Healthcare Waste Management in 7 MNPB

HCWM Plan:“Healthcare for the Poor in 7 Northern Upland Provinces”

Ministry of Health

Project management board

Healthcare for the poor in

7 Northern Upland Provinces

Final report on

Building up the plan for

healthcare waste management and treatment

by: PhD. MBA. Ngo Kim Chi, Local consultant

Center for consultancy and technological transfer

on safe water supply and environment

24 Sep, 2007

Table of contents

Introduction

TASK 1. ASSESSMENT OF LEGISLATIVE FRAMEWORK FOR HEALTHCARE WASTE MANAGEMENT

1.1. Existing legislation, regulatory framework for HCWM

1.1.1 Governmental law and local regulation on healthcare waste management.

1.2. Review of definitions and standards relating to healthcare waste

1.2.1 Definitions of HCW:

1.2.2 Healthcare waste identification and classification, treatment

1.2.3 Proposal on the main items to be reviewed on HCWM

1.3 Comparison with international standards and identification of gaps

1.3.1 Review the best HCWM requirements in the world

1.3.2 Strategy for healthcare waste treatment in some countries

1.3.3 Regulation on healthcare waste management, the Ministry of Health

1.3.4 Vietnam and international standards - identification of gaps

1.3.5. Comparing Vietnam HCW practical regulations with WHO/international guides

1.3.6 Comparison of WHO and Vietnam classification

1.3.7 Healthcare waste incinerators in Vietnam

1.4. Recommendations for strengthening the legislative framework

TASK 2. ASSESSMENT OF INSTITUTIONAL FRAMEWORK

2.1 Roles, responsibilities, interactions: environmental, health institutions, stakeholders

2.1.1. Role of environmental sector

2.1.2. Role of healthcare sector

2.1.3 Role of healthcare facilities

2.1.4.Role of public service

2.1.5. Inter-institutional issues

2.1.6 Budget line for HCWT

2.2. Different staff groups: assessment of associated capacity within hospital on HCWM.

2.2.1 Within hospital responsibilities on HCWM

2.2.2 Within the Ministry of heath

Task 3: Assessment of HCWM in the projected provinces

3.1 Project introduction

3.2 Healthcare services in projected provinces and district hospitals of 7 mountainous provinces

3.2.1 Description of project provinces and healthcare services

3.2.2. Healthcare service in projected district hospital

3.3 Assessment on HCW characteristics, rate of generation in project district hospitals

3.3.1 Field trip survey

3.3.2 Assessment of volume of Hz HCSW, generation rate at projected DHs

3.3.3. Assessment of Group of Hz HCSW in practices

3.3.4 Assessment of Segregation, Collection, onsite Transportation of Hz HCSW in projected DH.

3.3.5 Assessment of HCWM team, internal guideline, training course in HCWM

3.3.6 Assessment of Hz HCW treatment

3.3.7. Assessment of the HCWM practices in 7 provinces

3.4 Liquid infectious waste, hospital wastewater treatment

3.4.1 Situation of infectious liquid waste in projected hospitals

3.4.2. Assessment of Hospital waste water treatment.

3.5 Financial source for HCWM

3.6 Risk associate with current HCWM practices and role of Provincial DOH in HCWM inspection

HCWM in Bac Kan project district hospitals

HCWM in Son La province.

HCWM in Cao Bang province.

HCWM in Dien Bien

HCWM in Laocai and Laichau project district hospitals

3.7 Recommendation on HCWM in projected provinces

3.7.1 Main findings and recommendations

3.7.2 Building capacity on HCWM at projected provinces by training practices

3.7.3 Waste treatment facility providing

3.7.4 Creating budget for HCW management (solid and liquid).

Task 4: Proposal Action Plan of HCWM in 7 northern mountainous provinces

4.1 Proposal Action plan for Enhancing Regulation, Policy framework

4.1.1. Recommendations for strengthening the legislative framework

4.1.2 Institutional Framework Development for projected provinces

4.2 Preparation of district hospital specific HCWM plans

4.3 Procurement HCWM equipment and supplies

4.3.1 Supplying HzHCSW collection tools and HCSW treatment facilities

4.3.2 Standard design of waste water treatment, pilot demonstration and setup WWTF in projected DHs

4.4 Other hazardous waste management

Task 5: provision budget line for HCWM action plan in 7 projected provinces

5.1 Estimation cost for HCWM and treatment at 7 projected provinces

5.2 Schedule

Annex 1: Natural – social condition of 7 projected provinces

Annex 2: District hospital and results from survey

Annex 2: District hospital and results from survey

Annex 3: Minute of meeting and pictures

Annex 4: References – TCVN7380, TCVN7381, TCVN7382-2004

Annex 5: Questionnaires

References: for task 1,2

References for task 3,4

Abbreviation

DOSTE: Department of Science, Technology & Environment DoNRE;

DOSTE: Department of Science, Technology & Environment,

DONRE: Department of Natural Resources and Environment DoC: Department of Construction DoF: Department of Finance

EIA: Environmental Impact Assessment

DH: District hospital

DoH: Provincial Department of Health

ICT: Infectious Control (IC) - Infectious Control Team

IEC: Information Education Communication

GDPM: General Depart. Preventive Medicine

MP: Master Plan

MoH: Ministry of Health

MoNRE: Ministry of Natural Resources and Environment

MoSTE: Ministry of Science Technology and Environment

HCW: Healthcare waste

HCSW: Healthcare solid waste

HCSWM: Healthcare Solid Waste Management

Hz HCSW: Hazardous Healthcare Solid Waste

HCWMP: Healthcare waste management Plan

HCSWT: Healthcare Solid Waste Treatment

PH: Provincial hospital

PGH: Provincial general hospital

PL: Polyclinic

PMB: Project management Board

RMW: Regulated medical waste

TCVN: National standard

URENCO: Urban Environmental Company

WWTF: Waste water treatment facility/plant

WMO: Waste management Officer

WMT: Waste management Team

Introduction

The report on Assessment health care waste management/treatment concerns to the Project on “Healthcare Fund for the poor in 07 Northern Upland provinces”

The output of this report is the following:

An evaluation of Healthcare waste management regulation and recommendation on revising the HCWM legislative.

Surveying and assessment of HCWM (liquid and solid waste) generation and segregation, collection, storage, transportation and treatment in 07 projected provinces and project district hospitals.

A development of action plan and training course for HCWM, especially for projected district hospitals.

The assessment of the findings and the development of an action plan is key outputs of the report. Minutes of meetings and filled out questionnaires during the field trips and surveys are presented in Annex, with Table B-1 to Table B-4.

The methodology of assessments: Studies on the existing regulations on the Ministry of Health, related Ministries and international regulations, guidelines. The master plan of HCSWM, the documents of the local and international workshop have been referenced. Studying the previous studies on HCW generation rate to selection of the appropriate generation rates combining with the field trip surveys and collection of the questionnaires, in depth interview of the responsible staff and directly related to the HCWM to find the estimation of the generation rate of hospital waste and assessment on the HCWM activities in projected district hospitals for this report.

TASK 1. ASSESSMENT OF LEGISLATIVE FRAMEWORK FOR HEALTHCARE WASTE MANAGEMENT

Vietnam currently have 13102 healthcare hospitals including 1000 state-owned ones and 40 private others with 184 484 (2003 general statistic) beds. The healthcare waste (According to the report of master plan on healthcare waste management, Department of Treatment, MOH, 2003) is estimated to be produced 30 tons/day and 11,000 tons/year. The healthcare hazardous waste is expected to increase up to 70-80 tons/day in 2010. Due to the increase of healthcare establishments, beds, health services and population and urbanization and people are day by day being more assess to health services.

In spite of the Regulations on healthcare waste management issued 1999, Vietnam has no master plan on healthcare solid waste management, thereof, no direction of organizing and choosing the treatment technology throughout the country. In many healthcare establishments, all of healthcare waste are being classified and collected to dump in hospital area or outside or in public rubbish dumping. In general infectious wastes are classified in central and provincial hospitals that contrast with one in healthcare establishments at district and communal levels. In Vietnam, there are about 30% provinces lacking of equipments for healthcare waste treatment especially in remote and mountainous areas.

Analyzing the list of hospital budget, there is no money to spend on the healthcare waste treatment and training activities relating to this issue. The healthcare budget is too limited. Therefore, the hospital budgets for healthcare waste treatment decided by their own directors are not united.

Currently, there are comprehensive and best technical measures for healthcare waste treatment and management outside hospital and at home individually. Under the circumstance of current tropical and emerging seriousness of diseases, healthcare waste treatment and management is especial consideration.

1.1. Existing legislation, regulatory framework for HCWM

1.1.1 Governmental law and local regulation on healthcare waste management.

The management of healthcare waste in Vietnam at the moment is based on Decision 2557/BYT-QD dated on December 26th 1996 and the Regulation on HCWM issused by MoH on 29/8/1999. There are several new regulation and national standards on the technical requirement on medical solid waste incinerator, air emission discharged standard from medical waste incinerator, discharged effluent standards from hospital waste water treatment plant. The existing regulations relating to healthcare waste management and HCWT facilities are summarized as:

Table 1a: The summary of regulations relating to healthcare waste management at nation level

1.1.2 Decision No. 2575/1999/QD-BYT, August 27, 1999, of the Minister of Health on healthcare waste management.

The management regulations apply for all hospitals, institutes of medicine, district health centers, policlinic, lying-in stations, health post, private health services, preventive health centers and health training institutions (They are called health establishments).

This regulation is regarded as the basic foundation for the healthcare waste management and for investing the infrastructure for treating of solid, liquid and gaseous wastes derived from health establishments. However, it only concentrates on management of health solid waste.

This regulation makes concretely on classification, identification of healthcare waste and the process of healthcare solid waste collecting at heath establishments, regulations on on-site and off-site transportation of solid hazardous waste. Moreover, they also introduce some models, technology and measures for treatment and destruction of solid, liquid, gaseous waste as well as regulations for implementation, Vietnamese standards of environmental hygiene to apply.

1. Waste classification and identification

Wastes derived from health establishments can be categorised into 5 types:

- Clinical waste

- Radioactive waste

- Chemical waste

- Pressurized containers.

- General waste

- Clinic waste is divided into five groups:

+ Group A waste - Infectious waste: waste containing pathogenic organisms like bacteria, viruses, parasites and fungi in sufficient quantities to cause disease in susceptible hosts. Infectious wastes are materials or equipment that have been in contact with patient blood and excretion (e.g. bandages, cotton wool, dressings, gloves, swabs, cloths, etc.)

+ Group B waste – sharps items: All items that pose a risk of injury and infection due to their puncture and cutting properties such as discarded syringes, needles, scalpels, knives, broken glass, pipettes, blades and similar items having a pointed or sharp edge or that are likely to break during transportation and result in such an edge.

+ Group C waste –clinical waste: clinical wastes are generated from laboratories (e.g. pathology, haematology and blood transfusion, microbiology, histology) such as: gloves, test-tubes, cultures and stocks of infectious agents, blood bags etc.

+ Group G waste: Pharmaceutical waste

+ Group E waste: Human and animal tissues and body parts.

- Radioactive waste is any solid, liquid, gaseous or pathological waste contaminated with radioactive isotopes of any kind.

- Chemical waste is divided into two groups:

+ Non-hazardous chemical wastes consist of sugars, amino acids, and certain organic and inorganic salts.

+ Hazardous chemical wastes consist of Formaldehyde, Photographic chemicals, solvents, trichloroethylene, and organic and inorganic chemicals.

- Pressurized containers

- General wastes is the waste generated from in- or out-patient activities that are not contaminated or stained with blood or body fluids from surgical operations, injection room (other than sharps) etc.

2. Collecting process of solid waste at health establishments

2.1: General principles: Segregation should be taken place as close as possible to where the waste is generated and hazardous waste are not mixed with the general waste.

2.2 Standards of waste bags, boxes and bag-holders

- Color coding of waste bags, boxes and bag-holders: yellow used to contain clinical wastes, marked with the symbol of biological hazard, green used for general wastes, black used for chemical wastes, radioactive material and cytotoxic drugs.

- Criteria of waste bag: waste bag should be PE and PP plastic bag with maximum capacity of 0.1 m3 and should have a horizontal line indicated when wastes reach two third capacity of the bag.

- Criteria of a box containing sharp – pointed things: a box containing sharp – pointed things should be intact without any puncture or any leak. It should be made of rigid material and can be destroyed with fire. There needs some different capacities of the box (2.5l, 6l, 12l, 20l) that be suitable for containing different kinds of sharp – pointed things. The box should have an appropriate design for containing needles, syringes and other sharp – pointed things without any leakage of waste during normal. It requires handles and a lid for sealing. That is a yellow box with a horizontal line to indicate when the box is two third full.

- Criteria of a bag - holder: a bag - holder are made of polyethylene of high density with hard, thick wall and a lid, if a bag – holder with large capacity, attached wheels are necessary. The bag - holder colour should be accordance with waste bag colour and the bag - holder is marked with a line to indicate the level of two third total its capacity.

2.3: General and hazardous waste location must be clearly defined and as close as possible to where the waste is generated.

2.4. Waste collection at the source: orderlies are responsible for collecting waste from the source to storage area. Before being taken away from department and ward, all clinical wastes should be enclosed in regulated colour plastic bags. These bags must be bound tightly. Do not close these bags by stapling.

2.5. Transportation of wastes inside health establishments: Health establishments must have regulations on route and time, means of transportation from departments to waste storage area. These means of transportation should be only used for carrying wastes; they should be washed after being operated. Designing characteristics of these means of transport should be suitable for being cleaned, disinfected, dried and also wastes can be loaded and unloaded easily.

2.6. Storage of waste in health establishments

- The storage area of waste:

• should have safe distance to food stores or food preparation areas or roads.

• It should be possible to lock the store to prevent access by unauthorized persons.

• A supply of cleaning equipment, protective clothing, and waste bags or containers should be located conveniently.

• Easy access for waste-collection vehicles is essential.

• There should be a water supply for cleaning purposes.

• There should be protection from the sun.

• Hazardous waste should be kept separately from the general waste.

- Storage times for healthcare waste: