Transcription

MEDICALWASTEMANAGEMENT

International Committee of the Red Cross19, avenue de la Paix1202 Geneva, SwitzerlandT 41 22 734 60 01 F 41 22 733 20 57E-mail: [email protected] www.icrc.org ICRC, November 2011

MEDICALWASTEMANAGEMENT

2MEDICAL WASTE MANAGEMENTTABLE OF CONTENTSPREFACE61. INTRODUCTION82. DEFINITION AND DESCRIPTION OF “MEDICAL WASTE”2.1 Description of medical waste2.2 Quantification of medical waste3. MEDICAL WASTE RISKS AND IMPACT ON HEALTHAND THE ENVIRONMENT3.1 Persons potentially exposed3.2 Risks associated with hazardous medical waste3.2.1 Risks of trauma and infection3.2.2 Survival of micro-organisms in the environment3.2.3 Biological risks associated with exposure to solidhousehold refuse3.2.4. Chemical risks3.3 Risks associated with the inappropriate processingand dumping of hazardous medical waste3.3.1. Incineration risks3.3.2. Risks related to random disposal or uncontrolled dumping3.3.3. Risks related to the discharge of raw sewage4. LEGISLATION4.1 International agreements4.2 National Legislation1112141516171719212124242525272830

TABLE OF CONTENTS5. FUNDAMENTAL PRINCIPLES OF A WASTE MANAGEMENTPROGRAMME5.15.25.35.45.55.6Assigning responsibilitiesSub-contracting, regional cooperationInitial assessmentPreparing the waste management planEstimating costsImplementing the waste management plan3333437373839406. MINIMIZATION, RECYCLING417. SORTING, RECEPTACLES AND HANDLING7.1 Sorting principles7.2 How to sort waste7.3 Handling of bags454647508. COLLECTION AND STORAGE519. TRANSPORT53545556569.19.29.39.4Vehicles and means of conveyanceOn-site transportOff-site transportCross-border transport

4MEDICAL WASTE MANAGEMENT10. TREATMENT AND ng treatment and disposal methodsIncinerationChemical disinfectionAutoclavingNeedle extraction or destructionShreddersEncapsulationDisposal in a sanitary landfill or waste burial pitDisposal of liquid wastes in the sewage11. STAFF PROTECTION MEASURES11.111.211.311.4Personal protective equipmentPersonal hygieneVaccinationMeasures to be taken in the event of accidental exposureto blood11.5 Emergency measures in the event of spills or contaminationof surfaces11.6 Emergency measures in the event that personshave been contaminated12. TRAINING575862686971737475777981838484868812.1 Why and how12.2 Content89909113. FURTHER INFORMATION93

TABLE OF CONTENTSANNEX 1 WASTE DATA SHEETSData sheet no. 1: Sharps (category 1)Data sheet no. 2: Waste entailing risk of contamination (category 2.a)Data sheet no. 3: Anatomical waste (category 2.b)Data sheet no. 4: Infectious waste (category 2.c)Data sheet no. 5: Pharmaceutical waste (category 3.a)Data sheet no. 6: Cytotoxic waste (category 3.b)Data sheet no. 7: Mercury waste (category 3.c)Data sheet no. 8: Photographic development liquids (category 3.d)Data sheet no. 9: Chemical waste (category 3.d)Data sheet no. 10: Pressurized containers (category 4)Data sheet no. 11: Radioactive waste (category 5)ANNEX 2 METHOD DATA SHEETSData sheet 12: Choosing sharps containersData sheet 13: Burial pitData sheet 14: Burial pit for anatomical wasteData sheet 15 : Sharps pitANNEX 3 TOOLS FOR IMPLEMENTING THE WASTEMANAGEMENT PLANAnnex 3.1Annex 3.2Annex 3.3Annex 3.4Annex 3.5Annex 3.6Example of a form for quantifying waste generationChecklist for describing the current situationExample of a waste flow diagramAudit checklistInternational transport of dangerous goods by roadExample of a poster: What to do in the event of 24127128129134135145150ANNEX 4 LIST OF SYMBOLS AND PICTOGRAMS151LIST OF TABLES AND FIGURES156LIST OF ABBREVIATIONS158

6MEDICAL WASTE MANAGEMENTPREFACEThe world is generating more and more waste and hospitals and health centres are no exception. Medical waste canbe infectious, contain toxic chemicals and pose contamination risks to both people and the environment. If patientsare to receive health care and recover in safe surroundings,waste must be disposed of safely.Choosing the correct course of action for the different typesof waste and setting priorities are not always straightforward, particularly when there is a limited budget. Thismanual provides guidance on what is essential and whatactions are required to ensure the good management ofwaste.Drawing on the most up-to-date professional practice, themanual provides practical recommendations for use in thedifferent contexts where the ICRC works. It includes technical sheets ready for use, ideas for training and examples ofjob descriptions for hospital staff members. The guidancein this manual is applicable in resource poor countries aswell as in countries where there is a more developed healthinfrastructure.

INTRODUCTIONThe management of the waste from health services iscomplex and to be successful it must be understood andaddressed by everyone working in health services fromthose washing the floors to the senior administrators. Wehope that this manual will convince readers that the management of medical waste is an essential component ofhealth facilities that must be a priority shared by ICRC staffand our valued partner organisations.Translating best practice for very different environmentsinto clear and concise guidance for use by different professions is a rare skill. This manual would not have been possible without the expertise of Sylvie Praplan who has beenthe main partner and advisor in this adventure. Thanks arealso due to the expertise of many staff working in the fieldand in the Headquarters of the ICRC and in particular toMargrit Schäfer, in charge of Hospital Administration andMartin Gauthier, Environmental Engineer, for their perseverance and guidance throughout the process.Elizabeth TwinchHead of Assistance DivisionInternational Committee of the Red Cross

8MEDICAL WASTE MANAGEMENT1. INTRODUCTIONHealth-care activities are a means of protecting health,curing patients and saving lives. But they also generatewaste, 20 percent of which entail risks either of infection, oftrauma or of chemical or radiation exposure.Although the risks associated with hazardous medicalwaste and the ways and means of managing that wasteare relatively well known and described in manuals andother literature, the treatment and elimination methodsadvocated require considerable technical and financialresources and a legal framework, which are often lackingin the contexts in which the International Committee of theRed Cross (ICRC) works. The staff is often unequipped forcoping with this task.Hospitals areresponsible for thewaste they produce.They must ensurethat the handling,treatment and disposalof that waste willnot have harmfulconsequences forpublic health or theenvironment.Poor waste management can jeopardize care staff, employees who handle medical waste, patients and their families,and the neighbouring population. In addition, the inappropriate treatment or disposal of that waste can lead toenvironmental contamination or pollution.In unfavourable contexts, the risks associated with hazardous medical waste can be significantly reduced throughsimple and appropriate measures. This manual is intendedas a practical and pragmatic tool for the routine management of dangerous hospital wastes. It does not under anycircumstances replace any existing national waste management legislation and plans.

1. INTRODUCTIONThis manual is designed for the medical, technical oradministrative staff working in medium-sized hospitals(approximately 100-bed capacity) that are managed orsupported by the ICRC.The manual includes data sheets in the Annex. It deals withwastes that are created in the course of surgical, medical,laboratory and radiological activities with the exceptionof specialties such as oncology, nuclear medicine or prosthetic/orthotic workshops. It deals mainly with so-calledhazardous or special medical waste except for genotoxicwaste such as cytotoxic substances or radioactive material,which are wastes that ICRC health care activities generallydo not produce.9

2. DEFINITIONAND DESCRIPTIONOF “MEDICAL WASTE”

12MEDICAL WASTE MANAGEMENT2.1Description of medical wasteThe term “medical waste” covers all wastes produced inhealth-care or diagnostic activities.75 % to 90 % of hospital wastes are similarto household refuse or municipal waste anddo not entail any particular hazard.Refuse similar to household waste can be put through thesame collection, recycling and processing procedure asthe community’s municipal waste. The other 10% to 25% iscalled hazardous medical waste or special waste. This typeof waste entails health risks.It can be divided into five categories according to the risksinvolved. Table 2.1 gives a description of those various categories and their sub-groups.

2. DEFINITION AND DESCRIPTION OF “MEDICAL WASTE”Table 2.1Classification of hazardous medical waste1.Sharps Waste entailing risk of injury.2.a. Waste entailing risk ofcontaminationb. Anatomical waste Waste containing blood, secretions orexcreta entailing a risk of contamination. Body parts, tissue entailing a risk ofcontamination Waste containing large quantities ofmaterial, substances or cultures entailingthe risk of propagating infectious agents(cultures of infectious agents, waste frominfectious patients placed in isolationwards).c. Infectious waste3.a. Pharmaceutical wasteb. Cytotoxic wastec. Waste containing heavy metalsd. Chemical waste Spilled/unused medicines, expired drugsand used medication receptacles. Expired or leftover cytotoxic drugs,equipment contaminated with cytotoxicsubstances. Batteries, mercury waste (brokenthermometers or manometers, fluorescentor compact fluorescent light tubes). Waste containing chemical substances:leftover laboratory solvents, disinfectants,photographic developers and fixers.4.Pressurized containers Gas cylinders, aerosol cans.5.Radioactive waste Waste containing radioactive substances:radionuclides used in laboratories ornuclear medicine, urine or excreta ofpatients treated.13

14MEDICAL WASTE MANAGEMENTThe various categories of waste are set out in detail in thedata sheets in Annex 1 (sheets 1 to 11). Cytotoxic and radioactive wastes are dealt with briefly in that annex.2.2Quantification of medical wasteThe quantity of waste produced in a hospital depends onthe level of national income and the type of facility concerned. A university hospital in a high-income country canproduce up to 10 kg of waste per bed per day, all categoriescombined.An ICRC hospital with 100 beds will produce an averageof 1.5 to 3 kg of waste per patient per day dependingon the context (all categories combined and includinghousehold refuse).An estimate of the quantities of waste produced must bedrawn up in each facility (see chapter 5.3 and Annex 3.1).

3. MEDICALWASTE RISKSAND IMPACTON HEALTH ANDTHE ENVIRONMENT

16MEDICAL WASTE MANAGEMENT3.1Persons potentially exposedAll persons who are in contact with hazardous medicalwaste are potentially exposed to the various risks it entails:persons inside the establishment generating the waste,those who handle it, and persons outside the facilitywho may be in contact with hazardous wastes or theirby-products, if there is no medical waste management orif that management is inadequate.The following groups of persons are potentially exposed: Inside the hospital: care staff (doctors, nursing staff,auxiliaries), stretcher-bearers, scientific, technicaland logistic personnel (cleaners, laundry staff,waste managers, carriers, maintenance personnel,pharmacists, laboratory technicians, patients, familiesand visitors). Outside the hospital: off-site transport personnel,personnel employed in processing or disposalinfrastructures, the general population (includingadults or children who salvage objects found aroundthe hospital or in open dumps).

3. MEDICAL WASTE RISKS AND IMPACT ON HEALTH AND THE ENVIRONMENT3.2Risks associated with hazardous medicalwasteThe health risks associated with hazardous medical wastecan be divided into five categories: risk of trauma(waste category 1); risk of infection(waste categories 1 and 2); chemical risk(waste categories 3 and 4); risk of fire or explosion(waste categories 3 and 4); risk of radioactivity(waste category 5, which is not dealt with in this manual).The risk of environmental pollution and contaminationmust be added to these categories.3.2.1 RISKS OF TRAUMA AND INFECTIONHealth-care wastes are a source of potentially dangerousmicro-organisms that can infect hospital patients, personnel and the general public. There are many different exposure routes: through injury (cut, prick), through contactwith the skin or mucous membranes, through inhalationor through ingestion.Table 3.1 gives examples of infections that can be causedby hazardous medical waste.17

18MEDICAL WASTE MANAGEMENTTable 3.1Examples of infections that can be causedby hazardous medical waste1Type of infectionInfective agentTransmission onella, Vibrio cholerae,Shigella, etc.)Faeces, vomitRespiratoryinfectionsMycobacterium tuberculosis,Streptococcus pneumoniae,SARS virus (Severe AcuteRespiratory Syndrome),measles virusInhaled secretions, salivaEye infectionsHerpes virusEye secretionsSkin infectionsStreptococcusPusAnthraxBacillus anthracisSkin secretionsMeningitisNeisseria meningitidisCerebro-spinal fluidAIDSHuman ImmunodeficiencyVirus (HIV)Blood, sexual secretions, otherbody fluidsHaemorrhagicfeverLassa, Ebola, Marburg,and Junin virusesBlood and secretionsViral hepatitis AHepatitis A virusFaecesViral hepatitis Band CHepatitis B and C virusesBlood and other biologicalfluidsAvian influenzaH5N1 virusBlood, faecesSome accidental exposure to blood (AEB) or to other bodyfluids are examples of accidental exposure to hazardousmedical waste.note11Source: A. Prüss, E. Giroult, and P. Rushbrook, Safe management of wastes fromhealth-care activities, WHO, 1999.

3. MEDICAL WASTE RISKS AND IMPACT ON HEALTH AND THE ENVIRONMENTAs regards viral infections such as AIDS and hepatitis Band C, it is nursing staff who are most at risk of infectionthrough contaminated needles. Sharps and pathogeniccultures are regarded as the most hazardous medical waste.In 2000, the World Health Organisation (WHO) estimatedthat at world level accidents caused by sharps accountedfor 66,000 cases of infection with the hepatitis B virus,16,000 cases of infection with hepatitis C virus and 200to 5,000 cases of HIV infection amongst the personnel ofhealth-care facilities.Some wastes, such as anatomical wastes, do notnecessarily entail a health risk or risk for the environmentbut must be treated as special wastes for ethical orcultural reasons.A further potential risk is that of the propagation of microorganisms outside health-care facilities which are presentin those facilities and which can sometimes be resistant aphenomenon that has not yet been sufficiently studied.3.2.2 SURVIVAL OF MICRO-ORGANISMSIN THE ENVIRONMENTPathogenic micro-organisms have a limited capacity of survival in the environment. Survival depends on each microorganism and on environmental conditions (temperature,humidity, solar radiation, availability of organic substrate,presence of disinfectants, etc.). Bacteria are less resistantthan viruses. Very little is known as yet about the survivalof prions and the agents of degenerative neurological diseases (such as Creutzfeldt-Jakob’s disease, Kuru, and so on),which seem to be more resistant than viruses.Table 3.2 gives a summary of what is known about the survival of various pathogens.19

20MEDICAL WASTE MANAGEMENTTable 3.2:Examples of the survival time of certain pathogens2Pathogenicmicro-organismObserved survival timeHepatitis B virus Several weeks on a surface in dry air 1 week on a surface at 25 C Several weeks in dried blood 10 hours at 60 C Survives 70% ethanol.Infectious dose ofhepatitis B and C viruses 1 week in a drop of blood in a hypodermic needleHepatitis C 7 days in blood at 4 C.HIV 3 7 days in ambient air Inactivated at 56 C 15 minutes in 70% ethanol 21 days in 2 μl of blood at ambient temperature Drying the virus reduces its concentration by 90-99%within the next few hours.The concentration of micro-organisms in medical waste, with the exception oflaboratory cultures of pathogens and the excreta of infected patients, is generally nohigher than in household refuse. However, medical waste contain a wider variety ofmicro-organisms.On the other hand, the survival time of the micro-organisms present in medical wasteis short (probably because the wastes contain disinfectants).The role played by carriers such as rats and insects must alsobe taken into account in the evaluation of micro-organismsurvival time in the environment. They are passive carriersof pathogens, and measures must be taken to control theirproliferation.2WHO 2010, Public Health Agency of Canada 2001, Thomson et al. 2003.

3. MEDICAL WASTE RISKS AND IMPACT ON HEALTH AND THE ENVIRONMENT3.2.3 BIOLOGICAL RISKS ASSOCIATED WITH EXPOSURETO SOLID HOUSEHOLD REFUSESince exposure conditions are often the same for employees dealing with household refuse and those dealing withmedical waste, the impact on the health of the former canbe used as an indicator for the latter.Various studies conducted in high-income countries haveshown the following results:Compared to the general population, in the case of persons employed in the processing of household waste the risk of infection is 6 times higher; the risk of contracting an allergic pulmonary disease is2.6 times higher; the risk of contracting chronic bronchitis is 2.5 timeshigher; and the risk of contracting hepatitis is 1.2 times higher.Pulmonary diseases and bronchitis are caused by exposureto the bio-aerosols contained in the air at the sites wherethe refuse is dumped, stored or processed.33.2.4. CHEMICAL RISKSMany chemical and pharmaceutical products are used inhealth-care facilities. Most of them entail a health risk dueto their properties (toxic, carcinogenic, mutagenic, reprotoxic, irritant, corrosive, sensitizing, explosive, flammable,etc.). There are various exposure routes for contact withthese substances: inhalation of gas, vapour or droplets,contact with the skin or mucous membranes, or ingestion.Some substances (such as chlorine and acids) are incompatible and can generate toxic gases when mixed.3These bio-aerosols contain gram-positive and gram-negative bacteria, aerobicActinomycetes and sewage fungi.21

MEDICAL WASTE MANAGEMENTThe identification of potential hazards caused by certainsubstances or chemical preparations can be easily donethrough labelling: symbols, warning statements or hazardstatements. More detailed information is set outin the material safety data sheet (MSDS).Some examples of the European and international hazardsymbols are shown in Annex 4. Figures 3.1 and 3.2 giveexamples of European and international labelling (GloballyHarmonized System - GHS).Cleaning products and, in particular, disinfectants areexamples of dangerous chemicals which are used in largequantities in hospitals. Most are irritant or even corrosive,and some disinfectants (such as formaldehyde) can be sensitizing and 46Highly flammable.Irritating to the eyes.Repeated exposure maycause skin dryness orcracking.Vapours may cause drowsinessand dizziness.Risk statements(R-statements)AcetoneKeep container in a well-ventilatedplace.Keep away from sources ofignition – No smoking.In case of contact with eyes,rinse immediately with plentyof water and seek medicaladvice.If swallowed, seek medical adviceimmediately and show thiscontainer or label.Precautionary statements(P-statements)22Name, address and telephone numberof the firm responsible in Switzerland.Figure 3.1: Example of the labelling of chemicals (Europeansystem applicable until 2015)

3. MEDICAL WASTE RISKS AND IMPACT ON HEALTH AND THE ENVIRONMENTAcetoneP210P361P403/333P305/351/338Keep away from heat/sparks/open flames/hot surfaces –No smoking.Avoid breathing vapours.Store in a well-ventilatedplace. Keep container tightlyclosed.If in eyes: Rinse carefullywith water for severalminutes. Remove contactlenses if present andeasy to do – continuerinsing.Name, address and telephone numberof the firm responsible in Switzerland.Figure 3.2: Example of the labelling of chemicals according tothe new (international) system (GHS)Mercury is a heavy metal in liquid form at room temperature and pressure. It is very dense (1 litre of mercury weighs13.5 kg!). It evaporates readily and can remain for up to ayear in the atmosphere. It accumulates in sediments,where it is converted into methylmercury, a more toxicorganic derivative. Mercury is found mainly in thermometers, manometers, dental alloys, certain types of battery,electronic components and fluorescent or compact fluorescent light tubes. Health-care facilities are one of the mainsources of mercury in the atmosphere due to the incineration of medical waste. These facilities are also responsiblefor the mercurial pollution of surface water.Precautionary statements(P-statements)Highly flammable liquid andvapour.H319Causes serious eyeirritation.H335May cause drowsiness ordizziness.EUHD55 Repeated exposure maycause skin dryness orcracking.Hazard statements(H-statements)H22523

24MEDICAL WASTE MANAGEMENTMercury is highly toxic. There is no threshold under which itdoes not produce any undesirable effect.Mercury can cause fatal poisoning when inhaled.4 It is alsoharmful in the event of transcutaneous absorption and hasdangerous effects on pregnancy.Silver is another toxic element that is found in hospitals(photographic developers). It is bactericidal. Bacteria whichdevelop resistance to silver are also thought to be resistantto antibiotics.54The trading and use of expired medicines also entail a public health risk whenever this type of waste is not controlled.This manual does not cover the risk associated with cytotoxic drugs (see information outlined in Annex 1 – datasheet no. 6).3.3Risks associated with the inappropriateprocessing and dumping of hazardousmedical waste3.3.1. INCINERATION RISKSIn some cases, particularly when wastes are incinerated atlow temperature (less than 800 C) or when plastics containing polyvinyl chloride (PVC) are incinerated, hydrochloricacid (which causes acid rain), dioxins, furans and variousother toxic air-borne pollutants are formed. They are foundin emissions but also in residual and other air-borne ashand in the effluent gases released through incineratorchimneys. Exposure to dioxins, furans and other coplanarpolychlorinated biphenyls can have effects that are harmfulto public health.65456The disease caused by exposure to mercury is called mercurialism.Anon 2007, Chopra 2007, Senjen & Illuminato 2009.Long-term exposure to low doses of dioxins and furans can result in immunesystem disorders in humans as well as abnormal development of thenervous system, endocrine disruption and reproductive damage. Short-termexposure to high doses can cause skin lesions and impaired liver function. TheInternational Agency for Research on Cancer (IARC) classes dioxins as knownhuman carcinogens.

3. MEDICAL WASTE RISKS AND IMPACT ON HEALTH AND THE ENVIRONMENTThese substances are persistent, that is to say, the molecules do not break down in the environment and theyaccumulate in the food chain. The bulk of human exposureto dioxins, furans and coplanar polychlorinated biphenylstakes place through food intake.Even in high-temperature incinerators (over 800 C) thereare cooler pockets at the beginning or the end of theincineration process where dioxins and furans can form.Optimization of the process can reduce the formation ofthese substances if it is ensured, for example, that incineration takes place only at temperatures above 800 C and ifthe formation of combustion gas is prevented at temperatures of 200 - 400 C (see good incineration practices inChapter 10.2).And lastly, the incineration of metals or of materials with ahigh metal content (especially lead, mercury and cadmium)can result in metals being released into the environment.3.3.2. RISKS RELATED TO RANDOM DISPOSALOR UNCONTROLLED DUMPINGIn addition to the above-mentioned risks, burial and random dumping on uncontrolled sites can have a directimpact on the environment in terms of soil and waterpollution.3.3.3. RISKS RELATED TO THE DISCHARGEOF RAW SEWAGEPoor management of wastewater and sewage sludge canresult in the contamination of water and soil with pathogens or toxic chemicals.Pouring chemical and pharmaceutical wastes down thedrain can impair the functioning of biological sewage treatment plants or septic tanks. These can end up polluting theecosystem and water sources.septiques. Antibiotics andtheir metabolites are excreted in the urine and faeces of25

26MEDICAL WASTE MANAGEMENTpatients under treatment and end up in sewage. Hospitalsewage contains 2 to 10 times more antibiotic-resistantbacteria than domestic wastewater, a phenomenon whichcontributes to the emergence and propagation of pathogens such as MRSA (methicillin-resistant Staphylococcusaureus ).

4. LEGISLATION

28MEDICAL WASTE MANAGEMENT4.1International agreementsSeveral international agreements have been concludedwhich lay down fundamental principles concerning publichealth, environmental protection and the safe management of hazardous wastes. These principles and conventions are set out below and must be taken into account inthe planning of hazardous medical waste management.Basel Convention on the Control of TransboundaryMovements of Hazardous Wastes and Their Disposal (UNEP,1992)The main objectives of the Basel Convention are to minimize thegeneration of hazardous wastes, treat those wastes as close as possibleto where they were generated and reduce transboundary movementsof hazardous wastes.It stipulates that the only case where the cross-border movement ofhazardous waste is legitimate is the export of waste from a countrywhich does not have the expertise or the infrastructure for safe disposalto a country which does.Bamako Convention (1991)This treaty banning the importation of any hazardous wastes into Africahas been signed by 12 nations.Stockholm Convention on Persistent Organic Pollutants(UNEP, 2004)This convention aims to reduce the production and use of persistentorganic pollutants and to eliminate uncontrolled emissions ofsubstances such as dioxins and furans.Polluter pays principleAny producer of waste is legally and financially liable for disposing ofthat waste in a manner that is safe for people and the environment(even if some of the processes are sub-contracted).

4. LEGISLATIONPrecautionary principleWhen the risk is uncertain it must be regarded as significant andprotective measures must be taken accordingly.Proximity principleHazardous wastes must be treated and disposed of as close as possibleto where they are produced.Agenda 21 (plan of action for the 21st century adopted by173 heads of State at the Earth Summit held in Rio in 1992To minimize the generation of waste, to re-use and recycle, treat anddispose of waste products by safe and environmentally sound methods,placing all residue in sanitary landfills.WHO and UNEP initiatives concerning mercury andDecision VIII/33 of the Conference of the Parties to theBasel Convention on mercury wastesMeasures should be taken as soon as possible to identify populations atrisk of exposure to mercury and to reduce anthropogenic wastes. TheWHO is ready to guide countries in implementing a long-term strategyto ban appliances containing mercury.The ISWA76(International Solid Waste Association) is aninternational network of waste treatment and management experts. Its purpose is to exchange information witha view to promoting modern waste management strategies and environmentally sound disposal technologies. TheISWA is currently active in over 20 countries with some 1200members throughout the world.7http://www.iswa.org29

30MEDICAL WASTE MANAGEMENT4.2National LegislationNational legislation constitutes a basis which must bedrawn on to improve waste treatment practices in a country. Many countries are currently drawing up nationalmedical waste management plans. The Global Alliance forVaccines and Immunization (GAVI) has been financing aproject in collaboration with the WHO in this context since2006, the aim being to help 72 countries adopt a policy,strategy and plan for managing the wastes generated inhealth-care activities.The following countries are concerned:AfricaAngola, Benin, Burkina Faso, Burundi, Cameroon, Chad,Comoros, Congo, Central African Republic, Côte d’Ivoire,Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea Bissau,Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali,Mauritania, Mozambique, Niger, Nigeria, Uganda, Rwanda,Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Togo,Zambia, Zimbabwe.South AmericaBolivia, Cuba, Guyana, Haiti, Honduras, Nicaragua.Middle East:Afghanistan, Djibouti, Pakistan, Yemen.EuropeArmenia, Azerbaijan, Kyrgyzstan, Georgia, Moldavia,Uzbekistan, Tajikistan, Ukraine.AsiaBangladesh, Bhutan, Cambodia, Democratic People’sRepublic of Korea, India, Indonesia, Laos, Mongolia,Myanmar, Nepal, Solomon Islands, Sri Lanka, Timor-Leste,Viet Nam.

4. LEGISLATIONThe ICRC will have to investigate these various measures.Other national legislative provisions will have to be takeninto account in the medical waste management context: general legislation on waste; legislation on public health and environmentalprotection; legislation on air and water quality; legislation on the prevention and control of infections; legislation on radiation protection; legislation on the transport of hazardous substances; occupational safety and health legislations andregulations.31

5. FUNDAMENTALPRINCIPLESOF A WASTEMANAGEMENTPROGRAMME

34MEDICAL WASTE MANAGEMENT5.1Assigning responsibilitiesThe proper manageme

2.1 Description of medical waste The term “medical waste” covers all wastes produced in health-care or diagnostic activities. Refuse similar to household waste can be put through the same collection, recycling and processing procedure as the community’s municipal waste. The other 10% to 25% is called h