmentally friendly. In developing countries, a trade-off has to be made between direct health risks resulting from the absence of a waste management strategy, and indirect health risks created by environmental pollution (e.g., by production of dioxins from inadequate incineration). Despite the difficult tradeoffs in waste management approaches, countries are better off with a waste management strategy than without one. Some countries have made significant improvements by adopting purchase policies that consider the waste stream and/or by isolating and treating the most harmful segments of the waste. At the global level, vaccine manufacturers and injection equipment suppliers are also seeking solutions. Crucell, for example, is adopting a holistic approach to its pentavalent vaccine, looking for solutions that can meet the needs of complex, developing-country environments. First, it changed its formulation from lyophilized to liquid, thus reducing opportunities for reconstitution errors, eliminating multiple procedural steps, shortening the vaccination session, shrinking storage needs, and minimizing waste. Next, it offered the vaccine in single-dose vials, thus reducing vaccine wastage, eliminating the need for preservatives, and minimizing the possibility of contamination. Recently it has begun to explore the feasibility of offering liquid pentavalent vaccine in the UnijectTM injection system, a plastic, compact prefilled autodisable system. Belying its big name, Uniject is nothing more than a small bubble of plastic attached to a needle. It is precisely prefilled with a single dose by manufacturers, thus eliminating vaccine wastage or improper dosing. It is so easy to use that health workers need a scant two hours of training before successfully using it. From a waste-management perspective, Uniject cannot be reused, thus minimizing the threat of disease transmission. It contains only about 35 percent of the plastic of a standard disposable syringe, and the type of plastic used in Uniject can be incinerated without generating toxic fumes (unlike those produced by with a rubber piston). By testing and seeking solutions such as these, pharmaceutical companies like Crucell can ameliorate some of the health care waste management problem countries face. Ultimately, the waste management conundrum must be addressed at all levels, from upstream technology development to downstream waste minimization and management, to ensure that health care can be delivered without side effects on health care workers, communities, or the environment. To comment, click reply.

As a result of our posting on Tech Net we were made aware of a technique for melting syringes and suspending the needles in the innards of a plastic block formed by the melting plastic syringes. This technique eliminates exposed needles and reduces the volume of the waste by 70%. The technique is described in the article "Oven melting encapsulization of hypodermic needles by syringes" by T. Fortner, H. Wynn, H. Heffner and J. Colton, Journal of Medical Engineering and Technology 2009.  The Sun Frost "Tubular Oven" previously described could be used to form these sterilized blocks. This technique would be more environmental sound then incineration. Please let us know if you can see applications for this technique.

Many thanks to Ashley Iwanaga for sending in the latest UNDP GEF Healthcare Waste Management Project report. Dear Colleagues, The UNDP GEF Project on Healthcare Waste Management is excited to share its first Project Update report (in English, French, and Spanish). The goal of the project is to demonstrate best environmental practices and best available techniques for healthcare waste to avoid dioxin and mercury releases in eight countries: Argentina, India, Latvia, Lebanon, Philippines, Senegal, Tanzania, and Vietnam. The project facilitates the implementation of the Stockholm Convention on Persistent Organic Pollutants (POPs). Since its beginning in August 2008, the project has accomplished multiple national and global activities. The attached report highlights the project's progress and achievements. For more information about the project, please visit our website at http://www.gefmedwaste.org. Dr. Jorge Emmanuel, Chief Technical Advisor Ashley Iwanaga, MPH, Global Technical Coordinator ##text## ##text## ##text## The document is available in [i]English,French, and Spanish.

The Lagos State Waste Management Authority organised their fourth Medical Waste Summit, which was held on 26 and 27 October, 2009 at the National Arts Theatre Iganmu, Lagos with the theme “Safe Management of Healthcare Waste: The Time is Now”. This short report on the proceedings has been shared with the TechNet21 readers by Dr Abimbola O. SOWANDE, Country Director, USAID/AIDSTAR-One. ##text##

The Supply Chain Management Team within the USAID | DELIVER PROJECT is pleased to announce the availability of a new technical document, Logistics of Health Care Waste Management Information and Approaches for Developing Country Settings You can find the document on the USAID | DELIVER website http://www.deliver.jsi.com, or at the direct link here. http://deliver.jsi.com/dlvr_content/res ... stMgmt.pdf Abstract: Medical or health care waste (HCW) refers to all waste generated by health care facilities, research facilities, and laboratories. Health care waste management (HCWM) is a major health and environmental concern. Hazardous waste, including sharps and other infectious waste, pose a serious risk to human health and the general environment. In many developing countries, disposing of this waste is complicated by limited financial and human resources. This document considers the reality of HCWM practices in resource-limited settings. Solutions offered within this text are based on actual experience in developing countries and are presented as practical solutions to vexing logistics problems in HCWM. Marcia N. Rock, MPH Technical Officer HCWM Focal Point John Snow, Incorporated 1616 N. Fort Myer Drive Arlington, VA 22209-3100 Tel (703)310-5257 Fax (703)528-7480

Seychelles injection safety and waste management assessment 25th June-7th July2009 Seychelles is a multi-ethnic tri-lingual state with its origin from three continents: Africa, Asia and Europe. It is an upper middle income developing country organised into 25 districts with a 2009 estimated midyear mid-year population of 87,409. Seychelles has been using predominantly disposable syringes and needles for both curative and preventive interventions including immunization and it is feared that reuse may be common outside the health care system. Whilst there is great awareness on the risks posed by health care waste to health workers and the community in general, there is no policy on health care waste disposal. Most wards and outpatient facilities use safety boxes, but these boxes are not properly mounted and recapping of needles is often practiced. Waste segregation is not common except in the maternity ward, exposing health workers and workers handling waste to the risk of infection. Seychelles being small has one final disposal site where health care waste is incinerated using liquefied petroleum gas incinerator. The incinerator operators are not trained in the care and maintenance and operation leading to the production of black sooty smoke. The incinerator emits the sooty effluent into a habitable neighborhood which causes lot of complaints and criticism of the hospital. Fear has been expressed about the dangerous nature of this emission and the hospital had requested WHO to assist to assess the function and safety of the incinerator. A holistic injection safety and health care waste management assessment which will lead to the development of a comprehensive health care waste management policy and guidelines. Objective of the surveyo To review the current status of injection safety, including therapeutic and preventive injections.o To assess the health care waste management systemo To propose environmentally friendlier incinerators for health care waste. Specific objectiveso To determine whether a health facility where injections are given or procedures undertaken with needle and syringe meets necessary requirements for staff competence, equipment, supplies, and waste disposal;o To determine whether the critical steps of an injection administration are executed according to recommended best practices;o To identify the unsafe practices that may lead to infections and that should be targeted by injection safety interventions;o To estimate the proportion of healthcare facilities where injection practices are safeo To determine the status of the health care waste management system in the health facilitiesStudy designA cross sectional, observational study will be carried out using WHO Questionnaire. It will consist of:A structured observation of equipment and supplies available at the facility, A structured observation of all injections given and other skin piercing procedures conducted given during the visit in hospital and veterinary clinic.An interview of injection providers and supervisors.Interview and curriculum search for Injection safety in NIHSS (pre- service institution)An interview of the incinerator operators and their supervisorsStudy areaAll government and private facilities and veterinary clinic will be studied Day unitsHospitalsLarge Health centreSmall health centrePre-service institutionVeterinary clinicDisposal sites for used injection equipment and other Health waste materials[/list] Two consultants for injection safety and Health care waste management recruited by WHO are assisting in this survey from 25thJune -7th July 2009. It is hoped that the finding and recommendations of this assessment will help in the development of injection safety and health care waste policy and strategic plan

Hello, I would like to enquire if someone has worked on setting up a manufacturing plant for safety boxes in Africa. If such an attempt has been made, what have the outcomes been. I am assuming the safety boxes are currently being imported from elsewhere. Regards, Abhisheka Jhunjhunwala

Dear Colleagues, Below please find information on newly devised incineratorfor healthcare waste and immunization waste developed by healthcare wasteexpert in Tanzania. The incinerator has the following features coupled together: 1) High tech chamber with burner(s), operated at 900C 2) Gas cooler, used to generate hot water for patients andhospital use (sanitation in theaters, use in laundry, and sluice room) 3) Flue Gas cleaning facility developed for incineratorsand other fuel and waste combustion systems after a research for 6 years atUniversity of dare s Salaam. The technology has been in development since 2003 and it hasproved perfect for use in rather congested areas without smoke problems, whichhas been a nuisance for many years. The technology is suited for different purposes, lab waste,chemical waste, injection waste, and can be made mobile or fixed. The progress of development was a collaborative work betweenWHO-Dar (EPI), MoH Dar, and University of Dar es Salaam. We will post more information as time allows, to informinterested parties. For those who are interested and have questions about thistechnology, please contact the founder and pioneer of the technology: Prof. Samwel V. Manyele University of dare s Salaam Department of Chemical and process Engineering, P.O. box 35131, dare s Salaam, Tanzania +255 716 941 061 +255 784 860 944 __________ Information from ESET NOD32 Antivirus, version of virus signature database 4105 (20090526) __________ The message was checked by ESET NOD32 Antivirus. http://www.eset.com

Hello, With the advent of the new Pneumococcal and Rotavirus vaccines packaged in single dose pre-filled glass syringes, we are likely to be facing a complication in waste management. It's my understanding that this is likely to be a transitory trend for many of the new vaccines in the future, which means that infrastructure (programmatic and technological) needs to be thought up and disseminated as part of national and program health care waste management plans. If you have been administering these in your country, would you be so kind as to take a few minutes to briefly share your experiences with safely disposing of Pre-filled Glass Syringes? If you are getting these vaccines soon, but haven't started using them yet, perhaps you could share your basic strategy with this group. If you are a waste management consultant and are already experiencing issues with these, please tell us your stories. Many thanks, Tory Hart Consultant for Health and Environment ##text##

POST 01421E: SYRINGE MELTERS FOLLOW-UP ON POSTS 01406E & 01411E 24 APRIL 2009 ****************************************** Joanie Robertson responds to Hans Everts’s questions regarding how many syringes of a given type can be melted and whether the melter is easily transportable. --------- The syringe melters have 2 containers, each can hold about 250 syringes of the typical immunization AD type, so the total number of syringes processed per cycle is about 500. In the India trial, the needles were removed from the syringes with a needle remover prior to melting. Without doing this, the capacity in the containers would be reduced to about 150 per container for a total of 300 per melt cycle. If it is a campaign, transport is available via jeep or other vehicle, then it is transportable. It would be too heavy for the healthcare workers to carry in public transport or on foot. Joanie Robertson Technical Officer PATH

POST 01411E: SYRINGE MELTER FOLLOW-UP ON POST 01406E 2 APRIL 2009 ****************************************** In addition to mentioning that the capacity is sufficient and that the melter can deal with 1-3 liters of syringes, it would be useful to know how many syringes of a given type can be melted. It will not be rocket science, but give an indication. Is the melter mobile enough to be used during campaigns or should syringes (that need to be disposed of) first be brought back from the field? Regards Hans Everts WHO Geneva Technical officer EPI Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01406E: EVALUATION OF SYRINGE MELTER 22 MARCH 2009 ****************************************** Dear TechNet moderator, I am forwarding a report of an evaluation of a syringe melter conducted in Andhra Pradesh in 2008. The melter was developed by Mike Werner, then of New Paradigm Automation, under funding from the United States Center for Disease Control (CDC). Dr. Satish Kaipilyawar and his staff in the PATH office in Andhra Pradesh managed the India-based field study with funding from CDC and US Agency for International Development. The melter from New Paradigm included some improvements that were indicated by a similar study of several melters, including an earlier version of the New Paradigm device, conducted by PATH in Indonesia in 2006. Any questions about the study may be directed through Joanie Robertson ([email=jrobertson@path.org]jrobertson@path.org[/email]) at PATH. Joanie Robertson, ([email=jrobertson@path.org]jrobertson@path.org[/email]) Technical Officer PATH (http://www.path.org) Post generated using Mail2Forum (http://www.mail2forum.com) ##text##

POST 01307E: HEALTHCARE WASTE MANAGEMENT: NEED FOR TRAINING/SUPERVISION FOLLOW-UP ON POSTS 01295E, 01296E & 01305E 19 AUGUST 2008 ******************************************* Dear Friends, In Developing country settings (like India) Biomedical Waste Management is given low priority in absence of quality training and poor supervision. In a study conducted by dept. of community medicine, of a medical college in Himachal Pradesh, India, (unpublished), the knowledge regarding Biomedical waste management and desirable practices was low especially among sweepers who collect and dispose the waste. This was common even among those who were trained. What is required is good quality trainings and proper supervision of waste segregation and handling. We still have to address the basic issues in developing countries. Incinerators often go out of order (? due to waste not being segragated) and then remain out of order for long periods in absence of appropriate mechanisms to maintain them.Rajesh Sood ([email=drrksood@GMAIL.COM]drrksood@GMAIL.COM[/email]) -------- The references below are cross-posted from SIGN (30 July 2008) with thanks. 1. Report: Hospital waste management--awareness and practices: a study of three states in India (Waste Management Research. 2008 Jun: 26(3): 297-303; Rao PH, Center for Human Development, Administrative Staff College of India, Bella Vista, Khairatabad, Hyderabad, India. [email=drphrao@asci.org.in]drphrao@asci.org.in[/email] ([email=drphrao@asci.org.in]drphrao@asci.org.in[/email])) The study was conducted in Andhra Pradesh, Maharashtra and Uttar Pradesh in India. Hospitals/nursing homes and private medical practitioners in urban as well as rural areas and those from the private as well as the government sector were covered. Information on (a) awareness of bio-medical waste management rules, (b) training undertaken and (c) practices with respect to segregation, use of colour coding, sharps management, access to common waste management facilities and disposal was collected. Awareness of Bio-medical Waste Management Rules was better among hospital staff in comparison with private medical practitioners and awareness was marginally higher among those in urban areas in comparison with those in rural areas. Training gained momentum only after the dead-line for compliance was over. Segregation and use of colour codes revealed gaps, which need correction. About 70% of the healthcare facilities used a needle cutter/destroyer for sharps management. Access to Common Waste Management facilities was low at about 35%. Dumping biomedical waste on the roads outside the hospital is still prevalent and access to Common Waste facilities is still limited. Surveillance, monitoring and penal machinery was found to be deficient and these require strengthening to improve compliance with the Bio-medical Waste Management Rules and to safeguard the health of employees, patients and communities. 2. Report: Healthcare waste characterization in Chittagong Medical College Hospital, Bangladesh (Waste Management Research 2008 Jun: 26(3): 291-6; Alam MM, Sujauddin M, Iqbal GM, Huda SM; Institute of Forestry and Environmental Sciences, Chittagong University, Chittagong, Bangladesh) Healthcare waste management (HCWM) options are inconsistent in Bangladesh. One of the first critical steps in the process of developing a reliable waste management plan requires a comprehensive understanding of the quantities and characteristics of the waste that needs to be managed. This study took into consideration both the quantity and quality of the generated waste to determine the generation rates and physical properties of healthcare waste (HCW) in Chittagong Medical College Hospital (CMCH) and also to estimate the amount of infectious and non-infectious waste generated in different wards. CMCH, the second largest hospital in Bangladesh, comprises 34 wards, 12 of which were selected randomly. Waste materials were collected from these wards and then segregated and weighed. Waste generation per day was found to be 73.22 kg/ward, 1.28 kg/bed and 0.57 kg/patient. A total of 2490 kg of HCW was produced each day in CMCH (37% being infectious and the rest being non-infectious waste). Infectious waste was 27.07 kg per ward, 0.47 kg per bed and 0.21 kg per patient and the non-infectious waste was 46.15 kg per ward, 0.81 kg per bed and 0.36 kg per patient per day. HCW comprised eight categories of waste materials with vegetable/food waste being the largest component (50.21%) and varied significantly (P < 0.05) among the 12 different wards studied. The greatest amount of HCW was recorded (154 kg) in Orthopaedics followed by 96.66 kg in the Medicine Unit-3 and the smallest amount was recorded in Casualty (8.79 kg). The amount of HCW was positively correlated with the number of occupied beds (rxy = 0.79, P < 0.01). There is no structured form of medical waste treatment in CMCH and most waste materials are dumped in open areas for natural degradation or re-sold by scavengers. It is essential to develop a national policy and implement a comprehensive action plan for HCWM that will provide environmentally sound technological measures to improve HCWM in Bangladesh. 3. Modelling seasonal variation in biomedical waste generation at healthcare facilities (Waste Management Research: 2008 Jun: 26(3): 241-6; Katoch SS, Kumar V; Department of Chemical Engineering, Thapar Institute of Engineering & Technology, Deemed University, Patiala, India.) A mathematical model can help waste planners to optimize waste management systems related to environmental protection. It can also help government bodies set guidelines and regulations, and evaluate prevailing strategies for handling and disposal of waste. In this paper, a technique to develop a mathematical model to correlate the generation rate of biomedical waste (contaminated with blood and body fluid) as a function of bed occupancy and type of ailment (in terms of seasonal changes) using data for two consecutive years from three different healthcare facilities is presented. The data exhibit different trends in biomedical waste generation rates and number of beds occupied in two different years. However, the seasonal variation in biomedical waste production rate remained nearly the same during these 2 years. The fixed trend in biomedical waste generation rate in two consecutive years could be due to similar seasonal illnesses pattern and social factors. 4. Utilizing a 'systems' approach to improve the management of waste from healthcare facilities: best practice case studies from England and Wales (Waste Management Research: 2008 Jun: 26(3): 233-40; Tudor TL, Woolridge AC, Bates MP, Phillips PS, Butler S, Jones K. SITA Centre for Sustainable Wastes Management, University of Northampton, Northampton, UK. [email=terry.tudor@northampton.ac.uk]terry.tudor@northampton.ac.uk[/email] ([email=terry.tudor@northampton.ac.uk]terry.tudor@northampton.ac.uk[/email])) Changes in environmental legislation and standards governing healthcare waste, such as the Hazardous Waste Regulations are expected to have a significant impact on healthcare waste quantities and costs in England and Wales. This paper presents findings from two award winning case study organizations, the Cardiff and Vale NHS Trust and the Cornwall NHS Trust on 'systems' they have employed for minimizing waste. The results suggest the need for the development and implementation of a holistic range of systems in order to develop best practice, including waste minimization strategies, key performance indicators, and staff training and awareness. The implications for the sharing of best practice from the two case studies are also discussed. 5. Resolving complexities in healthcare waste management: a goal programming approach (Waste Management Research: 2008 Jun: 26(3): 217-32; Chaerul M, Tanaka M, Shekdar AV; Graduate School of Natural Science and Technology, Okayama University, Japan. [email=dns16607@cc.okayama-u.ac.jp]dns16607@cc.okayama-u.ac.jp[/email]) ([email=dns16607@cc.okayama-u.ac.jp]dns16607@cc.okayama-u.ac.jp[/email]) A planning model is presented that is based on a trans-shipment goal programming approach wherein the waste flow is optimized for multiple objectives under different priority structures or with different relative importance (weights). The use of the model is demonstrated as a decision-making tool that would help the management to understand the effects of their policies on the system performance. The model is validated for a case application representing a real-life situation. It can be easily seen that, in the case in which the management is biased toward a higher level of safety protection towards infection control, they have to compromise on cost control and to some extent on environmental pollution control. 6. Healthcare waste management in the capital city of Mongolia (Waste Management: 2008: 28(2):435-41. Epub 2007 April; Shinee E, Gombojav E, Nishimura A, Hamajima N, Ito K; Department of Young Leaders' Program, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan: [email=shinee_e@hotmail.com]shinee_e@hotmail.com[/email] ([email=shinee_e@hotmail.com]shinee_e@hotmail.com[/email])) Inconsistencies are present in the management options for healthcare wastes in Mongolia. One of the first critical steps in the process of developing a reliable waste management plan requires the performance of a waste characterization analysis. The objectives of this study were an assessment of the current situation of healthcare waste management (HCWM) and characterization of healthcare wastes generated in Ulaanbaatar. A total about 2.65 tonnes of healthcare wastes are produced each day in Ulaanbaatar (0.78 tons of medical wastes and 1.87 tons of general wastes). The medical waste generation rate per kg/patient-day in the inpatient services of public healthcare facilities was 1.4-3.0 times higher than in the outpatient services (P ([email=mbongwe@mopipi.ub.bw]mbongwe@mopipi.ub.bw[/email])) Healthcare waste management continues to present an array of challenges for developing countries, and Botswana is no exception. The possible impact of healthcare waste on public health and the environment has received a lot of attention such that Waste Management dedicated a special issue to the management of healthcare waste (Healthcare Wastes Management, 2005. Waste Management 25(6) 567-665). As the demand for more healthcare facilities increases, there is also an increase on waste generation from these facilities. This situation requires an organised system of healthcare waste management to curb public health risks as well as occupational hazards among healthcare workers as a result of poor waste management. This paper reviews current waste management practices at the healthcare facility level and proposes possible options for improvement in Botswana. Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01305E: HEALTHCARE WASTE MANAGEMENT: WEIGHTED DECISION-MAKING APPROACH FOLLOW-UP ON POSTS 01295E & 01296E 15 AUGUST 2008 ******************************************* Dear Moderator, I would like to respond to the important issues raised by Vijay on July 29, 2008. Safe, affordable, and appropriate solutions for treatment and final disposal of health care waste continue to be major challenges. For countries looking to identify technologies that are financially and technically feasible and environmentally safe, the factors for consideration are many and complicated, as alluded to by Vijay in his recent message. I would like to share with the TechNet community a brief description of collaboration among PATH (through its USAID-funded HealthTech project), the Making Medical Injections Safer Project, Health Care Without Harm, and several ministries and a private hospital in Botswana. The primary goal of the collaboration is to develop and model a facility-based, decision-making approach to identify an appropriate clinical waste treatment system with the focus on reduction of negative environmental and health impact. The emphasis is on developing a practical, participatory approach that will be used to characterize the clinical waste needs and identify key costs and benefits for improved treatment options, including health and environmental factors such as those Vijay mentions. The process will result in recommendations for a type of technology based on a clearly documented rationale, enabling decision-makers in Botswana to select an appropriate, improved clinical waste management solution for a designated facility. This collaboration is expected to result in a decision-making approach to identify appropriate treatment solutions that can be weighted to reflect the priorities of a country or facility. We anticipate the process will conclude by the end of 2008 and plan to write a case study on the experience to be shared with the global health community. PATH continues to look for new appropriate technologies for health care waste management to meet the needs in low-resource settings. In addition to developing new solutions, we continue to explore ways to modify and optimize existing technologies. As we look toward the future, it will be increasingly important to identify technologies that safely and affordably convert waste to fuel or other useful byproducts. As countries continue to gain experience with new technologies and approaches for health care waste management in low resource settings, it is critical we document and share findings and outcomes through publications and postings in forums like TechNet. Regards, Nancy Muller ([email=nmuller@path.org]nmuller@path.org[/email])
 Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01302E: SYRINGE MELTING DEVICES FOLLOW-UP ON POST 01285E 10 AUGUST 2008 ******************************************* Dear Moderator, In response to Anthony Battersby's syringe melting posting of 30 June 2008, PATH would like to offer the following thoughts on the subject: PATH has conducted three field evaluations of several different designs of syringe melters to assess usability, acceptability, system-fit of each design, and of the class of devices overall. Two of the devices evaluated were powered by biomass fuel; the third was a passive solar melter design. For the complete results of one evaluation of biomass melters please refer to the report posted to TechNet in June 2007 (POST 01103E). A report on a second evaluation of a modified biomass melter design is forthcoming. Biomass melters: The biomass syringe melters performed relatively well with no visible smoke, but often produced a strong odor. Health workers occasionally found sharps protruding from the melted plastic blocks. Though no longer infectious, protruding needles present a risk of injury. In such cases, disposal of these plastic blocks in a protected pit may be a viable solution. In general, participants found the biomass melters easy to use and maintain, practical for managing small volumes of sharps waste, and affordable to operate. Melting of used syringes reduces the volume of plastic by approximately 5 to 10 times. Challenges related to acceptability include: the need for appropriately designed containers for point-of-use syringe collection and melting; the need for supervision of the melter to maintain temperatures; and a strong smell from fumes produced during the melting process. The potential effect of these emissions on communities and the environment is not yet known. Solar melters: During the evaluation, the solar melter successfully melted syringes when there was sufficient sun to achieve proper melting temperatures. Although the amount of solar radiation accumulated by several designs of solar collectors is theoretically sufficient to melt medical grade polypropylene and polycarbonate syringes, in practice the prototype design did not achieve consistent and reliable performance with an acceptable level of health worker skill and labor. Other designs have been developed but not rigorously tested. Proper placement of the solar melter is essential, as is ensuring the melter site will experience enough sunny days to melt syringe waste on a regular basis. Sequential days without sun and seasonal changes in the position of the sun are limitations. Further exploration is needed to determine if syringe melters can be optimized to provide an affordable sharps waste management alternative, specifically one that does not emit harmful gasses and that also isolates the sharps waste at point of use, produces plastic blocks of a consistent quality for recycling (when used in combination with needle removal), and does not require significant extra work for the health worker or result in unacceptable expenses incurred by the health facility. Electric melters are another approach and need to be further tested, particularly in certain urban environments where the melted plastic blocks could be safely and consistently channeled to recyclers or into the domestic waste stream. Sincerely, Nancy Muller ([email=nmuller@path.org]nmuller@path.org[/email]) Senior Program Officer PATH Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01296E: BETTER TO HAVE SOME WASTE DISPOSAL SYSTEM THAN NONE AT ALL FOLLOW-UP ON POST 01295E 30 JULY 2008 ******************************************* Vijay- Thank you for making this excellent point that we need a feasibility baseline before adopting a medical waste disposal "system". I prefer the word "system" to "technology" because we definitely need to think about the waste issue in a comprehensive manner¾For instance, waste segregation, when systematically implemented can reduce considerably the volume of waste and subsequently render the transportation and final disposal a bit less problematic. The technology is part of the system, and, of course it is important to have the appropriate technology. Even though I see your point and understand the rationale of it, I don't think that we should condemn some methods as "totally unacceptable" before we have in place "acceptable" methods in place¾People should get some credit for trying to dispose of the waste, rather than dumping them in unsupervised areas. However, we should be more aggressive in recommending that every country puts in place national standards/or policy to guide partners and populations. Furthermore, it is not unreasonable to demand from each partner that wants to support any health program to put a 2 to 5% waste management budget line. Once this becomes a standard by itself, I think waste management will not be viewed as an unpleasant afterthought. Dr. Jules Millogo ([email=jmillogo@VANISHPOINT.COM]jmillogo@VANISHPOINT.COM[/email]) Medical Director Retractable Technologies Inc. Washington, DC Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01286E: WASTE MANAGEMENT CHALLENGES/SOLAR TECHNOLOGY FOLLOW-UP ON POSTS 01273E, 01283E, 01284E, 01285E 2 JULY 2008 ******************************************* NEW PRESENTATION OF PNEUMOCOCCAL VACCINE I agree fully with Anthony, I would warn however that at least one of the new vaccines (pneumococcal) targeted to hit the market by 2009 is currently presented in a pre-filled glass non-AD type syringe. This will add a whole new dimension of complexity to waste management. I understand efforts are underway by GAVI/UNICEF to address this issue. Terry Hart ([email=tjh@itpi.co.in]tjh@itpi.co.in[/email]) ------ REQUIRE RECYCLING SYSTEMS Dear Anthony This is an excellent idea, but let's not forget that immunizations represent only a fraction of injections. If manufacturers are called to task to develop recycling SYSTEMS, it should address all injections. I am highlighting the word "systems" because it would not be enough to have a cool device that melts the plastic. It would be important to propose something that can be profitable to manufacturers- otherwise, someone will have to pay for the system. At the moment, it seems very challenging to make a profitable system. Thanks Jules ([email=jmillogo@VANISHPOINT.COM]jmillogo@VANISHPOINT.COM[/email]) ------ SOLAR REFIGERATION: SUSTAINABLE AND GREEN Dear forum, We welcome the solar technology Refrigerators and would like to share experiences of constraints in maintaining cold chain in our settings. While working as Surveillance Officer for NPSP in Bihar (a underdeveloped state in India), I realised that electricity was erratic and the only place where generators could run and be monitored was the district cold store. There were no systems to ensure power supply for cold chain at lower levels. Often the generators would be turned off when our vehicle left the hospital campus to save on fuel costs. Apart from diesel based generators being having higher running cost for cold chain, there was noise and air pollution all over the place. Solar powered refrigerators are an appropriate technology especially for regions with poor electricity supply. Solar Technology comes as the only green and sustainable option and needs to be promoted. Dr Rajesh K Sood ([email=drrksood@GMAIL.COM]drrksood@GMAIL.COM[/email]) Centre For Health Promotion, India. ----------- Sustainable Packaging Coalition [/ol] Sustainable packaging: Is beneficial, safe & healthy for individuals and communities throughout its life cycle; Meets market criteria for performance and cost; Is sourced, manufactured, transported, and recycled using renewable energy; Maximizes the use of renewable or recycled source materials; Is manufactured using clean production technologies and best practices; Is made from materials healthy in all probable end of life scenarios; Is physically designed to optimize materials and energy; Is effectively recovered and utilized in biological and/or industrial cradle to cradle cycles. 2. Weekly Epidemiological Record (30 May 2008) ...The introduction of new vaccines poses challenges to the existing logistics and cold-chain requirements, because of their current presentations. In particular, the high volume of the pre-ï¬

POST 01285E: REDUCING ENVIRONMENTAL IMPACT OF IMMUNIZATION SERVICES FOLLOW-UP ON POSTS 01273E, 01283E, 01284E 30 JUNE 2008 ******************************************* SYRINGE MELTING DEVICES Dear Moderator, The single biggest issue for climate change in immunization is the destruction of used syringes. We have been trying for years to get a manufacturer to develop melting devices that will render syringes into a block of plastic that can then be recycled. I field tested an electrical device in 2003 in Palestine, a wood burning device has been developed and tested in Indonesia, a solar device has been developed and field tested by IT Power India, but none has yet gone commercial. The device perhaps could also melt plastic packing for recycling. We need to give a sufficiently strong signal to developers that they invest in making these devices a reality. Perhaps the SIGN meeting in Moscow this year could be the venue for really getting something moving on syringe melting. It is in my view the best way of destroying syringes in a way that the world can afford. best wishes Anthony Battersby ([email=FBA@COMPUSERVE.COM]FBA@COMPUSERVE.COM[/email]) FBA Health Systems Analysts ------ SOLAR-POWERED REFRIGERATORS Dear Moderator The environmental impacts of some immunization services can be reduced beginning at the time of equipment selection. One example are the opportunities in the selection of vaccine refrigeration equipment. Solar power is widely viewed as a positive step towards reducing pollution and climate change. Solar powered vaccine refrigeration is evolving into the preferred technology for health centers in remote areas where the other choices are limited to absorption refrigeration fueled by kerosene or bottled gas. Compared to kerosene, solar brings improved temperature performance and reduced maintenance in addition to the obvious benefits of using clean, renewable energy from the sun. As fuel costs increase the economic advantages of solar power increase. The PQS expanded the opportunity for using solar by adding standards for solar powered fridges that do not rely on batteries. While this technology is in development there continue to be highly reliable solar powered 'fridges using the traditional battery backup. Batteries do contain lead; however, the Battery Council International asserts that nearly the entire battery can be recycled. William McDonough, architect and co-author of Cradle to Cradle makes the case that well designed programs that initially include resource reuse, recycling and (better yet) upcyling make both environmental and economic sense. A well-designed cold chain program will effectively train technicians in correct installation, train users in proper use and also plan for eventual repair, replacement and recycling - even remote areas. Steve McCarney ([email=mccarneys@COMCAST.NET]mccarneys@COMCAST.NET[/email]) Footprint Energy Solutions ------ VACINE PACKING MATERIALS I think this dialogue is very important. Two linked actions would have a huge and immediate environmental impact in developing countries: 1) oblige pharmaceutical and medical equipment manufacturers to state the constituents of their primary and secondary packing materials in their product labels and specifications; 2) encourage (by international recommendation) national health procurement authorities to purchase only pharmaceutical and medical equipment products that do not include materials that when incinerated release environmental pollutants (e.g. PVC blood bags: dioxins and furans, the 'banned' materials may be listed) If 1) is long and hard to achieve, establish a register of current packing materials included in a set of essential drugs and supplies and equipment now commonly used in DCs. WHO could require this information through the manufacturers associations. John Lloyd ([email=jlloyd@PATH.ORG]jlloyd@PATH.ORG[/email]) PATH ----------- 1. Cradle to Cradle: Remaking the Way We Make Things William McDonough's book, written with his colleague, the German chemist Michael Braungart, is a manifesto calling for the transformation of human industry through ecologically intelligent design. Through historical sketches on the roots of the industrial revolution; commentary on science, nature and society; descriptions of key design principles; and compelling examples of innovative products and business strategies already reshaping the marketplace, McDonough and Braungart make the case that an industrial system that "takes, makes and wastes" can become a creator of goods and services that generate ecological, social and economic value. 2. SIGN Meeting 2008 (Discussion Topics) 3. PQS: Solar Refrigerators Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01284E: CLIMATE CHANGE/PLASTIC AND PACKAGING FOLLOW-UP ON POST 01283E 26 JUNE 2008 ******************************************* Rosamund Lewis, Member of the HPV Global Community of Practice Steering Committee, shares with us the web address of a site that suggests practical ways in which we can address climate change. In this context she also brings up the issue of how we can reduce the impact of immunization services delivery on the environment. Readers please do share experiences and innovations. Thanks to Rowan Wagner for sharing with us an interesting piece on bio-degradable plastics. ----------- Dear moderator, You have presented a terrific resource with your summary on climate change and health. Those interested in doing something about climate change, whether personally, organizationally or politically, are encouraged to have a look at this website: http://www.celsias.com Perhaps we could start a series of initiatives to reduce the impact of immunization services delivery on climate change, such as reducing the volume of packaging for vaccines and injection supplies. Those familiar with the programme to accelerate the switch-over to CFC-free vaccine fridges could also tell their stories. Rosamund ([email=rosamund_lewis@yahoo.ca]rosamund_lewis@yahoo.ca[/email]) ----------- Making packaging greener – biodegradable plastics Biodegradable plastics made with plant-based materials have been available for many years. Their high cost, however, has meant they have never replaced traditional non-degradable plastics in the mass market. A new Australian venture is producing affordable biodegradable plastics that might change all that. Indeed, biodegradable plastic products currently on the market are from 2 to 10 times more expensive than traditional plastics. But environmentalists argue that the cheaper price of traditional plastics does not reflect their true cost when their full impact is considered. For example, when we buy a plastic bag we don’t pay for its collection and waste disposal after we use it. Environmental packaging waste regulations (Pharmaceutical Technology: 1 October 2006) Recent EU legislation has imposed restrictions on the amount of waste produced as a result of packaging and labelling. This has had a knock-on effect in the packaging departments of pharmaceutical companies, which are now required to find and use solutions that do not produce excessive amounts of waste. Recycling Of Packaging Yields Environmental Gains The sorting of packaging waste at source and recycling can lead to increased transport. But in terms of the environment, advantages outweigh the disadvantages. The recycling of packaging is good for the environment and saves resources, not least energy. This is the conclusion of a report from the Swedish EPA to the Swedish government, evaluating producer responsibility for packaging. Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01222E: SMALL-SCALE INCINERATORS FOR SAFETY BOXES 5FEBRUARY 2008 Follow-up on post: POST 01220E ************************************************************ In response to the question you raised about a small-scale incinerator that can burn safety boxes, I wish to direct you to contact Dr Musaazi of Makerere University, Kampala who has developed a small-scale incinerator that requires no fuel to start it. For details you can reach him by email or get him on phone: 256 0772 408762 [log in to unmask]" title="mailto:[log in to unmask]">Patrick [log in to unmask]">Isingoma ------------------------------------------------------------------------------------ We are now trying to use a new type of small incinerator for EPI activities. This incinerator releases minimum dioxins when we incinerate medical waste including syringes; the emission test result can clear Japanese regulation. Stella Environment Science Corporation MIC 303 3-4-1 Mita Minato-ku Tokyo 98-0073, Japan TEL +81-3-3452-2827 FAX +81-6902-0288 e-mail: [log in to unmask] Dr. [log in to unmask]" title="mailto:[log in to unmask]">YOSHIKUNI SATO Medical Officer WHO/WPRO/EPI TEL +63-2-528-9742 (Direct) FAX +63-2-521-1036 ------------------------------------------------------------------------------------------- All members of the TechNet21 e-Forum are invited to send comments on any posting or to use the forum to raise a new discussion or request technical information in relation to immunization services. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Padmini Menon and is hosted in cooperation with IT Power India (http://www.itpi.co.in)

POST 01220E: WANTED-SMALL-SCALE INCINERATORS FOR SAFETY BOXES 31 JANUARY 2008 _____________________________________________________________ Toryalai Hart writes in with a query for SSIs that can handle healthcare waste which comprises large quantities of plastic. **************************************************************** Hello Techneters - I'm in the process of compiling a database of small-scale incinerators and am in particular lacking options for systems capable of handling loads of 100% safety boxes (pure plastic). Most small-scale incinerators require mixing infectious waste bags with safety boxes to avoid damaging the unit. This is fine until a country undertakes a national immunization campaign, and floods the medical waste stream with tons of plastic that they are unable to cleanly destroy. So far, I have DeMontfort, Turbo 2000, Waste Disposal Unit (WDU), DD Best, DD Mini, and Medicin 400. There are pros and cons for many of these products (durability, electricity/fuel required, emissions quality, temperature gage, price of civil works, availability of materials in country, etc), and analysis will be done factoring all of this in. Please note that technology should operate at temperatures higher than 600 degrees, and smoke from stack should be clear while running. If anyone has good field experience with a particular brand/model (diesel, LPG, electric, biomass, auto-combustion, other), please share details so I can add it to the database. Many thanks, Toryalai Hart Consultant, Health and Information Technology IT Power India Pvt. Ltd. http://www.itpi.co.in Office Tel: +91 4132342488 Usual Tel: +212 24390997 Usual Cell: +212 79953847 Current Cell: +509 6376327 ______________________________________________________________________ All members of the TechNet21 e-Forum are invited to send comments on any posting or to use the forum to raise a new discussion or request technical information in relation to immunization services. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. _________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. _________________________________________________________________________ To UNSUBSCRIBE, send a message to : [email=LISTSERV@listserv.technet21.org]LISTSERV@listserv.technet21.org[/email] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E _________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Padmini Menon and is hosted in cooperation with IT Power India (http://www.itpi.co.in) _________________________________________________________________________

POST 01180E : WASTE MANAGEMENT 2 November 2007 ______________________________ Two documents are now available on-line on the WHO Healthcare Waste Management website. "WHO core principles for achieving safe and sustainable management of health care waste". And the final version of the "International health care waste management meeting report", which took place at WHO Geneva in June 20-22, 2007. (1.2 MB) Best greetings, Yves Yves CHARTIER Public health engineer Assessment and Management of Environmental Risks to Health Department for Public Health and Environment World Health Organization ______________________________________________________________________________ All members of the TechNet21 e-Forum are invited to send comments on any posting or to use the forum to raise a new discussion or request technical information in relation to immunization services. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [email=LISTSERV@listes.ulaval.ca]LISTSERV@listes.ulaval.ca[/email] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________

POST 01121E : WASTE MANAGEMENT Follow-up on Post 01111E 13 July 2007 _____________________________________ Modibo Dicko's message generated three contributions. The first is from [log in to unmask]">Henrique Menezes d'Alva, from Angola. [log in to unmask]">John Lloyd, from PATH/France, then asks judicious questions and replies are expected from authors. Finally, [log in to unmask]">Bibata Paré from Burkina Faso shares her opinion, giving Haïti as an example. _____________________________________ Dear Colleagues, Many thanks to have shared with us these experiences. I think that the comments made by our Colleague Dr Modibo Dicko around this subject are very important for all of us who have been dealing with this kind of matter. I support these comments and initiative for engaging all process in this way. I think that it will be useful for all the needed countries if we can be able to implement these proposals to available them with these kinds of equipments which supposed to be installed in countrywide at all District level. Implementing that in practice we can save a lot of resources as it was raised in comments, as well as the environment and be able to equip all health structure with tools to be used for a long period. Warm regards. Henrique Eng. Henrique MENEZES D’ALVA EPI Logistician / Vaccine Manager WHO-Angola Luanda-Angola --------------- We are very supportive of the principle that immunization campaigns should be used as an opportunity to build and reinforce the permanent infrastructure of infectious sharps waste disposal. But industrial kilns achieve higher temperatures and have less emissions than WDUs, so surely this is a better option if transport costs allow it? I wonder what was the cost breakdown in these two countries - between the cost of collection and the cost of incineration - both for the industrial kilns and for the WDU network? Maybe the network of WDUs might be the most economic for x% of sites and industrial kilns for y% of sites? A hybrid solution, different in urbanised and in rural zones - not just a 'single solution fits all'? Transport is often the critical cost factor (South Africa too): if dedicated vehicles are provided with drivers by a private sector enterprise for waste collection, the cost can be prohibitive for routine waste collection. But if vehicle use is shared between immunization supplies/vaccine distribution and collection of safety boxes, this integrated system should have lower costs attributable to waste collection. The interval between collections will also be kept low (monthly) so storage of filled safety boxes can be minimized. The critical issue is - how are we going to achieve safe shared use of vehicles? - by partitioning? (not very flexible) - by routine disinfection? (without rotting the vehicle floor!) - by trailers? (good roads only?) - by roof-racks? Low transport costs will permit better centralization of waste desruction and therefore better environmental emission control. Any ideas out there? John Lloyd PATH ------------------------- Indeed, with campaigns imminent, all kind of strategies for the destruction of waste are under consideration (sometimes without due regard to cost), provided we get rid of the waste by all means! I find very interesting indeed Adama Sawadogo’s idea. Instead of using industrial kilns at exorbitant costs for one-off destruction of waste, the could be used to purchase more durable equipment for health centres. Because management of routine immunisation waste is a real headache! However, a great deal of work is still to be done in order for countries and partners as well, to be aware of the problem. I still remember that when a similar suggestion was made in Burkina Faso, immunisation officials did not accept the idea. They still preferred industrial kilns. Where are we today? If we managed to order these prefabricated Waste Disposal Units (WDU), that would solve the problem of waste disposal for a long time. Haiti quickly understood and just received 10 WDU procured by UNICEF at a cost of US$ 44400. Ten more are expected by the end of July. There is a planned users’ training session in the days to come, in preparation for the measles/rubella campaign scheduled for October this year. Isn’t it a good example to follow? Mrs. PARE Bibata EPI Logistics /Burkina Faso ______________________________________________________________________________ All members of the TechNet21 e-Forum are invited to send comments on any posting or to use the forum to raise a new discussion or request technical information in relation to immunization services. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________

POST 01111E : WASTE MANAGEMENT 23 June 2007 _____________________________________ [log in to unmask]">Modibo [log in to unmask]"> Dicko, from WHO/AFRO, shares two interesting documents on waste management with his analysis and conclusions. Hyperlinks below will give access to respective documents. It's a pity that they will be accessible only to those who can read French as they have not been translated. The second is an excellent reminder as it was circulated on TechNet in post 00846E in October 2005. _____________________________________ These two documents are highly instructive on waste management issues from immunisation campaigns in Burkina Faso in 2004 (by Adama Sawadogo) and in Côte d’Ivoire in 2005 (by Attéméné Godiskine and Mamadou Moustapha Sy). On the basis of these two experiences and taking into consideration the measles, yellow fever and meningitis campaigns being planned in Burkina Faso, Mr. A. Sawadogo advocates for a plan consisting of the following points: - In 2004, the collection, transportation and destruction in 2 industrial kilns (located in Ouagadougou and Bobo-Dioulasso) of 3.2 million used AD syringes (that is32000 security boxes), costed 26 million CFA Francs or about 8 CFA Francs per syringe. - The measles, yellow fever and meningitis campaigns planned in Burkina Faso for 2007 and 2008 will generate 15 million used syringes; assuming 10 CFA Francs (taking inflation into account) for the collection and destruction cost per syringe, a total of 150 million CFA Francs will be required for the whole operation - This amount of 150 million Francs CFA will also go-up "in smoke" the same way the 26 million Francs CFA were "burnt" following the Measles campaign in 2004. Worst still, Health Districts will have to use the famous B&B solution "burn and bury" for the destruction of all their waste from routine activities, simply because their waste management capacity will not have been strengthened! Instead of adopting this catastrophic scenario, Mr. Sawadogo proposes that monies required for the collection, transportation and destruction in industrial kilns, of used syringes from campaigns, be used instead to strengthen health districts’ waste management capacities in the following manner: - Have every district come up with a waste management plan - Equip each one of the 55 health districts in Burkina Faso with a "Waste Destruction Unit", WDU type, marketed by IT Power India at a unit cost of 2.5 million CFA Francs, for a total of 137.5 million CFA Francs. These WDU would be used for the destruction of waste during campaigns and remain afterwards for daily use by health districts for the destruction of waste produced by routine activities. As opposed to the first generation De Montfort Incinerators, WDUs are built with adapted materials and an improved design that helps avoid problems encountered with the first De Montfort. As Adama puts it in a wordplay, they are no more "Demons Forts", but "Demons très Forts"! (untranslatable : strong devils and very strong devils). The scheme proposed by Adama could be made however a bit more flexible by allowing districts, to choose other types of other equipment than WDUs according to their exact needs: for instance regional hospitals and those in larger districts could choose industrial incinerators better adapted to their daily needs, but also very useful during campaigns. For example, MACROBURN incinerators manufactured in South Africa and currently used successfully in Zambia and many other countries, or HWI or UNIVERS incinerators manufactured in Germany by TTM ("Transfer of Technology Marburg". I genuinely believe that Sawadogo’suggestions, based on a long field experience as inter-country logistician and regional waste management officer for WHO/AFRO, are worth serious thinking, especially for stakeholders in initiatives against measles (for example the "Partnership against Measles", yellow fever and meningitis among others. Modibo ______________________________________________________________________________ All members of the TechNet21 e-Forum are invited to send comments on any posting or to use the forum to raise a new discussion or request technical information in relation to immunization services. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________ =======================================================================Date: Mon, 25 Jun 2007 10:00:30 -0400 Reply-To: [log in to unmask] Sender: Technical network for strengthening immunization services Comments: RFC822 error: MESSAGE-ID field duplicated. Last occurrence was retained. From: TechNet Subject: POST 01112E : COSTS - REQUEST FOR INFORMATION MIME-version: 1.0 Content-type: text/html; charset=us-ascii Content-transfer-encoding: 7BIT TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: [log in to unmask]">[log in to unmask] or use your reply button! __________________________________________________________ POST 01112E : COSTS - REQUEST FOR INFORMATION 25 June 2007 _____________________________________ I am looking for recent data on refrigeration energy and maintenance costs. I have some information from Emmanuel Taylor and Bob Davis and am wondering if anybody else has done work in this area. Specifically I am looking for the following: - Bottled gas prices/gas refrigerator running costs. - Kerosene prices/kerosene refrigerator running costs. - Electricity prices/ electric refrigerator running costs. - Lifetime maintenance costs for gas, kerosene, electric and solar refrigerators. - Any available data on cold room maintenance costs. Regards, Andrew Andrew Garnett ______________________________________________________________________________ All members of the TechNet21 e-Forum are invited to send comments on any posting or to use the forum to raise a new discussion or request technical information in relation to immunization services. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________ =======================================================================Date: Wed, 27 Jun 2007 11:17:48 -0400 Reply-To: [log in to unmask] Sender: Technical network for strengthening immunization services Comments: RFC822 error: MESSAGE-ID field duplicated. Last occurrence was retained. From: TechNet Subject: POST 01113E : APPREHENDED PANDEMIC MIME-version: 1.0 Content-type: text/html; charset=us-ascii Content-transfer-encoding: 7BIT TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: [log in to unmask]">[log in to unmask] or use your reply button! __________________________________________________________ POST 01113E : APPREHENDED PANDEMIC 27 June 2007 _____________________________________ The recent spread of avian influenza in wild birds and poultry may be a precursor to the emergence of a human pandemic. While it is accepted that in 1918 the virus originated in birds, it is debated whether it went directly to humans, or transited in mammals where the virus was reassorted (type of mutation). Nevertheless, countries have started to prepare for such a pandemic. A set of activities identified in the World Health Organization's (WHO's) new Global pandemic influenza action plan to increase vaccine supply requires immediate and sustained action and funding, if the world is to be prepared for an influenza pandemic to which there would be almost universal susceptibility. FluRadar reports on an article recently published in the Public Library of Science (Medicine) online journal that questions vaccination strategies in the event of a pandemic. In "Optimizing the Dose of Pre-Pandemic Influenza Vaccines to Reduce the Infection Attack Rate", authors Steven Riley, Joseph T. Wu and Gabriel M. Leung conclude that it would be better to give smaller doses to more people than target specific groups. Read the full text and/or an interesting commentary by Christophe Fraser Can these conclusions have wider implications that just the framework of preparedness to a potential influenza pandemic, for example for the administration of other vaccines? Share your ideas and comments! ______________________________________________________________________________ All members of the TechNet21 e-Forum are invited to send comments on any posting or to use the forum to raise a new discussion or request technical information in relation to immunization services. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________ =======================================================================Date: Fri, 29 Jun 2007 19:05:28 -0400 Reply-To: [log in to unmask] Sender: Technical network for strengthening immunization services Comments: RFC822 error: MESSAGE-ID field duplicated. Last occurrence was retained. From: TechNet Subject: POST 01114E : STOCK MANAGEMENT SOFTWARE MIME-version: 1.0 Content-type: text/html; charset=us-ascii Content-transfer-encoding: 7BIT TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: [log in to unmask]">[log in to unmask] or use your reply button! __________________________________________________________ POST 01114E : STOCK MANAGEMENT SOFTWARE 29 June 2007 _____________________________________ Technet21 policy is to the effect of not posting advertisement on its site or e-forum. We already asked in the past whether we should make this rule more flexible. The message below is indeed advertisement. After consulting Secretariat however, it was decided to post it. The reason is that the product is offered free-of-charge to individuals from developing countries or to non-profit organisations. Posting of this message does not constitute in any way an endorsement of the product by WHO, TechNet21 and/or any of their partners, neither a judgment on its quality. There is a lack of good-quality stock management software in the world. If any of you were to decide to give this product a try, your comments would be appreciated, on the forum or by using the "Equipment performance" form available on the TechNet21 homepage, leaving blank the box for PIS/PQS code. _____________________________________ Dear Technet subscribers, We are pleased to announce the latest release of our pharmaceutical supply chain / inventory management software- mSupply version 1.96r3. At the suggestion of Mogens Munck we have spent considerable time in the last few months to enable location management in mSupply, specifically with a view to its use in cold chains. We still have a long way to go, but we think the current version is usable, and we would appreciate feedback on what needs changing for future versions. Location management features include: * Management by volume. Define volumes for locations and for each item. * Report on space used and free space at each location. * Quick visual feedback on whether stock about to be ordered will fit at the nominated locations. Same for goods receipting operations. Helpful links: * Home page * Demo version * User guide * Location management tutorial * Other documentation mSupply remains free for use in single-user mode if: - you are in a developing country - your organisation is not-for-profit mSupply has been in use in developing countries since 1998. It is now used in over 20 countries, primarily in pharmaceutical warehouses, and in hospital dispensaries. Best regards, [log in to unmask]">Craig [log in to unmask]">Drown Sustainable Solutions Kathmandu, Nepal Auckland, New Zealand ______________________________________________________________________________ All members of the TechNet21 e-Forum are invited to send comments on any posting or to use the forum to raise a new discussion or request technical information in relation to immunization services. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ________________________________________________________________________

POST 01077E : WASTE MANAGEMENT REPORT 12 April 2007 ____________________________________ Carib Nelson (mailto:cnelson@path.org) from PATH is sending the following report. ____________________________________ At the following link is a report on a successful non-incineration system for management of injection waste at the service delivery level that has been established in Andhra Pradesh State in India. http://www.technet21.org/pdf_file/AndhraPradesh_Sharps_Waste_Report_2007Feb16.pdf (200K) The Partnership Project in Andhra Pradesh -- a collaborative effort between the Government of Andhra Pradesh and PATH –- was designed to strengthen immunization systems, with improvements to injection safety as a major goal. A critical element of this work was introduction and scale up of a practical system for sharps waste management. The sharps management system included reducing the number of injections given, needle removal, syringe disinfection, and collection of syringe plastic for recycling. Impacts of the project included: * Stimulus to create a national injection safety policy. * 85 percent reduction in the number of injectable medications procured by the state government's procurement agency, resulting in hundreds of millions fewer injections and greatly reduced medical waste. * A comprehensive system of sharps waste management at Andhra Pradesh's PHCs and subcenters. * Training 30,000 medical officers, supervisors, and health workers in injection safety and proper management of sharps waste. * Establishing needlestick reporting mechanisms at the PHC and subcenter levels. * Effective use of needle removers, which lowered the incidence of syringe reuse among curative injections, reduced reported needlestick injuries, prevented the burning of hundreds of thousands of syringe-filled safety boxes, and enabled safe recycling of thousands of kilograms of plastic syringe barrels. * Replicating the sharps waste management system in HIV testing centers and the private sector. The project is now fully sustained by the government of Andhra Pradesh and is being expanded to other states of India. At the direct hyperlink above is the complete report on the sharps waste management aspects of the project. A broader report describing the complete immunization strengthening activities and result of the project is available at: http://www.path.org/vaccineresources/files/CVP_AP.pdf For more information about the project contact: Dr. Satish Kaipilyawar (mailto:satish@pathindia.org) ______________________________________________________________________________ All members of the TechNet21 e-Forum are invited to send comments on any posting or to use the forum to raise a new discussion or request technical information in relation to immunization services. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : mailto:LISTSERV@listes.ulaval.ca Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org) ______________________________________________________________________________