Republic of Rwanda (2016) National Guidelines on Health care Waste Management, Rwanda

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.


National Health Care Waste Management Guidelines Page 30


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;


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


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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
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