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Republic of Rwanda (2016) National Guidelines on Health care Waste Management, Rwanda.pdf
Republic of Rwanda (2016) National Guidelines on Health care Waste Management, Rwanda
National Health Care Waste Management Guidelines Page 1
National Health Care Waste Management Guidelines Page 2
National Health Care Waste Management Guidelines Page 3
Table of contents
Table of contents ............................................................................................................................. 3
List of Annexes ............................................................................................................................... 6
List of tables .................................................................................................................................... 7
List of figures .................................................................................................................................. 7
List of abbreviation ......................................................................................................................... 8
CHAPTER 1: INTRODUCTION ................................................................................................... 9
1.1 About these guidelines .......................................................................................................... 9
1.2 Background ........................................................................................................................... 9
CHAPTER 2: HEALTH EFFECT OF HEALTH CARE WASTE .............................................. 11
2.1 Hazardfrom health care waste ............................................................................................. 11
2.2 Risks caused by poor management of health care wastes ................................................... 11
CHAPTER 3: CHARACTERIZATION OF HEALTH CARE WASTES ................................... 12
3.1. Source of Health Care waste .............................................................................................. 12
3.2. Categories of waste ............................................................................................................ 12
3.2.1. Infectious waste ........................................................................................................... 12
3.2.2. Pathological waste; ................................................................................................. 12
3.2.3. Sharps waste ................................................................................................................ 13
3.2.4. Pharmaceutical waste .................................................................................................. 13
3.2.5. Radioactive waste ........................................................................................................ 13
3.2.6. Chemical waste ............................................................................................................ 13
3.2.7. Non-hazardous general waste ...................................................................................... 13
CHAPTER 4: LEGISLATIVE FRAMEWORK .......................................................................... 14
4.1Organic law N° 04/2005 of 08/04/2005 determining the modalities of protection,
conservation and promotion of environment in Rwanda .......................................................... 14
4.2 Law N° 47/2012 of 14/01/2013 relating to the regulation and inspection of food and
pharmaceutical products. ........................................................................................................... 14
4.3 Environmental health policy ............................................................................................... 14
4.4 National Policy on Injection Safety, Prevention of Transmission of Nosocomial Infection
and Health Care Waste Management; ....................................................................................... 14
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CHAPTER 5: HEALTH CARE WASTE MANAGEMENT PLANNING ................................. 15
5.1 Preliminary Planning for Health Care Waste Management ................................................ 15
5.2 Implementation of the waste management plan .................................................................. 15
5.3 Duties and responsibilities .................................................................................................. 16
5.3.1 Roles and Responsibilities for Head of Health Facilities ............................................. 16
5.3.2 Roles and responsibilities for different levels .............................................................. 17
5.4 Management of health care waste from scattered small source .......................................... 19
5.4.1 Marking of Waste ......................................................................................................... 20
5.4.2 Dedicated vehicles ........................................................................................................ 20
5.4.3 Storage .......................................................................................................................... 20
5.4.4 Employees knowledge of guidelines ............................................................................ 20
CHAPTER 6: WASTE MINIMIZATION, RECYCLE AND REUSE ....................................... 21
6.1 Minimization of waste ......................................................................................................... 21
6.2 Waste Segregation and packaging....................................................................................... 21
6.3 Safe reuse and recycling ...................................................................................................... 23
CHAPTER 7: HANDLING, LABELING, CONTAINMENT, TRANSPORT AND STORAGE
....................................................................................................................................................... 25
7.2 Internal transportation ......................................................................................................... 25
7.3 Waste labeling ..................................................................................................................... 25
7.4 Health Care Waste Tracking ............................................................................................... 25
7.5 Handling waste bags............................................................................................................ 26
7.6 Storage ................................................................................................................................. 26
7.6.1 Storage for waste .......................................................................................................... 26
7.7 Spill Management ............................................................................................................... 27
7.7.1 General spill management ............................................................................................ 27
7.7.2 Infectious waste spill kit. .............................................................................................. 27
7.7.3 Cytotoxic spill kit ......................................................................................................... 27
7.7.4 Mercury spill kit ........................................................................................................... 28
7.8 Collection ............................................................................................................................ 28
7.9 Transportation ..................................................................................................................... 29
7.10 On-site transport for collection purposes .......................................................................... 30
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7.11 Off-site transportation of waste ......................................................................................... 31
7.11.1 Regulation and control system ................................................................................... 31
7.11.2 Routing ....................................................................................................................... 31
CHAPTER 8: TREATMENT AND DISPOSAL FOR HEALTH CARE WASTE .................... 32
8.1 Treatment and disposal options ........................................................................................... 32
8.2 Waste disposal options ........................................................................................................ 32
8.2.1 General disposal options ............................................................................................... 32
8.2.2 Inertization .................................................................................................................... 33
8.2.3 Options of health care waste treatment and disposal as per level of care .................... 34
CHAPTER 9: REQUIREMENT FOR OCCUPATIONAL HEALTH AND SAFETY
PRACTICES ................................................................................................................................. 35
9.1 Occupational health and safety provisions .......................................................................... 35
9.2 Employee responsibility ...................................................................................................... 35
9.3 Personal Protective Equipment (PPE) ................................................................................. 36
9.4 Hygiene Committee............................................................................................................. 37
9.5 Monitoring Hygiene Committee ......................................................................................... 37
9.5.1 Hygiene ......................................................................................................................... 37
9.6 Precautions for sharps, Blood and Body fluids exposure.................................................... 38
9.7 Response to injury and exposure ......................................................................................... 38
CHAPTER 10: TRAINING .......................................................................................................... 40
10.1Technical Training and deployment ................................................................................... 40
CHAPTER 11: COMMUNITY HEALTH CARE WASTE MANAGEMENT ........................... 41
11.1 Medical waste generated during Community Health Outreach ........................................ 41
11.2 Sharps management........................................................................................................... 41
11.3 Waste transportation .......................................................................................................... 41
CHAPTER 12: COLLECTIONS AND DISPOSAL OF WASTE WATER FROM HEALTH
FACILITIES ................................................................................................................................. 42
12.1 Characteristics and hazards of waste water from health facilities .................................... 42
12.2 Waste water management.................................................................................................. 42
12.3 On-Site treatment or pre-treatment of waste water ........................................................... 42
12.4 Sludge treatment ................................................................................................................ 43
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12.5. Minimum safety requirements for sewerage treatment .................................................... 43
12.6. Sanitation .......................................................................................................................... 44
12.7. Safe management of wastes from health facilities ........................................................... 44
ANNEXES: ................................................................................................................................... 45
List of Annexes
Annex 1Sample sheet for assessment of waste generation ........................................................... 45
Annex 2 Color code for biomedical waste .................................................................................... 46
Annex 3 International waste labeling symbols ............................................................................. 47
Annex 4 Alternative labels for hazardous wastes ......................................................................... 48
Annex 5 Health care waste tracking form sample 1 ..................................................................... 49
Annex 6 Health care waste tracking form sample 2 ..................................................................... 50
Annex 7 Waste treatment methods ............................................................................................... 51
Annex 8 Management of spillages ................................................................................................ 52
Annex 9 Recycling index .............................................................................................................. 53
Annex 10 A sample tag for shipment ........................................................................................... 54
Annex 11 Facility Health care waste management plan ............................................................... 55
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List of tables
Table 1 Responsibility at Central and District level ..................................................................... 17
Table 2 Responsibility at Health Facility level ............................................................................. 18
Table 3 Roles and responsibility of Community Health Worker ................................................. 19
Table 4 Options of health care waste treatment and disposal as per level of care ........................ 34
List of figures
Figure 1 The waste management hierarchy .................................................................................. 23
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List of abbreviation
BCC : Behavior Change Communication
DH : District Hospital
EHO : Environmental Health Officer
HBV : Hepatitis B Virus
HC : Health Center
HCW : Health Care Waste
HCWM : Health Care Waste Management
HCWMP : Health Care Waste Management Plan
HF : Health Facility
i/c : In charge
IPC : Infection Prevention Control
MGBs : Mobile Garbage Bins
O i/c : Officer in charge
PPE : Personal protective Equipment
RURA : Rwanda Utility Regulatory Agency
SOP : Standard Operating Procedure
SOPs : Standard Operating Procedures
WHO : World Health Organization
HP : Health Post
HIV/AIDS : Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
Kg : Kilograms
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CHAPTER 1: INTRODUCTION
1.1 About these guidelines
These guidelines provide a minimum standard for safeguarding public health and the
environment through efficient management of health care waste. All types of health care waste
are considered in these guidelines and each health facility (HF) is responsible for managing its
waste, from the point of generation to final disposal.
The guidelines provide a framework of waste management strategies outlined below:
a) Hygiene and Infection Prevention Control committees for waste management, planning
and auditing;
b) Reduce, recycle and reuse
c) Waste labeling and containment;
d) Proper waste handling, segregation, storage and transport;
e) Correct waste treatment and disposal
These guidelines are recommended to all stakeholders in the health sector and in particular all
those involved in delivery of health care services in Rwanda.
Adoption of these guidelines should be accompanied by commitment of each HF through the
establishment of Hygiene and IPC committees and development of a Health Care Waste
Management Plan (HCWMP) that will assist HFs to manage its waste. The operations of these
guidelines should be incorporated into the HF Action Plan.
1.2 Background
In Rwanda, efforts to improve health care waste management and injection safety are remarkable
in public health facilities settings and in community.
Actually the Government of Rwanda has an Organic Law determining the modalities of
protection, conservation and promotion of environment in Rwanda and other rules and
regulations related. It is also signatory to a number of conventions, notably, the
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BaselConvention, the Rotterdam Convention 1, the Montreal Protocol 2 and the Biodiversity
Convention,3 that have some relevance to how HCW is managed.
Despite to the above mentioned national and international legal frameworks, currently there are
no national guidelines on health care waste management.
To ensure rationale management of medical waste, The Ministry of Health has taken all
necessary measures to minimize the riskslikely to result from improper medical waste
management both in health facilities and in communities. In this regard, Health care waste
management and injection safety have also been given due priority where training of health care
providers has been conducted, national and district hospital incinerators purchased and plans to
purchase additional ones are underway. Provision of personal protective equipment, auto disable
syringes and needles, disinfectants and availing post exposure prophylaxis to victims of
accidental occupational exposures (blood and amniotic fluid during labor and delivery) is being
implemented. Safe storage of sharp waste, separation of waste according to their category at
production site, waste transportation and destruction in a safe manner is extremely vital.
The primary purpose of these guidelines is to provide guidance to health professionals and waste
handlers in proper collection, segregation, transportation, treatment and final disposal of
medical wastes in a manner that does not endanger the lives of health care providers, supporting
staff and community along the road where medical waste is transported.
1.3 Objective
The objectives of these guidelines are to maintain public health safety by:
a) Minimizing health care waste generation and impacts to the environment.
b) Setting standardized Health care waste management practices.
c) Specifying roles and responsibilities within Health Facilities.
1 Rotterdam convention on the Prior Informed Consent Procedures for Certain Hazardous
Chemicals Pesticides in International Trade; adopted 10 September 1998 in force on 24 February 2004)
2 Montreal Protocol on Substances that Deplete the Ozone Layer, 1 January 1998 (Revisions 1190 – 1999)
3 Convention on Biological Diversity (CBD) known as Biodiversity Convention, 29 December 1993.
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CHAPTER 2: HEALTH EFFECT OF HEALTH CARE WASTE
Health Facilities produces waste during the diagnosis, treatment and carrying out of research.
Annually theseHFs produce large quantities of infectious, pathological, sharps, chemicals,
pharmaceutical and radioactive wastes.
Home based care generates pharmaceutical, infectious and contaminated disposable materials
such as treatment by Community Health Workers, home dialysis and used needles from insulin
injection, or even illicit intravenous drug use.
2.1 Hazardfrom health care waste
All individuals exposed to hazardous health-care waste are potentially at risk, including those
within health-care establishments that generate hazardous waste, and those outside these sources
who either handle such waste or are exposed to it as a consequence of careless management. The
main groups at risk are the following:
a) Health care Providers and hospital maintenance personnel
b) Patients in health-care facilities or receiving home care
c) Visitors to health-care facilities
d) Worker in support services allied to health care establishments, such cleaners, laundry
staff and waste handlers including scavengers.
2.2 Risks caused by poor management of health care wastes
Poor management of HCW causes serious risk to personnel, waste handlers, patients, and the
community. Sources of illness from infectious waste include injuries from used needles, reuse by
other people, and diseases that may result from contact with this dangerous waste.
During handling of waste, health care personnel and waste handlers (within and outside the
health facility) can come into contact with this waste if it has not been packaged safely. Needle
stick injuries arising from improperly stored needles and syringes may occur. At landfills or
waste dumps, waste recyclers or scavengers may come in contact with infectious waste if the
waste has been disposed of without prior segregation and treatment.
The reuse of syringes by the general public represents a significant public health problem.
As opposed to direct contact with HCW, waste can also contaminate the environment, water, air,
or land and therefore can indirectly impact on health.
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CHAPTER 3: CHARACTERIZATION OF HEALTH CARE WASTES
3.1. Source of Health Care waste
Major sources of health-care waste are the following: Health Facilities (Referral, Provincial,
District, HC, HPs),Community Health Workers, Emergency Medical Care, Long-term health-
care establishments and Hospices, Transfusioncenters,Military medical services, Prison hospitals
or clinics, Related laboratories and research centers, Medical and Biomedical Laboratories,
Biotechnology Laboratories and Institutions, Medical Research centers, Mortuary and Autopsy
centres, Animal Research and Testing, Blood Banks and Blood Collection Services, Nursing
Homes for the elderly.
3.2. Categories of waste
3.2.1. Infectious waste
Infectious waste is material suspected to contain pathogens (bacteria, viruses, parasites or fungi)
in sufficient concentration or quantity to cause disease in susceptible hosts. This category
includes:
a) Waste contaminated with blood or other body fluids;
b) Cultures and stocks of infectious agents from laboratory work;
c) Waste from infected patients in isolation wards, surgery and autopsies (e.g excreta, tissue,
and dressing from infected or surgical wounds, clothes soiled with human blood or other
body fluid).
3.2.2. Pathological waste;
a) Pathological waste could be considered a subcategory of infectious waste, but is often
classified separately – especially when special methods of handling, treatment and
disposal are used.
b) Pathological waste consists of tissues, organs, body parts, blood, body fluids and other
waste from surgery and autopsies on patients with infectious diseases;
c) It also includes human fetuses and infected animal carcasses; Recognizable human or
animal body parts are sometimes called anatomical waste.
d) Pathological waste may include healthy body parts that have been removed during a
medical procedure or produced during medical research.
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3.2.3. Sharps waste
Sharps are items that could cause cuts or puncture wounds, including needles, hypodermic
needles, scalpels and other blades, knives, infusion sets, saws, broken glass and pipettes.
Whether or not they are infected, such items are usually considered highly hazardous health-care
waste.
3.2.4. Pharmaceutical waste
Pharmaceutical waste includes expired, unused, spilt and contaminated pharmaceutical products,
this also includes drugs, vaccines and sera (serum) that are no longer required. The category also
includes discarded items used in the handling of pharmaceuticals, such as bottles or boxes with
residues and drugs vials.
3.2.5. Radioactive waste
Radioactive waste includes solids, liquid and gaseous materiel contaminated with radionuclide. It
is produced as result of procedures such as in vitro analysis of body tissue and fluid, in vivo
organ imaging and tumour localization, and various investigative and therapeutic practices.
3.2.6. Chemical waste
a) Hazardous chemical waste consists of discarded solid, liquid and gaseous chemicals; for
example, from diagnostic and experimental work and from cleaning and disinfecting
procedures. In the context of protecting health, it is consider to be hazardous if it is
corrosive (e.g. acids of pH <2 and bases of pH >12), flammable, reactive (explosive,
water reactive, shock sensitive) and oxidizing.
b) Non-hazardous chemical waste consists of chemicals with none of the above properties;
for example, sugars, amino acids and certain organic and inorganic salts, which are
widely used in transfusion liquids.
3.2.7. Non-hazardous general waste
Non-hazardous or general waste is waste that has not been in contact with infectious agents,
hazardous chemicals or radioactive substances and does not pose a sharps hazard. It is generated
from offices, kitchen, packaging material and from stores. It is similar to domestic waste.
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CHAPTER 4: LEGISLATIVE FRAMEWORK
4.1Organic law N° 04/2005 of 08/04/2005 determining the modalities of protection,
conservation and promotion of environment in Rwanda
This organic law determines the modalities of protecting, conserving and promoting the
environment in Rwanda: This Organic law aims at:
a) Conserving the environment, people and their habitats; setting up fundamental principles
related to protection of environment and any means that may degrade the environment
with the intention of promoting the natural resources, to discourage any hazardous and
destructive means;
b) Promoting the social welfare of the population considering equal distribution of the
existing wealth; considering the durability of the resources with an emphasis especially
on equal rights on present and future generations;
c) Guarantee to all Rwandans sustainable development which does not harm the
environment and the social welfare of the population; setting up strategies of protecting
and reducing negative effects on the environment and replacing the degraded
environment.
4.2 Law N° 47/2012 of 14/01/2013 relating to the regulation and inspection of food and
pharmaceutical products.
This Law relates to the regulation and inspection of food and pharmaceutical products;
4.3 Environmental health policy
The Environmental Health Policy aim is provision of adequate environmental health services to
all Rwandans with their active participation to the reduction of infant, child and adult morbidity
and mortality rates by reducing and eliminating health risks associated with environmental
hazards, which are the direct causes and spread of diseases and conditions related to
environmental health.
4.4 National Policy on Injection Safety, Prevention of Transmission of Nosocomial Infection
and Health Care Waste Management;
The overall objective of this policy is to ensure no person is infected as a result of health-care
she/he has received. It aims at putting in place mechanisms, systems and practices to prevent
transmission of infection through injections and other medical procedures and ensuring that
medical waste is disposed in a safe manner that does not have any risk to Health personnel,
patients and the community.
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CHAPTER 5: HEALTH CARE WASTE MANAGEMENT PLANNING
5.1 Preliminary Planning for Health Care Waste Management
Planning for health care waste management involves:
a) Setting the management objectives.
b) Defining a strategy that will facilitate careful implementation of the necessary measures
and the appropriate allocation of resources according to the identified priorities. A
suitable, safe, and cost effective strategy will be concerned principally with transport,
recycling, treatment and disposal options.
c) Conducting surveys on waste generation shall provide baseline information on the
quantities and classes of waste generated. A HF survey of Health care waste will provide
a basis for identifying actions, taking into account conditions, needs, and possibilities. On
the basis of waste generation surveys and recommendations, the waste management focal
person (Environmental Health Officer) should provide estimates on the amount and type
of waste generated to the Hygiene Committee/IPC.
d) Setting the targets-for waste minimization, reuse, recycling, and cost reduction. A sample
sheet for assessment of waste generation is provided in Annex 1.
e) Proper management of health-care waste depends largely on good administration and
organization
f) Adequate legislation and financing is also required.
g) Active participation by trained and informed staff is necessary.
h) Each HF should have a contingency plan for emergency situations
5.2 Implementation of the waste management plan
The overall responsibility of implementation lies with the Head of the facility. It involves the
following steps:
a) A Gantt chart should be developed, showing management of wastes.
b) Provision for future waste storage facilities should be made.
c) The EHO should monitor the deployment ofpersonnel to the posts with responsibility for
waste management.
d) The EHO in liaison with the Hygiene Committee/IPC should organize and supervise
training programmes for all staff on HCWM.
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e) The Hygiene Committee/IPC should review the waste management plan annually and
initiate changes necessary to upgrade.
f) Design and implement Monitoring and Evaluation mechanisms for the plan.
g) A report should be prepared and submitted to the relevant authorities as required
(Monthly, Quarterly and Annual).
5.3 Duties and responsibilities
5.3.1 Roles and Responsibilities for Head of Health Facilities
The head of health facilities are responsible for the safe disposal of health-care waste generated
in their establishments.
They should therefore, take all reasonable measures to:-
a) Prevent health-care waste from causing environmental pollution or adverse effects on
human health;
b) Ensure that health-care waste is adequately segregated and safely packed, especially in
the case of sharps which should be packed in puncture-proof containers;
c) Ensure that bags or containers of health-care waste are handled only by those officially
licensed to transport and/or dispose of such waste;
d) Ensure that a transfer note describing the waste is handed to the recipient when waste is
transferred;
e) Check for proof that the driver of the collection vehicle is aware of the procedures
governing transport of hazardous goods. Such proof shall include but not limited to an
authorization letter or a certificate indicating form of training in transportation of health
care waste.
f) If on-site treatment is impossible or uneconomical, cooled storage facilities should be
provided and there should be a regular collection by a contractor who has suitable
incineration facilities.
g) When an injection is carried out at a patient’s home, the practitioner is responsible for
disposing of syringes, needles, and all other items used including incontinence pads and
swabs.
h) The patient or the care giver shall be responsible for safe disposal of health care waste in
case of home based treatment, for example in the case of diabetics.
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i) Ensure that ambulances are equipped with puncture-proof containers of appropriate size,
mainly for infectious waste and sharps.
j) Ensure that staff is trained in the safe handling of health-care waste.
k) Ensure that any contractual arrangement for research by workers outside the
establishment should include adequate provisions for the safe handling and disposal of
waste.
5.3.2 Roles and responsibilities for different levels
Table 1 Responsibility at Central and District level
Title Responsibility
Central level
Put in place favorable
policies and guidelines to ensure safe and appropriate waste
management practices.
Incorporate waste management commodities in existing essential
medicines and supplies lists.
Provide technical supportive supervision.
Capacity building of HF staff on health care waste management.
Mobilize resources.
District level
Build awareness on the risks of health care waste and the need for
proper disposal
Supervise the management/handling of health care waste at health
facilities through management committees
Advocate for increased allocation of district financial resources to
support the management of health care waste at health facilities
Promote the benefits of the public-private partnership model for
providing best, affordable, and sustainable alternatives for managing
health care waste.
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Table 2 Responsibility at Health Facility level
Title Responsibility
Managerial
Staff
Obtain and be familiar with national waste management policies and
guidelines.
Enforce facility waste management plan (goal, budget, staff, roles,
supervision, training, reporting, etc.).
Monitor waste management practices
Liaison with the waste management focal person (EHO)
Ensure staff is trained on the proper procedures of HCWM.
Budget for adequate supply of HCWM products and activities.
Ensuring availability of health care waste management commodities
Advocate for staff health and safety.
Clinical Staff
Follow waste management policies and procedures.
Practice safe operating procedures and wear appropriate PPE.
Follow color-coded waste segregation system.
Notify Support Staff when HCW containers are ¾ full for collection and
replacement.
Notify Stores when HCW container stock is running low to ensure sound
stock control.
Support Staff
Place appropriate HCW containers at designated locations.
Know colour-coding system and use it correctly.
Practice safe operating procedures and wear appropriate PPE.
Collect correctly filled (no more than ¾) HCW containers.
Ensure a clean and orderly environment at the facility.
Record keeping––record number of filled HCW containers, identify supply
needs, report stock outs.
Ensure temporary storage of HCW in a dedicated and secure location.
Technical Staff
Follow waste management policies and procedures.
Practice safe operating procedures and wear appropriate PPE.
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Ensure adequate supply of HCWM products.
Follow colour-coded waste segregation system.
Notify Support Staff when HCW containers are no more than ¾ full.
Environmental
Health Officer
Obtain and be familiar with national and programme waste management
policies and guidelines.
Directly supervise collection, segregation, storage, transportation, treatment
and disposal of health-care waste.
Liaison with all department to raise the profile of health care waste
management
Enforce facility waste management plan (goal, budget, staff, roles,
supervision, training, reporting, etc.).
Identify training needs on health care waste management
Organize and supervise staff training on safe waste management
Conduct quality survey sonquantity and type of waste generated and verify
compliance with HCWM SOPs and National Guidelines.
Monitoring injuries and infection incidences related to health care waste
Record-keeping
Table 3 Roles and responsibility of Community Health Worker
Responsibility
Minimize waste generation;
Conduct waste segregation;
Ensure appropriate storage before final disposal of HCW;
Return hazardous waste and the used sharps (in the safety box) to the health facility
for treatment and disposal;
Protect oneself and the community against potential health hazards;
Conduct public awareness on the risk of health Care Waste.
5.4 Management of health care waste from scattered small source
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The management of health care waste from scattered small sources shall include but not limited
to private medical practitioners, research facilities, nursing homes, home treatment, ambulance
services and veterinary centers.
The options for safe collection, transportation and disposal of health-care waste from small
sources, which do not treat their own waste, include the following:
a) An authorized contractor should collect the waste for treatment and take it to a DH
incinerator or other treatment facility;
b) An authorized contractor collects and treats the waste at the treatment facility;
c) The Local authority shall oversee the collection, treatment and final disposal of HCW to
ensure adherence to set guidelines and SOPs.
5.4.1 Marking of Waste
a) All waste should be clearly marked with self-adhesive indicating source and type of
waste. Infectious, Pathological and Sharp waste should also be marked with the
international biohazard symbol. Chemicals should also be marked with the appropriate
international chemical hazard symbol. Radioactive waste must be labeled with the
appropriate warning symbol as provided in Annex 3.
b) Any contract for collection by a private registered health-care waste carrier should
identify the disposal or treatment facility to be used.
5.4.2 Dedicated vehicles
a) The carrier should, use dedicated vehicles for the collection and transportation of
infectious waste.
b) Collection and transportation of health-care waste from their source should be regular and
according to schedule.
5.4.3 Storage
Any storage of waste before treatment or collection for off-site disposal should be in a secure
location designated for the purpose.
5.4.4 Employees knowledge of guidelines
All employees should be made aware of these Guidelines, which contain details of the
procedures to follow in case of a needle-stick injury or exposure to infected blood.
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CHAPTER 6: WASTE MINIMIZATION, RECYCLE AND REUSE
6.1 Minimization of waste
The preferred management solution is quite simply not to produce the waste, by avoiding wasteful ways
of working. To achieve lasting waste reduction (or minimization), the focus should be on working with
medical staff to change clinical practices to ones that use less materials. Although waste minimization is
most commonly applied at the point of its generation, health-care managers can also take measures to
reduce the production of waste through adapting their purchasing and stock control strategies.
6.2 Waste Segregation and packaging
Waste segregation is separation of wastes according to types and categories.
a) Segregation should;
i. Always be the responsibility of the waste producer,
ii. Take place as close as possible to where the waste is generated, and
iii. Be maintained in storage areas, during transportation, treatment and disposal.
b) The most appropriate way of identifying the categories of health-care waste is by
separating the waste into colour-coded plastic bags or containers. The recommended
colour-coding scheme is provided in Annex 2.
c) In addition to the colour coding of waste containers, the following practices are
recommended:
i. General (non-infectious) health-care waste can join the stream of domestic refuse
for disposal if none can be salvaged.
ii. Sharps should all be collected together, regardless of whether or not they are
contaminated.
d) Sharps containers should be;
i. Puncture-proof (usually made of cardboard or high-density plastic) and fitted with
covers.
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ii. Be rigid and impermeable so that they safely retain not only the sharps but also
any residual liquids from syringes.
iii. To discourage abuse, containers should be tamper-proof (difficult to open or
break) and needles and syringes should be rendered unusable.
e) Liner bags used should be;
i. Highly resistant to puncturing and tearing with exceptional strength and stretch
properties.
ii. They should be of a gauge not less than 150 microns.
iii. Where bins are unavailable or too costly, containers made of dense cardboard are
recommended:
iv. Bags and containers for infectious waste should be marked with the international
infectious substance symbol (Refer to annex 3).
f) Highly infectious waste should, whenever possible,
i. Be sterilized immediately by autoclaving.
ii. It needs to be packaged in bags that are compatible with the proposed treatment
process. Red bags suitable for autoclaving are recommended.
g) Waste collection bags for waste types needing incineration shall not be made of
chlorinated plastics.
h) Cytotoxic waste, most of which is produced in major hospital or research facilities,
should be collectedin strong, leak-proof containers clearly labeled “Cytotoxic wastes”.
i) Small amounts of chemical or pharmaceutical waste may be;
i. Collected together with infectious waste.
ii. Large quantities of obsolete or expired pharmaceuticals stored in hospital wards
or departmentsshould be returned to the pharmacy for disposal.
iii. Other pharmaceutical waste generated, such as spilled or contaminated drugs or
packagingcontaining drug residues should not be returned because of the risk of
contaminating the pharmacy; it should be deposited in the correct container at the
point of generation.
iv. Large quantities of chemical waste should be packed in chemical resistant
containers.
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6.3 Safe reuse and recycling
Medical and other equipment used in a health-care establishment may be reused provided that it
is designed for the purpose and will withstand the sterilization process.
a) Proper disinfection and sterilization can ensure the safe use of invasive and non-invasive medical
devices. The choice of disinfectant, concentration, and exposure time is based on the risk for
infection associated with use of the equipment and other factors discussed in this guideline
b) Reusable items may include certain sharps, such as scalpels, syringes, glass bottles and
containers, etc. After use, these should be collected separately from non-reusable items,
carefully washed and may then be sterilized by either thermal or chemical sterilization.
c) Plastic syringes and catheters should not be thermally or chemically sterilized; they
should be discarded.
d) Other non infectious wastes such as paper, glass, polythene, food remains should be
recycled and reused.
e) Other types of wastes not mentioned here are not recommended for recycling or re-use.
Figure 1 The waste management hierarchy
National Health Care Waste Management Guidelines Page 24
PREVENT
REDUCE
REUSE
RECYCLE
RECOVER
TREAT
LEAST PREFERABLE
DISPOSAL
MOST PREFERABLE
National Health Care Waste Management Guidelines Page 25
CHAPTER 7: HANDLING, LABELING, CONTAINMENT, TRANSPORT
AND STORAGE
This section explains the importance of streamlining the process of waste collection, handling
and transport to ensure compliance with occupational health and safety and environmental
control requirements.
7.1 Organization
Each HF must have a dedicated staff/company of waste handlers.
Waste handlers must be trained and equipped to undertake the handling, internal transportation,
spillmanagement, blood, body fluid exposure management and storage requirements of the HF.
7.2 Internal transportation
All HF should conduct a review to optimize the waste collection process, reduce handling
andtransportation, and to promote safe work practices.
Transportation routes should avoid where possible food preparation and heavily used areas.
7.3 Waste labeling
All waste liner bags and waste containers are to be color coded (Annex 2) and inscribed with
hazard marks or stickers and identified in accordance with international waste labeling symbols
as provided in Annex 3.
7.4 Health Care Waste Tracking
Tracking of HCW is necessary to enable both the regulatory bodies and all other stakeholders’to
follow the movement of waste from generation to safe final disposal. Tracking helps to rapidly
identify the source of waste, facilitates segregation, provides feedback, assists in providing data
for education purposes, decision making facilitates auditing and may be used to allocate
resources for HCWM.
The use of tracking forms is therefore necessary and would enable both the regulatory bodies and
all concerned to follow the movement of waste from generation to safe final disposal. Samples of
waste tracking forms are provided in Annex 4.
National Health Care Waste Management Guidelines Page 26
All liner bags /containers of waste must be clearly marked to identify the HF, unit (e.g. Maternity
Ward) and date of collection.
The illegal dumping of Health care waste by unscrupulous waste collectors/generators poses a
great risk to public health. Tracking the movement of waste from the points of generation
through transportation to the final disposal point would guard against the malpractice of illegal
dumping (see Annex 4).
7.5 Handling waste bags
a) Sharps must always be placed in injection safety boxes and never be placed in waste
bags.
b) Waste must be contained in colour coded and well labeled plastic bags
c) General waste should be contained in well labeled black bags.
d) Waste bags must not be over filled (approx 2/3 of capacity).
e) The volume of a waste bag should not exceed 55 liters.
f) Excess air should be excluded without compaction, prior to closure using a bag tie at the
point of waste generation.
g) All bags should be held away from the body by the closed top of the bag, and placed
directly into a mobile garbage bin or trolley.
h) Where waste bags are sealed and stored pending collection, they should be in a secure
place with restricted access.
i) There should be a Waste collection schedule.
7.6 Storage
7.6.1 Storage for waste
a) A storage location for health-care waste should be designated inside the HF.
b) Unless a refrigerated storage room is available, storage times for Health care waste (i.e.
the delay between production and treatment) should not exceed the following:
i. 48 hours during the cool season
ii. 24 hours during the hot season
c) Cytotoxic waste should be stored separately from other health-care waste in a designated
secure location.
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d) Radioactive waste should be stored in containers that prevent dispersion, behind lead
shielding. Wastethat is to be stored during radioactive decay should be labeled with the
type of radionuclide, the date, and details of required storage conditions.
7.7 Spill Management
7.7.1 General spill management
HF should manage waste spills as they occur in the facility.
a) In the case of gross spills, containment is the principal role.
b) It is essential that personnel involved in spill management receive education and training
in emergency procedures and handling requirements.
c) Spill kits should be readily available throughout the hospital with their location known by
all staff.
d) Spill kits that have been used should be disposed of with the type of waste that has been
cleaned up, e.g. used cytotoxic spill kits should be disposed of with cytotoxic waste.
e) All spillage should be documented per department and per facility.
7.7.2 Infectious waste spill kit.
Infectious waste spill kit should contain at least:
a) Broom, a pan and scraper, mop and mop bucket
b) A large (10 liter) reusable plastic container or bucket with fitted lid, containing;
c) 2 infectious waste bags for the disposal of clinical waste;
d) Disinfectant containing (1%) 10,000 ppm available chlorine or equivalent;
e) Rubber gloves suitable for cleaning
f) Detergent, sponges / disposable cloths
g) Personal protective equipment including eye protection, an apron or long
h) Sleeve impervious gown, a face mask, heavy duty gloves.
i) Incident report form
j) Waste spill sign.
7.7.3 Cytotoxic spill kit
Cytotoxic spill kit should contain at least:
a) Mop and mop bucket, a pan and scraper.
b) A large (10 litre) reusable plastic container or bucket with fitted lid, containing;
National Health Care Waste Management Guidelines Page 28
c) 2 cytotoxic waste bags for the disposal of cytotoxic waste
d) 2 hooded overalls, shoe covers, long heavy duty gloves, latex gloves, a face
e) Mask and eye protection
f) Absorbent toweling / absorbent spill mat
g) Incident report form
h) Waste spill sign
7.7.4 Mercury spill kit
Mercury spill kit should contain at least:
a) 2 unbreakable lidded containers
b) Spill sign
c) Pasteur pipette, eye dropper
d) Sodium thiosulphate
e) Face mask
f) Dust pan and brush
g) Sulfur powder
h) Incident report form.
7.8 Collection
a) Wastes should not be allowed to accumulate at the point of production. For this reason a
routineprogramme for their collection should be established as part of the health-care
waste management plan.
b) Nursing and other clinical staff should ensure that waste bags are tightly closed or sealed
when they areabout three-quarters full.
c) Light-gauge bags can be closed by tying the neck, but heavier-gauge bags probably
require a plasticsealing tag of the self-locking type.
d) Bags should not be closed by stapling.
e) Sealed sharps containers should be placed in a labelled, yellow infectious health-care
waste bag beforeremoval from the hospital ward or department.
f) The following recommendations should be followed by the waste handlers:
i. Waste should be collected daily (or as frequently as required) and transported
to the designated central storage site.
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ii. No bags should be removed unless they are labeled with their point of
production (hospital and ward or department) and contents.
iii. The bags or containers should be replaced immediately with new ones of the
same type.
iv. A supply of fresh collection bags or containers should be readily available at
all locations where waste is produced.
v. The person in charge should ensure that adequate supplies (3 months) are
available and thatprocurement is timely to ensure the facility does not run out
of waste collection bags.
7.9 Transportation
a) All transporters of biomedical waste must be appointed by the Ministry of Health or
Manager of the healthfacility and must obtain a transportation license from RURA.
b) The transporter shall collect waste from the designated area of operations or storage areas
and shalldeliver such waste to the designated storage site, disposal site or plant.
c) The Ministry or Manager of a HF shall ensure that:
i. The collection and transportation of such waste is conducted in such a manner
that will notcause scattering, escaping and/or flowing out of the waste;
ii. The vehicles and equipment for the transportation of waste are in such a state that
shall notcause the scattering of, escaping of, or flowing out of the waste or
emitting of noxious smellsfrom the waste;
iii. The vehicles for transportation and other means of conveyance of waste shall
follow thescheduled routes approved by RURA from the point of collection to the
disposal site or plant;and
iv. During the transportation of waste, the transporter should possess at all times a
duly filled tracking document and shall produce the same on demand to any law
enforcement officer.
d) Biomedical waste shall be:
i. Transported in a specially designed vehicle or other means of conveyance so as to
prevent scattering, escaping, flowing, spillage or leakage of the waste.
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ii. It is recommended that the vehicle is closely lockable, covered, labeled, leak
proof and corrosionproof preferably internally lined with aluminium or stainless
steel.
iii. Any vehicle used for transportation of waste or any other means of conveyance
shall be appropriately labeled.
7.10 On-site transport for collection purposes
a) Mobile garbage bins (MGBS) and trolleys should be used when transporting waste to
decrease spills, minimize collector contact with waste and minimize manual handling.
b) Loads contained in MGBs and trolleys should be less than 55kgs.
c) All bins must be colour coded and marked as specified in Annex 2.
d) Health-care waste should be transported within the hospital or other facility by means of
wheeled trolleys or containers that are not used for any other purpose and meet the
following specifications:
i. Easy to load and unload;
ii. No sharp edges that could damage waste bags or containers during loading and
unloading;
iii. Easy to clean.
e) Trolleys and MGBs must be dedicated singularly for collecting waste and must be made
of rigid material, lidded, lockable (if used for storage), leak proof and washable.
f) These MGBs and trolleys should be labelled according to the type of wastes contained,
cleaned regularly and must never be overfilled.
g) Waste collection rounds should be performed as often as necessary to minimize
housekeeping hazards.
h) When cleaning trolleys and MGBs:
i. Rinse with cold water then wash with warm water and a neutral detergent.
ii. Trolleys and MGBs should then be drained to sewer and left to dry.
iii. Clean trolleys and bins should be stored separately to soiled containers.
iv. Appropriate personal protective equipment should be worn when cleaning MGBs.
v. Waste water may only be diverted to the sewer.
i) The vehicles should be cleaned and disinfected daily with an appropriate disinfectant
(Glutaraldehyde or Peracetic acid).
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j) All waste-bag seals should be in place and intact at the end of transportation.
k) Use of wheelbarrows is not recommended for transportation.
7.11 Off-site transportation of waste
7.11.1 Regulation and control system
a) The health-care waste producer is responsible for safe packaging and adequate labeling of
waste to be transported off-site and for authorization of its destination.
b) The tracking form (Annex 5 or 6) has to be signed at the point of destination and shall be
kept as records by the health facility as proof of proper disposal of waste.
c) The signed tracking form will be submitted as part of records in the reports.
d) Packaging and labeling of waste should comply with the Ministry of Health HCWM
Guidelines and with international agreements (such as the Basel Convention) if wastes
are shipped abroad for treatment and disposal.
e) The control strategy for health-care waste should have the following components:
i. A consignment note (Annex 6) should accompany the waste from its place of
production to the site of final disposal. On completion of the journey, the
transporter should complete the part of the consignment note especially reserved
for him and return it to the waste producer.
ii. The transporting organization should be registered with RURA.
iii. Handling and disposal facilities other than the DH should hold a permit, issued by
RURA, allowing the facilities to handle and dispose of health-care waste.
7.11.2 Routing
a) Health-care waste should be transported by the quickest possible route, which should be
planned before the journey begins.
b) After departure from the waste production point, every effort should be made to avoid
further handling.
c) If handling cannot be avoided, it should be pre-arranged and take place in adequately
designed and authorized premises by the Waste Management focal person.
d) Handling requirements can be specified in the contract established between the waste
producer and the carrier.
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CHAPTER 8: TREATMENT AND DISPOSAL FOR HEALTH CARE
WASTE
8.1 Treatment and disposal options
a) Health care waste should be treated prior to disposal so as to ensure protection from
potential hazards posed by these wastes.
b) To be effective, treatment must reduce or eliminate the risk present in the waste so that it
no longer poses a hazard to persons who may be exposed to it.
c) The common method of treatment is: incineration; steam sterilization, chemical
disinfection, autoclaving and microwave irradiation.
d) Other methods that can be used include encapsulation and inertization, shredding,
macerations and grinding.
e) However treatment methods should be chosen according to the type of waste and these
guidelines.
f) In-case of infectious and sharp wastes, all the treatment methods are applicable (Annex
7).
8.2 Waste disposal options
8.2.1 General disposal options
a) After disinfection or incineration, infectious health care waste becomes non-risk waste
and may be finally disposed of in landfill sites. The commonly used disposal method in
Rwanda is land disposal which include District disposal sites, protected ash and waste
pits.
b) However, certain types of Health care waste, such as anatomical waste, will still have an
offensive visualimpact and this is culturally unacceptable in Rwanda. Such wastes
shouldtherefore be buried and use of placenta pits.
c) Other methods may include the return of the wastes to the supplier/manufacture.
d) Aerosol containers may be collected with general health care waste once they are
completely empty, provided that the waste is not destined for incineration. Contractors
for recycling the cans can be called upon.
National Health Care Waste Management Guidelines Page 33
e) All radioactive waste (e.g. swabs, syringes for diagnostic or therapeutic use) may be
collected in yellow bags or containers for infectious waste if these are destined for
incineration.
f) Appropriate containers or bag holders should be placed in all locations where particular
categories of waste may be generated.
g) Instructions on waste separation and identification should be posted at each waste
generation and collection point to remind staff of the procedures.
h) Containers should be removed when they are three-quarters full.
i) Staff should never attempt to correct errors of segregation by removing items from a bag
or container after disposal or by placing one bag inside another bag of a different colour.
j) If general and hazardous wastes are accidentally mixed, the mixture should be treated as
hazardous Health care waste.
8.2.2 Inertization
Inertization
a) The process of “inertization” involves mixing waste with cement and other substances
before disposal in order to minimize the risk of toxic substances contained in the waste
migrating into surface water or groundwater.
b) It is especially suitable, for pharmaceuticals and for incineration ashes with a high metal
content (in this case the process is also called “stabilization”).
c) For the inertization of pharmaceutical waste, the packaging should be removed, the
pharmaceuticals ground, and a mixture of water, lime, and cement added.
d) A homogeneous mass is formed and cubes or pellets are produced on site and then can be
transported to a suitable storage site.
e) Alternatively, the homogeneous mixture can be transported in liquid state to a landfill and
poured into District waste.
f) The following are typical proportions for the mixture:
i. 65% pharmaceutical waste;
ii. 15% lime;
iii. 15% cement;
iv. 5% water.
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The process is reasonably inexpensive and can be performed using relatively
unsophisticated equipment.
g) Other than personnel, the main requirements are a grinder or road roller to crush the
Pharmaceuticals, a concrete mixer, and supplies of cement, lime, and water.
h) The main way to achieve this is to sort the Health care waste into the various categories
to minimize the need for expensive or complicated disposal methods.
8.2.3 Options of health care waste treatment and disposal as per level of care
Table 4 Options of health care waste treatment and disposal as per level of care
CHWs/Heal
th Post
Health
Center
District
Hospital
Provincial
Hospital
Referral
Hospital
Sharps
Transfer to
HC
Incineration
with
DeMont
Fort/
Transfer to
DH
Incineration Incineration Incineration
Infectious Transfer to
HC
Incineration
and deep
burial
Incineration/de
ep burial
Incineration/
deep burial
Incineration/deep
burial
Highly
infectious
Transfer to
HC
Deep burial Incineration Incineration Incineration
Pharmaceutic
al
Transfer to
HC
Return to
DH
Incineration,
return to
source or
manufacturer
Incineration,
return to
source or
manufacturer
Incineration,
return to source
or manufacturer
Type of waste
Facility level
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CHAPTER 9: REQUIREMENT FOR OCCUPATIONAL HEALTH AND
SAFETY PRACTICES
Each Health Facility is responsible for providing a safe, healthy workplace and safe systems of work for
all. The management of waste presents a number of potential hazards to employees requiring the
appropriate measure of risk identification, risk assessment, and risk control.
Health care workers have an obligation to follow instructions regarding safe work practices. This section
explains their responsibilities and obligations.
9.1 Occupational health and safety provisions
a) Health care waste management plans should include provision for the continuous
monitoring of workers’ health and safety to ensure that correct handling during
segregation, storage, collection, transportation, treatment and disposal procedures of
waste are being followed.
b) Essential occupational health and safety measures include the following:
i. Training of workers on infection transmission.
ii. Provision of personal protective equipment;
iii. Establishment of an effective occupational health programme that includes
immunization, post-exposure prophylactic treatment, and medical surveillance.
c) Training in health and safety should ensure that workers know of and understand the
potential risksassociated with health-care waste, the value of immunization against viral
hepatitis B among otherdiseases, and the importance of consistent use of personal
protection equipment.
9.2 Employee responsibility
a) Health facility management is responsible to provide appropriate information, education,
training and ensuring that safe systems of work are developed and maintained.
b) Key among the responsibilities is to provide information on hepatitis B vaccination
among other required vaccinations and a register of vaccinated personnel maintained.
c) Official Rwanda language translations should be provided to workers where necessary.
d) Standard Operating procedures should:
National Health Care Waste Management Guidelines Page 36
i. Specify accepted waste management practices, waste segregation procedures and
approved waste handling procedures;
ii. Detail appropriate steps required for waste generators, and handlers;
iii. Specify personal protective equipment required for waste handling tasks;
iv. Detail spill management strategies and designate trained personnel for spill
management onsite;
v. Identify first aid resources and needle stick injury treatment protocol; and
vi. Specify how to operate the information, education, training and safe working
systems
9.3 Personal Protective Equipment (PPE)
a) Hygiene Committee/IPC should assess risks and recommend suitable PPE for the nature
and degree of the hazard HF staff are likely to be exposed to.
b) PPE must be worn when required.
c) Waste collectors are under obligation to wear appropriate PPE. The risk of spills or
splash exposures necessitates the wearing of face and eye protection. Protection of the
legs is also required.
d) Carrying of HCW bags is to be minimized and where it cannot be avoided, the waste
collector should wear protective garments and apron to minimize the risk of injury.
e) Protective garments should be worn whenever collecting waste, even if the process
involves wheeling a securely covered waste trolley to the holding area.
f) The type of protective clothing used will depend on the risk associated with the health-
care waste, but the following should be made available to all personnel who collect or
handle health-care waste:
i. Helmets, with or without visors-depending on the operation.
ii. Face masks-depending on operation.
iii. Eye protectors (safety goggles)-depending on operation.
iv. Overalls (coveralls)-obligatory.
v. Industrial aprons-obligatory.
vi. Leg protectors and/or industrial boots-obligatory.
vii. Disposable gloves (medical staff) or heavy-duty gloves (waste workers) -
obligatory.
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g) Operators of manually loaded incinerators should wear protective face visors and
helmets.
h) During ash and slag removal and other operations that create dust, dust masks should be
provided for operators.
i) Employees should comply with health care waste management guidelines and SOPsgiven
on correct use of safety and protective equipment for the protection of their own health
and safety and the health and safety of others.
9.4 Hygiene Committee
a) The hygiene committee has responsibilities to review:
i. Monitor and Evaluate provision and installation of facilities and protective
equipment;
ii. Work practices;
iii. Incidents and accidents;
iv. Provision and status of information, education and training;
v. Relevant records;
9.5 Monitoring Hygiene Committee
b) Incident and accident reporting and recording is an essential management information
system for identifying causative factors of injuries relating to waste handling.
c) Incident and accident reporting and recording should facilitate costing of associated
financial loss and enable management to make injury prevention investment decisions
based upon accurate data.
d) Waste treatment, operating and disposal costs should be reviewed periodically to evaluate
any fluctuations.
9.5.1 Hygiene
a) Regular washing and maintenance of equipment used to contain and transport waste
should be done by providing hand-washing facilities (with warm running water and soap)
for employees.
b) It is important for health care facilities to promote regular hygiene procedures that
comply with the National HCWM Guidelines and SOPs. This is of particular importance
at storage and incineration facilities.
National Health Care Waste Management Guidelines Page 38
c) It may be useful also to designate specific areas for equipment maintenance in hygienic
workplaces that are properly equipped with emergency shower rooms and drainage to
sewers or septic tanks.
d) Emergency shower rooms should be provided in all health care facilities.
9.6 Precautions for sharps, Blood and Body fluids exposure
Precautions must be implemented to protect against exposure to sharps, blood and body fluids.
These precautions include:
a) Providing a purposely designed sharps container as close as practicable to the point of
generation of the sharps;
b) Providing appropriate PPE for potential blood and body substance exposures;
c) Conducting compliance checks to confirm that people wear protective clothing;
d) Investigating all incidents to identify causes of exposures
e) Take remedial action to eliminate risks;
f) Hygiene Committee must review incident reports and confirm appropriate action taken;
g) Train staff in first aid and injury management procedures for sharps injury and body
substance exposure;
h) Reinforce the need for staff to report all incidents and injuries;
i) Analyze statistics to identify any risk exposure trends for necessary interventions.
9.7 Response to injury and exposure
All personnel who handle health care waste should be trained to deal with injuries and exposures.
The programme should include the following elements:
a) Immediate first-aid measures, such as cleansing of wounds and skin, and irrigation
(splashing) of eyes with clean water;
i. An immediate report of the incident to a designated responsible person;
ii. Retention, if possible, of the item involved in the incident;
iii. Details of its source for identification of possible infection;
iv. Additional medical attention in an accident and emergency
v. Alerting occupational health committee, as soon as possible;
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vi. Medical surveillance;
vii. Blood or other tests if indicated;
viii. Recording of the incident;
ix. Investigation of the incident; identification and implementation of remedial
action.
b) Waste handlers are particularly at risk from the waste. In all stages they require:-
i. PPE
ii. Hold waste containers at the handle or at the top of liner bag
iii. Avoid any waste falling on the floor during collection and transportation
iv. Non-complying waste (in terms of segregation) should not be sorted by hand
v. Waste storage/chamber should be well ventilated and compartmentalized.
vi. Cloak rooms for changing and showering
vii. Waste handlers should also receive post exposure prophylaxis for HIV/AIDS
National Health Care Waste Management Guidelines Page 40
CHAPTER 10: TRAINING
10.1Technical Training and deployment
a) Only technically trained and certified persons shall be deployed in health care waste
management. Managers should facilitate education and training in the following levels
i. Health Facility Managers training
ii. Operational training
iii. Waste handlers training (generators, handlers, collectors, transporters)
iv. Public awareness and behaviour change communication (BCC).
b) The Ministry of Health should develop and update training manuals to facilitate this
process.
c) Continuous training on HCWM should be organized to address the performance gaps.
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CHAPTER 11: COMMUNITY HEALTH CARE WASTE MANAGEMENT
Community Health is a range of services based on community health outreach and other services
provided by Community Health Workers.
11.1 Medical waste generated during Community Health Outreach
a) It is vital that the health facility management ensures clinical wastes are returned to the
health facility for appropriate disposal.
b) Waste must be transported in a designated vehicle supplied with a spill kit.
11.2 Sharps management
Safety boxes should be supplied at all sites that generate sharps
11.3 Waste transportation
The following points should be observed:
a) Lids shall be securely fitted to the containers to ensure that the wastes are prevented from
spilling;
b) Containers should be thoroughly cleansed and disinfected before re-use;
c) Containers used for the transportation of clinical wastes shall be clearly marked;
d) During transportation, containers holding the wastes shall be securely held inside the
vehicle to prevent movement of the containers and spillage of wastes; and
e) The transporter shall ensure that vehicles being used for the transportation of clinical
wastes shall be securely locked when left unattended.
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CHAPTER 12: COLLECTIONS AND DISPOSAL OF WASTE WATER
FROM HEALTH FACILITIES
12.1 Characteristics and hazards of waste water from health facilities
a) Wastewater from health facilities contains a high content of enteric pathogens, including
bacteria, viruses, and helminths, which are easily transmitted through water.
b) Contaminated wastewater is produced by wards treating patients with enteric diseases
and is a particular problem during outbreaks of diarrhoeal disease.
c) It may also contain various potentially hazardous components, such as microbiological
pathogens, hazardous chemicals, pharmaceuticals and radioactive materials which are
discussed below:-
i. Small amounts of chemicals from cleaning and disinfection operations are
regularly discharged into sewers.
ii. Small quantities of pharmaceuticals are usually discharged to the sewers from
hospital pharmacies and from the various wards.
iii. Radioactive isotopes should be discharged into holding tanks by oncology
departments
iv. The toxic effects of any chemical pollutants contained in wastewater on the active
bacteria of the sewage purification process may give rise to additional hazards.
12.2 Waste water management
a) The basic principle underlying effective wastewater management is a strict limit on the
discharge of hazardous liquids to sewers.
b) Where water use is commonly high, sewage is usually diluted.
c) For effluents treated in treatment plants, no significant health risks should be expected,
even without further specific treatment of these effluents.
12.3 On-Site treatment or pre-treatment of waste water
a) Health Facility should have their own sewage treatment plants e.g. septic tanks.
b) Efficient on-site treatment of sewage should include the following operations:
National Health Care Waste Management Guidelines Page 43
i. Primary treatment
ii. Secondary biological purification. Most helminths will settle in the sludge
resulting from secondary purification, together with 90-95% of bacteria and a
significant percentage of viruses; the secondary effluent will thus be almost free
of helminths, but will still include infective concentrations of bacteria and viruses.
iii. Tertiary treatment. The secondary effluent will probably contain at least 20
mg/litre suspended organic matter, which is too high for efficient chlorine
disinfection. It should therefore be subjected to a tertiary treatment, such as
lagooning. If no space is available for creating a lagoon, rapid sand filtration may
be substituted to produce a tertiary effluent with a much reduced content of
suspended organic matter (<10mg/litre).
iv. Chlorine disinfection. To achieve pathogen concentrations comparable to those
found in natural waters, the tertiary effluent will be subjected to chlorine
disinfection to the breakpoint. This may be done with chlorine dioxide (which is
the most efficient), sodium hypochlorite, or chlorine gas, chlorine powder.
v. Another option is ultraviolet light disinfection.
c) Disinfection of the effluents is particularly important if they are discharged into maritime
waters (Rivers, Lakes…)
12.4 Sludge treatment
a) The sludge from the sewage treatment plant requires anaerobic digestion to ensure
thermal elimination of most pathogens.
b) Alternatively, it may be dried in natural drying beds and then incinerated together with
solid infectious health-care waste.
12.5. Minimum safety requirements for sewerage treatment
For health facilities that are unable to afford any sewage treatment, the following measures
should be implemented to minimize health risks:
a) No chemicals or pharmaceuticals should be discharged into the sewer.
National Health Care Waste Management Guidelines Page 44
b) Sludge from hospital cesspools should be dehydrated on natural drying beds and
disinfected chemically (e.g. with sodium hypochlorite, chlorine gas, or preferably
chlorine dioxide).
c) Sewage should never be used for agricultural or aquaculture purposes.
d) Hospital sewage should not be discharged into natural water bodies that are used to
irrigate fruit or vegetable crops, to produce drinking water, or for recreational purposes.
12.6. Sanitation
Human excreta are the principal vehicle for the transmission and spread of a wide range of
communicable diseases, and excreta from hospital patients may be expected to contain far higher
concentrations of pathogens, and therefore to be far more infectious, than excreta from
households.
a) In most HFs, human sanitation is often by pit latrines. Excreta collected from patients are
usually disposed of via the same route, creating a risk of infection to other people.
b) Sufficient toilets should be available; the recommended minimum is one toilet per 20
users for inpatient medical areas, and at least four toilets per outpatient location (one each
for male and female staff, one for female patients, one for male patients) (WHO, 2008).
12.7. Safe management of wastes from health facilities
A health facility should ideally be connected to a sewerage system.
a) Where there are no sewerage systems, technically sound on-site sanitation such as the
simple pit latrine, ventilated pit latrine, and pour-flush latrine, and the more advanced
septic tank with soak-away should be provided.
b) In temporary field hospitals during outbreaks of communicable diseases, other options
such as chemical toilets may also be considered.
c) In addition, convenient washing facilities (with warm water and soap available) should be
available for patients, personnel, and visitors in order to limit the spread of infectious
diseases within the Health Facility.
National Health Care Waste Management Guidelines Page 45
ANNEXES:
Annex 1Sample sheet for assessment of waste generation
Name of the health facility: .............Week: ..........................Date:………… Month………………………..
Waste collection
point:
department/location
Waste
category
(specify)
Quantity of waste generated per day (weight and volume)Saturday
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Kg litre Kg litre Kg litre Kg litre Kg litre Kg litre Kg litre
National Health Care Waste Management Guidelines Page 46
Annex 2 Color code for biomedical waste
NO TYPE OF WASTE COLOUR OF
CONTAINER
AND MARKINGS
TYPE OF CONTAINER
1 Infectious Yellow with biohazard
sign
Strong leak proof-
plastic bag
with biohazard symbol
2 Pathological/anatomical Red with biohazard
sign \
3 Sharps Yellow – (marked
sharps
4 Chemicals Brown (marked
chemicals)
5 Pharmaceutical Brown
6 General waste/Noninfectious/non
hazardous(Non-clinical)
7 Radioactive waste Symbol for radioactive
waste
8 Genotoxic/ Cytotoxicwaste Purple
9 e-Waste Refer to e-waste
guidelines
SOURCE: WHO COLOUR CODE1
National Health Care Waste Management Guidelines Page 47
Annex 3 International waste labeling symbols
potentially explosive waste
Radioactive waste
Potentially corrosive waste
Label for infectious waste
Waste containing flammable
material
Label for waste containing oxidizing
chemicals
Waste containing toxic materials
Highly infectious/sharps waste
National Health Care Waste Management Guidelines Page 48
Annex 4 Alternative labels for hazardous wastes
HAZARDOUS WASTE
CYTOSTATIC
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. -------------------------------------
Signature of O i/c -----------------------------------
HAZARDOUS WASTE
“SHARPS: INFECTIOUS”
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. -------------------------------------
Signature of O i/c -----------------------------------
HAZARDOUS WASTE
BIOLOGICAL
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. ------------------------------------
-
Signature of O i/c ----------------------------------
-
HAZARDOUS WASTE
CHEMICALS
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. -------------------------------------
Signature of O i/c -----------------------------------
HAZARDOUS WASTE
INFECTIOUS
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. ------------------------------------
-
Signature of O i/c ----------------------------------
-
HAZARDOUS WASTE
PHARMACEUTICAL
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. -------------------------------------
Signature of O i/c -----------------------------------
National Health Care Waste Management Guidelines Page 49
Annex 5 Health care waste tracking form sample 1
HEALTH CARE WASTE TRACKING FORM
Date of shipment DD/MM/YYYY
Source (Name of HF/Hospital/Clinic)……………………………………
Physical address ………………………………………………………….
Generation Point: ………………………………………….
Postal address:
Tel : 07…………………………………….
Email: ……………………………………….
TRANSPORTER:
NAME
Physical address
Postal address
Tel:0000000
Email……………………………………..
National Health Care Waste Management Guidelines Page 50
Annex 6 Health care waste tracking form sample 2
[Name, Address and
telephone number of]
Registration number from regulatory agency
Originator’s reference
CONSIGNMENT NOTE FOR THE CARRIAGE AND DISPOSAL OF HAZARDOUS WASTE
A.
Producer’s
Certificate
(1) The material described in B below is to be collected from
(location)...…...........................and taken to
(location)……………………………………….
Name…………………………………….Signed……………………………………...
On behalf of ………………………………..
Designation…………………………………
Address …………………………………….Tel. no…………………………………..
Date ………………………………………Time of collection…………..
B.
Description
of the waste
(1) General description and physical nature of waste....................................................
(2) Relevant chemical and biological components and maximum concentrations
....................
(3) Quantity of waste and size, type and number of containers.....................................
(4) Process (es) from which waste originated............................................................
C.
Carriers
Collection
Certificate
I certify that I collected the consignment of waste and the information given in A (1)
and(2) and B (1) and (3) is correct, subject to any amendment listed in this space
I collected this consignment on…………………………….. at……………….Time
Signed ………………………. Name ………………………….. Date ………………
On behalf of ………………………………………… Vehicle reg. No. .. .……….
Address …………………………………………………Tel. No. ……..……………..
D.
Producer’s
Collection
Certificate
I certify that the information given in B and C is correct and the carrier was advised
of appropriate precautionary measures.
Signed ……………………Name …………………………………………………
Date……………………………………. Tel. no. …………………………………..
E.
Disposer’s
Certificate
I certify that Waste Disposal License No………….., issued by ……………………...
[name of issuing body], authorizes the treatment/disposal at this facility of the waste
described in B (and as amended where necessary at C)
Name and address of facility………………………………………………………...
…………………………………………………………………………………………
This waste was delivered in vehicle …………[reg. No.] at ……………………
Time ………………….. [date] and the carrier gave his name as
…………………….. on behalf of ………………………………Proper instructions
were given that the waste should be taken to
………………………………………………………………………
Signed ………………….. Name ……………………………… Position …………..
Date ………………………on behalf of ……………………………………………
F.
For use by
Producer/
Carrier/Dispose
National Health Care Waste Management Guidelines Page 51
Annex 7 Waste treatment methods
Infectious Wastes Treatment method
Cultures and stock Steam sterilization/microwave
Contaminated bedding/patient care waste Steam sterilization or Incineration
Contaminated small equipment Steam sterilization or Incineration
Contaminated large equipment Formaldehyde decontamination
Biological Waste Steam sterilization or Incineration/ microwave
Contaminated laboratory waste Steam sterilization/ microwave
Dialysis unit waste Steam sterilization
Pathological waste
Anatomical wastes Steam sterilization or Incineration/Grinding
Surgery waste Steam sterilization or Incineration
Human blood and blood products Steam sterilization or Incineration
Contaminated animal carcasses Incineration
Autopsy waste Incineration
Sharps
Contaminated and unused sharps Steam sterilization and Incineration/grinding
Pharmaceutical Wastes
Pharmaceutical waste See separate Pharmaceutical waste guidelines,
microwave
Anti-neoplastic drug waste Incineration
Low level Radioactive waste Consult Radiation protection board
National Health Care Waste Management Guidelines Page 52
Annex 8 Management of spillages
(Example of General Procedure for Dealing with Spillages’)
1. Evacuate the contaminated area.
2. Decontaminate the eyes and skin of exposed personnel immediately.
3. Inform the designated person (usually the Waste Management Officer), who should
coordinate the necessary actions.
4. Determine the nature of the spill.
5. Evacuate all the people not involved in cleaning up if the spillage involves a particularly
hazardous substance.
6. Provide first aid and medical care to injured individuals.
7. Secure the area to prevent exposure of additional individuals.
8. Provide adequate protective clothing to personnel involved in cleaning-up.
9. Limit the spread of the spill.
10. Neutralize or disinfect the spilled or contaminated material if indicated.
11. Collect all spilled and contaminated material. [Sharps should never be picked up by
hand; brushes and pans or other suitable tools should be used.] Spilled material and
disposable contaminated items used for cleaning should be placed in the appropriate
waste bags or containers.
12. Decontaminate or disinfect the area, wiping up with absorbent cloth. The cloth (or other
absorbent material) should never be turned during this process, because this will spread
the contamination. The decontamination should be carried out by working from the least
to the most contaminated part, with a change of cloth at each stage. Dry cloths should be
used in the case of liquid spillage; for spillages of solids, cloth impregnated with water
(acidic, basic, or neutral as appropriate) should be used.
13. Rinse the area, and wipe dry with absorbent cloth.
14. Decontaminate or disinfect any tools that were used.
15. Remove protective clothing and decontaminate or disinfect it if necessary.
16. Seek medical attention if exposure to hazardous material has occurred during the
operation.
National Health Care Waste Management Guidelines Page 53
Annex 9 Recycling index
Uncontaminated Paper and Cardboard
Category Action Outcome
Cardboard Flatten & Bundle Cartons Recycled
Confidential documents Shred Recycled Paper
Office Paper Separate & Bundle Recycled Paper
Metals
Aluminium Contact a scrap merchant Reprocessed Cans
Dental Amalgam Contact a silver recovery
Contractor
Recovered Silver
Mercury Contact a recovery Contractor Recovered Mercury
Scrap Steel. Contact a scrap merchant Reprocessed Steel
Silver X-Ray Films and
Processors
Contact a silver recovery
Contractor
Recovered Silver
Glass
Bottles & Jars
Clear, Brown and Green
Separate , re-use and contact a
Recycler
Reused item or
reprocessed glass
Broken glass Separate, store in rigid
containers and contact a
recycler
Reprocessed glass
OILS
Waste Oil Separate and contact a
recycler
Refined or used as fuels
Food remains/leftovers and
Green Waste
Food remains/leftovers Separate from other types of
waste into appropriate colour
coded bins
-Garden Compost
-Pig swill
Plastics
High and low Density
Polyethylene
Return to Supplier Reprocessed
PET Polyethylene
Terephthalate Soft Drink
Bottles
Separate and arrange
collection
Recycled Bottles
PP Polypropylene Car Battery
Casings
Separate and arrange
collection
Reprocessed
PPVC Plasticised Polyvinyl
Chloride Plastic Tubing
Separate and arrange
collection
Reprocessed
PS Polystyrene Foam cups and
Packaging
Separate and arrange
collection
Reprocessed or reused
UPVC Unplasticised
Polyvinyl Chloride
Separate and arrange
collection
Reprocessed
National Health Care Waste Management Guidelines Page 54
Annex 10 A sample tag for shipment
HEALTH CARE WASTE
GENERATOR Date of shipment ______/________/_________
NAME OF HEALTH FACILITY ______________________________________
Physical address - ______________________________________
Postal address - __________________ Tel: ________________
TRANSPORTER:
NAME - ______________________________________
Physical address – _____________________________________
_____________________________________
Postal address - _________________ Tel: ________________
HEALTH CARE WASTE
National Health Care Waste Management Guidelines Page 55
Annex 11 Facility Health care waste management plan
Name of Facility: Date:
Who is responsible overall for supervising HCWM at your facility?
Attach supervision structure organogram of your facility
Who is responsible for performing waste disposal for each area of your facility?
Attach job descriptions for all cadres of staff at your facility.
Outline Current HCWM Status at Facility
Define type and amounts of waste generated.
Type Amount (per week)
Non-infectious waste
Infectious waste
Highly infectious waste
Highly infectious waste
List number of staff and their designations at your facility
Designation Number
National Health Care Waste Management Guidelines Page 56
Outline HCWM practices used currently.
Concept Current Practice
Is waste classified and segregated into
differentcoloured waste bins?
escribe how.
How are sharps (needles) disposed?
How are safety boxes used?
Are full safety boxes recorded?
Where are they stored?
How are they transported to their final
disposal location?
Where are different categories of waste
disposed?
Describe the disposal process
Outline Ideal Practices: Establishing Standards
Concept Current Practice
Segregating waste (different types,
corresponding colours of waste liners)
Prioritising sharps (use of safety boxes or
needle removers, if applicable)
Recording, handling and transport of safety
boxes
Final waste disposal for each category of
waste
(including sharps barrel, if applicable)
Hepatitis B and tetanus toxoid immunization
for all cadres of staff
National Health Care Waste Management Guidelines Page 57
List Improvements Needed
Define type and amounts of waste generated.
Item Date for Introduction Total Cost Responsible Party
What supplies needed for the next 6 months? (Protective clothing, cleaning supplies, waste bin, liners,
safety boxes)
Supplies Quantity Total Cost
What training is needed at your facility for each cadre of staff ?
Cadre of Staff for Training Topics Date completion
`
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ee
MINISTRY OF HEALTH
NATIONAL GUIDELINES ON HEALTH CARE WASTE
MANAGEMENT
www.moh.gov.rw
Foreword
As materials are used and disposed off regularly across all areas of the health sector, even the
most efficient, effective Health care system creates waste. The guidelines found here have been
developed to guide health service providers in managing waste generated from Health care
activities. Such guidelines are crucial in sustaining efforts that are already employed in Health
care waste management and injection safety.
The mismanagement of Health care waste poses a serious risk to the population, the
environment, and the health care system itself. Medical waste can be hazardous if not disposed
off correctly. Health personnel, waste handlers, and community members risk being seriously
injured or infected if proper disposal methods are not used. Standards must be maintained no
matter where Health care is provided, from the facility to the community level. Establishing and
following a standard of practice for proper handling and disposal of Health care waste is an
integral, ongoing aspect of the Health care delivery system.
These waste management guidelines will go a long way in mitigating risks of exposure and
subsequent transmission of infections to health service providers, patients, and the communities
being served. In addition, once the guidelines are effectively implemented, the environment will
be protected against the undesirable resulting effects from using less than optimal methods of
waste management and disposal.
The Ministry of Health takes this opportunity to renew its commitment to creating an enabling
environment for the implementation of these guidelines in partnership with districts authorities,
health facilities, development partners, the private sector, and other stakeholders. By
maintaining these standards together, the risk of harm on human health and the environment
condition can be reduced and the health care system will be allowed to continue to grow and
thrive in a safe, sustainable setting.
Dr. Agnes BINAGWAHO
Minister of Health
RADIOACTIVE
7
STS
BIOH/
Gu
TF
OXIDIZER
5A
DANGEROUS,
National Health Care Waste Management Guidelines Page 1
National Health Care Waste Management Guidelines Page 2
National Health Care Waste Management Guidelines Page 3
Table of contents
Table of contents ............................................................................................................................. 3
List of Annexes ............................................................................................................................... 6
List of tables .................................................................................................................................... 7
List of figures .................................................................................................................................. 7
List of abbreviation ......................................................................................................................... 8
CHAPTER 1: INTRODUCTION ................................................................................................... 9
1.1 About these guidelines .......................................................................................................... 9
1.2 Background ........................................................................................................................... 9
CHAPTER 2: HEALTH EFFECT OF HEALTH CARE WASTE .............................................. 11
2.1 Hazardfrom health care waste ............................................................................................. 11
2.2 Risks caused by poor management of health care wastes ................................................... 11
CHAPTER 3: CHARACTERIZATION OF HEALTH CARE WASTES ................................... 12
3.1. Source of Health Care waste .............................................................................................. 12
3.2. Categories of waste ............................................................................................................ 12
3.2.1. Infectious waste ........................................................................................................... 12
3.2.2. Pathological waste; ................................................................................................. 12
3.2.3. Sharps waste ................................................................................................................ 13
3.2.4. Pharmaceutical waste .................................................................................................. 13
3.2.5. Radioactive waste ........................................................................................................ 13
3.2.6. Chemical waste ............................................................................................................ 13
3.2.7. Non-hazardous general waste ...................................................................................... 13
CHAPTER 4: LEGISLATIVE FRAMEWORK .......................................................................... 14
4.1Organic law N° 04/2005 of 08/04/2005 determining the modalities of protection,
conservation and promotion of environment in Rwanda .......................................................... 14
4.2 Law N° 47/2012 of 14/01/2013 relating to the regulation and inspection of food and
pharmaceutical products. ........................................................................................................... 14
4.3 Environmental health policy ............................................................................................... 14
4.4 National Policy on Injection Safety, Prevention of Transmission of Nosocomial Infection
and Health Care Waste Management; ....................................................................................... 14
National Health Care Waste Management Guidelines Page 4
CHAPTER 5: HEALTH CARE WASTE MANAGEMENT PLANNING ................................. 15
5.1 Preliminary Planning for Health Care Waste Management ................................................ 15
5.2 Implementation of the waste management plan .................................................................. 15
5.3 Duties and responsibilities .................................................................................................. 16
5.3.1 Roles and Responsibilities for Head of Health Facilities ............................................. 16
5.3.2 Roles and responsibilities for different levels .............................................................. 17
5.4 Management of health care waste from scattered small source .......................................... 19
5.4.1 Marking of Waste ......................................................................................................... 20
5.4.2 Dedicated vehicles ........................................................................................................ 20
5.4.3 Storage .......................................................................................................................... 20
5.4.4 Employees knowledge of guidelines ............................................................................ 20
CHAPTER 6: WASTE MINIMIZATION, RECYCLE AND REUSE ....................................... 21
6.1 Minimization of waste ......................................................................................................... 21
6.2 Waste Segregation and packaging....................................................................................... 21
6.3 Safe reuse and recycling ...................................................................................................... 23
CHAPTER 7: HANDLING, LABELING, CONTAINMENT, TRANSPORT AND STORAGE
....................................................................................................................................................... 25
7.2 Internal transportation ......................................................................................................... 25
7.3 Waste labeling ..................................................................................................................... 25
7.4 Health Care Waste Tracking ............................................................................................... 25
7.5 Handling waste bags............................................................................................................ 26
7.6 Storage ................................................................................................................................. 26
7.6.1 Storage for waste .......................................................................................................... 26
7.7 Spill Management ............................................................................................................... 27
7.7.1 General spill management ............................................................................................ 27
7.7.2 Infectious waste spill kit. .............................................................................................. 27
7.7.3 Cytotoxic spill kit ......................................................................................................... 27
7.7.4 Mercury spill kit ........................................................................................................... 28
7.8 Collection ............................................................................................................................ 28
7.9 Transportation ..................................................................................................................... 29
7.10 On-site transport for collection purposes .......................................................................... 30
National Health Care Waste Management Guidelines Page 5
7.11 Off-site transportation of waste ......................................................................................... 31
7.11.1 Regulation and control system ................................................................................... 31
7.11.2 Routing ....................................................................................................................... 31
CHAPTER 8: TREATMENT AND DISPOSAL FOR HEALTH CARE WASTE .................... 32
8.1 Treatment and disposal options ........................................................................................... 32
8.2 Waste disposal options ........................................................................................................ 32
8.2.1 General disposal options ............................................................................................... 32
8.2.2 Inertization .................................................................................................................... 33
8.2.3 Options of health care waste treatment and disposal as per level of care .................... 34
CHAPTER 9: REQUIREMENT FOR OCCUPATIONAL HEALTH AND SAFETY
PRACTICES ................................................................................................................................. 35
9.1 Occupational health and safety provisions .......................................................................... 35
9.2 Employee responsibility ...................................................................................................... 35
9.3 Personal Protective Equipment (PPE) ................................................................................. 36
9.4 Hygiene Committee............................................................................................................. 37
9.5 Monitoring Hygiene Committee ......................................................................................... 37
9.5.1 Hygiene ......................................................................................................................... 37
9.6 Precautions for sharps, Blood and Body fluids exposure.................................................... 38
9.7 Response to injury and exposure ......................................................................................... 38
CHAPTER 10: TRAINING .......................................................................................................... 40
10.1Technical Training and deployment ................................................................................... 40
CHAPTER 11: COMMUNITY HEALTH CARE WASTE MANAGEMENT ........................... 41
11.1 Medical waste generated during Community Health Outreach ........................................ 41
11.2 Sharps management........................................................................................................... 41
11.3 Waste transportation .......................................................................................................... 41
CHAPTER 12: COLLECTIONS AND DISPOSAL OF WASTE WATER FROM HEALTH
FACILITIES ................................................................................................................................. 42
12.1 Characteristics and hazards of waste water from health facilities .................................... 42
12.2 Waste water management.................................................................................................. 42
12.3 On-Site treatment or pre-treatment of waste water ........................................................... 42
12.4 Sludge treatment ................................................................................................................ 43
National Health Care Waste Management Guidelines Page 6
12.5. Minimum safety requirements for sewerage treatment .................................................... 43
12.6. Sanitation .......................................................................................................................... 44
12.7. Safe management of wastes from health facilities ........................................................... 44
ANNEXES: ................................................................................................................................... 45
List of Annexes
Annex 1Sample sheet for assessment of waste generation ........................................................... 45
Annex 2 Color code for biomedical waste .................................................................................... 46
Annex 3 International waste labeling symbols ............................................................................. 47
Annex 4 Alternative labels for hazardous wastes ......................................................................... 48
Annex 5 Health care waste tracking form sample 1 ..................................................................... 49
Annex 6 Health care waste tracking form sample 2 ..................................................................... 50
Annex 7 Waste treatment methods ............................................................................................... 51
Annex 8 Management of spillages ................................................................................................ 52
Annex 9 Recycling index .............................................................................................................. 53
Annex 10 A sample tag for shipment ........................................................................................... 54
Annex 11 Facility Health care waste management plan ............................................................... 55
National Health Care Waste Management Guidelines Page 7
List of tables
Table 1 Responsibility at Central and District level ..................................................................... 17
Table 2 Responsibility at Health Facility level ............................................................................. 18
Table 3 Roles and responsibility of Community Health Worker ................................................. 19
Table 4 Options of health care waste treatment and disposal as per level of care ........................ 34
List of figures
Figure 1 The waste management hierarchy .................................................................................. 23
National Health Care Waste Management Guidelines Page 8
List of abbreviation
BCC : Behavior Change Communication
DH : District Hospital
EHO : Environmental Health Officer
HBV : Hepatitis B Virus
HC : Health Center
HCW : Health Care Waste
HCWM : Health Care Waste Management
HCWMP : Health Care Waste Management Plan
HF : Health Facility
i/c : In charge
IPC : Infection Prevention Control
MGBs : Mobile Garbage Bins
O i/c : Officer in charge
PPE : Personal protective Equipment
RURA : Rwanda Utility Regulatory Agency
SOP : Standard Operating Procedure
SOPs : Standard Operating Procedures
WHO : World Health Organization
HP : Health Post
HIV/AIDS : Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
Kg : Kilograms
National Health Care Waste Management Guidelines Page 9
CHAPTER 1: INTRODUCTION
1.1 About these guidelines
These guidelines provide a minimum standard for safeguarding public health and the
environment through efficient management of health care waste. All types of health care waste
are considered in these guidelines and each health facility (HF) is responsible for managing its
waste, from the point of generation to final disposal.
The guidelines provide a framework of waste management strategies outlined below:
a) Hygiene and Infection Prevention Control committees for waste management, planning
and auditing;
b) Reduce, recycle and reuse
c) Waste labeling and containment;
d) Proper waste handling, segregation, storage and transport;
e) Correct waste treatment and disposal
These guidelines are recommended to all stakeholders in the health sector and in particular all
those involved in delivery of health care services in Rwanda.
Adoption of these guidelines should be accompanied by commitment of each HF through the
establishment of Hygiene and IPC committees and development of a Health Care Waste
Management Plan (HCWMP) that will assist HFs to manage its waste. The operations of these
guidelines should be incorporated into the HF Action Plan.
1.2 Background
In Rwanda, efforts to improve health care waste management and injection safety are remarkable
in public health facilities settings and in community.
Actually the Government of Rwanda has an Organic Law determining the modalities of
protection, conservation and promotion of environment in Rwanda and other rules and
regulations related. It is also signatory to a number of conventions, notably, the
National Health Care Waste Management Guidelines Page 10
BaselConvention, the Rotterdam Convention 1, the Montreal Protocol 2 and the Biodiversity
Convention,3 that have some relevance to how HCW is managed.
Despite to the above mentioned national and international legal frameworks, currently there are
no national guidelines on health care waste management.
To ensure rationale management of medical waste, The Ministry of Health has taken all
necessary measures to minimize the riskslikely to result from improper medical waste
management both in health facilities and in communities. In this regard, Health care waste
management and injection safety have also been given due priority where training of health care
providers has been conducted, national and district hospital incinerators purchased and plans to
purchase additional ones are underway. Provision of personal protective equipment, auto disable
syringes and needles, disinfectants and availing post exposure prophylaxis to victims of
accidental occupational exposures (blood and amniotic fluid during labor and delivery) is being
implemented. Safe storage of sharp waste, separation of waste according to their category at
production site, waste transportation and destruction in a safe manner is extremely vital.
The primary purpose of these guidelines is to provide guidance to health professionals and waste
handlers in proper collection, segregation, transportation, treatment and final disposal of
medical wastes in a manner that does not endanger the lives of health care providers, supporting
staff and community along the road where medical waste is transported.
1.3 Objective
The objectives of these guidelines are to maintain public health safety by:
a) Minimizing health care waste generation and impacts to the environment.
b) Setting standardized Health care waste management practices.
c) Specifying roles and responsibilities within Health Facilities.
1 Rotterdam convention on the Prior Informed Consent Procedures for Certain Hazardous
Chemicals Pesticides in International Trade; adopted 10 September 1998 in force on 24 February 2004)
2 Montreal Protocol on Substances that Deplete the Ozone Layer, 1 January 1998 (Revisions 1190 – 1999)
3 Convention on Biological Diversity (CBD) known as Biodiversity Convention, 29 December 1993.
National Health Care Waste Management Guidelines Page 11
CHAPTER 2: HEALTH EFFECT OF HEALTH CARE WASTE
Health Facilities produces waste during the diagnosis, treatment and carrying out of research.
Annually theseHFs produce large quantities of infectious, pathological, sharps, chemicals,
pharmaceutical and radioactive wastes.
Home based care generates pharmaceutical, infectious and contaminated disposable materials
such as treatment by Community Health Workers, home dialysis and used needles from insulin
injection, or even illicit intravenous drug use.
2.1 Hazardfrom health care waste
All individuals exposed to hazardous health-care waste are potentially at risk, including those
within health-care establishments that generate hazardous waste, and those outside these sources
who either handle such waste or are exposed to it as a consequence of careless management. The
main groups at risk are the following:
a) Health care Providers and hospital maintenance personnel
b) Patients in health-care facilities or receiving home care
c) Visitors to health-care facilities
d) Worker in support services allied to health care establishments, such cleaners, laundry
staff and waste handlers including scavengers.
2.2 Risks caused by poor management of health care wastes
Poor management of HCW causes serious risk to personnel, waste handlers, patients, and the
community. Sources of illness from infectious waste include injuries from used needles, reuse by
other people, and diseases that may result from contact with this dangerous waste.
During handling of waste, health care personnel and waste handlers (within and outside the
health facility) can come into contact with this waste if it has not been packaged safely. Needle
stick injuries arising from improperly stored needles and syringes may occur. At landfills or
waste dumps, waste recyclers or scavengers may come in contact with infectious waste if the
waste has been disposed of without prior segregation and treatment.
The reuse of syringes by the general public represents a significant public health problem.
As opposed to direct contact with HCW, waste can also contaminate the environment, water, air,
or land and therefore can indirectly impact on health.
National Health Care Waste Management Guidelines Page 12
CHAPTER 3: CHARACTERIZATION OF HEALTH CARE WASTES
3.1. Source of Health Care waste
Major sources of health-care waste are the following: Health Facilities (Referral, Provincial,
District, HC, HPs),Community Health Workers, Emergency Medical Care, Long-term health-
care establishments and Hospices, Transfusioncenters,Military medical services, Prison hospitals
or clinics, Related laboratories and research centers, Medical and Biomedical Laboratories,
Biotechnology Laboratories and Institutions, Medical Research centers, Mortuary and Autopsy
centres, Animal Research and Testing, Blood Banks and Blood Collection Services, Nursing
Homes for the elderly.
3.2. Categories of waste
3.2.1. Infectious waste
Infectious waste is material suspected to contain pathogens (bacteria, viruses, parasites or fungi)
in sufficient concentration or quantity to cause disease in susceptible hosts. This category
includes:
a) Waste contaminated with blood or other body fluids;
b) Cultures and stocks of infectious agents from laboratory work;
c) Waste from infected patients in isolation wards, surgery and autopsies (e.g excreta, tissue,
and dressing from infected or surgical wounds, clothes soiled with human blood or other
body fluid).
3.2.2. Pathological waste;
a) Pathological waste could be considered a subcategory of infectious waste, but is often
classified separately – especially when special methods of handling, treatment and
disposal are used.
b) Pathological waste consists of tissues, organs, body parts, blood, body fluids and other
waste from surgery and autopsies on patients with infectious diseases;
c) It also includes human fetuses and infected animal carcasses; Recognizable human or
animal body parts are sometimes called anatomical waste.
d) Pathological waste may include healthy body parts that have been removed during a
medical procedure or produced during medical research.
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3.2.3. Sharps waste
Sharps are items that could cause cuts or puncture wounds, including needles, hypodermic
needles, scalpels and other blades, knives, infusion sets, saws, broken glass and pipettes.
Whether or not they are infected, such items are usually considered highly hazardous health-care
waste.
3.2.4. Pharmaceutical waste
Pharmaceutical waste includes expired, unused, spilt and contaminated pharmaceutical products,
this also includes drugs, vaccines and sera (serum) that are no longer required. The category also
includes discarded items used in the handling of pharmaceuticals, such as bottles or boxes with
residues and drugs vials.
3.2.5. Radioactive waste
Radioactive waste includes solids, liquid and gaseous materiel contaminated with radionuclide. It
is produced as result of procedures such as in vitro analysis of body tissue and fluid, in vivo
organ imaging and tumour localization, and various investigative and therapeutic practices.
3.2.6. Chemical waste
a) Hazardous chemical waste consists of discarded solid, liquid and gaseous chemicals; for
example, from diagnostic and experimental work and from cleaning and disinfecting
procedures. In the context of protecting health, it is consider to be hazardous if it is
corrosive (e.g. acids of pH <2 and bases of pH >12), flammable, reactive (explosive,
water reactive, shock sensitive) and oxidizing.
b) Non-hazardous chemical waste consists of chemicals with none of the above properties;
for example, sugars, amino acids and certain organic and inorganic salts, which are
widely used in transfusion liquids.
3.2.7. Non-hazardous general waste
Non-hazardous or general waste is waste that has not been in contact with infectious agents,
hazardous chemicals or radioactive substances and does not pose a sharps hazard. It is generated
from offices, kitchen, packaging material and from stores. It is similar to domestic waste.
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CHAPTER 4: LEGISLATIVE FRAMEWORK
4.1Organic law N° 04/2005 of 08/04/2005 determining the modalities of protection,
conservation and promotion of environment in Rwanda
This organic law determines the modalities of protecting, conserving and promoting the
environment in Rwanda: This Organic law aims at:
a) Conserving the environment, people and their habitats; setting up fundamental principles
related to protection of environment and any means that may degrade the environment
with the intention of promoting the natural resources, to discourage any hazardous and
destructive means;
b) Promoting the social welfare of the population considering equal distribution of the
existing wealth; considering the durability of the resources with an emphasis especially
on equal rights on present and future generations;
c) Guarantee to all Rwandans sustainable development which does not harm the
environment and the social welfare of the population; setting up strategies of protecting
and reducing negative effects on the environment and replacing the degraded
environment.
4.2 Law N° 47/2012 of 14/01/2013 relating to the regulation and inspection of food and
pharmaceutical products.
This Law relates to the regulation and inspection of food and pharmaceutical products;
4.3 Environmental health policy
The Environmental Health Policy aim is provision of adequate environmental health services to
all Rwandans with their active participation to the reduction of infant, child and adult morbidity
and mortality rates by reducing and eliminating health risks associated with environmental
hazards, which are the direct causes and spread of diseases and conditions related to
environmental health.
4.4 National Policy on Injection Safety, Prevention of Transmission of Nosocomial Infection
and Health Care Waste Management;
The overall objective of this policy is to ensure no person is infected as a result of health-care
she/he has received. It aims at putting in place mechanisms, systems and practices to prevent
transmission of infection through injections and other medical procedures and ensuring that
medical waste is disposed in a safe manner that does not have any risk to Health personnel,
patients and the community.
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CHAPTER 5: HEALTH CARE WASTE MANAGEMENT PLANNING
5.1 Preliminary Planning for Health Care Waste Management
Planning for health care waste management involves:
a) Setting the management objectives.
b) Defining a strategy that will facilitate careful implementation of the necessary measures
and the appropriate allocation of resources according to the identified priorities. A
suitable, safe, and cost effective strategy will be concerned principally with transport,
recycling, treatment and disposal options.
c) Conducting surveys on waste generation shall provide baseline information on the
quantities and classes of waste generated. A HF survey of Health care waste will provide
a basis for identifying actions, taking into account conditions, needs, and possibilities. On
the basis of waste generation surveys and recommendations, the waste management focal
person (Environmental Health Officer) should provide estimates on the amount and type
of waste generated to the Hygiene Committee/IPC.
d) Setting the targets-for waste minimization, reuse, recycling, and cost reduction. A sample
sheet for assessment of waste generation is provided in Annex 1.
e) Proper management of health-care waste depends largely on good administration and
organization
f) Adequate legislation and financing is also required.
g) Active participation by trained and informed staff is necessary.
h) Each HF should have a contingency plan for emergency situations
5.2 Implementation of the waste management plan
The overall responsibility of implementation lies with the Head of the facility. It involves the
following steps:
a) A Gantt chart should be developed, showing management of wastes.
b) Provision for future waste storage facilities should be made.
c) The EHO should monitor the deployment ofpersonnel to the posts with responsibility for
waste management.
d) The EHO in liaison with the Hygiene Committee/IPC should organize and supervise
training programmes for all staff on HCWM.
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e) The Hygiene Committee/IPC should review the waste management plan annually and
initiate changes necessary to upgrade.
f) Design and implement Monitoring and Evaluation mechanisms for the plan.
g) A report should be prepared and submitted to the relevant authorities as required
(Monthly, Quarterly and Annual).
5.3 Duties and responsibilities
5.3.1 Roles and Responsibilities for Head of Health Facilities
The head of health facilities are responsible for the safe disposal of health-care waste generated
in their establishments.
They should therefore, take all reasonable measures to:-
a) Prevent health-care waste from causing environmental pollution or adverse effects on
human health;
b) Ensure that health-care waste is adequately segregated and safely packed, especially in
the case of sharps which should be packed in puncture-proof containers;
c) Ensure that bags or containers of health-care waste are handled only by those officially
licensed to transport and/or dispose of such waste;
d) Ensure that a transfer note describing the waste is handed to the recipient when waste is
transferred;
e) Check for proof that the driver of the collection vehicle is aware of the procedures
governing transport of hazardous goods. Such proof shall include but not limited to an
authorization letter or a certificate indicating form of training in transportation of health
care waste.
f) If on-site treatment is impossible or uneconomical, cooled storage facilities should be
provided and there should be a regular collection by a contractor who has suitable
incineration facilities.
g) When an injection is carried out at a patient’s home, the practitioner is responsible for
disposing of syringes, needles, and all other items used including incontinence pads and
swabs.
h) The patient or the care giver shall be responsible for safe disposal of health care waste in
case of home based treatment, for example in the case of diabetics.
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i) Ensure that ambulances are equipped with puncture-proof containers of appropriate size,
mainly for infectious waste and sharps.
j) Ensure that staff is trained in the safe handling of health-care waste.
k) Ensure that any contractual arrangement for research by workers outside the
establishment should include adequate provisions for the safe handling and disposal of
waste.
5.3.2 Roles and responsibilities for different levels
Table 1 Responsibility at Central and District level
Title Responsibility
Central level
Put in place favorable
policies and guidelines to ensure safe and appropriate waste
management practices.
Incorporate waste management commodities in existing essential
medicines and supplies lists.
Provide technical supportive supervision.
Capacity building of HF staff on health care waste management.
Mobilize resources.
District level
Build awareness on the risks of health care waste and the need for
proper disposal
Supervise the management/handling of health care waste at health
facilities through management committees
Advocate for increased allocation of district financial resources to
support the management of health care waste at health facilities
Promote the benefits of the public-private partnership model for
providing best, affordable, and sustainable alternatives for managing
health care waste.
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Table 2 Responsibility at Health Facility level
Title Responsibility
Managerial
Staff
Obtain and be familiar with national waste management policies and
guidelines.
Enforce facility waste management plan (goal, budget, staff, roles,
supervision, training, reporting, etc.).
Monitor waste management practices
Liaison with the waste management focal person (EHO)
Ensure staff is trained on the proper procedures of HCWM.
Budget for adequate supply of HCWM products and activities.
Ensuring availability of health care waste management commodities
Advocate for staff health and safety.
Clinical Staff
Follow waste management policies and procedures.
Practice safe operating procedures and wear appropriate PPE.
Follow color-coded waste segregation system.
Notify Support Staff when HCW containers are ¾ full for collection and
replacement.
Notify Stores when HCW container stock is running low to ensure sound
stock control.
Support Staff
Place appropriate HCW containers at designated locations.
Know colour-coding system and use it correctly.
Practice safe operating procedures and wear appropriate PPE.
Collect correctly filled (no more than ¾) HCW containers.
Ensure a clean and orderly environment at the facility.
Record keeping––record number of filled HCW containers, identify supply
needs, report stock outs.
Ensure temporary storage of HCW in a dedicated and secure location.
Technical Staff
Follow waste management policies and procedures.
Practice safe operating procedures and wear appropriate PPE.
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Ensure adequate supply of HCWM products.
Follow colour-coded waste segregation system.
Notify Support Staff when HCW containers are no more than ¾ full.
Environmental
Health Officer
Obtain and be familiar with national and programme waste management
policies and guidelines.
Directly supervise collection, segregation, storage, transportation, treatment
and disposal of health-care waste.
Liaison with all department to raise the profile of health care waste
management
Enforce facility waste management plan (goal, budget, staff, roles,
supervision, training, reporting, etc.).
Identify training needs on health care waste management
Organize and supervise staff training on safe waste management
Conduct quality survey sonquantity and type of waste generated and verify
compliance with HCWM SOPs and National Guidelines.
Monitoring injuries and infection incidences related to health care waste
Record-keeping
Table 3 Roles and responsibility of Community Health Worker
Responsibility
Minimize waste generation;
Conduct waste segregation;
Ensure appropriate storage before final disposal of HCW;
Return hazardous waste and the used sharps (in the safety box) to the health facility
for treatment and disposal;
Protect oneself and the community against potential health hazards;
Conduct public awareness on the risk of health Care Waste.
5.4 Management of health care waste from scattered small source
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The management of health care waste from scattered small sources shall include but not limited
to private medical practitioners, research facilities, nursing homes, home treatment, ambulance
services and veterinary centers.
The options for safe collection, transportation and disposal of health-care waste from small
sources, which do not treat their own waste, include the following:
a) An authorized contractor should collect the waste for treatment and take it to a DH
incinerator or other treatment facility;
b) An authorized contractor collects and treats the waste at the treatment facility;
c) The Local authority shall oversee the collection, treatment and final disposal of HCW to
ensure adherence to set guidelines and SOPs.
5.4.1 Marking of Waste
a) All waste should be clearly marked with self-adhesive indicating source and type of
waste. Infectious, Pathological and Sharp waste should also be marked with the
international biohazard symbol. Chemicals should also be marked with the appropriate
international chemical hazard symbol. Radioactive waste must be labeled with the
appropriate warning symbol as provided in Annex 3.
b) Any contract for collection by a private registered health-care waste carrier should
identify the disposal or treatment facility to be used.
5.4.2 Dedicated vehicles
a) The carrier should, use dedicated vehicles for the collection and transportation of
infectious waste.
b) Collection and transportation of health-care waste from their source should be regular and
according to schedule.
5.4.3 Storage
Any storage of waste before treatment or collection for off-site disposal should be in a secure
location designated for the purpose.
5.4.4 Employees knowledge of guidelines
All employees should be made aware of these Guidelines, which contain details of the
procedures to follow in case of a needle-stick injury or exposure to infected blood.
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CHAPTER 6: WASTE MINIMIZATION, RECYCLE AND REUSE
6.1 Minimization of waste
The preferred management solution is quite simply not to produce the waste, by avoiding wasteful ways
of working. To achieve lasting waste reduction (or minimization), the focus should be on working with
medical staff to change clinical practices to ones that use less materials. Although waste minimization is
most commonly applied at the point of its generation, health-care managers can also take measures to
reduce the production of waste through adapting their purchasing and stock control strategies.
6.2 Waste Segregation and packaging
Waste segregation is separation of wastes according to types and categories.
a) Segregation should;
i. Always be the responsibility of the waste producer,
ii. Take place as close as possible to where the waste is generated, and
iii. Be maintained in storage areas, during transportation, treatment and disposal.
b) The most appropriate way of identifying the categories of health-care waste is by
separating the waste into colour-coded plastic bags or containers. The recommended
colour-coding scheme is provided in Annex 2.
c) In addition to the colour coding of waste containers, the following practices are
recommended:
i. General (non-infectious) health-care waste can join the stream of domestic refuse
for disposal if none can be salvaged.
ii. Sharps should all be collected together, regardless of whether or not they are
contaminated.
d) Sharps containers should be;
i. Puncture-proof (usually made of cardboard or high-density plastic) and fitted with
covers.
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ii. Be rigid and impermeable so that they safely retain not only the sharps but also
any residual liquids from syringes.
iii. To discourage abuse, containers should be tamper-proof (difficult to open or
break) and needles and syringes should be rendered unusable.
e) Liner bags used should be;
i. Highly resistant to puncturing and tearing with exceptional strength and stretch
properties.
ii. They should be of a gauge not less than 150 microns.
iii. Where bins are unavailable or too costly, containers made of dense cardboard are
recommended:
iv. Bags and containers for infectious waste should be marked with the international
infectious substance symbol (Refer to annex 3).
f) Highly infectious waste should, whenever possible,
i. Be sterilized immediately by autoclaving.
ii. It needs to be packaged in bags that are compatible with the proposed treatment
process. Red bags suitable for autoclaving are recommended.
g) Waste collection bags for waste types needing incineration shall not be made of
chlorinated plastics.
h) Cytotoxic waste, most of which is produced in major hospital or research facilities,
should be collectedin strong, leak-proof containers clearly labeled “Cytotoxic wastes”.
i) Small amounts of chemical or pharmaceutical waste may be;
i. Collected together with infectious waste.
ii. Large quantities of obsolete or expired pharmaceuticals stored in hospital wards
or departmentsshould be returned to the pharmacy for disposal.
iii. Other pharmaceutical waste generated, such as spilled or contaminated drugs or
packagingcontaining drug residues should not be returned because of the risk of
contaminating the pharmacy; it should be deposited in the correct container at the
point of generation.
iv. Large quantities of chemical waste should be packed in chemical resistant
containers.
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6.3 Safe reuse and recycling
Medical and other equipment used in a health-care establishment may be reused provided that it
is designed for the purpose and will withstand the sterilization process.
a) Proper disinfection and sterilization can ensure the safe use of invasive and non-invasive medical
devices. The choice of disinfectant, concentration, and exposure time is based on the risk for
infection associated with use of the equipment and other factors discussed in this guideline
b) Reusable items may include certain sharps, such as scalpels, syringes, glass bottles and
containers, etc. After use, these should be collected separately from non-reusable items,
carefully washed and may then be sterilized by either thermal or chemical sterilization.
c) Plastic syringes and catheters should not be thermally or chemically sterilized; they
should be discarded.
d) Other non infectious wastes such as paper, glass, polythene, food remains should be
recycled and reused.
e) Other types of wastes not mentioned here are not recommended for recycling or re-use.
Figure 1 The waste management hierarchy
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PREVENT
REDUCE
REUSE
RECYCLE
RECOVER
TREAT
LEAST PREFERABLE
DISPOSAL
MOST PREFERABLE
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CHAPTER 7: HANDLING, LABELING, CONTAINMENT, TRANSPORT
AND STORAGE
This section explains the importance of streamlining the process of waste collection, handling
and transport to ensure compliance with occupational health and safety and environmental
control requirements.
7.1 Organization
Each HF must have a dedicated staff/company of waste handlers.
Waste handlers must be trained and equipped to undertake the handling, internal transportation,
spillmanagement, blood, body fluid exposure management and storage requirements of the HF.
7.2 Internal transportation
All HF should conduct a review to optimize the waste collection process, reduce handling
andtransportation, and to promote safe work practices.
Transportation routes should avoid where possible food preparation and heavily used areas.
7.3 Waste labeling
All waste liner bags and waste containers are to be color coded (Annex 2) and inscribed with
hazard marks or stickers and identified in accordance with international waste labeling symbols
as provided in Annex 3.
7.4 Health Care Waste Tracking
Tracking of HCW is necessary to enable both the regulatory bodies and all other stakeholders’to
follow the movement of waste from generation to safe final disposal. Tracking helps to rapidly
identify the source of waste, facilitates segregation, provides feedback, assists in providing data
for education purposes, decision making facilitates auditing and may be used to allocate
resources for HCWM.
The use of tracking forms is therefore necessary and would enable both the regulatory bodies and
all concerned to follow the movement of waste from generation to safe final disposal. Samples of
waste tracking forms are provided in Annex 4.
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All liner bags /containers of waste must be clearly marked to identify the HF, unit (e.g. Maternity
Ward) and date of collection.
The illegal dumping of Health care waste by unscrupulous waste collectors/generators poses a
great risk to public health. Tracking the movement of waste from the points of generation
through transportation to the final disposal point would guard against the malpractice of illegal
dumping (see Annex 4).
7.5 Handling waste bags
a) Sharps must always be placed in injection safety boxes and never be placed in waste
bags.
b) Waste must be contained in colour coded and well labeled plastic bags
c) General waste should be contained in well labeled black bags.
d) Waste bags must not be over filled (approx 2/3 of capacity).
e) The volume of a waste bag should not exceed 55 liters.
f) Excess air should be excluded without compaction, prior to closure using a bag tie at the
point of waste generation.
g) All bags should be held away from the body by the closed top of the bag, and placed
directly into a mobile garbage bin or trolley.
h) Where waste bags are sealed and stored pending collection, they should be in a secure
place with restricted access.
i) There should be a Waste collection schedule.
7.6 Storage
7.6.1 Storage for waste
a) A storage location for health-care waste should be designated inside the HF.
b) Unless a refrigerated storage room is available, storage times for Health care waste (i.e.
the delay between production and treatment) should not exceed the following:
i. 48 hours during the cool season
ii. 24 hours during the hot season
c) Cytotoxic waste should be stored separately from other health-care waste in a designated
secure location.
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d) Radioactive waste should be stored in containers that prevent dispersion, behind lead
shielding. Wastethat is to be stored during radioactive decay should be labeled with the
type of radionuclide, the date, and details of required storage conditions.
7.7 Spill Management
7.7.1 General spill management
HF should manage waste spills as they occur in the facility.
a) In the case of gross spills, containment is the principal role.
b) It is essential that personnel involved in spill management receive education and training
in emergency procedures and handling requirements.
c) Spill kits should be readily available throughout the hospital with their location known by
all staff.
d) Spill kits that have been used should be disposed of with the type of waste that has been
cleaned up, e.g. used cytotoxic spill kits should be disposed of with cytotoxic waste.
e) All spillage should be documented per department and per facility.
7.7.2 Infectious waste spill kit.
Infectious waste spill kit should contain at least:
a) Broom, a pan and scraper, mop and mop bucket
b) A large (10 liter) reusable plastic container or bucket with fitted lid, containing;
c) 2 infectious waste bags for the disposal of clinical waste;
d) Disinfectant containing (1%) 10,000 ppm available chlorine or equivalent;
e) Rubber gloves suitable for cleaning
f) Detergent, sponges / disposable cloths
g) Personal protective equipment including eye protection, an apron or long
h) Sleeve impervious gown, a face mask, heavy duty gloves.
i) Incident report form
j) Waste spill sign.
7.7.3 Cytotoxic spill kit
Cytotoxic spill kit should contain at least:
a) Mop and mop bucket, a pan and scraper.
b) A large (10 litre) reusable plastic container or bucket with fitted lid, containing;
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c) 2 cytotoxic waste bags for the disposal of cytotoxic waste
d) 2 hooded overalls, shoe covers, long heavy duty gloves, latex gloves, a face
e) Mask and eye protection
f) Absorbent toweling / absorbent spill mat
g) Incident report form
h) Waste spill sign
7.7.4 Mercury spill kit
Mercury spill kit should contain at least:
a) 2 unbreakable lidded containers
b) Spill sign
c) Pasteur pipette, eye dropper
d) Sodium thiosulphate
e) Face mask
f) Dust pan and brush
g) Sulfur powder
h) Incident report form.
7.8 Collection
a) Wastes should not be allowed to accumulate at the point of production. For this reason a
routineprogramme for their collection should be established as part of the health-care
waste management plan.
b) Nursing and other clinical staff should ensure that waste bags are tightly closed or sealed
when they areabout three-quarters full.
c) Light-gauge bags can be closed by tying the neck, but heavier-gauge bags probably
require a plasticsealing tag of the self-locking type.
d) Bags should not be closed by stapling.
e) Sealed sharps containers should be placed in a labelled, yellow infectious health-care
waste bag beforeremoval from the hospital ward or department.
f) The following recommendations should be followed by the waste handlers:
i. Waste should be collected daily (or as frequently as required) and transported
to the designated central storage site.
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ii. No bags should be removed unless they are labeled with their point of
production (hospital and ward or department) and contents.
iii. The bags or containers should be replaced immediately with new ones of the
same type.
iv. A supply of fresh collection bags or containers should be readily available at
all locations where waste is produced.
v. The person in charge should ensure that adequate supplies (3 months) are
available and thatprocurement is timely to ensure the facility does not run out
of waste collection bags.
7.9 Transportation
a) All transporters of biomedical waste must be appointed by the Ministry of Health or
Manager of the healthfacility and must obtain a transportation license from RURA.
b) The transporter shall collect waste from the designated area of operations or storage areas
and shalldeliver such waste to the designated storage site, disposal site or plant.
c) The Ministry or Manager of a HF shall ensure that:
i. The collection and transportation of such waste is conducted in such a manner
that will notcause scattering, escaping and/or flowing out of the waste;
ii. The vehicles and equipment for the transportation of waste are in such a state that
shall notcause the scattering of, escaping of, or flowing out of the waste or
emitting of noxious smellsfrom the waste;
iii. The vehicles for transportation and other means of conveyance of waste shall
follow thescheduled routes approved by RURA from the point of collection to the
disposal site or plant;and
iv. During the transportation of waste, the transporter should possess at all times a
duly filled tracking document and shall produce the same on demand to any law
enforcement officer.
d) Biomedical waste shall be:
i. Transported in a specially designed vehicle or other means of conveyance so as to
prevent scattering, escaping, flowing, spillage or leakage of the waste.
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ii. It is recommended that the vehicle is closely lockable, covered, labeled, leak
proof and corrosionproof preferably internally lined with aluminium or stainless
steel.
iii. Any vehicle used for transportation of waste or any other means of conveyance
shall be appropriately labeled.
7.10 On-site transport for collection purposes
a) Mobile garbage bins (MGBS) and trolleys should be used when transporting waste to
decrease spills, minimize collector contact with waste and minimize manual handling.
b) Loads contained in MGBs and trolleys should be less than 55kgs.
c) All bins must be colour coded and marked as specified in Annex 2.
d) Health-care waste should be transported within the hospital or other facility by means of
wheeled trolleys or containers that are not used for any other purpose and meet the
following specifications:
i. Easy to load and unload;
ii. No sharp edges that could damage waste bags or containers during loading and
unloading;
iii. Easy to clean.
e) Trolleys and MGBs must be dedicated singularly for collecting waste and must be made
of rigid material, lidded, lockable (if used for storage), leak proof and washable.
f) These MGBs and trolleys should be labelled according to the type of wastes contained,
cleaned regularly and must never be overfilled.
g) Waste collection rounds should be performed as often as necessary to minimize
housekeeping hazards.
h) When cleaning trolleys and MGBs:
i. Rinse with cold water then wash with warm water and a neutral detergent.
ii. Trolleys and MGBs should then be drained to sewer and left to dry.
iii. Clean trolleys and bins should be stored separately to soiled containers.
iv. Appropriate personal protective equipment should be worn when cleaning MGBs.
v. Waste water may only be diverted to the sewer.
i) The vehicles should be cleaned and disinfected daily with an appropriate disinfectant
(Glutaraldehyde or Peracetic acid).
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j) All waste-bag seals should be in place and intact at the end of transportation.
k) Use of wheelbarrows is not recommended for transportation.
7.11 Off-site transportation of waste
7.11.1 Regulation and control system
a) The health-care waste producer is responsible for safe packaging and adequate labeling of
waste to be transported off-site and for authorization of its destination.
b) The tracking form (Annex 5 or 6) has to be signed at the point of destination and shall be
kept as records by the health facility as proof of proper disposal of waste.
c) The signed tracking form will be submitted as part of records in the reports.
d) Packaging and labeling of waste should comply with the Ministry of Health HCWM
Guidelines and with international agreements (such as the Basel Convention) if wastes
are shipped abroad for treatment and disposal.
e) The control strategy for health-care waste should have the following components:
i. A consignment note (Annex 6) should accompany the waste from its place of
production to the site of final disposal. On completion of the journey, the
transporter should complete the part of the consignment note especially reserved
for him and return it to the waste producer.
ii. The transporting organization should be registered with RURA.
iii. Handling and disposal facilities other than the DH should hold a permit, issued by
RURA, allowing the facilities to handle and dispose of health-care waste.
7.11.2 Routing
a) Health-care waste should be transported by the quickest possible route, which should be
planned before the journey begins.
b) After departure from the waste production point, every effort should be made to avoid
further handling.
c) If handling cannot be avoided, it should be pre-arranged and take place in adequately
designed and authorized premises by the Waste Management focal person.
d) Handling requirements can be specified in the contract established between the waste
producer and the carrier.
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CHAPTER 8: TREATMENT AND DISPOSAL FOR HEALTH CARE
WASTE
8.1 Treatment and disposal options
a) Health care waste should be treated prior to disposal so as to ensure protection from
potential hazards posed by these wastes.
b) To be effective, treatment must reduce or eliminate the risk present in the waste so that it
no longer poses a hazard to persons who may be exposed to it.
c) The common method of treatment is: incineration; steam sterilization, chemical
disinfection, autoclaving and microwave irradiation.
d) Other methods that can be used include encapsulation and inertization, shredding,
macerations and grinding.
e) However treatment methods should be chosen according to the type of waste and these
guidelines.
f) In-case of infectious and sharp wastes, all the treatment methods are applicable (Annex
7).
8.2 Waste disposal options
8.2.1 General disposal options
a) After disinfection or incineration, infectious health care waste becomes non-risk waste
and may be finally disposed of in landfill sites. The commonly used disposal method in
Rwanda is land disposal which include District disposal sites, protected ash and waste
pits.
b) However, certain types of Health care waste, such as anatomical waste, will still have an
offensive visualimpact and this is culturally unacceptable in Rwanda. Such wastes
shouldtherefore be buried and use of placenta pits.
c) Other methods may include the return of the wastes to the supplier/manufacture.
d) Aerosol containers may be collected with general health care waste once they are
completely empty, provided that the waste is not destined for incineration. Contractors
for recycling the cans can be called upon.
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e) All radioactive waste (e.g. swabs, syringes for diagnostic or therapeutic use) may be
collected in yellow bags or containers for infectious waste if these are destined for
incineration.
f) Appropriate containers or bag holders should be placed in all locations where particular
categories of waste may be generated.
g) Instructions on waste separation and identification should be posted at each waste
generation and collection point to remind staff of the procedures.
h) Containers should be removed when they are three-quarters full.
i) Staff should never attempt to correct errors of segregation by removing items from a bag
or container after disposal or by placing one bag inside another bag of a different colour.
j) If general and hazardous wastes are accidentally mixed, the mixture should be treated as
hazardous Health care waste.
8.2.2 Inertization
Inertization
a) The process of “inertization” involves mixing waste with cement and other substances
before disposal in order to minimize the risk of toxic substances contained in the waste
migrating into surface water or groundwater.
b) It is especially suitable, for pharmaceuticals and for incineration ashes with a high metal
content (in this case the process is also called “stabilization”).
c) For the inertization of pharmaceutical waste, the packaging should be removed, the
pharmaceuticals ground, and a mixture of water, lime, and cement added.
d) A homogeneous mass is formed and cubes or pellets are produced on site and then can be
transported to a suitable storage site.
e) Alternatively, the homogeneous mixture can be transported in liquid state to a landfill and
poured into District waste.
f) The following are typical proportions for the mixture:
i. 65% pharmaceutical waste;
ii. 15% lime;
iii. 15% cement;
iv. 5% water.
National Health Care Waste Management Guidelines Page 34
The process is reasonably inexpensive and can be performed using relatively
unsophisticated equipment.
g) Other than personnel, the main requirements are a grinder or road roller to crush the
Pharmaceuticals, a concrete mixer, and supplies of cement, lime, and water.
h) The main way to achieve this is to sort the Health care waste into the various categories
to minimize the need for expensive or complicated disposal methods.
8.2.3 Options of health care waste treatment and disposal as per level of care
Table 4 Options of health care waste treatment and disposal as per level of care
CHWs/Heal
th Post
Health
Center
District
Hospital
Provincial
Hospital
Referral
Hospital
Sharps
Transfer to
HC
Incineration
with
DeMont
Fort/
Transfer to
DH
Incineration Incineration Incineration
Infectious Transfer to
HC
Incineration
and deep
burial
Incineration/de
ep burial
Incineration/
deep burial
Incineration/deep
burial
Highly
infectious
Transfer to
HC
Deep burial Incineration Incineration Incineration
Pharmaceutic
al
Transfer to
HC
Return to
DH
Incineration,
return to
source or
manufacturer
Incineration,
return to
source or
manufacturer
Incineration,
return to source
or manufacturer
Type of waste
Facility level
National Health Care Waste Management Guidelines Page 35
CHAPTER 9: REQUIREMENT FOR OCCUPATIONAL HEALTH AND
SAFETY PRACTICES
Each Health Facility is responsible for providing a safe, healthy workplace and safe systems of work for
all. The management of waste presents a number of potential hazards to employees requiring the
appropriate measure of risk identification, risk assessment, and risk control.
Health care workers have an obligation to follow instructions regarding safe work practices. This section
explains their responsibilities and obligations.
9.1 Occupational health and safety provisions
a) Health care waste management plans should include provision for the continuous
monitoring of workers’ health and safety to ensure that correct handling during
segregation, storage, collection, transportation, treatment and disposal procedures of
waste are being followed.
b) Essential occupational health and safety measures include the following:
i. Training of workers on infection transmission.
ii. Provision of personal protective equipment;
iii. Establishment of an effective occupational health programme that includes
immunization, post-exposure prophylactic treatment, and medical surveillance.
c) Training in health and safety should ensure that workers know of and understand the
potential risksassociated with health-care waste, the value of immunization against viral
hepatitis B among otherdiseases, and the importance of consistent use of personal
protection equipment.
9.2 Employee responsibility
a) Health facility management is responsible to provide appropriate information, education,
training and ensuring that safe systems of work are developed and maintained.
b) Key among the responsibilities is to provide information on hepatitis B vaccination
among other required vaccinations and a register of vaccinated personnel maintained.
c) Official Rwanda language translations should be provided to workers where necessary.
d) Standard Operating procedures should:
National Health Care Waste Management Guidelines Page 36
i. Specify accepted waste management practices, waste segregation procedures and
approved waste handling procedures;
ii. Detail appropriate steps required for waste generators, and handlers;
iii. Specify personal protective equipment required for waste handling tasks;
iv. Detail spill management strategies and designate trained personnel for spill
management onsite;
v. Identify first aid resources and needle stick injury treatment protocol; and
vi. Specify how to operate the information, education, training and safe working
systems
9.3 Personal Protective Equipment (PPE)
a) Hygiene Committee/IPC should assess risks and recommend suitable PPE for the nature
and degree of the hazard HF staff are likely to be exposed to.
b) PPE must be worn when required.
c) Waste collectors are under obligation to wear appropriate PPE. The risk of spills or
splash exposures necessitates the wearing of face and eye protection. Protection of the
legs is also required.
d) Carrying of HCW bags is to be minimized and where it cannot be avoided, the waste
collector should wear protective garments and apron to minimize the risk of injury.
e) Protective garments should be worn whenever collecting waste, even if the process
involves wheeling a securely covered waste trolley to the holding area.
f) The type of protective clothing used will depend on the risk associated with the health-
care waste, but the following should be made available to all personnel who collect or
handle health-care waste:
i. Helmets, with or without visors-depending on the operation.
ii. Face masks-depending on operation.
iii. Eye protectors (safety goggles)-depending on operation.
iv. Overalls (coveralls)-obligatory.
v. Industrial aprons-obligatory.
vi. Leg protectors and/or industrial boots-obligatory.
vii. Disposable gloves (medical staff) or heavy-duty gloves (waste workers) -
obligatory.
National Health Care Waste Management Guidelines Page 37
g) Operators of manually loaded incinerators should wear protective face visors and
helmets.
h) During ash and slag removal and other operations that create dust, dust masks should be
provided for operators.
i) Employees should comply with health care waste management guidelines and SOPsgiven
on correct use of safety and protective equipment for the protection of their own health
and safety and the health and safety of others.
9.4 Hygiene Committee
a) The hygiene committee has responsibilities to review:
i. Monitor and Evaluate provision and installation of facilities and protective
equipment;
ii. Work practices;
iii. Incidents and accidents;
iv. Provision and status of information, education and training;
v. Relevant records;
9.5 Monitoring Hygiene Committee
b) Incident and accident reporting and recording is an essential management information
system for identifying causative factors of injuries relating to waste handling.
c) Incident and accident reporting and recording should facilitate costing of associated
financial loss and enable management to make injury prevention investment decisions
based upon accurate data.
d) Waste treatment, operating and disposal costs should be reviewed periodically to evaluate
any fluctuations.
9.5.1 Hygiene
a) Regular washing and maintenance of equipment used to contain and transport waste
should be done by providing hand-washing facilities (with warm running water and soap)
for employees.
b) It is important for health care facilities to promote regular hygiene procedures that
comply with the National HCWM Guidelines and SOPs. This is of particular importance
at storage and incineration facilities.
National Health Care Waste Management Guidelines Page 38
c) It may be useful also to designate specific areas for equipment maintenance in hygienic
workplaces that are properly equipped with emergency shower rooms and drainage to
sewers or septic tanks.
d) Emergency shower rooms should be provided in all health care facilities.
9.6 Precautions for sharps, Blood and Body fluids exposure
Precautions must be implemented to protect against exposure to sharps, blood and body fluids.
These precautions include:
a) Providing a purposely designed sharps container as close as practicable to the point of
generation of the sharps;
b) Providing appropriate PPE for potential blood and body substance exposures;
c) Conducting compliance checks to confirm that people wear protective clothing;
d) Investigating all incidents to identify causes of exposures
e) Take remedial action to eliminate risks;
f) Hygiene Committee must review incident reports and confirm appropriate action taken;
g) Train staff in first aid and injury management procedures for sharps injury and body
substance exposure;
h) Reinforce the need for staff to report all incidents and injuries;
i) Analyze statistics to identify any risk exposure trends for necessary interventions.
9.7 Response to injury and exposure
All personnel who handle health care waste should be trained to deal with injuries and exposures.
The programme should include the following elements:
a) Immediate first-aid measures, such as cleansing of wounds and skin, and irrigation
(splashing) of eyes with clean water;
i. An immediate report of the incident to a designated responsible person;
ii. Retention, if possible, of the item involved in the incident;
iii. Details of its source for identification of possible infection;
iv. Additional medical attention in an accident and emergency
v. Alerting occupational health committee, as soon as possible;
National Health Care Waste Management Guidelines Page 39
vi. Medical surveillance;
vii. Blood or other tests if indicated;
viii. Recording of the incident;
ix. Investigation of the incident; identification and implementation of remedial
action.
b) Waste handlers are particularly at risk from the waste. In all stages they require:-
i. PPE
ii. Hold waste containers at the handle or at the top of liner bag
iii. Avoid any waste falling on the floor during collection and transportation
iv. Non-complying waste (in terms of segregation) should not be sorted by hand
v. Waste storage/chamber should be well ventilated and compartmentalized.
vi. Cloak rooms for changing and showering
vii. Waste handlers should also receive post exposure prophylaxis for HIV/AIDS
National Health Care Waste Management Guidelines Page 40
CHAPTER 10: TRAINING
10.1Technical Training and deployment
a) Only technically trained and certified persons shall be deployed in health care waste
management. Managers should facilitate education and training in the following levels
i. Health Facility Managers training
ii. Operational training
iii. Waste handlers training (generators, handlers, collectors, transporters)
iv. Public awareness and behaviour change communication (BCC).
b) The Ministry of Health should develop and update training manuals to facilitate this
process.
c) Continuous training on HCWM should be organized to address the performance gaps.
National Health Care Waste Management Guidelines Page 41
CHAPTER 11: COMMUNITY HEALTH CARE WASTE MANAGEMENT
Community Health is a range of services based on community health outreach and other services
provided by Community Health Workers.
11.1 Medical waste generated during Community Health Outreach
a) It is vital that the health facility management ensures clinical wastes are returned to the
health facility for appropriate disposal.
b) Waste must be transported in a designated vehicle supplied with a spill kit.
11.2 Sharps management
Safety boxes should be supplied at all sites that generate sharps
11.3 Waste transportation
The following points should be observed:
a) Lids shall be securely fitted to the containers to ensure that the wastes are prevented from
spilling;
b) Containers should be thoroughly cleansed and disinfected before re-use;
c) Containers used for the transportation of clinical wastes shall be clearly marked;
d) During transportation, containers holding the wastes shall be securely held inside the
vehicle to prevent movement of the containers and spillage of wastes; and
e) The transporter shall ensure that vehicles being used for the transportation of clinical
wastes shall be securely locked when left unattended.
National Health Care Waste Management Guidelines Page 42
CHAPTER 12: COLLECTIONS AND DISPOSAL OF WASTE WATER
FROM HEALTH FACILITIES
12.1 Characteristics and hazards of waste water from health facilities
a) Wastewater from health facilities contains a high content of enteric pathogens, including
bacteria, viruses, and helminths, which are easily transmitted through water.
b) Contaminated wastewater is produced by wards treating patients with enteric diseases
and is a particular problem during outbreaks of diarrhoeal disease.
c) It may also contain various potentially hazardous components, such as microbiological
pathogens, hazardous chemicals, pharmaceuticals and radioactive materials which are
discussed below:-
i. Small amounts of chemicals from cleaning and disinfection operations are
regularly discharged into sewers.
ii. Small quantities of pharmaceuticals are usually discharged to the sewers from
hospital pharmacies and from the various wards.
iii. Radioactive isotopes should be discharged into holding tanks by oncology
departments
iv. The toxic effects of any chemical pollutants contained in wastewater on the active
bacteria of the sewage purification process may give rise to additional hazards.
12.2 Waste water management
a) The basic principle underlying effective wastewater management is a strict limit on the
discharge of hazardous liquids to sewers.
b) Where water use is commonly high, sewage is usually diluted.
c) For effluents treated in treatment plants, no significant health risks should be expected,
even without further specific treatment of these effluents.
12.3 On-Site treatment or pre-treatment of waste water
a) Health Facility should have their own sewage treatment plants e.g. septic tanks.
b) Efficient on-site treatment of sewage should include the following operations:
National Health Care Waste Management Guidelines Page 43
i. Primary treatment
ii. Secondary biological purification. Most helminths will settle in the sludge
resulting from secondary purification, together with 90-95% of bacteria and a
significant percentage of viruses; the secondary effluent will thus be almost free
of helminths, but will still include infective concentrations of bacteria and viruses.
iii. Tertiary treatment. The secondary effluent will probably contain at least 20
mg/litre suspended organic matter, which is too high for efficient chlorine
disinfection. It should therefore be subjected to a tertiary treatment, such as
lagooning. If no space is available for creating a lagoon, rapid sand filtration may
be substituted to produce a tertiary effluent with a much reduced content of
suspended organic matter (<10mg/litre).
iv. Chlorine disinfection. To achieve pathogen concentrations comparable to those
found in natural waters, the tertiary effluent will be subjected to chlorine
disinfection to the breakpoint. This may be done with chlorine dioxide (which is
the most efficient), sodium hypochlorite, or chlorine gas, chlorine powder.
v. Another option is ultraviolet light disinfection.
c) Disinfection of the effluents is particularly important if they are discharged into maritime
waters (Rivers, Lakes…)
12.4 Sludge treatment
a) The sludge from the sewage treatment plant requires anaerobic digestion to ensure
thermal elimination of most pathogens.
b) Alternatively, it may be dried in natural drying beds and then incinerated together with
solid infectious health-care waste.
12.5. Minimum safety requirements for sewerage treatment
For health facilities that are unable to afford any sewage treatment, the following measures
should be implemented to minimize health risks:
a) No chemicals or pharmaceuticals should be discharged into the sewer.
National Health Care Waste Management Guidelines Page 44
b) Sludge from hospital cesspools should be dehydrated on natural drying beds and
disinfected chemically (e.g. with sodium hypochlorite, chlorine gas, or preferably
chlorine dioxide).
c) Sewage should never be used for agricultural or aquaculture purposes.
d) Hospital sewage should not be discharged into natural water bodies that are used to
irrigate fruit or vegetable crops, to produce drinking water, or for recreational purposes.
12.6. Sanitation
Human excreta are the principal vehicle for the transmission and spread of a wide range of
communicable diseases, and excreta from hospital patients may be expected to contain far higher
concentrations of pathogens, and therefore to be far more infectious, than excreta from
households.
a) In most HFs, human sanitation is often by pit latrines. Excreta collected from patients are
usually disposed of via the same route, creating a risk of infection to other people.
b) Sufficient toilets should be available; the recommended minimum is one toilet per 20
users for inpatient medical areas, and at least four toilets per outpatient location (one each
for male and female staff, one for female patients, one for male patients) (WHO, 2008).
12.7. Safe management of wastes from health facilities
A health facility should ideally be connected to a sewerage system.
a) Where there are no sewerage systems, technically sound on-site sanitation such as the
simple pit latrine, ventilated pit latrine, and pour-flush latrine, and the more advanced
septic tank with soak-away should be provided.
b) In temporary field hospitals during outbreaks of communicable diseases, other options
such as chemical toilets may also be considered.
c) In addition, convenient washing facilities (with warm water and soap available) should be
available for patients, personnel, and visitors in order to limit the spread of infectious
diseases within the Health Facility.
National Health Care Waste Management Guidelines Page 45
ANNEXES:
Annex 1Sample sheet for assessment of waste generation
Name of the health facility: .............Week: ..........................Date:………… Month………………………..
Waste collection
point:
department/location
Waste
category
(specify)
Quantity of waste generated per day (weight and volume)Saturday
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Kg litre Kg litre Kg litre Kg litre Kg litre Kg litre Kg litre
National Health Care Waste Management Guidelines Page 46
Annex 2 Color code for biomedical waste
NO TYPE OF WASTE COLOUR OF
CONTAINER
AND MARKINGS
TYPE OF CONTAINER
1 Infectious Yellow with biohazard
sign
Strong leak proof-
plastic bag
with biohazard symbol
2 Pathological/anatomical Red with biohazard
sign \
3 Sharps Yellow – (marked
sharps
4 Chemicals Brown (marked
chemicals)
5 Pharmaceutical Brown
6 General waste/Noninfectious/non
hazardous(Non-clinical)
7 Radioactive waste Symbol for radioactive
waste
8 Genotoxic/ Cytotoxicwaste Purple
9 e-Waste Refer to e-waste
guidelines
SOURCE: WHO COLOUR CODE1
National Health Care Waste Management Guidelines Page 47
Annex 3 International waste labeling symbols
potentially explosive waste
Radioactive waste
Potentially corrosive waste
Label for infectious waste
Waste containing flammable
material
Label for waste containing oxidizing
chemicals
Waste containing toxic materials
Highly infectious/sharps waste
National Health Care Waste Management Guidelines Page 48
Annex 4 Alternative labels for hazardous wastes
HAZARDOUS WASTE
CYTOSTATIC
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. -------------------------------------
Signature of O i/c -----------------------------------
HAZARDOUS WASTE
“SHARPS: INFECTIOUS”
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. -------------------------------------
Signature of O i/c -----------------------------------
HAZARDOUS WASTE
BIOLOGICAL
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. ------------------------------------
-
Signature of O i/c ----------------------------------
-
HAZARDOUS WASTE
CHEMICALS
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. -------------------------------------
Signature of O i/c -----------------------------------
HAZARDOUS WASTE
INFECTIOUS
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. ------------------------------------
-
Signature of O i/c ----------------------------------
-
HAZARDOUS WASTE
PHARMACEUTICAL
Institution/Hospital: -------------------------------
Department/ward: ---------------------------------
Signature of i/c. -------------------------------------
Signature of O i/c -----------------------------------
National Health Care Waste Management Guidelines Page 49
Annex 5 Health care waste tracking form sample 1
HEALTH CARE WASTE TRACKING FORM
Date of shipment DD/MM/YYYY
Source (Name of HF/Hospital/Clinic)……………………………………
Physical address ………………………………………………………….
Generation Point: ………………………………………….
Postal address:
Tel : 07…………………………………….
Email: ……………………………………….
TRANSPORTER:
NAME
Physical address
Postal address
Tel:0000000
Email……………………………………..
National Health Care Waste Management Guidelines Page 50
Annex 6 Health care waste tracking form sample 2
[Name, Address and
telephone number of]
Registration number from regulatory agency
Originator’s reference
CONSIGNMENT NOTE FOR THE CARRIAGE AND DISPOSAL OF HAZARDOUS WASTE
A.
Producer’s
Certificate
(1) The material described in B below is to be collected from
(location)...…...........................and taken to
(location)……………………………………….
Name…………………………………….Signed……………………………………...
On behalf of ………………………………..
Designation…………………………………
Address …………………………………….Tel. no…………………………………..
Date ………………………………………Time of collection…………..
B.
Description
of the waste
(1) General description and physical nature of waste....................................................
(2) Relevant chemical and biological components and maximum concentrations
....................
(3) Quantity of waste and size, type and number of containers.....................................
(4) Process (es) from which waste originated............................................................
C.
Carriers
Collection
Certificate
I certify that I collected the consignment of waste and the information given in A (1)
and(2) and B (1) and (3) is correct, subject to any amendment listed in this space
I collected this consignment on…………………………….. at……………….Time
Signed ………………………. Name ………………………….. Date ………………
On behalf of ………………………………………… Vehicle reg. No. .. .……….
Address …………………………………………………Tel. No. ……..……………..
D.
Producer’s
Collection
Certificate
I certify that the information given in B and C is correct and the carrier was advised
of appropriate precautionary measures.
Signed ……………………Name …………………………………………………
Date……………………………………. Tel. no. …………………………………..
E.
Disposer’s
Certificate
I certify that Waste Disposal License No………….., issued by ……………………...
[name of issuing body], authorizes the treatment/disposal at this facility of the waste
described in B (and as amended where necessary at C)
Name and address of facility………………………………………………………...
…………………………………………………………………………………………
This waste was delivered in vehicle …………[reg. No.] at ……………………
Time ………………….. [date] and the carrier gave his name as
…………………….. on behalf of ………………………………Proper instructions
were given that the waste should be taken to
………………………………………………………………………
Signed ………………….. Name ……………………………… Position …………..
Date ………………………on behalf of ……………………………………………
F.
For use by
Producer/
Carrier/Dispose
National Health Care Waste Management Guidelines Page 51
Annex 7 Waste treatment methods
Infectious Wastes Treatment method
Cultures and stock Steam sterilization/microwave
Contaminated bedding/patient care waste Steam sterilization or Incineration
Contaminated small equipment Steam sterilization or Incineration
Contaminated large equipment Formaldehyde decontamination
Biological Waste Steam sterilization or Incineration/ microwave
Contaminated laboratory waste Steam sterilization/ microwave
Dialysis unit waste Steam sterilization
Pathological waste
Anatomical wastes Steam sterilization or Incineration/Grinding
Surgery waste Steam sterilization or Incineration
Human blood and blood products Steam sterilization or Incineration
Contaminated animal carcasses Incineration
Autopsy waste Incineration
Sharps
Contaminated and unused sharps Steam sterilization and Incineration/grinding
Pharmaceutical Wastes
Pharmaceutical waste See separate Pharmaceutical waste guidelines,
microwave
Anti-neoplastic drug waste Incineration
Low level Radioactive waste Consult Radiation protection board
National Health Care Waste Management Guidelines Page 52
Annex 8 Management of spillages
(Example of General Procedure for Dealing with Spillages’)
1. Evacuate the contaminated area.
2. Decontaminate the eyes and skin of exposed personnel immediately.
3. Inform the designated person (usually the Waste Management Officer), who should
coordinate the necessary actions.
4. Determine the nature of the spill.
5. Evacuate all the people not involved in cleaning up if the spillage involves a particularly
hazardous substance.
6. Provide first aid and medical care to injured individuals.
7. Secure the area to prevent exposure of additional individuals.
8. Provide adequate protective clothing to personnel involved in cleaning-up.
9. Limit the spread of the spill.
10. Neutralize or disinfect the spilled or contaminated material if indicated.
11. Collect all spilled and contaminated material. [Sharps should never be picked up by
hand; brushes and pans or other suitable tools should be used.] Spilled material and
disposable contaminated items used for cleaning should be placed in the appropriate
waste bags or containers.
12. Decontaminate or disinfect the area, wiping up with absorbent cloth. The cloth (or other
absorbent material) should never be turned during this process, because this will spread
the contamination. The decontamination should be carried out by working from the least
to the most contaminated part, with a change of cloth at each stage. Dry cloths should be
used in the case of liquid spillage; for spillages of solids, cloth impregnated with water
(acidic, basic, or neutral as appropriate) should be used.
13. Rinse the area, and wipe dry with absorbent cloth.
14. Decontaminate or disinfect any tools that were used.
15. Remove protective clothing and decontaminate or disinfect it if necessary.
16. Seek medical attention if exposure to hazardous material has occurred during the
operation.
National Health Care Waste Management Guidelines Page 53
Annex 9 Recycling index
Uncontaminated Paper and Cardboard
Category Action Outcome
Cardboard Flatten & Bundle Cartons Recycled
Confidential documents Shred Recycled Paper
Office Paper Separate & Bundle Recycled Paper
Metals
Aluminium Contact a scrap merchant Reprocessed Cans
Dental Amalgam Contact a silver recovery
Contractor
Recovered Silver
Mercury Contact a recovery Contractor Recovered Mercury
Scrap Steel. Contact a scrap merchant Reprocessed Steel
Silver X-Ray Films and
Processors
Contact a silver recovery
Contractor
Recovered Silver
Glass
Bottles & Jars
Clear, Brown and Green
Separate , re-use and contact a
Recycler
Reused item or
reprocessed glass
Broken glass Separate, store in rigid
containers and contact a
recycler
Reprocessed glass
OILS
Waste Oil Separate and contact a
recycler
Refined or used as fuels
Food remains/leftovers and
Green Waste
Food remains/leftovers Separate from other types of
waste into appropriate colour
coded bins
-Garden Compost
-Pig swill
Plastics
High and low Density
Polyethylene
Return to Supplier Reprocessed
PET Polyethylene
Terephthalate Soft Drink
Bottles
Separate and arrange
collection
Recycled Bottles
PP Polypropylene Car Battery
Casings
Separate and arrange
collection
Reprocessed
PPVC Plasticised Polyvinyl
Chloride Plastic Tubing
Separate and arrange
collection
Reprocessed
PS Polystyrene Foam cups and
Packaging
Separate and arrange
collection
Reprocessed or reused
UPVC Unplasticised
Polyvinyl Chloride
Separate and arrange
collection
Reprocessed
National Health Care Waste Management Guidelines Page 54
Annex 10 A sample tag for shipment
HEALTH CARE WASTE
GENERATOR Date of shipment ______/________/_________
NAME OF HEALTH FACILITY ______________________________________
Physical address - ______________________________________
Postal address - __________________ Tel: ________________
TRANSPORTER:
NAME - ______________________________________
Physical address – _____________________________________
_____________________________________
Postal address - _________________ Tel: ________________
HEALTH CARE WASTE
National Health Care Waste Management Guidelines Page 55
Annex 11 Facility Health care waste management plan
Name of Facility: Date:
Who is responsible overall for supervising HCWM at your facility?
Attach supervision structure organogram of your facility
Who is responsible for performing waste disposal for each area of your facility?
Attach job descriptions for all cadres of staff at your facility.
Outline Current HCWM Status at Facility
Define type and amounts of waste generated.
Type Amount (per week)
Non-infectious waste
Infectious waste
Highly infectious waste
Highly infectious waste
List number of staff and their designations at your facility
Designation Number
National Health Care Waste Management Guidelines Page 56
Outline HCWM practices used currently.
Concept Current Practice
Is waste classified and segregated into
differentcoloured waste bins?
escribe how.
How are sharps (needles) disposed?
How are safety boxes used?
Are full safety boxes recorded?
Where are they stored?
How are they transported to their final
disposal location?
Where are different categories of waste
disposed?
Describe the disposal process
Outline Ideal Practices: Establishing Standards
Concept Current Practice
Segregating waste (different types,
corresponding colours of waste liners)
Prioritising sharps (use of safety boxes or
needle removers, if applicable)
Recording, handling and transport of safety
boxes
Final waste disposal for each category of
waste
(including sharps barrel, if applicable)
Hepatitis B and tetanus toxoid immunization
for all cadres of staff
National Health Care Waste Management Guidelines Page 57
List Improvements Needed
Define type and amounts of waste generated.
Item Date for Introduction Total Cost Responsible Party
What supplies needed for the next 6 months? (Protective clothing, cleaning supplies, waste bin, liners,
safety boxes)
Supplies Quantity Total Cost
What training is needed at your facility for each cadre of staff ?
Cadre of Staff for Training Topics Date completion
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ee
MINISTRY OF HEALTH
NATIONAL GUIDELINES ON HEALTH CARE WASTE
MANAGEMENT
www.moh.gov.rw
Foreword
As materials are used and disposed off regularly across all areas of the health sector, even the
most efficient, effective Health care system creates waste. The guidelines found here have been
developed to guide health service providers in managing waste generated from Health care
activities. Such guidelines are crucial in sustaining efforts that are already employed in Health
care waste management and injection safety.
The mismanagement of Health care waste poses a serious risk to the population, the
environment, and the health care system itself. Medical waste can be hazardous if not disposed
off correctly. Health personnel, waste handlers, and community members risk being seriously
injured or infected if proper disposal methods are not used. Standards must be maintained no
matter where Health care is provided, from the facility to the community level. Establishing and
following a standard of practice for proper handling and disposal of Health care waste is an
integral, ongoing aspect of the Health care delivery system.
These waste management guidelines will go a long way in mitigating risks of exposure and
subsequent transmission of infections to health service providers, patients, and the communities
being served. In addition, once the guidelines are effectively implemented, the environment will
be protected against the undesirable resulting effects from using less than optimal methods of
waste management and disposal.
The Ministry of Health takes this opportunity to renew its commitment to creating an enabling
environment for the implementation of these guidelines in partnership with districts authorities,
health facilities, development partners, the private sector, and other stakeholders. By
maintaining these standards together, the risk of harm on human health and the environment
condition can be reduced and the health care system will be allowed to continue to grow and
thrive in a safe, sustainable setting.
Dr. Agnes BINAGWAHO
Minister of Health
RADIOACTIVE
7
STS
BIOH/
Gu
TF
OXIDIZER
5A
DANGEROUS,
Phone numbers
- 250
- 149
Phone numbers
- 1 ..................................................................... 49
- 2 ..................................................................... 50
Law code
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