VIETNAM HOSPITAL WASTE MANAGEMENT SUPPORT PROJECT OPERATIONAL MANUAL

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized E2591 VIETNAM HOSPITAL WASTE MANAGEMENT SUPPORT PROJECT OPERATIONAL MANUAL TABLE OF CONTENT PART I PROJECT IMPLEMENTATION ARRANGEMENT Chapter 1 Project background Chapter 2 Project implementation arrangement Chapter 3 Reporting, monitoring and evaluation of project implementation PART II GUIDELINES FOR FINANCIAL ACCOUNTING WORKS Chapter 1 Project financial planning Chapter 2 Bank and account Chapter 3 Disbursement and claim Chapter 4 Project accounting Chapter 5 Reporting, auditing Chapter 6 Project closure PART III GUIDELINES FOR PROCUREMENT Chapter 1 General introduction Chapter 2 Bidding document Chapter 3 Procurement plan Chapter 4 Procurement of consultants Chapter 5 Procurement of goods and construction Chapter 6 Checking PART IV GUIDELINES FOR SUB-GRANT IMPLEMENTATION Chapter 1 Overview Chapter 2 Principles in sub-grant implementation Chapter 3 Relating documents Chapter 4 Guidelines for specific issues Chapter 5 Implementation arrangement 1

2 PART V ENVIRONMENTAL RISKS MANAGEMENT ANNEX: Annex 1 Annex2 Annex 3 Annex 4 Selection of technology for healthcare solid waste treatment Selection of technology for hospital waste water treatment Template of provincial healthcare waste management plan Template of hospital waste management plan 2

3 PART V ENVIRONMENTAL RISKS MANAGEMENT I. Background The Hospital Waste Management Support Project (HCWM) supports an important public health and environmental policy objective in Vietnam. The proposed development objective is reduced environmental degradation due to health care waste in Vietnam. This will be achieved through improved management of health care waste in Vietnam hospitals, and through improved Government stewardship role in regulating, providing implementation support, monitoring and enforcing good health care waste management practices. In 2010, Vietnam has 1186 hospitals with capacity of patient beds. They are the largest sources of hazardous waste, generating about 350 tons/day of healthcare waste including 40 tons/day of hazardous waste. If not managed well, the toxic, carcinogenic, hazardous healthcare, and other hazardous properties of this waste pose a significant threat to public health and the environment. It is estimated that only 50% of these hospitals segregate and collect healthcare waste according to regulations. There has been significant media coverage on improper medical waste management practices. Achieving the goal of safe and cost-effective management and disposal of waste is a major challenge, requiring concerted efforts by government, industries, hospitals, solid waste operators, and individuals. II. Categorization of health care waste 1.1. Solid waste All waste produced in a hospital is defined as hospital waste. Almost 75-90% of this waste constitutes general waste and has no higher risk than general municipal solid waste. Hazardous waste (between 10-25% by weight) refers to waste comprising 4 categories: - Infectious waste: sharps, non-sharp infectious waste, pathological waste and highly infectious waste - Chemical waste: chemicals commonly used in healthcare, formaldehyde, photochemicals, heavy metals, pharmaceutical waste and cytotoxic waste. - Radioactive waste - Pressurized containers 3

4 Generation of hospital waste varies wildly, depending on hospital services and quality and situation of hospital waste management. According to estimation of Ministry of Health 1, quantity of hazardous hospital waste is presented as follows: Table 1: Average hospital hazardous waste generation rate Hospitals by level and specialization Central general hospital Central specialist hospital Provincial general hospital Provincial specialist hospital District or branch hospital Quantity of hazardous solid waste (kg/bed/day) Table 2: Healthcare waste generation from Vietnam project hospitals General hospitals Specialist hospitals Central level Provincial level Interdistrict Obstetric Pediatric Tuberculosis, infectious diseases Mental, nursing, traditional medicine Cancer Others Infectious waste Sharps Non-sharps Highly infectious Anatomical waste /- +/- Chemical waste Pharmaceuticals Hz.Chemicals Cytotoxics + + +/ Radioactive waste + +/ Presurized containers General waste Note: + + generation, larger quantities; + generation, smaller quanitities; - no generation ; +/- generation or not, depend on services; 1 Draft National action plan for healthcare waste management in Vietnam,

5 1.2 Hospital wastewater Wastewater from healthcare facilities comprises water that is adversely affected in quality by anthropogenic influence during providing healthcare services. Such wastewater can contain micro-organisms, heavy metals, toxic chemicals, and radioactive elements, in addition to general storm-water, which is non-polluting by nature. Each hospital may generate m 3 of wastewater per bed per day, the volume depends on water supply and use, hospital services, number of patient and their relatives. However, concentrations of suspended solids (SS), organic substances (such as BOD5), and common nutrients (such as NO4, NO2) in hospital wastewater may be lower than those in urban wastewater. Concentration of BOD5 varies from mg/l. The principal area of concern is high content of enteric pathogens which are easily transmitted through water. Hospital wastewater contains significant amount of pharmaceuticals, chemicals which may negatively affect biological treatment process. Many surveys on quality of hospital influent have been conducted and summary of main findings can be seen in the following table. Table 3: Polluted parameters in hospital wastewater No Hospitals ph DO (mg/l) H2S (mg/l) BOD5 (mg/l) COD (mg/l) Total Phospho (mg/l) Total Nitrogen (mg/l) SS (mg/l) 1 By referral system 1.1 Central level Provincial level Sectoral By specialist 2.1 General Tuberculosis Obstetric gynecology III. Hazards of health care waste 2.1 Hazards to health Exposure to hazardous health-care waste can result in disease or injury. All individuals exposed to hazardous health-care waste are potentially at risk, including those within health-care establishments and those outside these sources. The main groups at risk are the following: - Health staff: doctors, nurses, technicians 5

6 - Patients - Relatives and visitors of patients - Workers in support services allied to health-care establishments, such as laundries, waste handling, and transportation; - Workers in waste disposal facilities (such as landfills or incinerators), including scavengers Hazards of infectious waste and sharps Pathogens in infectious waste may enter the human body by a number of routes: through a puncture, abrasion, or cut in the skin; through the mucous membranes; by inhalation; by ingestion. The existence in health-care establishments of bacteria resistant to antibiotics and chemical disinfectants may also contribute to the hazards created by poorly managed health-care waste. Sharps may not only cause cuts and punctures but also infect these wounds if they are contaminated with pathogens. Sharp injuries are most popular accidents in health facilities. A survey conducted by National Institute of occupational health and environment in 2006 found that 35% of health staff have been suffered from sharp injuries for last 6 months and 70% of them have been suffered from sharp injuries in their career. Sharps injury is the potentially main transmission way of several dangerous infectious diseases such as HIV, HBV, and HCV. About 80% of occupational infections of HIV, HBV, HCV are resulted from injuries by contaminated needles and sharps. Recycling of untreated infectious waste, including sharps and plastics can have long-term impact on public health Hazards of chemical and pharmaceutical waste Many of the chemicals and pharmaceuticals used in health-care establishments are hazardous (e.g. toxic, genotoxic, corrosive, flammable, reactive, explosive, shock-sensitive) but commonly present in small quantities. Acute or chronic exposure to chemicals by absorption through the skin or the mucous membranes, or from inhalation or ingestion. Injuries to the skin, the eyes, or the mucous membranes of the airways can be caused by contact with flammable, corrosive, or reactive chemicals (e.g. formaldehyde and other volatile substances). The most common injuries are burns. Disinfectants are used in large quantities and are often corrosive. During collection, transportation and storage, hazardous waste can be leaked and spilled. Spillage of infectious waste, especially highly infectious waste can spread pathogens through the hospital, which could result in outbreak of nosocomial infection among health staff and patients, or cause ground and water pollution Hazards of cytotoxic waste Many cancer treatment drugs are cytotoxic. They may be irritants and have harmful local effects after direct contact with skin or eyes, and may also cause dizziness, nausea, headache, or dermatitis. Hospital staff, especially those who are 6

7 responsible for waste collection, can be exposed to antineoplasma drugs by are inhalation of dust or aerosols, absorption through the skin, ingestion of food accidentally contaminated with cytotoxic drugs Hazards of radioactive waste Type and extent of exposure to radioactive waste determines the impact on human health, which can range from headache, dizziness, and vomiting to more serious long-term and/or genetic problems. 2.2 Hazards to environment Hazards to water environment Water resources may become contaminated by certain hazardous materials contained in hospital wastes. They can contain water-borne transmitted pathogens. They may contain heavy metals, largely mercury from thermometers and silver from the processing of X-ray films. Certain pharmaceuticals, if deposited without treatment, may also cause toxic agents to leach into water supplies. In addition, the leachate generated by the biological degradation of clinical wastes, like that from municipal solid waste, has the potential to cause water contamination, by reason of its high BOD Hazards to soil environment Unsafe disposal of hazardous waste including incinerator ash and sludge from wastewater treatment plant is very problematic as pollutants from landfill sites have been known to seep out, polluting soil and local water sources which have long-term health impacts Hazards to air environment The risk of air pollution arises largely from the fact that most hazardous wastes are incinerated or burnt in sub-optimal conditions. Inefficient combustion, for example when temperatures are too low or when waste is loaded in too large a quantity, will cause noxious black smoke. The presence of significant quantities of PVC plastic in the waste, together with certain pharmaceuticals, can produce acid gases, notably HCl and SO 2. During combustion with low temperature halogen ingredients (F, Cl,. Br, I..) in the waste are able to be transformed in e.g. hydrochloride (HCl). This causes a risk of forming dioxins, which are extremely toxic substances, even in small concentrations. Volatile heavy metals, notably mercury, can be emitted from hospital incinerators. These environmental risks can impact wildlife and biodiversity and also pose long-term risks to public health. 2.3 Public sensitivity 7

8 The general public and neighboring communities are sensitive to the visual impacts of anatomical waste, while poorly run incinerators emitting fumes cause disturbances to neighborhoods. IV. Hazards resulting from inappropriate treatment and disposal 4.1 Solid waste treatment and disposal Solid waste, if improperly treated and disposed in municipal landfills or recycling centres, can cause impacts to human health and environment, as detailed above. Improper operations and poor maintenance of incinerators can result in the emission of a wide range of pollutants besides dioxins and furans, including include heavy metals (lead, mercury and cadmium), fine dust particles, hydrogen chloride, sulphur dioxide, carbon monoxide, and nitrogen oxides. Two surveys conduced by Institute of health facility and equipment in 2003 and 2008 found that concentrations of dioxin in gas emission emitted from incinerators were much higher than allowable threshold; and most of incinerators were generating black smoke and cause air pollution during their operation. Safe disposal of incinerator ash is also very problematic as pollutants from landfill sites can pollute soil and local water sources. 4.2 Wastewater treatment Improper management, collection, treatment and disposal of wastewater and sludge can result in the pollution of local water sources with pathogens, causing numerous water borne diseases and vector borne diseases and the spread of parasites. Poor maintenance and operation are the biggest problems of effective wastewater treatment and inaccurate disposal of sludge can result in contamination of soil and ground and surface water. 4.3 Chemical disposal Chemical residues discharged into the sewerage system may have adverse effects on the operation of biological sewage treatment plants or toxic effects on the natural ecosystems of receiving waters. Similar problems may be caused by pharmaceutical residues, which may include antibiotics and other drugs, heavy metals such as mercury, phenols, and derivatives, and disinfectants and antiseptics. V. Government of Vietnam Policy Framework There are many legal documents relating directly or indirectly to healthcare waste management, including standards and technical regulations on incinerators. Important documents are presented as follows: 8

9 - Law 55/2005/QH11 dated 29/11/2005 on Environmental Protection Decree 59/2007/ND-CP dated 9/4/2007 on solid waste management - Decision 43/2007/QD-BYT dated 30/11/2007 of Minister of Health promulgating Healthcare waste management regulations - Circular No 12/2006/TT-BTNMT dated 26/12/2006 on Guiding the practice conditions, procedures for compilation of dossiers, registration and licensing of practice and hazardous waste management identification numbers In addition, there are environmental standards and technical regulations as follows: - QCVN 02:2008/BTNMT: National technical regulations on gas emission of healthcare waste incinerator - TCVN 7380:2004 Healthcare waste incinerator Technical requirements - TCVN 7381: Healthcare waste incinerator - Assessment and appraisal methods - TCVN 7382:2004 Hospital wastewater discharge standard - TCVN 5945:2005 Industrial wastewater discharge standard - TCVN 7957:2008 on design of drainage and sewerage external networks and facilities - TCXDVN 365:2007 Guidance on general hospital design Ministry of Health developed master plan for healthcare solid waste treatment, for environmental protection in health sector, and an Action plan for healthcare waste management is being prepared. Proposed Guidelines for healthcare wastewater treatment, proposed Vietnam standard on hospital wastewater treatment facilities technical requirements for design, operation and maintenance and proposed Master plan for healthcare waste management provide suggestion of wastewater treatment process diagrams applicable to different hospitals. In December 2009, a review of legal documents was conducted to identify weaknesses and to provide proposal for improvement. VI. Description of project The main components of the project are as follows: Component 1: Improving policy and institutional environment for health care waste management The aim of this component is to create a conducive policy environment for effective management of health care waste generated in the health care system, and to strengthen the institutional capacities to regulate, implement, monitor and enforce 9

10 proper health care waste management practices. Component 1 is a critical component of the project even though it receives a modest share of the total project costs (9 million USD). Component 1 will be composed of three sub-components. Sub-component 1.1 will focus on streamlining and strengthening the existing policy and regulatory framework for health care waste management. Sub-component 1.2 will focus on strengthening institutional capacities of the central and provincial level agencies responsible for regulating health care waste management practices, monitoring the compliance of health care facilities with the regulations, and providing technical support to hospitals in implementing health care waste management practices. Training of the staff of health care facilities in segregation of health care waste, and operation/management of health care waste technologies will be done under Component 2. Sub-component 1.3 will focus on establishing monitoring and surveillance system for health care waste management. These outputs will be produced through technical assistance (consulting services), training, acquisition of testing and laboratory equipment, provision of vehicles, upgrading of offices space and equipment, and incremental operating costs. Training in norms, standards, and organization and execution of the monitoring and surveillance function will be done as part of the integrated training process under Sub-Component 1.2. Component 2: Hospital Waste Management Support Facility This component would set up a facility to provide sub-grants linked to clear outputs and outcomes to health care facilities to improve health care waste management based on agreed eligibility criteria and agreed financial management arrangements. There could be a menu of sub-grant components based on the type and size of particular health care facility, technology proposed. Such menu would include options for solid waste management upgrade, liquid waste management upgrade, management support at the facility level, and support for recurrent cost for agreed period of time after the upgrade will have been completed. Sub-grants will be provided to central hospitals for upgrades for waste water treatment and strengthening the internal health care waste management procedures and capacity, including waste minimization, segregation, collection, and storage and worker safety practices. Sub-grants will also be allocated to provincial level health care facilities in one or two adjacent regions, based on readiness assessment. Component 3: Project Implementation Support and Coordination At the central level, a Project Steering Committee (PSC) in MOH will provide guidance on overall project direction and project coordination, including HCWM issues. Central Project Management Unit (CPMU) at the central level would be in charge of project management at the central level and coordination of the subnational activities implemented through the sub-grant mechanism. An integrated 10

11 management arrangement will be put in place for sub-grant project implementation at provincial and hospital levels. VII. Proposed Mitigatory Measure for Healthcare Waste management 8.1 Solid Waste Segregation At the source, solid waste will be segregated into colour-coded plastic bags and bins. Orderlies or environmental workers will transport waste to interim storage area for storage upto a maximum of 48 hours. If central treatment and disposal facility for hazardous waste is available in the province/town, the hazardous waste will be transported to central facility for treatment and disposal. Only when hospital can not access to centralized or clustering treatment and disposal facility, hazardous waste is treated and disposed onsite. General waste will be transported by municipal environmental company to landfill for disposal. Recyclable waste will be sold to recycling facility having licence. Approach to safe management of hospital solid waste is illustrated in the following figure: 8.2 Storage area The project will provide hospitals with financial assistance to establish interim storage facilities. sub-component 1.1 will support MoH/VIHEMA to develop technical requirements for design and operation of hazardous waste storage. Budget for waste storage area by hospital size is presented in the list of technology and costing. 11

12 8.3 Equipment for segregation, collection, onsite transportation Under component 2, the project will provide hospitals with financial assistance to procure equipment for segregation, collection, on-site transportation of hazardous waste. These include waste bags, bins and containers and waste transportation trolleys. Under component 1.1, MoH/VIHEMA will develop specification standards for such equipment which will be included in the Provincial Plan and Facility specific plans and procured by Provincial Department of Health and project hospitals. 8.4 Vehicle for off-site transportation The project provides hospitals financial assistance to procure vehicle for offsite transportation of hazardous to central treatment facility. However, only hospitals not having access to safe off-site transportation service or serving as central treatment facility will receive this support. Under sub-component 1.1, MoH will develop regulations on vehicle for off-site transportation and management of hazardous waste outside hospitals, to be funded under Component Waste treatment technology The project encourages hospitals to apply environmentally sound treatment technologies. Under component 2, the project will provide hospitals with financial assistance to use non-burn technologies. A menu of appropriate technologies from the list of non-burn technologies and respective costing has been developed. The table 3 in Annex 3 summarizes main advantages and disadvantages of common non-burn technologies. Under sub-component 1.1, the project will also support MoH to develop specifications and performance standards for non-burning technologies. The project will not support installation of new incinerators. However, funds will be still available for upgrading old incinerator (such as installation of gas emission controlling device or raising chimney) only if proposed incinerator meets stringent criteria, which will be defined in the Eligibility Checklist. 8.6 Final disposal Hazardous chemicals such as incinerator s ash or heavy metal contained chemicals will be safely buried in concrete pit, or innertized by cement, or transported to special landfill for hazardous waste. Sludge from hospital wastewater treatment plant which is considered as hazardous waste will be regularly removed and disposed by waste company having special device and license. Recyclable waste such as plastic, cardboard, metal boxes will be sold to registered recycling facility. Domestic waste will be transported by municipal environmental company to landfill for final disposal. To ensure proper disposal and recycle of waste, the hospital must sign contract to waste company having license and establish a waste documentation system to track the waste from source to final disposal. All relevant 12

13 staff and workers will be made aware of the hazards and appropriately trained to undertake these tasks. 8.7 Wastewater collection and treatment Under component 2, each project hospital is provided financial assistance to construct and install wastewater treatment plant and wastewater collection system separated from storming water collection system. In parallel, under sub-component 1.1, policy framework on hospital wastewater management will be improved. The following Figure describes hospital wastewater management scheme Hospital wastewater collection and treatment system shall be in line with Plumbing code and Vietnamese standard TCVN 7957:2008 on design of drainage and sewerage external networks and facilities and proposed Vietnamese standard on design, operation and maintenance of hospital wastewater treatment plant. Effluent of hospital wastewater treatment plant must meet Vietnamese standard TCVN 7382:2004-hospital wastewater effluent standard. The project hospitals in urban area shall select treatment process diagrams combining decentralized primary treatment and centralized biological treatment. The project hospitals having large area or in rural area are encouraged to apply the naturally biological treatment in order to reduce investment and operational cost. Disinfection can be performed by chlorine, ozone, or ultraviolet irradiation. Sludge which is considered as hazardous waste can be removed and disposed of by waste company or treated onsite by dewatering, drying bed e.g. A hospital wastewater treatment plant can apply single option or many options of biological treatment, provided that the effluent meet Vietnamese standard TCVN 7382:2004 and the plant is suitable to hospital s circumstance. 13

14 Under Component 2, the project provides hospitals with financial assistance to regularly remove and disposal of sludge from wastewater treatment plant. If waste company for sludge removal and disposal is not available in the province/town, the hospitals may construct or install sludge drying and treating facility. These details will be provided in the Hospital waste management plan 8.8 Operation and maintenance The project will take many measures to ensure proper operation and maintenance of invested technologies. Under component 2, the Memorandum of Understanding between the Ministry of Health and the sub-grant beneficiary will include the hospital management commitment to cover recurrent operations and management cost of waste management systems. To help to internalize O&M cost into management practice, the project will make available to hospitals an optional partial subsidy to operate invested waste treatment facilities in one year after finish of investment. This financial support will help hospitals to cover the cost for training on operation and maintenance; fuel, electricity, consumbles necessary for operation. The supplier of technology will be required to responsible for at least 2 year warranty and preventive service. Under sub-component 1.1, cost norms will be revised and guidelines will be complied to ensure proper operation and maintenance of technology. 8.9 Occupational Safety and Personal protective equipment (PPE) Component 1 will prepare the generic guidelines for occupational safety in health care waste management in health care facilities and provide training. With resources from sub-grants, the project hospitals will develop facility specific guidelines and management manuals and provide training to health care facility staff about occupational safety issues. Sub-grants will also provide resources to purchases sufficient PPEs for staff involving in collection, transportation, storage, treatment and disposal of healthcare waste. PPEs for different categories of hospitals are presented the list of technologies and costing. Training on use of PPEs for internal logistic is integrated in basic training for auxiliary staff, meanwhile, training on use of PPEs for off-site transportation, treatment and disposal is integrated in training on technology transfer from supplier. The project will also organize a series of information campaigns to increase the awareness of the general population with regard to the importance of managing and reducing health care waste. Sub-Component 1.1 will support production of information and reference materials (standards and technical requirements; summary of policies and regulations, manuals for health care waste management, etc.) for wider dissemination of policies and good practices Institutional capacity 14

15 Policy and monitoring Under Component 1, the project will support VIHEMA/MoH to design and implement training and communication program (sub-component 1.2) and health environmental monitoring program (sub-component 1.3). The main objective will be to equip institutions responsible for regulating and monitoring the health care waste management with adequate skills, knowledge, human resources, organizational arrangements and technologies/infrastructure to perform their function prescribed by the relevant laws and regulations. Sub-Component 1.2 will support a wide range of training activities tailored to different professional groups. The project will finance foreign technical assistance for developing the training curricula in the above areas. The MoH s VIHEMA will be responsible for the overall coordination of these. In order to ensure the efficient and rapid roll out of the training activities, the project will start training of trainers (TOT) in the above subjects. The project will support the institutions involved in the organization and execution of training with training materials, equipment and supplies that are necessary for carrying out training. Also the project will finance short term consultants (administrative assistants) to help the training institutions in the organization of training activities. Technology Adequate technologies and infrastructure are required for carrying out effectively regulation and monitoring of health care waste management practices and compliance. Sub-Component 1.3 will support investment for upgrading laboratory facilities and monitoring hardware at the central and provincial levels. Information Systems Sub-Component 1.3 will support development of an online database which will include information on health care waste management practices in all hospitals in the country, the status of their compliance with the standards and technical requirements, the type of waste treatment equipment they operate, and statistics of the environmental impact of their waste management practice. Establishment of such an online database will improve the efficiency of monitoring, will improve communication and information exchange between various agencies, and will reduce the workload of monitoring agencies by avoiding overlapping monitoring by several agencies. The project will finance technical assistance to develop the database platform and train the end users in the operation and maintenance of the database. 15

16 Hospitals Component 2 of project provide financial support to improve healthcare waste management capacity in central and provincial hospitals. Improvement measures include: (i) Hospital waste management plan and manual; (ii) Training; (iii) Communication; (iv) Monitoring and supervision. VIII. Process and Procedures: Application for Sub-Grant: At provincial level, provincial DoH will develop provincial healthcare waste management plan according to agreed template (see Annex 1) and ensure individual hospital waste management plan to be in line with provincial plan. To apply for sub-grant, project hospitals must prepare a hospital waste management plan for their individual facility. This plan will propose the chosen technology and will include measures to strengthen organizational structure and improve capacity for technology operation and maintenance (see Annex 2: Template of facility healthcare waste management plan). The hospital shall meet the following criteria: (i) appoint persons responsible for waste treatment facility operation and maintenance; (ii) train appointed staff on operation and maintenance; (iii) fully perform procedures of operation and maintenance; (iv) allocate sufficient budget for operation and maintenance of invested technologies. Technology suppliers shall provide hospitals with the following: (i) training course on technology operation and maintenance; (ii) Operational manual, maintenance manual, and illustrated part catalog; (iii) equipment to perform maintenance processes as described in maintenance manual; (iv) at least 2 year warranty and 2 year preventive maintenance after finalzation of installation. Capacity of maintenance shall be criteria to select supplier. Consultants who prepare feasibility study report for sub-grant application (or economical and technical report) shall describe operational and maintenance processes; staff requirements; estimated cost for training, operation and maintenance of waste treatment technology according to international practice. At central level, MoH will revise cost norms and ensure compliance with guidelines to ensure proper operation and maintenance of technology. Provincial inter-agency taskforce will monitor and supervise implementation of healthcare waste plan in hospitals. Hospital Waste Management Plan and Manual Each participating hospital has to develop a healthcare waste management plan and manual according to agreed template. The plan requires situation assessment and improvement measures including financial, technical and organizational measures. The Hospital HCWM plans shall be in line with provincial orientation of 16

17 HCWM treatment model and technologies that are described in provincial HCWM plan. The technical advisory group is responsible for reviewing both provincial and hospital HCWM plan. In addition, guidelines or standards on monitoring and verification of non-burning technologies should be developed in framework of Component 1. Hospital waste management manual is a tool for ensuring quality of waste management activities in the hospital. The manual will describe clearly hospital waste management system, including waste management objectives; organizational structure and responsibility assignment of persons/units involving healthcare waste management; sanctions to violence of internal regulations; healthcare waste relating processes such as minimization, segregation, collection, transportation, storage, reuse, recycle, treatment, disposal, planning, training, monitoring and supervision; and working instructions such as recording and reporting forms. Environmental Assessment, Registration and Authorization Each hospital shall submit documentation to Provincial Department of Natural Resource and Environment (DoNRE) for: (i) registration of hazardous waste owner, (ii) authorization of hazardous waste transportation if hospital transports hazardous waste outside its precinct; (iii) authorization of hazardous waste treatment if hospital having on-site hazardous waste treatment facility; and (iv) authorization of discharging wastewater into environment. Documentation includes an application form for registration/authorization and approved Environmental Impact Assessment report. The procedures for registration and authorization are described in Circular No 12/2006/TT-BTNMT dated 26/12/2006 on guiding the practice conditions, procedures for compilation of dossiers, registration and licensing of practice and hazardous waste management identification numbers. The procedures for environmental assessment are described in Circular No 05/2008/TT-BTNMT dated 8/12/2008 guiding on strategically environmental assessment, environmental impact assessment and environmental protection engagement (see Annex III: EIA in feasibility study and project approval). Expenditures for registration, authorization and environmental assessment are taken from counterpart fund. Disclosure Provincial and hospital health care waste management plans will be publicly disclosed locally via appropriate channels, including internet, local newspaper and/or public bulleting boards at local government and health cre facilities. Training The hospitals receive financial support to train their staff on healthcare waste management. For each project hospital, three key staff will receive 3 day advanced training on healthcare waste management; two staff will receive 3 day training on management, operation and maintenance of waste treatment facility in additional to 17

18 training of technology transfer from supplier; all hospital staff including doctors, nurses, members of infection control committee and auxiliary staff will receive basic training on healthcare waste management. Training curriculum and trainers are made available by sub-component 1.2. Communication Awareness raising communication program will be designed at central level, under component 1. Hospitals will be provided with financial assistance to implement communication program in hospitals in order to raise awareness of healthcare waste management among patients and community. Monitoring and supervision Hospitals will be provided with financial assistance to implement monitoring and supervision of healthcare waste management as regulated by MoH and MoNRE. The monitoring and supervision program includes 2 parts: (i) monitoring and supervision of complance to standard operating procedures; (ii) monitoring of healthcare waste and environmental quality to evalute effectiveness of mitigation measures. A firm will be mobilized to independetly verify the results of implementing the sub-grants. 18

19 Annex 1 GUIDELINES FOR SELECTION OF SOLID HEALTH CARE WASTE TREATMENT TECHNOLOGY I. Treatment and disposal of health care waste 1. According to Regulations on healthcare waste management and official letter No.7164/BYT-KCB dated 20/10/2008 of Ministry of health, the hospitals and health facilities are allowed to apply one of the following models of treatment and disposal: - In central managed cities where density of hospitals and healthcare facilities is high, traffic system is favorable, hospitals apply centralized model of hazardous healthcare solid waste treatment, one treatment facility treat all hazardous healthcare solid waste generated in city in order to save investment and operational cost. - In other provinces and cities, hospitals apply cluster model of hazardous healthcare solid treatment for hospitals, healthcare facilities locating within or surround cities and towns (distance to treatment facility is less than 30 km). - Hospitals, healthcare facilities locating in remote area, traffic poor area apply onsite waste treatment, use suitable treatment technology. 2. Centralized treatment models are being applied in Hà N i, H Chí Minh city and some other provinces. The hospitals sign contract with waste management companies (such as URENCO in Hà N i and CITENCO in H Chí Minh city) to off-site transportation and treatment of hazardous healthcare solid waste. Such models in those cities/provinces have proven to be effective in performance and cost. In other provinces, cluster treatment model is often applied to provincial level hospitals and other health facilities locating in provincial center; inter-district hospitals, district hospitals, polyclinics and commune health station often have small scale treatment facilities. 3. Any province participating in the project shall develop a provincial healthcare waste management plan. This plan shall analyse current situation of healthcare waste management and select the most suitable model of treatment for their province. The template of provincial healthcare waste management plan is available in the Annex 4. II. Technology Options II.A: Incineration 4. Minister of Health issued official letter No.7164/BYT-KCB dated 20/10/2008 requesting hospitals to limit installation of new incinerator, to provide air pollution control device for procured incinerator, and to promote application of environmentally sound non-incineration technologies. According to proposed Master plan for healthcare waste management, solid waste 19

20 treatment technology is expected to be environmentally sound, able to eliminate pathogens in infectious waste and not cause secondary pollution. 5. The Government has promulgated several standards for medical incinerators, including TCVN 7380:2004: Healthcare solid waste incinerator Technical specifications; TCVN 7381:2004: Healthcare solid waste incinerator Assessment and verification method; QCVN 02:2008/BTNMT: National technical regulation on healthcare solid waste incinerator s gas emission 6. Operational cost of on-site incinerator is high, while the cost for off-site transportation and treatment in a cluster model is negotiated by hospitals. II.B Non-burn technologies 7. Non-burn technologies which are applicable under this project include: Wet thermal disinfection (autoclave), microwave irradiation, chemical disinfection for infectious waste treatment; Shredder for waste volume reduction; Cutter or destroyer for needle treatment; Concrete bury pit for anatomical waste and sharps; Innertization and capsulation for hazardous chemicals and pharmaceutical waste treatment; Safety storage radioactive waste decay; Return chemical waste and pressurized containers to supplier. Outsourcing to registered and eligible transportation and treatment facilities 8. Each of these options is adequate for specific types of waste, as detailed in Table 1, while Table 2 provides the relative advantages of each. Therefore, it is necessary to combine different non-burn technologies to treat properly all kind of hospital waste. The regulations on healthcare waste management (in accordance with Decision 43/2007/QD-BYT dated 30/11/2007 of Minister of Health) and WHO s guidelines on healthcare waste management provide more detailed guidelines non-burn technologies applicable to each categories of healthcare waste 9. Investment costs of these technologies varydepending on capacity and sophistication of the operation. Operational costs are reasonable, and include costs of electricity, water, special bags and labor.simple technologies such as needle cutters needle destroyers, cement bury pit have low operational costs. 10. Project hospitals need to prepare a healthcare waste management plan which describes categories of waste generated, chosen technology options and respective capacities and specifications. Needle cutters and destroyers are critical for shraps management and must be maintained at all hospitals. 20

21 Table 4: Treatment and disposal methods suitable for different categories of healthcare waste Pyrolytic incinerator Wet thermal disinfection (autoclave) Microwave irradition Chemical disinfection Safe burying Innertization Infectious waste Sharps Yes Yes Yes Yes Yes No - Non-shaprs Yes Yes Yes Yes Yes No - Highly infectious Yes Yes Yes Yes Yes No - Anatomical Yes No No No Yes No - Chemical waste Pharmaceuticals Cytotoxic waste Hz. chemicals Radioactive waste Presurized containers For small quantities No No No Yes Yes No No No No No Yes For small quantities No No No No No No No No No No No No No No No Yes No Others Return to supplier Return to supplier Return to supplier Decay by storage Return to supplier 21

22 Table 5: Main advantage and disadvantages of solid health care waste treatment technologies Technology Advantages Disadvantages Cost (in 2010) Non-incineration technologies Needle cutter - Prevent needle reuse - Easy to operate, low cost - Syringe can be recycled - Needles need further treatment after cut and separated - Investment cost: 2-80 USD - Durability: 200,000 Needle destroyer Innertization Cement bury pit Safe burying - Needle is disinfected and destroyed by electricity - Easy to operate, low cost - Syringe can be recycled - Applicable to chemical waste and pharmaceutical waste - Simple to operate, low cost - Applicable to sharps and pathological waste - Simple to operate, low cost - Relatively safe if access to site is restricted and where natural infiltration is limited. - Low investment and operation cost - Require electricity - Stem of needle still exists after destroying. cutting times - Investment cost: USD - Not applicable to other waste - Investment cost of cement, sand - Requires land and space - Potential impact to underground water if poor design, construction - Only apply to hospitals in mountainous and rural area - Investment cost: USD/m 3 - Investment cost: labour, roof, fence Disinfection by steam (autoclave) Disinfection by microwave irradiation - Highly efficient disinfection - Reduction in waste volume if shredder available - Low operational cost - Environmentally sound - Well-known technology in hospitals - Highly efficient disinfection - Reduction in waste volume if shredder available - Low operational cost - Environmentally sound - Well-known technology in hospitals - Inadequate for anatomical, pharmaceutical and chemical waste, and waste that is not readily steam permeable. - Requires trained operator - High investment cost, requires thermal resistant waste bags - Inadequate for anatomical, pharmaceutical and chemical waste, and waste that is not readily steam permeable. - Requires trained operator - High investment cost, requires - Investment cost: ,000 USD - Operational cost: 0.33 USD/kg - Investment cost: 70,000 50,000 USD - Operational cost: 0.33 USD/kg 22

23 Disinfection by steam & microwave Chemical disinfection Incineration technologies Single chamber incinerator Two chamber or Pyrolytic incinerator - Highly efficient disinfection - Reduction in waste volume if shredder available - Low operational cost - Environmentally sound - Well-known technology in hospitals - Highly efficient disinfection of pathogen in infectious waste, especially for liquid waste - Reduction in waste volume if shredder available - Some chemical disinfectants are inexpensive - Good disinfection efficiency - Drastic reduction of weight and volume of waste - No need for highly trained operator - Adequate for all infectious waste, most chemical waste, and pharmaceutical waste - Drastic reduction of weight and volume of waste thermal resistant waste bags - Inadequate for anatomical, pharmaceutical and chemical waste, and waste that is not readily steam permeable. - Requires trained operator - High investment cost, requires thermal resistant waste bags - Inadequate for anatomical waste, sharps, chemical and pharmaceutical waste - Requires trained operator - Hazardous chemicals can cause environmental pollution - Emission of air pollutants - Inefficiency in destroying thermal resistant chemicals and drugs - Incomplete destruction of cytotoxics - Relatively high investment - High operational cost - Requires qualified operator - Emissions of air pollutants in case of improper operation and maintenance - Investment cost: 180, ,000 USD - Operational cost: 0.33 USD/kg - Operational cost for disinfectants - Investment cost: USD - Operational cost: 0.6 USD/kg or more expensive - Investment cost: 20, ,000 USD - Operational cost: 0.6 USD/kg or more expensive 23

24 Annex 2 GUIDELINES FOR SELECTING TECHNOLOGY FOR HOSPITAL WASTE WATER TREATMENT I. Treatment of hospital wastewater 1. According to current policies in Vietnam, each hospital shall install and operate a waste water treatment plant so that hospital effluent meet Vietnamese standard TCVN 7382:2004. These are in process of being revised and converted into national technical regulation (QCVN). The Government has promulgated Vietnamese standard TCVN 7957:2008 on design of drainage and sewerage external networks and facilities. Guidelines on healthcare wastewater treatment are being developed by Ministry of Health; and a Vietnamese standard on design, operation and maintenance of hospital wastewater treatment plant is being developed by Ministry of Construction. 2. Wastewater from hospitals is of a similar quality to urban wastewater. The principal area of concern is high content of enteric pathogens which are easily transmitted through water. If healthcare waste is not well managed, hospital wastewater contains significant amount of pharmaceuticals, chemicals which may negatively affect biological treatment process. Many surveys on quality of hospital influent have been conducted and summary of main findings can be seen in the following Table. Table 6: Polluted parameters in hospital wastewater No Hospitals ph 1 By referral system DO (mg/l) H2S (mg/l) BOD5 (mg/l) COD (mg/l) Total Phosph o (mg/l) Total Nitroge n (mg/l) SS (mg/l ) 1.1 Central level Provincial level Sectoral By specialist 2.1 General Tuberculosis Obstetric gynecology II. Wastewater technologies: Hospital waste water technologies can be divided into 4 groups of options. 24

25 Option 1: Hospital wastewater is primarily treated by septic tanks, settlement tanks and then finally treated by disinfectants, bio-lake or constructed wetland (see Figure 1). Figure 1: Technological diagram of Option 1 Wastewater Septic tank ettlement tank Disinfection Outfall Wastewater Septic tank ettlement tank Bio-lake or Constructed Outfall wetland Option 2: Hospital wastewater undertakes primary treatment process (in septic tanks and settlement tanks), man-made biological treatment process (in biological filter or activated sludge reactor) and disinfection process (see Figure 2). Vietnamese hospitals have applied this group of technology since Up to now, this group of technology is the most popular in Vietnam. Figure 2: Technological diagram of Option 2 Wastewater Septic tank Collection tank + waste screen Biological treatment facility Outfall Septic tank Secondary settlement tank Option 3: Wastewater is primarily treated in a combined block, secondarily treated in modular biological treatment equipment and disinfected before discharged. Examples of wastewater treatment plants using combined and modular approach known in Vietnam are CN2000, V69 that have been used since

26 Figure 3: Technological diagram of Option 3 System of combined tanks Waste water Waste screen Collectio tank Balancing primary treatment tank Pumping hole & submerged pumps Sludge tank Outfall Disinfection equipment Secondary treatment tan Treatment equipment aerolift aeroten with high rate microbiological filting materials Modules of equipment Option 4: These are new technologies recently imported into Vietnam including Sequence Batch Reactor and the so-called AAO (anaerobic anoxic oxic) technology. Figure 4: Technological diagram of wastewater treatment plant using Sequence Batch Reactor Wastewater Automatic waste screen Collection and balancing tank Biological treatment Sequencing Batch Reacto Outfall Disinfection by Ozone Table 7: Performance specifications: Option 1 Option 2 Option 3 Option 4 BOD load (kg/m 3 /day) Suspended solid (mg/l) Adaptation of activated Medium Medium Not stable sludge adaptation adaptation High, stable Retention time Low Medium Medium High Treatment efficiency for 67% - 70% 85% - 95% 80% - 87% 90% - 97% 26