Federal Republic of Nigeria. National Agency for the Control of AIDS. Second HIV/AIDS Program Development Project (HPDP 2)

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Federal Republic of Nigeria National Agency for the Control of AIDS Second HIV/AIDS Program Development Project (HPDP 2) HIV/AIDS FINAL REPORT Submitted to: The Director General National Agency for the Control of AIDS (NACA) Plot 823 Ralph Sodeinde Street Central Business District, Abuja Nigeria Maximizing Resources and Sustaining Development December 2008 E2049 v1

2 Table of Contents Table of Contents... i List of Figures... iii List of Tables... iv Executive Summary... vii Chapter 1: Introduction...1 Chapter 2: Baseline Situation General Description and Location Socio Economy of Nigeria Status of Health Care Institutions and Facilities HIV Prevalence in Nigeria...7 Chapter 3: Medical (or Health Care) Wastes and Legal Provisions Definition Health Impacts Sources of HIV/AIDS Medical Waste Health Care Waste Management Legal and Regulatory Framework National Health Care Waste Management Plan...14 Chapter 4: Analysis of Medical Waste Management Medical Waste Composition Medical Waste Handling Practices Responsibility for Medical Waste Management...18 Chapter 5: Medical Waste Generation and Management Practices Waste Generation Waste Management Practices Potential Impacts of Existing Medical Waste Management Practices Existing Disposal Facilities...23 Chapter 6: Technologies for Medical Wastes Disposal in HPDP Medical Waste Treatment and Disposal Technologies...25 Chapter 7: Institutional Arrangements and Implementation Responsibilities Training Needs Assessment Training Strategy HIV/AIDS Cost Estimate for of HIV/AIDS...39

3 Chapter 8: Monitoring and Evaluation Monitoring and Evaluation Objectives Monitoring Indicators Monitoring Plan Monitoring of HIV/AIDS Waste Management Plan Implementation...48 Chapter 9: Public Awareness and Consultation Objectives Potential Stakeholders Consultation Strategies...49 References...51 Annex A Disposable HCW Containers...52 A.1 Specification for Disposable Containers...52 A.1.2 Specification of Reusable Containers...53 B Specification for HCW Brackets and Baskets...55 Annex C: Data Collection Instruments...58 C.1 Data entry form...58 C.2 Survey Questionnaire for HCWM...60 C.3 Short Questionnaire for Health Care Facilities Officers...74 Annex D: List of People Met...76 Annex E: HCWM Procedures to be Applied in Health-Care Facilities...77 Annex F: Health Care Waste Management Procedures to be Applied in Medical Laboratories...82 Annex G: HIV/AIDS ( )...84

4 List of Figures Figure 4.1: Administrative Map of Nigeria...4 Figure 5.1: Synopsis of the HIV/AIDS Waste Stream...19 Figure 5.2: Boxes for Sharps Disposal...22 Figure 6.1: Flow diagram of a Typical Autoclave/Steam Sterilisation Plant...26 Figure 6.2: Flow Diagram of a Typical Microwave Plant...26 Figure 6.3: Flow Diagram of a Modern Incineration Plant....28

5 List of Tables Table 2.1: Demographic Data...5 Table 2.2 Health Care Facilities by State in Nigeria...6 Table 2.3: State Level figures for HIV Prevalence in Nigeria...7 Table 3.1: Major Categories of Medical Waste...10 Table 4.1: Findings from Field Assessment...18 Table 5.1: Typical Waste Generated in Hospitals...20 Table 5.2: Recommended Colour-Coding for Health Care Waste (WHO/FMOH)...21 Table 6.1: Advantages and Disadvantages of Autoclaving and Microwaving...27 Table 6.2: Characteristics of Waste Suitable/Unsuitable for Incineration...28 Table 6.3: Advantages and Disadvantages of Incineration...30 Table 6.4: Recommended Treatment and Disposal Technology for Health Care Facilities...30 Table 7.1 HIV/AIDS...35 Table 7.2 HIV/AIDS...35 Table 7.3: Break down of Total Indicative Budget for HIV WMP...40 Table 7.4: Break down of HIV/AIDS Medical Waste Management Implementation Budget across all HCF levels...41 Table 7.5: HIV/AIDS Tertiary Health Care Facility Expenditure...42 Table 7.6: HIV/AIDS Secondary Health Care Facility Expenditure...43 Table 7.7: HIV/AIDS Primary Health Care Facility MWM Plan Expenditure (Urban)...44 Table 7.8: HIV/AIDS Primary Health Care Facility MWM Plan Expenditure (Rural)...45

6 Acronyms AI AIDS ART ARV BCC CBOs CSO DfID EIA ESM ESMF FEPA FMEH & UD FMENV FMOH GDP HAF HCF HCT HCW HCRW HIV HSDP II HPDP ISDS ITCZ LACA LAWMA LGA MAP M&E MWMP NAAQS NACA Avian Influenza Acquired Immune Deficiency Syndrome Anti-Retroviral Treatment Anti-Retroviral Behaviour change Communication Community Based Organizations Civil Society Organisation Department for International Development Environmental Impact Assessment Environmental Sound Management Environmental and Social Management Framework Federal Environmental Protection Agency Federal Ministry of Environment, Housing and Urban Development Federal Ministry of Environment Federal Ministry of Health Gross Domestic Product HIV/AIDS Fund Health Centre Facility HIV Consultancy and Testing Health Care Waste Health Care Risk Waste Human Immuno-deficiency Virus Second Health Systems Project Development HIV/AIDS Program Development Project Integrated Safeguards Sheet Inter-Tropical Convergence Zone Local Action Committee on Aids Lagos State Waste Management Agency Local Government Area Multi-Country AIDS Program for Africa Monitoring and Evaluating National Ambient Air Quality Standards National Agency for the Control of AIDS

7 NHP National Health Policy NSF National Strategy Framework ( ) NSF 2 Second National Strategic Framework 2 ( ) OPS Organized Private Sector OVC Orphans and Vulnerable Children PAD Project Appraisal Document PCN Project Concept Note PHC Primary Health Care PIU Project Implementation Unit PLWHA People Living With HIV/AIDS PLWA People Living With AIDS PMTCT Prevention of Mother to Child Transmission POP Persistent Organic Pollutant PPT Project Preparation Team ROP Resident Organic Pollutants RRF Rapid Respond Fund SACA State Action Committee on AIDS/State Agencies SEPA State Environmental Protection Agency SMOH State Ministry of Health TA Technical Assistance TB Tuberculosis TDS Total Dissolved Solids TOR Terms of Reference TOT Training of Trainers UNAIDS Joint United Nations Program on AIDS UNDP United Nations Development Program WHO World Health Organization

8 Executive Summary Introduction The World Bank launched the HIV/AIDS Program Development Project (Project 1: $90 million) as part of its Multi-Country AIDS Program for Africa (MAP). The Project became effective in April 2002 and was extended to June 2009, with $50 million of additional financing approved in May A joint review assessment of the project by DfID and the World Bank in 2006 concluded that that the Project has been successful in achieving a vibrant multi-sectoral response in Nigeria, through the engagement of a multitude of partners in the response. A joint World Bank /DfID scoping mission conducted in September 2007 revealed that the project was also successful in establishing the institutional framework necessary for a successful HIV/AIDS Program. The reviews and the evaluation reports, encourage ongoing support by the World Bank, recognizing the Bank as a lead organization in moving the response forward to the next stage. The proposed Second HIV/AIDS Program Development Project (HPDP2) will be tailored to build on the success of Project 1. The HPDP2 will build on the substantial success of Project 1 and to utilize the existing institutional structures in the national AIDS response. In fulfilling the requirements of the World Bank s procedures, the proposed project is expected to prepare a HIV/AIDS (MWMP) for the implementation of the project. The objective of the plan is to provide processes that the implementing agencies (NACA and SACAs) will follow to maximize project compliance with international and national environmental regulation and ensure that the disposal of medical wastes is conducted in an environmentally safe and sustainable manner. Medical Wastes (MW) are a reservoir of potentially harmful micro-organisms which can infect patients, health-care workers and the general public. Other risks include the spread of micro-organisms into the environment. These wastes can also cause injuries, e.g. radiation burns or sharps-inflicted injuries; poisoning and pollution, through the release of pharmaceutical products e.g. antibiotics or toxic elements such as mercury. There are over 20,000 Health Care Facilities (HCFs) with an estimated 243,000 beds in Nigeria and activities from these institutions generate about 5,000 kg of medical wastes daily, most of which are not handled or disposed off properly. These existing practices constitute a major risk to human health due to the hazardous, toxic and infectious characteristics of this waste stream. Careless and indiscriminate disposal of medical waste would contribute to the spread of HIV/AIDS. HIV/AIDS This HIV/AIDS MWMP describes the existing practice and proposes actions for a standardized approach to management of HIV/AIDS wastes. The study examined the current medical wastes handling practices within HCFs. The study shows that infectious and noninfectious wastes are dumped together in most hospitals, resulting in a mixing of the two, which are then disposed of with municipal waste at the dumping sites. It also assessed the level of knowledge among health-care staffs about the practices to be adopted, and the availability of treatment equipment such as incinerators, autoclaving and chemical treatment. Details of the first year of implementation of the HIV/AIDS MWMP can be seen in Annex G. Results The results of the study demonstrate the need for strict enforcement of existing provisions, capacity building and a better environmental management system for the disposal of medical wastes. vii

9 The findings reveal that: Medical Waste is usually not classified at source according to its type for easy of treatment and final disposal. Most HCFs do not take due responsibilities for the waste they generate to the environment and the public to ensure safe, efficient, sustainable and culturally acceptable methods for the collection, storage, transportation, treatment and final disposal both within and outside their premises. Local authorities do not have sound managerial approaches for dumpsites and the use of appropriate technologies, which would minimize health risks that result from inadequate management of hazardous and infectious medical waste. The level of knowledge among those involved in handling hazardous and infectious medical waste is low especially among those outside the HCF who are exposed to such waste due to poor management practices. The over arching National Health Care Waste Management Plan (NHCWMP) findings in the field and specifics derived from the HPDP2 formed the basis for the development of this HIV/AIDS MWMP. This is a practical MWMP that would ensure that wastes generated by the project are handled in accordance with universally upheld best practices. Specifically, some of the steps in this plan include waste minimization/generation, segregation, evacuation treatment and final disposal. Adequate provision is made for awareness creation, capacity building, incineration of sharps, septic tanks to handle the liquid stream of medical wastes and monitoring of the implementation of the MWMP. Budget: Health Care Facility (HCF) Category In order to adequately implement the HPDP2 HIV/AIDS MWMP in the 36 states and FCT Abuja, three scenarios for implementation of the HIV/AIDS MWMP were derived as seen in the table below. Total Cost Per HCF Category ($) No of Facilities intervened in 37 States SCENARIO 1 SCENARIO 2 SCENARIO 3 Total No of Total No of Estimated Facilities Estimated Facilities Amount intervened Amount for intervened for 37 states in 37states 37 states in 37 States ($) ($) Total Estimated Amount for 37 states ($) Tertiary HCFs 128, ,757, Secondary HCFs 126, ,692, ,692, Primary HCFs (Urban) 10, , ,955, ,084,651 Primary HCFs (Rural) 9, , ,364, ,729,692 Total Indicative Budget ,178, ,079,813 1,036 10,205,470 Scenario 3 is assumed to be the most cost effectiveness and has widespread impact amongst the three Scenarios. The break down of Scenario 3 is as follows: 518 Urban Primary Health Care Facilities * $10,571 = $ 5,084, Rural Primary Health Care Facilities *$ 9,130 = $ 4,729,692 Total Indicative Budget: = $ 10,205,470 The Total Indicative Budget to implement the HIV/AIDS (MWMP) in Nigeria in the first year is: Ten Million, Two Hundred and Five Thousand, Four Hundred and Seventy Thousand US Dollars ($10,205,470). viii

10 Chapter 1: Introduction Nigeria is one of the world s largest oil exporters, but poverty is pervasive with more than 70% of the population living on less than $1 per day. Nigeria has a population of over million people and GDP growth of 5.2%. The Human Development Report (UNDP) rates Nigeria 158 out of 177 countries. Life expectancy has dropped from 52 years in 1995 to 46.5 years in 2005 partly as a result of HIV/AIDS. Nigeria s HIV and AIDS epidemic is complex and comprises a generalized epidemic, affecting both urban and rural, population, but also pervasive sub-epidemics with high prevalence among geographic and social groupings. There were about 2,600,000 people living with HIV in 2007 out of which 370,000 were new infections with 170,000 AIDS deaths recorded for the year. Cumulative deaths from AIDS stand at 1.48 million. The situation is getting worse, according to UNAIDS figures in 2007; Nigeria now has the second highest burden of the disease. The main factors contributing to HIV/AIDS vulnerability include poverty, lack of awareness, dense commercial sex networks, early age of sexual debut, and poor gender empowerment, with religious and cultural factors obstructing open debate on sexuality. The World Bank launched the HIV/AIDS Program Development Project (Project 1: $90 million) as part of its Multi-Country AIDS Program for Africa (MAP). The Project became effective in April 2002 and was extended to July 2009, with $50 million of additional financing approved in May 2007.A joint review assessment of the project by DfID and the Bank in 2006 concluded that the Project has been successful in achieving a vibrant multisectoral response in Nigeria, through the engagement of a multitude of partners in the response. A joint World Bank/DfID scoping mission conducted in September 2007 revealed that the project was also successful in establishing the institutional framework necessary for a successful HIV/AIDS Program. The reviews and the evaluation reports encourage ongoing support by the World Bank, recognizing the Bank as a lead organization in moving the response forward to the next stage. The proposed Second HIV/AIDS Program Development Project (HPDP2) will be tailored to build on the success of Project 1. The HPDP2 will build on the substantial success of Project 1 and to utilize the existing institutional structures in the national AIDS response. It will directly address key emerging sector issues that have been identified by Government in partnership with a range of stakeholders, through epidemiological and behavioral surveys and the National Strategic Framework Mid Term Review (2007). These include: Radically scaling up access to prevention, treatment, care and support interventions in an informed and prioritized approach. There is also a need for better balance between prevention, treatment care and support, with treatment currently receiving substantial additional resources compared to other services. Strengthening the institutional capacity of the Federal Ministry of Health (FMOH) to plan and deliver sustainable integrated HIV and AIDS services within the primary and secondary health system, and to utilize existing resources from all partners. Continuing political commitment at the highest level of all tiers of Government. Sustaining and increasing the level of support at the Federal, State and Local Government Area (LGA) levels is essential for enabling country and local ownership of the response. Political support at the State and LGA levels has been particularly mixed. 1

11 Strengthening gender mainstreaming. The NSF ( ) provided for gender mainstreaming but the effect is yet to be seen. There is increasing feminization of the HIV/AIDS epidemics in Nigeria, as in other African countries. Evidence from treatment centers shows more women are infected, more women are affected as caregivers and more women are likely to be involved in sex work for economic reasons. Targeting. The recent Integrated Biological and Behavioural Surveillance Survey (IBBSS) among selected high-risk groups in Nigeria showed HIV prevalence among brothel and non-brothel based female sex workers at 37.4% and 30.2% respectively. The other two groups with high prevalence rates were men having sex with men and intravenous drug users at 13.5% and 5.5%. Strengthening the multisectoral response. At Federal and State levels, the response within line ministries should now follow the model set by Ministries of Education, Health and Information to become more strategic with a move from work place policies to planning activities targeted at the clients of those ministries. Strengthening the involvement of civil society. The role of Civil Society Organizations (CSOs) in prevention education is critical but the process of funding the CSOs needs to be improved, activities need to be better targeted, and the capacity of CSOs needs to be built and supervised through a more systematic approach that ensures sustainability. Strengthening the national M&E system, especially with regards to data quality and reporting. Although the existing system, NNRIMS, did benefit immensely from Project 1 and capacity building efforts from other partners, data dissemination, demand and use of information are relatively nascent activities that require considerable technical and human resource investments, going forward. The national M&E systems needs renewed focus to identify and scale up effective interventions targeting key sectors, high transmission populations and situations The project, although designed to strengthen institutional capacity to deal with HIV/AIDS will generate medical wastes as well as small site-specific negative environmental and social impacts related to construction and rehabilitation of health infrastructures. In fulfilling the requirements of the World Bank safeguard policies and existing national regulations, the proposed project is expected to produce a (MWMP) to address current medical waste management problems and an Environmental and Social Management Framework (ESMF) to address environmental and social impacts associated with the refurbishment, rehabilitation and construction of health related infrastructures. This report address the MWMP, the ESMF is prepared as a separate report. The MWMP and the ESMF will provide a framework for measures to mitigate adverse impacts during project implementation. In particular, the MWMP will provide a framework to ensure safe medical waste management at HCFs and waste dump sites to prevent further spread of HIV/AIDS due to unsafe medical waste management. The examination of the existing medical waste handling practices will: verify waste management practice in health-care institutions and management by municipal authorities after collection; appraise the level of knowledge among health-care staff (doctors, nurses etc.) about the practices to be adopted; assess the availability of equipment such as incinerators, autoclaves etc to deal with medical waste; and 2

12 verify and assess capacity building needs in medical waste management practices. The MWMP will be prepared according to national policies, regulations and guidelines as well as regulations of the World Bank. The objective of the plan is to provide processes that the implementing agencies (NACA, SACAs) will follow to maximize project compliance with international and national environmental regulation and ensure that management of HIV/AIDS medical waste is carried out in an environmentally sound and sustainable manner. 3

13 Chapter 2: Baseline Situation 2.1 General Description and Location Nigeria is situated in the western portion of Africa, and lies between latitudes N and N, and longitudes E and E. Nigeria is bordered by Chad to the northeast, Cameroon to the east, Benin Republic to the west, Niger to the northwest and the Atlantic Ocean to the south. The country s total area is 923,768 sq km, of which 910,768 sq km is land and 13,000 sq km is water. Nigeria was created by the merging of the northern and southern protectorate by the British Colonial Government in The country gained independence on October 1 st, 1960 and was declared a republic in The country is divided into 36 states and a federal territory. Sokoto Kebbi Zamfara Katsina Kano Jigawa Yobe Borno Niger Kaduna Bauchi Gombe 0 Oyo Ogun Lagos Kilometres Kwara Ekiti Osun Ondo Edo Delta Plateau FCT Nassarawa Kogi Benue Enugu Anambra Ebonyi Imo AbiaCrossRiver BayelsaRivers AkwaIbom Taraba Adamawa Geopolitical Zones North West North Central North East South West South South South East Figure 4.1: Administrative Map of Nigeria 2.2 Socio Economy of Nigeria The main characteristics of the biological, physical and socio-economic environment of the project area are summarized below Demographics Nigeria is the most populous country in Africa and ninth most populous country in the world. According to the 1991 census, the country s population was 88.5 million; with an average population density of 96 persons per sq km. 4

14 Table 2.1: Demographic Data Total population (000s) 96, , , , , ,922 Urbanization level (%) Urban population (000s) 33,664 44,184 56,651 71,121 87, ,699 Urban population growth rate (%) Rural population growth rate (%) Source: UN Habitat 2004 The United Nations estimated the population of Nigeria in 2003 to be 124 million and the 2006 national census report puts the population at million, which placed it among the ten most populous nations in the world. Regional differences are significant; population is densest in the south and sparsest in the north. According to the UN, the annual population growth rate for is 2.53%, with the projected population for the year 2015 at 190 million (Table 2.1) Economy Nigeria s economy depends heavily on the oil sector, which contributes 95 percent of export revenues, 76 percent of government revenues, and about a third of gross domestic product (GDP). Despite the country's relative oil wealth, poverty is widespread - about 37% of the population lives in extreme poverty (World Bank, 2006). Nigeria s major industries are located in Lagos, Sango Otta, Port Harcourt, Ibadan, Aba, Onitsha, Calabar, Kano, Jos and Kaduna Infrastructural Facilities The main transportation means in Nigeria is the road. Water transportation is fairly developed in some coastal areas. Air transportation is considered fair with major airports in Lagos, Abuja, Port Harcourt, Kano and Kaduna. The railway sector has experienced a major decline in the last decades but efforts are being made to revive it. Electricity is supplied through the national grid. The power supply is erratic; and government is promoting the development of independent power supply to augment the current inadequate supply. With regard to educational facilities, Nigeria is reasonably served. There are over 65 universities consisting of federal, state and private owned. High schools in most states are insufficient and are in dilapidated state. Presently the Federal Government is refurbishing all existing tertiary health institutions nationwide. There is at least One (1) primary health care institution in each of the 744 LGAs. 2.3 Status of Health Care Institutions and Facilities In Nigeria, there are more than 22,000 public and private health care institutions distributed among the 36 states and the federal capital. These institutions are categorized according to their administrative structure as follows: Tertiary Health Care Institutions These are funded by the federal government to provide highly specialized services. They include: - University Teaching Hospitals/Federal Medical Centres - State Specialist Hospitals - Medical Research Institutes/ Veterinary Research Institutes - Pharmaceutical Research Institutes 5

15 Secondary Health Care Institutions These are funded by the states and provide specialized services to patients referred from the primary health care centres. They include: - General Hospitals - Missionary Hospitals - Large Private Hospitals Primary Health Care Institutions These are funded by Local Governments to provide general medical services. They include: - Health Centres - Veterinary Clinics - Smaller private hospitals and clinics - Health Stations/Traditional Health Clinics Table 2.2 Health Care Facilities by State in Nigeria s/n State Tertiary Secondary Primary Private Public Total Beds Doctors Nurse 1 Abia , ,530 2 Abuja , ,280 3 Adamawa , ,976 4 AkwaIbom , ,422 5 Anambra , ,147 6 Bauchi , ,982 7 Bayelsa , ,548 8 Benue , ,488 9 Borno , , CrossRiver , , Delta , , Ebonyi , , Edo ,880 1,420 8, Ekiti , , Enugu , , Gombe , , Imo , , Jigawa , , Kaduna ,280 1,680 7, Kano ,860 1,420 8, Katsina , , Kebbi , , Kogi , , Kwara ,640 1,340 9, Lagos 4 1, , ,892 3,541 23, Nasarawa , , Niger , , Ogun ,850 1,684 11, Ondo ,845 1,453 10, Osun , , Oyo ,580 1,620 11, Plateau ,820 1,760 10, Rivers ,860 1,842 11, Sokoto , , Taraba , , Yobe , , Zamfara , ,980 Total 58 5,097 22,272 11,356 16, ,463 33, ,765 Table 2.2 clearly shows the distribution of HCFs in the 36 states and the F.C.T Abuja. In analyzing the distribution regionally, the South West (26%) has the largest proportion of beds in Nigeria, followed by the North Central (20%), North West (16%), South East (14%) ; 6

16 North East (12%) and the least number in the South South with 11%. The south West with the largest number f beds is mainly due the large population in Lagos and Ibadan. An evaluation of the bed capacity data of health care institutions shows the distribution as follows: South West (22%); North West. In terms of the hospital type, the southern part of the country has 73% of private and 36% of public HCFs compared to 27% private and 64% of public HCFs in the Northern part of Nigeria. 2.4 HIV Prevalence in Nigeria Table 4.4 gives us a break down of HIV prevalence in 36 states and FCT Abuja. Table 2.3: State Level figures for HIV Prevalence in Nigeria STATE HIV PREVALENCE 95% CONFIDENCE INTERVAL Benue Kogi Kwara Nasarawa Niger Plateau FCT Abuja North Central Region Adamawa Bauchi Borno Gombe Taraba Yobe North East Region Jigawa Kaduna Kano Katsina Kebbi Sokoto Zamfara North West Region Abia Anambra Ebonyi Enugu Imo South East Region Akwa Ibom Bayelsa Cross River Delta Edo Rivers South South Ekiti Lagos Ogun Ondo Osun Oyo South West Nigeria Source: NACA National AIDS Reproductive Health Survey

17 At 95% confidence interval, all the regions were statistically valid or fall within the acceptable/specified region. North Central is highest with prevalence rate of 5.7% followed by South West (3.5%) and North East (3.4%). As regards state level, Benue and Akwa Ibom have the highest prevalence rate (8.8%), Ogun with 8.5%, Nasarawa with 6.8% and Kaduna and Ebonyi with 6.3%. However, the result shows that the prevalence national average for Nigeria is still high (3.6%). although it is an improvement when compared against the prevalence rate (4.2%) in

18 Chapter 3: Medical (or Health Care) Wastes and Legal Provisions 3.1 Definition Medical or Health Care wastes are by-products of health care that includes sharps, nonsharps, blood, body parts, chemicals, pharmaceuticals, medical devices and radioactive materials. Poor handling of Medical Waste especially those emanating from HIV/AIDS management exposes health care workers, waste handlers and the community to disease and injuries. Although prevention and management of HIV/AIDS help to limit the spread of the deadly scourge and prolong the lives of carriers, the activities also generate wastes and byproducts that are hazardous to both human health and the environment. Wastes emanating from HIV/AIDS management include used condoms, hypodermic syringes, needles, hormonal preparations, expired medicines and sanitary towels. 3.2 Health Impacts HIV/AIDS medical waste is a reservoir of potentially harmful micro-organisms which can infect hospital patients, health-care workers and the general public. Major risks associated with HIV/AIDS medical waste include infections with HIV, hepatitis, sexually transmitted infections (STIs), and other diseases transmitted via body fluids or environmental pollution. The wastes and by-products can also cause injuries, e.g. radiation burns or sharps-inflicted injuries; poisoning and pollution, whether through the release of pharmaceutical products, in particular, antibiotics and catatonic drugs, through the waste water or through toxic elements or compounds such as mercury or dioxins. According to a World Health Organization (WHO) situation analysis regarding health-care waste, such risks are greatest among health care workers, waste handlers, scavengers retrieving items from dumpsites, people receiving injections with previously used needles or syringes, and children who may come into contact with contaminates by playing in areas without restricted access to waste disposal sites. The WHO report also cites data taken from health care settings indicating that a person receiving one needle stick injury from a contaminated sharp used on an infected patient has a probability of 30%, 1.8%, and 0.3% of being infected by Hepatitis B, Hepatitis C and HIV, respectively. Even treatment and disposal of health care waste which aims at reducing risks, may pose indirect health risks through the release of toxic pollutants into the environment during treatment or disposal if badly done. 3.2 Sources of HIV/AIDS Medical Waste The major sources of HIV/AIDS medical waste are hospitals, clinics, laboratories, blood banks and mortuaries; while the minor sources are dental clinics, pharmacies, etc. The main actors involved in medical waste management are: HCFs that generate the waste; service providers who collect the waste from the HCFs and transport it to the treatment facilities; and treatment facilities that process the waste to make it safe for final disposal. Based on WHO guidelines and the Basel Convention s Annexes I, II, VIII and IX classification, medical waste can be broken down into the major categories presented in Table

19 Table 3.1: Major Categories of Medical Waste Waste type Description 1. Infectious waste Infectious wastes are susceptible to contain pathogens (or their toxins) in sufficient concentration to cause diseases to a potential host. Examples include discarded materials or equipment, used for the diagnosis, treatment and prevention of disease that has been in contact with body fluids (dressings, swabs, nappies, blood bags etc). It also includes liquid waste such as faeces, urine, blood or other body secretions. 2. Pathological and anatomical waste Pathological waste consists of organs, tissues, body parts or fluids such as blood. Anatomical waste consists in recognizable human body parts, whether they may be infected or not. 3. Hazardous pharmaceutical waste Pharmaceutical waste includes expired, unused and contaminated pharmaceutical products, drugs and vaccines. This category also includes discarded items used in the handling of pharmaceuticals like bottles, vials and connecting tubing. 4. Hazardous chemical waste Chemical waste consists of discarded chemicals (solid, liquid or gaseous) that are generated during disinfecting procedures. They may be hazardous (toxic, corrosive, flammable or reactive) and must be used and disposed of according to the specification formulated on each container. 5. Waste with a high content of heavy metals Waste with high contents of heavy metals and derivatives are highly toxic (e.g. cadmium or mercury from thermometers or manometers). 6. Pressurized containers Pressurized containers consist of full or emptied containers or aerosol cans with pressurized liquids, gas or powdered materials 7. Sharps Sharps are items that can cause cuts or puncture wounds (e.g. needle stick injuries). They are highly dangerous and potentially infectious waste. They must be segregated, packed and handled specifically within the HCF to ensure the safety of the medical and ancillary staff. 8. Highly infectious waste This includes microbial cultures and stocks of highly infectious agents from medical laboratories. They also include body fluids of patients with highly infectious diseases. 9. Genotoxic/cytotoxic waste Genotoxic waste includes all the drugs and equipment used for mixing and administration of cytotoxic drugs. Cytotoxic drugs or genotoxic drugs are drugs that have the ability to reduce the growth of certain living cells and are used in chemotherapy for cancer. 10. Radioactive waste Radioactive waste includes liquids, gas and solids contaminated with radio nuclides whose ionizing radiations have genotoxic effects. These include x- and g-rays as well as a- and b- particles. Source: Safe Management of Wastes from Health-Care Activities, WHO

20 3.3 Health Care Waste Management Improper handling of health care waste (HCW), especially which due to HIV/AIDS management, can create harmful effects and reduce the overall benefits of health care. Generally, lack of awareness about the health hazards, poor management practice, insufficient financial and human resources and poor control of waste disposal are the most common problems connected with general medical waste management in developing countries. Most developing countries do not have appropriate regulations to cover medical waste and where these regulations exist they are not effectively enforced. A major issue is the lack of clarity on whose responsibility is it to handle and dispose medical waste. According to the 'polluter pays' principle, this responsibility lies with the waste producer i.e. the health care provider (hospitals, maternity homes etc). Urgent improvements are required in the following key areas: - build-up of a comprehensive system addressing responsibilities, resource allocation, handling and disposal; - awareness raising and training about risks related to health-care waste, and safe and sound practices; and - selection of safe and environmentally-friendly management options, to protect people from hazards when collecting, handling, storing, transporting, treating or disposing of waste. 3.4 Legal and Regulatory Framework This section reviews the current legal provisions for Health Care Waste Management (HCWM) in Nigeria. Currently, there are no specific provisions concerning the handling of wastes emanating from HIV/AIDS management. Legal and institutional HCWM policies on HCWM constitute the essential backbone for safe management of Health Care Waste (HCW) since they will: Establish a National Health Care Waste Management Policy compatible with the technical, institutional and financial capacities of the HCFs in Nigeria. Support the National Health Care Waste Management Plan, National Health Care Waste Management Policy, and National Health Care Waste Management Guidelines. Define the duties and responsibilities of each actor involved in HCWM in Nigeria. Set-up legal regulation of HCWM systems within the HCFs. There are a number of relevant government policies at Federal and State levels that are related to giving direction towards a safe and healthy environment which depends largely on the effective management of HCW in the country. However, they are scattered and there is no particular legislation specifically dealing with HCWM in Nigeria as of today Review of the Existing Environmental and Health Legislations At an international level, Nigeria has ratified the Basel Convention on the Control of Transboundary Movements of Hazardous Waste and their Disposal (1992). It is also party to the Stockholm Convention on the Persistent Organic Pollutants (2002). Although currently there is no specific legislation, regulations or bye-laws for the management of heath care waste in Nigeria, there are relevant laws and regulations pertaining to the protection of the environment and health: 11

21 Decree no 58 of 1988 establishes the Federal Environmental Protection Agency with: a) the responsibility to monitor and help enforce environmental protection measures; b) the duty to co-operate with Federal and State Ministries, Local Governmental Councils and research agencies on matters and facilities relating to environmental protection; c) the powers to establish standards, inspect, search, seize and arrest offenders. Decree no 42 of 1988 Harmful Waste (Special Criminal Provisions, etc) prohibits the carrying, depositing and dumping of harmful wastes (injurious, poisonous, toxic or noxious substance) and prescribes penalties for those found guilty of improper practices. Decree no 86 of 1992 sets out the procedures and methods for environmental impact assessments on both public and private projects and states that the construction of incineration plants requires an environmental assessment. Three regulations dealing with environmental issues have been identified including: S.I. 8 National effluent limitation of 1991 which makes it mandatory for industrial facilities to install anti-pollution equipment and make provision for effluent treatment. It also prescribes maximum limits of effluent parameters allowed for discharge. S.I. 9 National pollution abatement in industries and facilities generating wastes of 1991 imposes restrictions on the release of toxic substances and stipulates requirements for monitoring of pollution to ensure that permissible limits are not exceeded. S.I. 15 Management of Solid and Hazardous Wastes Regulation of 1991 deals with facilities that generate solid and hazardous waste. It also covers hazardous waste treatment and disposal facilities and indicates requirements for such facilities including contingency planning, emergency procedures, and alike. Part 12 of this regulation provides for the tracking of wastes from their point of generation to the final disposal with specific details regarding HCW. Nigeria s National Policy on Environment was first published in 1989 and revised in It describes strategies for achieving the policy goal of sustainable development. Sanitation and waste management as well as toxic and hazardous substances are presented. No specific mention is made of HCW, although a number of points can be applied to hazardous substances. There are several Legislation policies, guidelines, plans and blueprints that are applicable to HCWM in Nigeria. They are as follows: Summary. Definition. Comments. Suggestions. National Health-Care Waste Management Policy 2007 This document presents the national policy on waste management in Nigeria taking into account three (3) sections-(i) General consideration and institutional mechanism in policy implementation at national level, (ii) Requirements for management of HCW in the medical institutions including regulation and definition of institutional Health Care Waste Management Plans. The policy stipulates that HCW generated by both public and private medical institutions in Nigeria must be safely handled and disposed of by these medical institutions. This document contains specific formulated policies presently been used as well as a laid down framework of lines of responsibilities for all parties involved. There would certainly be the need for these policies to be formulated in the context of the present situation thus giving for a realistic implementation and adherence by all medical institutions involved to obtain effective results. 12

22 Summary Definition Comments Suggestion. National Health-Care Waste Management Guidelines 2007 This comprehensive document presents guidelines and strategies for the sustainable management of HCW taking into account waste generation, waste types and waste treatment technologies. Also highlighting a number of critical areas and possible solutions. Hazardous HCW is of primary concern in Nigeria, due to its potential to cause diseases and/or injuries. Hazards associated with HCW should be incorporated into Nigeria s HCWM legal, regulatory, technical and informational documents. HCWM is constitutionally the responsibility of the FMEH&UD and SEPAs, with necessary input and support from the health ministries. Formulation and implementation of HCWM policies and regulations rest with the FMEH&UD in collaboration with FMOH. There is certainly the need for HCWM planning, formulating and implementing bodies to take into consideration the challenges procuring pragmatic and affordable HCWM disposal technologies. Summary. Definition. Comments. National Health-Care Waste Management Plan 2007 This document presents strategies for the management of HCW taking into account the technical, financial and legal aspects, as well as public awareness, discussing also responsibility of the different levels of government (Local, State and Federal ) and furthermore highlighting critical areas and possible solutions. A NHCWM plan looks at practical steps to ensure that hazardous and non-hazardous medical wastes are managed properly to protect humans and the environment against the adverse effects which may occur as a result of indiscriminate handling of such wastes. This document provide basic information about the development and implementation of HCWM plans as well as HCW types, treatment and disposal methods, also thus defining duties and responsibilities of staffs for different categories of HCFs in Nigeria. Summary Definition Comment Suggestions Draft blueprint on Municipal Solid Waste Management in Nigeria 2000 This comprehensive document presents strategies for the sustainable management of municipal waste which take into account technical, legal and financial as well as public awareness aspects. It discusses the responsibilities of the different levels of authority (local government, state and federal) and highlights a number of critical areas and hints possible solutions. An integrated municipal solid waste management strategy is advocated. It is made up of a series of steps that comprise, source reduction, recycling, incineration and land filling. Solid waste management is constitutionally of the responsibility of the local government councils which in many instances don t have the means of enforcing current rules. This situation will have to be addressed by getting a better co-operation from the Nigerian Police Forces. There will most certainly be the need for harmonizing laws/bylaws or existing regulations within each state and ideally at national level so as to avoid potential inter-state movements of certain wastes. Summary Definition Comment Blueprint: Handbook on Hazardous Waste Management? This document provides a number of definitions and strategies regarding hazardous waste management as well as a categorization scheme based on the Basel Convention on Control of the Trans-boundary Movements of Hazardous Waste and their Disposal, signed and ratified by Nigeria. see handbook for details A few examples of industries which have adopted environmentally cleaner production practices are given, demonstrating that an ecological approach can also be economically interesting. 13

23 Summary Definition Comment Blueprint on Environmental Enforcement, a Citizen s Guide? This document aims at defining who the enforcers are (FMEH&UD, SEPA, LGA); how compliance, monitoring and inspections are conducted as well as types of enforcement actions and tools available. Citizens are encouraged to play an active role both by complying with environmental laws/rules at home and on the job as well as signalling any suspect activities they may notice. No specific definitions in relation with HCWM issues provided Suggests informing the general public about their duties and rights regarding environmental issues. To get the message across, it will nevertheless be necessary to conduct information campaigns within schools and with the use of the media. Summary Definition Blueprint on compliance monitoring inspections? This guide provides some basic information about the different types of inspections and how to carry them out. No specific definitions in relation with HCWM issues provided Review of Hospital Health Care Waste Regulations The proper management of HCW depends to a large extent on strong HCFs administration and organisation. HCFs should have well organized HCWM procedures with explicit HCWM rules. These resources must be made readily available as a written document to all personnel of the facility. HCWM regulations for hospitals must demand that financial and material resources are made available so that HCWM procedures can be safely and routinely practiced. Nigeria now has a National Waste Management Plan. This will be used in addition to this project-specific (MWMP) Need for Regulation and Plan for Handling of Wastes from HIV/AIDS management Over the last five years, public sector procurement of the male condom has grown substantially in Nigeria. The number of HIV Counseling and Testing (HCT) centres has also soared, and long-term care of People Living With HIV/AIDS (PLWHA) has moved largely from hospitals to communities and households. Also, public sector procurement of injectable contraceptives and female condom has increased. Increases in procurement suggest an increased utilization of these contraceptive methods and a commensurate increase in the generation of wastes. Considering the serious risks posed by wastes generated by HIV/AIDS management, there is an urgent need for a regulation and plan on handling wastes emanating from HIV/AIDS management. Already Nigeria has a National Health Care Waste Management Plan (NHCWMP). This document will provide the framework for handling wastes as a result of the Second HIV/AIDS Programme Development Project (HPDP2). 3.5 National Health Care Waste Management Plan There is a current National Health Care Waste Management (NMCWM) Plan which identifies the indicators to be tracked, specific tasks to be executed and assigns responsibility for waste collection to specific agencies. For the national plan to be effectively implemented, all HCFs in the country need to develop standardized plans based on their existing needs. Such plans should focus on treatment, recycling, transportation and disposal options through safe and cost effective treatment and disposal methods. The most critical needs for the implementation of the national plan are funding and skilled/well-trained manpower. The critical issues identified during the study include the following: 14

24 - Poor medical waste management practices in HCFs and government disposal sites with regard to handling and disposal - Lack of waste generation data - Inadequate waste treatment and disposal equipment - Inadequate knowledge among those involved in medical waste management - Lack of awareness on medical waste among health workers and the general public - Poor management practices at hospitals and dumpsites - Lack of code of conduct and technical guidelines for safety measures This project - specific medical waste management plan will operate within the confines of the National Health Care Waste Management Plan and seek ways and means that it will operationalize the action plan; especially the priority three year action plan. 15

25 Chapter 4: Analysis of Medical Waste Management An analysis of the current situation was conducted with respect to Medical Waste generation segregation, collection, transportation, and disposal. Medical wastes includes infectious wastes such as; swabs, syringes, blades, gloves are mostly mixed with municipal waste and disposed in open dumps where they are either burnt or left to decay. Existing waste management facilities differ among hospitals, it consists mostly of: - Incinerators built with primary and secondary burners, and in some cases, drum incinerators, which do not have air pollution abatement facilities; - Autoclaving; - Chemical disinfection - Microwave irradiation - Open ditches; sanitary landfills - Pit latrines and soak-away; - Transportation of medical waste to off-site disposal sites; and - Use of public drainage for infectious liquid disposal. In urban areas, unregulated practices by both public, private hospitals and private waste collectors has resulted in dumping of medical waste (infectious and sharps) at municipal dump sites. Scavenging at these disposal sites pose severe public health risks. Possibilities of infections are very high considering the fact that scavengers do not wear any form of personal protection. 4.1 Medical Waste Composition The average distribution on types of medical waste for purposes of waste management planning is approximately as follows: - 80% general domestic waste; - 15% infectious and biological (or pathological) waste; - 3% chemical or pharmaceutical waste; - 1% sharps; and - Less than 1% special waste, such as radioactive, cytotoxic, photographic wastes, pressurized containers, broken thermometers, used batteries, etc. The quantity of these wastes generated varies greatly between the different categories and location of HCFs. Variations in the composition of waste raises serious issues at the local level which require different approaches with respect to necessary medical waste management procedures to be applied in order to achieve sustainability. The variations may be due to several factors among which are differences in HCF specialization, numbers of qualified health care personnel available, medical waste management practices prevailing as well as recycling and reuse. 4.2 Medical Waste Handling Practices Medical waste handling is critical in minimizing Health Care associated risks to human health and the environment. The most significant risk occurs during transportation, this highlights the need for regulations and control measures to control segregation. In this respect, the following are necessary: Segregation of Medical Waste Segregation of wastes (infectious, non-infectious, sharps, anatomical parts) generated within hospitals helps in identifying the categories of waste and significantly reduces the risk associated with waste handling. At some teaching hospitals, wastes are segregated into various components. 16

26 - Sharps are systematically stored in separate sharp containers; - Infectious wastes are stored in yellow coloured containers, - Anatomical wastes are stored in red coloured containers - Other medical wastes are collected together into a variety of labeled waste bins and covered. This practice is however not followed in the other health care institutions visited where all wastes are dumped in the same waste bin. Injection Safety The disposal of sharps is unsatisfactory in many public HCF. This poses significant risk to patients, health workers and the surrounding communities. Although the reuse of syringes and needles was not recorded in most HCFs visited, this cannot be ruled out in the rural areas. Safe disposal of injection is a major cause of concern with respect to the spread of communicable diseases like hepatitis B and HIV/AIDS. Waste Collection Few hospitals have treatment facilities (about 15%) for the wastes generated; hence most of the facilities transport waste off-site for disposal. Where there are disposal sites, the wastes are not removed on schedule and are not properly transported to the disposal site. At some of the private hospitals, collection of waste is limited to once a day when the cleaner comes in the morning to clean the entire facility. Storage and collection was observed to be most organized at general and teaching hospitals. Waste Transportation Some facilities gather the wastes in bags and cartons and then transported off-site in secure trucks. In the rural areas, the wastes are often buried or burnt within the facility. At the Ikeja hospital (Lagos), sharps and other wastes are transported to a private landfill for burial while anatomical and pathological wastes are buried at Atan Cemetery. Waste Disposal Current disposal practices varied depending on the category of the facilities, and type of disposal facilities available. All categories of infectious wastes were burnt except placenta and other anatomical wastes that are buried. The scenario is different at some of the secondary, primary and private health centers visited. At the private clinics located in the semi-urban and rural areas, there are no significant differences in the way the medical waste and sharps are disposed. All waste are either buried or transported and dumped at the public dumpsite. Table 5.1 shows the findings from field assessment as regards handling of waste emanating from management of HIV/AIDS. 17

27 Table 4.1: Findings from Field Assessment Waste Disposal Practice Risks/Concerns Sharps and Used Medical Supplies Incinerated disposed in pits or in the open, collected by specialized firms, mixed with general waste to infection Condoms Sanitary Materials Via Solid Waste, pit laterines and toilets Collected by specialized firms, collected and burned in an onsite incinerator, concealed and disposed with general garbage, left discarded inside rooms Risk of infections at community level, exposure of garbage workers Exposure of children, unsightly and nuisance at community level, risks of disease acquisition, no disposal guidelines provided, blockage of sewage system Inadequate PPEs for cleaners, blockages of toilet drains, no posters to inform client on proper disposal, no disposal bins for lodges 4.3 Responsibility for Medical Waste Management Responsibilities for waste management are not well defined in most HCFs except in Tertiary and Secondary HCFs. It was observed that there were no adequately trained and competent personnel assigned to waste handling at most institutions. Most institutions do not have Environmental Health Officers and have delegated this duty to administrative staff. In Tertiary and Secondary HCFs, Medical waste Management Committees should be constituted and should include: Chief Medical Officer, Head of Hospital Departments, Chief Pharmacists, Radiation Officer, Financial Controllers, Senior Nursing Officer/ Head Matron and Hospital Administrator. In Primary HCFs (Rural and Urban), Medical Waste Management Committees should be constituted and should include: - Senior Nursing Officer/Matron - Hospital Administrator - Nurses Employers have a number of legal responsibilities which include: developing and maintaining a safe work environment and safe work practices; ensuring that hospital activities complies to state and national environmental standards; providing staff training and education for the safe handling of waste. Employees also have responsibilities which include: complying with safety instructions and the use of safe work practices for their own protection and for the protection of other staff and the public; actively supporting environmental initiatives introduced by the waste management committee; comply with the requirements for the handling of chemical substances according to Material Safety Data Sheets (MSDS). 18

28 Chapter 5: Medical Waste Generation and Management Practices This chapter analyses the present status of medical waste generation and management in Nigeria and subsequently recommends guidelines for collection, on-site handling, storage, transportation, treatment and safe disposal of medical wastes. Current management practices constitute both a public health and environmental hazard. When dump sites are visited, many scavengers can be seen sorting for recyclable materials, a practice which is dangerous for the scavengers. In addition, it was found that some staff in HCFs are unaware of the hazards of medical wastes. It is concluded that a new management system, which consists of segregation, material substitution, minimization, adequate treatment and sanitary land filling should be encouraged. The HIV/AIDS Waste generated with a HCF should follow an appropriate and well defined stream from their point of generation until their final disposal. The stream is composed of various steps as seen in Figure 5.1. Step Location Health Care Waste Stream Key points 0 Waste Minimization In 1 HIV/AIDS Medical Unit of HCF 2 Not recommended for HIV/AIDS infectious waste One of the most important steps to reduce risk and amount of waste 3 Protective equipment, sealed containers 4 Lockable easy to clean storage rooms; Inside limited storage time of 6 hrs HCF 5 Adequate storage room, limited of max. 6 hrs 6 Appropriate vehicle and consignment note. HCF is informed about final destination 7 Outside HCF Appropriate vehicle and consignment note to ensure final destination Figure 5.1: Synopsis of the HIV/AIDS Waste Stream 5.1 Waste Generation The medical wastes are generated from various sources. These sources can be classified as major or minor. The major sources include tertiary and secondary institutions i.e. teaching and specialist hospitals while minor sources include primary health care institutions including private hospitals, private laboratories, public health centers, dental clinics and pharmacies. The composition and quantity of the waste is often a characteristic of the source. For example, the operating theatres and surgical wards generate mainly anatomical waste such as tissues, organs, body parts and other infectious waste. - Solid Waste Solid waste generation depends on numerous factors, such as category of health-care institution, the proportion of patients treated on a daily basis and the degree of sterilization of the HCF. Hence, the teaching and specialist hospitals generate larger quantities of waste per 19

29 unit than other facilities. Solid wastes generated from healthcare activities include but not limited to the following: General waste e.g. paper, cartoons, plastic, food items, bottles etc Blood-soaked bandages Culture dishes and other glassware Discarded surgical gloves after surgery Discarded surgical instruments scalpels Needles used to give shots or draw blood Cultures, stocks, swabs used to inoculate cultures Removed body organs tonsils, appendices, limbs, etc. Lancets the little blades the doctor pricks your finger with to get a drop of blood. - Liquid Wastes Liquid wastes generated from Health Care activities include excreta, bath water from wards and waste water from laboratories (specimens, reagents etc), operating theatres and mortuaries. Some have highly infectious potential. Excreta are channeled into septic tanks that are emptied periodically or into various types of treatment plants. Most of the other liquid waste are poured down the drains of sinks and flow into open drains (gutters) which enter the external sewerage system ending up in water bodies draining the area. In some cases (particularly in the rural areas where plumbing facilities are rudimentary) some of these liquid wastes end up on the ground or on plants in the vicinity of the facilities. - Air Emissions Air emissions generated from healthcare activities are few compare to solid and liquid waste. Emission sources include sterilization process, catering and laundry activities. Other sources include open burning of refuse and incineration of infectious wastes. This emission may be in the form of vapour and smoke. Some facilities utilizes electric generators to augment power supply, these generating sets are powered by diesel or gasoline and result in emission of priority pollutants (NOx,SOx,CO 2 etc) Waste Categories The following classification of medical waste in Nigeria based on the point of generation, method of storage and the treatment options available by the health establishments are as follows: Table 5.1: Typical Waste Generated in Hospitals Classification /Description General Waste This are similar to domestic waste, which are not harmful e.g. papers, cartoons, offices, kitchen etc. Infectious Waste This are generated at in- and out-patients areas and are likely to contain pathogenic microbes Sharps Sharp edged waste stained or contaminated with blood or body fluids e.g. needles, syringes etc. Content / Examples Cardboard, plastic materials, kitchen waste ash, saw dust, pieces of wood etc. Microbiological laboratory waste potentially infected blood and human tissue Needles syringes, surgical blades, scalpels, test tubes, ampoules, glass instruments, pipettes 20

30 Patient Waste Include waste generated from in or out- patient activities, which may be contaminated with blood or body fluids from surgery, injection room etc Culture / Specimen Clinical specimen, laboratory culture and human tissue. Pathological / Organic Human Tissue This includes amputations and other body tissue resulting from surgery, autopsy, and birth. They require special treatment for ethical reasons. Hazardous Waste consist of materials hazardous characteristics and therefore require special management Pharmaceutical Waste These are waste generated from the pharmacy Photographic Chemical Waste Any waste material solid or liquid produced from image processing at the radiology department Radioactive Waste Any solid liquid or pathological waste contaminated with radioactive isotopes of any kind Laboratory Waste This is made up of basically spent chemicals for research and analytical laboratories and pharmaceutical companies Acids Alkali Solvents Organic Substances Heavy Metals Incinerator Ash and Sludge Waste generated from the combustion of waste which have to be disposed in a land fill site Stained or contaminated material (e.g. soiled cotton wool, used bandages/dressings, gloves, linen blood transfusion bags, urine, faeces Culture plus specimen (e.g. experimental specimen tissue culture, urine, stool). Urine faeces (stool) from laboratory Internal body organs, amputated limbs, placentas, foetus, human liquid wastes ( urine, blood products) pharmaceutical, laboratory, organic substances, heavy metals and other chemical contamination Expired drugs, plastic or glass containers Photographic developer/ Fixer solution X-ray photographic films Solid- papers, gloves, cotton swabs, needles (sharps), equipment etc. excretion, gastric content Spent radiation sources, Acid, Alkali, organic substances, Solvents and heavy metals/chromo sulphuric, Hydrochloric and Oxalic acid & Glacial acetic Peracetic acid, acetic acid Sodium/Potassium Hydroxide, Ethanol, etc. alcohol, formalin paraffin, phenol, and polyvinyl chloride tape Mercury from thermometers Incinerator fly ash and its residues, leachates 5.2 Waste Management Practices Segregation of Waste and Packaging - Solid Wastes Some health institutions visited practice segregation based on WHO/FMOH infection control sensitization programs as seen in Table 5.2. Although, there are no official waste segregation policies or system for categorization of medical wastes. Sharps (needles and syringes) and pathological wastes (e.g. placenta and body parts) were observed to be separated from the rest of the waste in most facilities. Table 5.2: Recommended Colour-Coding for Health Care Waste (WHO/FMOH) Type of waste Colour of container and markings Type of container Highly infectious waste Yellow, marked HIGHLY INFECTIOUS Reusable plastic container lined with strong leakproof plastic bag capable of being incinerated Other infectious waste, pathological and anatomical waste Yellow Reusable plastic container lined with strong leakproof plastic bag capable of being incinerated Sharps Yellow, marked SHARPS Puncture proof container Chemical and pharmaceutical Brown Leak-proof bag or container waste General health care waste Black Container lined with plastic bag 21

31 Needles and syringes were collected into specially designed boxes (Figure 6.1). See Annex 1 for specifications of sharp containers. When these boxes are not available, many institutions use improvised boxes with holes at the top. Few institutions especially in the rural areas however still combine sharps with general waste. UNICEF & WHO Safety Box: Cheaper Option HDPE boxes: a much more expensive option Figure 5.2: Boxes for Sharps Disposal Treatment of Waste - Chemical Disinfection This is used in some facilities for treating pathological waste in the form of placenta tissue prior to burial. Few institutions chemically disinfect needles before burning or burial. - Sterilization Autoclaves are principally used in most facilities to disinfect instruments and theatre linings and not for waste treatment. In rural facilities, steam disinfection by boiling is often employed, although this is not very effective as temperatures reached are not up to the required 1200 o C attained in autoclaving Waste Disposal Practices - Burial Placentas are usually buried. Sometimes the hole is very shallow with a high potential for being dug up by animals. Few hospitals have private off-site sites for burial. Other body parts (e.g. amputated limbs etc) are incinerated where incinerators are available or buried in public cemeteries. - Incineration Modern and efficient incinerators are available only in tertiary health centers e.g. National Orthopaedic Hospital, Igbobi and University College Hospital, Ibadan. Improvised (brick and drum) incinerators were observed in some hospitals for needles and syringes after immunizations. They are quite effective, but generate considerable air pollution. In rural areas, the open burning is applied to treat general, sharps and infectious wastes. - Open Dump Sites Open dumps are the disposal method currently employed for most of the solid waste i.e. infectious, general, pharmaceutical and in some cases, sharps. Currently, the dumping grounds are not engineered to serve as sanitary landfill sites. They therefore constitute a high risk potential for the spread of infections through run offs during rains and contamination of surface and ground water. 22