MINISTRY OF HEALTH AND CHILD CARE ZIMBABWE COVID-19 EMERGENCY RESPONSE PROJECT (ZCERP) INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Prepared for: The Ministry of Health and Child Care, Head office Kaguvi Building, Corner 4th Street and Central Avenue, P.O. Box CY 1122 Causeway Harare Zimbabwe October 2022 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) LIST OF TABLES ................................................................................................................................ 3 LIST OF FIGURES .............................................................................................................................. 4 LIST OF ABBREVIATIONS ................................................................................................................ 5 1 INTRODUCTION ........................................................................................................................... 7 1.1 Description of Project Components and Context ..................................................................................... 7 1.2 Health Facilities in Zimbabwe.................................................................................................................... 9 1.3 Design Requirements for Health Facilities .............................................................................................. 13 1.4 Zimbabwe Healthcare Waste Management Status ................................................................................ 16 1.5 Health Care Waste Situation in Zimbabwe ............................................................................................. 17 1.6 National Institutional, Organisational and Technical Capacity of Zimbabwe to Manage Non- Hazardous and non-Infectious Waste ........................................................................................................... 18 2 INFECTION CONTROL AND WASTE MANAGEMENT ................................................................. 19 2.1 Overview of Infection Control and Waste Management in HCF ............................................................ 19 2.2 Generation of Health Care Waste ........................................................................................................... 32 2.3 Management Measures ........................................................................................................................... 37 2.4 Types of Incinerators ............................................................................................................................... 57 2.5 Management of Health Care Workers .................................................................................................... 63 2.6 Safely Disposing of Grey Water or Water from Washing PPE, Surfaces and Floors .............................. 65 2.7 Roles and Responsibilities for ICWMP .................................................................................................... 66 3 EMERGENCY PREPAREDNESS AND RESPONSE ......................................................................... 68 3.1 Management of Spillages ........................................................................................................................ 68 3.2 Occupational Post-Exposure prophylaxis................................................................................................ 70 3.3 Reporting Accidents and Incidents .......................................................................................................... 72 3.4 Personal Protective Equipment ............................................................................................................... 73 3.5 Dilution of Sodium Hypochlorite ............................................................................................................. 73 4 INSTITUTIONAL ARRANGEMENTS AND CAPACITY BUILDING ................................................. 75 4.1 Zimbabwe COVID-19 Emergency Response Project (ZCERP) Level ........................................................ 75 4.2 National (Central) Level ........................................................................................................................... 75 4.3 Provincial Level ........................................................................................................................................ 76 4.4 District Level ............................................................................................................................................. 76 2 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 4.5 Facility Level (Urban and Rural Clinics) ................................................................................................... 77 4.6 Trainings ................................................................................................................................................... 78 4.7 External Supervision and Support Implementation ......................................................................... 80 5 MONITORING AND REPORTING................................................................................................ 81 5.1 Monitoring and Reporting Arrangements............................................................................................... 81 5.2 Estimating Amount of Health Care Waste Generated Per Facility ......................................................... 89 5.3 Reporting .................................................................................................................................................. 89 5.4 Implementation of Infection Control and Waste Management Plan (ICWMP) ..................................... 90 6 STAKEHOLDER CONSULTATIONS ............................................................................................ 105 7 RESOURCE LIST: COVID-19 GUIDANCE ................................................................................... 107 APPENDICES ................................................................................................................................ 109 Appendix 1: Infection Control and Waste Management Plan for MOHCC ................................................ 109 Appendix 2: Medical Waste Management Plan Template ......................................................................... 111 Appendix 3: Infection Control and Waste Management Checklist ............................................................ 115 Appendix 4: Incinerator Operation Checklist and Safety Guidelines ......................................................... 120 Appendix 5: Establishing a New Healthcare Waste Incinerator in Zimbabwe........................................... 126 Appendix 6: PPE Requirements ................................................................................................................... 131 Appendix 7: Stakeholder Consultations ...................................................................................................... 134 LIST OF TABLES TABLE 1-1 NUMBER OF TARGETED HEALTH FACILITIES UNDER ZCERP ....................................................................... 9 TABLE 1-2 HEALTH FACILITIES TARGETED BY THE PROJECT BY ACTIVITY...................................................................... 12 FIGURE 2-1 DIVERSE ROLES IN INFECTION PREVENTION AND CONTROL FOR HEALTH CARE DELIVERY............................. 24 FIGURE 2-2 THE CHAIN OF INFECTION ................................................................................................................. 27 FIGURE 2-3 STANDARD PRECAUTIONS ................................................................................................................ 30 TABLE 2-1 CATEGORIES OF HEALTH CARE WASTE ................................................................................................. 32 TABLE 2-2 ZCERP HEALTH CARE WASTE STREAM ................................................................................................ 35 FIGURE 2-4 INFECTIOUS HEALTHCARE WASTE MANAGEMENT ................................................................................ 38 FIGURE 2-5 WASTE MINIMIZATION STAGES .......................................................................................................... 39 TABLE 2-3 RECOMMENDED WASTE SEGREGATION AND COLLECTION SCHEME ........................................................... 41 TABLE 2-4 COLOUR CODING FOR WASTE SEGREGATION ........................................................................................ 42 TABLE 2-5 RESPONSIBILITY AND REQUIREMENTS FOR WASTE MANAGEMENT ............................................................ 42 TABLE 2-6 DEFINITIONS USED IN TREATMENT AND DISPOSAL OF WASTE .................................................................... 46 TABLE 2-7 RECOMMENDATIONS FOR MANAGEMENT OF HEALTHCARE WASTE .......................................................... 54 3 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) TABLE 2-8 COMPARISON OF EHS GUIDELINES AND ZIMBABWEAN EMISSION STANDARDS ........................................... 61 TABLE 3-1 EXAMPLE OF A LIST OF ITEMS FOR SPILLAGE CLEANING ............................................................................ 68 TABLE 3-2 MANAGEMENT OF HEALTH CARE WORKER FOLLOWING BLOOD/BODY FLUID EXPOSURE ............................. 71 FIGURE 3-1 FLOW CHARTS FOR HIV &HBV POST EXPOSURE PROPHYLAXIS................................................................ 72 TABLE 3-3 SODIUM HYPOCHLORITE DILUTIONS .................................................................................................... 74 TABLE 5-1 INFECTION CONTROL AND WASTE MANAGEMENT PLAN INDICATORS ........................................................ 82 TABLE 5-2 INFECTION CONTROL AND WASTE MANAGEMENT PLAN ........................................................................... 91 TABLE 5-3 TRAINING PLAN AND BUDGET FOR STAFF AND SUPPORT STAFF .............................................................. 103 TABLE 5-4- ESTIMATED IMPLEMENTATION BUDGET ............................................................................................ 104 FIGURE 6-1 STAKEHOLDER CONSULTATIONS FOR HSDSP AFV ICWMP ................................................................. 105 LIST OF FIGURES FIGURE 2-1 DIVERSE ROLES IN INFECTION PREVENTION AND CONTROL FOR HEALTH CARE DELIVERY............................. 24 FIGURE 2-2 THE CHAIN OF INFECTION ................................................................................................................. 27 FIGURE 2-3 STANDARD PRECAUTIONS ................................................................................................................ 30 FIGURE 2-4 INFECTIOUS HEALTHCARE WASTE MANAGEMENT ................................................................................ 38 FIGURE 2-5 WASTE MINIMIZATION STAGES .......................................................................................................... 39 FIGURE 6-1 STAKEHOLDER CONSULTATIONS FOR HSDSP AFV ICWMP ................................................................. 105 4 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) LIST OF ABBREVIATIONS AF Additional Funding DDC District Development Committee DEHO District Environmental Health Officer DMO District Medical Officer IEC Information, Education and Communication IPC Infection Prevention and Control IPCFP Infection Prevention and Control Focal Person ICWMP Infection Control and Waste Management Plan EMA Environmental Management Agency EHSD Environmental Health Service Department EHO Environmental Health Officer EHT Environmental Health Technicians ESCP Environmental and Social Commitment Plan GoZ Government of Zimbabwe HSDSP Health Sector Development Support Project HAI Healthcare Associated Infections HF Health Facility HCWMP Healthcare Waste Management Plan MFI Multilateral Financial Institutions MoHCC Ministry of Health and Child Care NIPCC National Infection Prevention and Control Committee NMRL National Microbiology Reference Laboratory PDC Provincial Development Committee PEHO Provincial Environmental Health Officer PIE Programme Implementing Entity 5 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) PIU Project Implementing Unit PMD Provincial Medical Director PPE Personal Protective Equipment POP Persistent Organic Pollutants RBF Result Based Financing RMNCAH Reproductive Maternal, Neonatal Child, Adolescent, Health and Nutrition SOP Standard Operating Procedure WB World Bank ZCERP Zimbabwe COVID-19 Emergency Response Project 6 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 1 INTRODUCTION 1.1 Description of Project Components and Context On 31 December 2019, the World Health Organisation (WHO) received a report of a cluster of pneumonia patients in Wuhan City, Hubei Province of China. One week later, on 7 January 2020, Chinese authorities confirmed that they had identified a novel (new) coronavirus as the cause of the pneumonia. The virus was named 2019‑nCoV, later renamed COVID-19.1 WHO Director General convened meetings of the International Health Regulations (2005) Emergency Committee on the outbreak of novel coronavirus (n-CoV) on the 23rd and 30th January 2020.2 Following the recommendation of the IHR (2005) Emergency Committee, WHO Declared the outbreak a Public Health Emergency of International Concern on the 30thJanuary 2020. In line with recommendations issued by the IHR (2005) Emergency Committee, all countries were urged to prepare for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of further human-to-human transmission of the virus. The disease continued to spread rapidly, and all the countries have now been affected. Zimbabwe recorded its first COVID-19 case on March 20, 2020, and by April 20, 2022, the cases had reached 247,383 with 5,467 deaths. Zimbabwe developed a National Preparedness and Response Plan to minimize morbidity and mortality resulting from COVID-19 and associated adverse socio-economic impact in the country while strengthening national core capacities under IHR (2005)3. The Government of Zimbabwe (GoZ), through the Ministry of Health and Child Care (MoHCC), has prepared the Zimbabwe COVID-19 Emergency Response Project (ZCERP) with World Bank technical and financial support to respond to this pandemic. The Government of Zimbabwe (GoZ) has prepared this ICWMP to present the standards and procedures that the ZCERP will take to prevent and control infections as well as for management and disposal of health care waste to prevent and or/ mitigate its negative environmental, health and safety impacts. The ICWMP is both a World Bank and Government of Zimbabwe requirement. GoZ requires that every generator of waste prepare a waste management plan specifying the types of waste produced with specific goals and plans for waste reduction, safe handling, transportation and disposal of such waste. This Infection Control and Waste Management Plan is part of the ESMF for the Zimbabwe COVID-19 Emergency Response Project (ZCERP). The activities under the ZCERP 1 Ministry of Health and Child Care, 2020 2 WHO (2020), WHO Director-General's statement on IHR Emergency Committee on Novel Coronavirus (2019-nCoV) on 30 January 2020. 3 Zimbabwe Preparedness and Response Plan, Corona Virus Disease 2019- COVID -19, Ministry of Health and Child Care 7 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) project are being financed through an Energy Sector Management Assistance Program (ESMAP)4 grant (US$1.575 million) and the Health Emergency Preparedness and Response Trust Fund (HEPRTF)5 (US$5 million). ZCERP will be implemented over 18 months, complementing activities being supported under the HSDSP AF V parent project. The Project Development Objective for HSDSP AF-(V) is to increase coverage and quality of an integrated package of RMNCAH-N services, as well as strengthen COVID-19 response and institutional capacity to manage peformance-based contracts consistent with GoZ ongoing health initiatives. HSDSP AF (V) allocated US$5 million of itsUS$25 million towards a COVID-19 response component being financed by a Global Financing facility (GFF) grant which became effective on 4 December 2020. The COVID-19 Response Component will support the GoZ to prevent the spread of COVID-19, prioritising infection prevention and control, while also strengthening the focus on results of the national COVID-19 response. ZCERP will also support Zimbabwe's COVID response, through the following components: 1. Vaccine Deployment, Related Risk Communication and Community Engagement, 1.1 Vaccine deployment, 1.2 Risk Communication and Community Engagement, 2. Climate Friendly Related Health System Strengthening, and 3. Overall Response Coordination,Project Management, Monitoring and Evaluation.6 Project activities include support for vaccine deployment and to laboratories. Vaccine deployment will directly increase the volume of infectious sharps (i.e. needles) to be disposed of. Genomic sequencing at the National Microbiology Reference Laboratory (NMRL) will be 4 ESMAP is a partnership between the World Bank and 19 partners to help low and middle-income countries reduce poverty and boost growth through sustainable energy solutions. Through the World Bank Group (WBG), ESMAP works to accelerate the energy transition required to achieve Sustainable Development Goal 7 (SDG7) to ensure access to affordable, reliable, sustainable and modern energy for all. It helps to shape WBG strategies and programs to achieve the WBG Climate Change Action Plan targets. 5 The HEPR Umbrella Trust Fund/TF Program supports countries that are not eligible for IDA/IBRD funding such as Zimbabwe to improve their capacities to prepare for, prevent, respond, and mitigate the impact of epidemics on populations. It was set up as a flexible mechanism to provide catalytic, upfront, and rapid financing at times that other sources of funding are not available for health emergency preparedness and to fill specific gaps in terms of health emergency responses. The Partnership Council endorsed an allocation of $5m to Zimbabwe to support COVID-19 response. The funding was intended to support all aspects of Zimbabwe’s COVID-19 response, including COVID-19 vaccine deployment. 6 Zimbabwe COVID-19 Emergency Response Project- Project Appraisal Document 8 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) strengthened by the procurement of a genomic sequencing machine and reagents. Therefore, ICWMP guidance on reagents management, storage and handling is necessary. Given that project interventions will contribute to the generation of health care waste from Covid-19 vaccination activities, this Infection Control and Waste Management Plan (ICWMP) has been drafted to manage the related waste. This ICWMP builds upon the HSDSP AF-V ICWMP. ZCERP vaccine deployment activities necessitated the updating of the ICWMP to incorporate the changes in scope. This ICWMP presents Standard Operating Procedures and a Waste Management Plan for project health facilities (HF) based on a rapid situation assessment. This ICWMP is a safeguard instrument that is part of the ZCERP’s Environmental and Social Management Framework (ESMF). 1.2 Health Facilities in Zimbabwe In Zimbabwe 14% of the health care facilities are in urban areas while 86% are in rural areas. The scope of the project is national covering all the 10 provinces (8 rural and 2 urban provinces) and targeting all the health facilities throughout the country. At Independence in 1980, Zimbabwe adopted the Primary Health Care (PHC) Approach in line with the Alma Ata Declaration of 1978. The implementation of the PHC approach resulted in decentralization of health service provision from central level (cities and towns) to administrative wards at district level in the rural communities. Four tiers for health service delivery were established as follows: • Quaternary Level: Central Teaching Hospitals with specialist medical services in the capital city Harare, the second largest city Bulawayo and in Chitungwiza. • Tertiary Level: Provincial Hospitals with ambulatory and inpatient specialist services in the eight rural provinces of Zimbabwe. • Secondary Level: District Hospitals with emergency, ambulatory and inpatient services in the sixty-two districts of Zimbabwe. • Primary Level: Rural Health Centres with primary care services in the rural areas of Zimbabwe. The targeted health care facilities which are being supported by ZCERP project are as follows: TABLE 1-1 NUMBER OF TARGETED HEALTH FACILITIES UNDER ZCERP Type of HCF Number of Facilities Central Hospitals 6 Provincial Hospitals 8 9 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) District Hospitals 44 Rural Hospitals 62 Primary Health Facilities (clinics, polyclinics, 1469 city council/ municipal clinics, mission clinics, Rural Health Centres) Total 1589 Source: Zimbabwe National Health Strategy The average bed capacity for the Rural Health Centres/ Clinics in supported facilities is 7 beds per facility, average bed capacity for the district hospitals is 130 beds per district hospital and the average bed capacity for provincial hospitals is 170 beds per provincial hospital. Under the more than 1500 health facilities are to be supported in vaccine deployment activities through PPE provision for health care workers, transportation of vaccines. Twenty-nine (29) HF are to be supported with energy generation equipment and 250 HF are to be supported with solar direct drive refrigerators. All these health facilities are generally easily accessible with good infrastructure such as road network, water and power supply. From the laboratories, waste will be increased from use of the COVID-19 genomic sequencing machine and reagents which the project is going to supply. The genomic sequencing machine will be supplied to the National Microbiology Reference Laboratory (NMRL). Chemical, biological waste will be generated which much be handled and disposed of safely. Traditionally 10-25% of healthcare waste is infectious waste. Incineration is the approved treatment for infectious sharps that will be produced from the use of needles to provide the vaccination. Since waste generated from ZCERP will be sent to facilities with an incinerator in a given province or district for disposal, emission levels are likely to increase to above national emission level of 150mg/Nm3 for NOx resulting in the offending facility being fined by EMA or prosecution Health facilities and laboratories will generate increased amount of waste, such as infectious sharps, infectious wastewater and increased incinerator usage resulting in toxic emissions and ash from incompletely combusted clinical waste which could contain high levels of POPs. Gases emitted by the incinerator are carbon dioxide, nitrous oxide, and sulphur dioxide. Emission levels will be higher if the incinerator is not reaching the required temperatures to completely burn the waste, 600-800oC. Many Zimbabwe HF incinerators do not reach the required temperatures leaving waste not completely neutralized. The health facilities and laboratories will generate increased amount of waste, such as infectious sharps, infectious wastewater and increased incinerator usage resulting in toxic emissions and ash from incompletely combusted clinical waste which could contain high levels of POPs. These will need to be managed properly to prevent environmental contamination and community exposure to POPs by implementing the requirements of the project ICWMP. Ash residues from incinerators will be disposed in on-site cement lined pits. It is important to note that since sharps will not be disinfected with chlorine 10 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) solutions, POPs are not expected to form during incineration. Health Care waste will be properly segregated at the point of generation to prevention sending for incineration material that will produce POPs. Waste handlers and practitioners must be provided with sufficient and appropriate PPE which must include face masks and eye protection (especially for cleaning of hazardous spills), and respirators (for spills or waste involving toxic dust or incinerator residue). However, overall, the total amount of emissions from ZCERP activity is not significant since the amount of sharps and other infectious waste will be small in comparison to the larger volumes from other health facility activities. See the ZCERP ESMF for further explanation. One challenge of hazardous waste incineration is to destroy POPs in the waste as completely as possible, while minimising the formation and release of POPs that form during the cooling of combustion gases. To avoid production of POPs, halogenated plastics such as polyvinyl chloride (PVC) and other chlorinated plastics and chlorinated compounds will not be introduced into the incinerator. The sharps and PPE are the biggest source of infectious waste under the project. As mentioned above, sharps used in vaccination will not be cleaned with chlorine prior to incineration so it is unlikely that the project will produce POPs. 1.2.1 Impacts from Health Care Activities Eight-five percent of waste generated from health care facilities is non-infectious while 15% is infectious, However due to COVID-19 pandemic medical waste generation has increased six- fold7 and project activities have not been spared, this will increase the cost of waste management supplies for example bin liners, exposure of healthcare workers to needle prick injuries, and gaseous emissions. With the COVID-19 pandemic, poor management of waste especially tissue used from sneezing and used PPE could increase disease transmission. None of these are new impacts introduced by the project, rather the project may just increase the amount of waste, exposure and other impacts. At the same time Government and other international organisations are working on similar initiatives in the concerted fight against the COVID-19 pandemic. All these efforts will result in a cumulative improvement in the quality of care and the increase of utilization of public health facilities. Currently none are expected as project interventions are very small-scale. For example, as already mentioned, any emissions from the incineration of sharps from project vaccinations is insignificant as 2kg sharps are generated per week for smaller rural facilities and 5-times as much for secondary facilities in these are managed on-site or transported for off-site incineration. In any case, project impacts will be managed and minimized through use of the ESMF, this ICWMP, the individual facility Medical Waste Management Plans and any site- specific or general Environmental Management Plans so there should not be much concern of the project significantly contributing to cumulative impacts. Each participating health facility is required to develop and implement its own individual Health Care Waste Management Plan before receiving project support for activities that will generate infectious medical waste. These 7 Sarkodie, S.A., Owusu, P.A. Impact of COVID-19 pandemic on waste management. Environ Dev Sustain 23, 7951–7960 (2021). https://doi.org/10.1007/s10668-020-00956-y 11 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) individual facility ICWMP will be developed by facility management with support from District Health Executives and Provincial Health Executives, MOHCC and PIE. Implementation of the ICWMP will contribute to the realisation of the MoHCC mission, which is to provide, administer, coordinate, promote and advocate for the provision of equitable, appropriate, accessible, affordable, and acceptable quality health services and care to Zimbabweans using available resources, in line with primary health care approach. Patients and health workers are at risk of acquiring avoidable infections within institutions (nosocomial infections), if infection prevention and control and disposal of medical waste are weak not only for patient safety but for health worker safety. Implementing the ICWMP will also contribute to the achievement of goals and objectives Quality Assurance and Quality Improvement (QA &QI) Policy, thus delivery of quality health care services. TABLE 1-2 HEALTH FACILITIES TARGETED BY THE PROJECT BY ACTIVITY ACTIVITY LOCATION Vaccine Deployment 214 central, provincial, district and rural hospital, 1122 clinics, 25 mission clinics, 307 rural health facilities, mission, and council clinics. Risk Communication Throughout the country and targeted hotspots and Community Engagement Installation of solar In 29 health facilities energy generation equipment Installation of solar Targeting 250 health facilities direct drive refrigerators Installation of 8 vaccine delivery trucks refrigerated units in trucks Central hospitals in Zimbabwe were not built for infectious diseases but in every city, there is an infectious disease hospital for treatment and care for those with infectious diseases. Zimbabwe had its first COVID-19 cases on the 20th of March and from then cases increased. However, the government of Zimbabwe has put up in place a national rapid response team for COVID-19 consisting of 9 pillars as follows: 12 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 1. Coordination and planning 2. Risk communication and community engagement 3. Surveillance 4. Point of entry 5. National laboratory systems 6. Infection prevention and control 7. Case management and continuity of essential services 8. Logistic procurement and supply management 9. Socio-economic pillar (outside the MOHCC) The Socio –economic pillar includes security. To oversee all these pillars, the President established a National Inter-Ministerial Committee which provides oversight to the response. In response to COVID –19, central, provincial and district hospitals were repurposed to compliment infectious disease hospitals as the cases increased. Infectious hospitals were upgraded to cater for critically ill patients who might need assisted ventilation. When repurposing or constructing healthcare facilities, infection prevention and control measures must be put in place to reduce transmission of infections. Measures to reduce the transmission of COVID-19 health facilities need to be actively implemented. Some of the recommended IPC measures include: • Hand hygiene • Respiratory hygiene • Maintaining physical distance of >1m • Rational use of PPE including universal use of masks • Screening and triage However, engineering/environmental, and administrative controls need to be well established to have effective implementation of IPC measure. 1.3 Design Requirements for Health Facilities When healthcare facilities are being designed, engineering or environmental controls should focus on the infrastructure as follows: • Layout of the different departments/units/wards in relation to each other and this will determine how staff and patients move within the facility, number of patients and type of equipment that can be accommodated • Availability of sufficient hand hygiene stations both for hand washing or sanitizing by staff, patients and visitors. • separation of clean / sterilized and dirty /contaminated materials and people flows, 13 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) • development and inclusion of adequate disinfection / sterilization procedures and facilities, • adequate space for the storage of recyclable materials (e.g. cardboard and plastic) for pickup; • selection of heating systems • provision of hazardous material and waste storage and handling areas; treatment and exhaust systems for hazardous and infectious agents; and selection of easily cleaned building materials that do not support microbiological growth, are slip-resistant, nontoxic, and nonallergenic, and do not include volatile organic compound (VOC)-emitting paints and sealants. • Availability and proper positioning of donning and doffing • Ventilation systems whether mechanical or natural • During this COVID-19 pandemic existing facilities have been repurposed to become isolation facilities and new structures (temporary or permanent) have been established to facilitate triaging of suspect and confirmed cases of COVID-19 • It is important to actively involve IPC practitioners/experts when constructing, repurposing or renovating healthcare facilities in order to make sure that the infrastructure will support good IPC practices. • Procurement of quality and correct size PPEs The project will ensure avoidance of the release of pollutants or, when avoidance is not feasible, minimize and control the concentration and mass flow of their release using the performance levels and measures specified in national law or the EHSGs, whichever is most stringent. This applies to the release of pollutants to air, water, and land due to routine, nonroutine, and accidental circumstances, and with the potential for local, regional, and transboundary impacts. Where the project includes new buildings and structures that will be accessed by members of the public, the project will consider the incremental risks of the public’s potential exposure to operational accidents or natural hazards, including extreme weather events. Where technically and financially feasible, the concept of universal access will also apply to the design and construction of such new buildings and structures. This project is unlikely to support any new (i.e., to be built) HF; however, it is important to note that for any new HCFs to be financed by the project, waste disposal facilities should be integrated into the overall design and an ESIA developed. 1.3.1 Administrative Controls and Operational Controls In the design of health care facilities, there is need to put in place administrative and operational controls as outlined below. 14 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) • Infection control policies, guidelines, and standard operating procedures (SOPs), to be availed and understood by all levels of staff. All staff to be trained on the policies, guidelines, and adherence to SOPs. • Human, financial resources and supplies to be availed. • Nurse patient ratios to be adhered to. • Capacitating all healthcare workers in current health issues e.g. COVID-19. • Provision of adequate and easy access to PPE (See Appendix 6) IPC Considerations when designing isolation and treatment centres When building or renovating consider space for the following: • Clinical practice • Hand hygiene facilities in the patient care areas • Reprocessing of medical devices • Staff areas (e.g. tea, rest, conference rooms) including separate space for ancillary staff • Clean and dirty areas (e.g. medicine preparation, sluice, waste holding areas) • Good ventilation (12 - 15 air changes per hour) • Type of floors, lighting and smooth walls • Patient comfort • Separate toilets for staff and patients • Isolation areas (single rooms or cohort facilities) with in-suite facilities • Storage for PPE, sterile items, drugs, etc. Staff and Patient Flow The movement of staff and patients in isolation and treatment facilities should be controlled and unidirectional hence there should be demarcated as 1. Low risk (green zone) 2. Intermediate risk (yellow zone) 3. High risk (red zone) Staff areas are considered to be low risk areas and direct movement from high-risk areas is prohibited. Intermediate risk is the nurse’s stations and duty rooms where one can enter coming from the red zone. Red zone area is the highest risk where the confirmed cases are taken care of and this is considered the highly infectious zone. 15 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 1.4 Zimbabwe Healthcare Waste Management Status The general situation and capacity on healthcare waste management in Zimbabwe is very low since it has partially collapsed. There is no proper infrastructure for healthcare waste management in most facilities. At the central hospitals, the old incinerators have broken down and are now irreparable. Some of the rural healthcare facilities have waste management facilities with Otto way pits, bottle crushers and pits, ash pit and incinerator. In HCF glass bottles are disposed in bottle pits which are fitted with a bottle crusher. The bottle crusher is used to crush the bottle before it is disposed of in the pit. This is done to ensure the pit does not fill up quickly. Some of the waste management areas are secured. The incinerators have very low temperatures which do not completely burn the waste such as sharps and bottles. The main source of fuel for incinerators is coal, but in rural healthcare facilities, they also have challenges with accessing coal to use for combustion and they end up resorting to firewood which is not always available and is not environmentally sustainable. In the ten provinces one or two provincial hospitals have an incinerator but they are no longer maintaining the required temperatures of 800-1000℃ to completely burn all the waste, due to shortages of fuel for combustion. However, in Harare there is a seasoned private waste management company Bromo and Bytes used by most private healthcare facilities in the Harare province, for final disposal of their waste This private company has an incinerator with temperatures of 1200 to 1400℃ which can even incinerate expired drugs. It assists in final disposal waste from private healthcare facilities. Public health care facilities can also contract with the private operator for the disposal of their waste for a fee. There are some private companies who also collect waste and sent it to these private incinerators for final disposal. Private companies collecting waste are required by law to register with EMA, and they are registered as required by law. MoHCC are the implementors of the Healthcare Waste Management Plan 2011 and EMA regulates and monitors all the activities related to waste management including health care waste. Besides the above-mentioned operator, there is also company now in the country, FENCRAFT, which is locally manufacturing incinerators. It manufactures incinerators of all sizes including standard and advanced models. The incinerators use coal or diesel for combustion. MoHCC can partner with this manufacturer so that they can get the incinerators at a low cost. Generally, the cost of an incinerator is 25000 united states dollars (USD 25,000). Effluents from isolation wards, treatment centres and medical diagnostic laboratories contain chemical and are considered as hazardous liquid waste that should receive specific treatment 16 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) (thermal, chemical and irradiation) before being discharged into the sewer/drainage system, if such a system exists. In addition, there are challenges related to inadequate resources for waste management in the public healthcare facilities. There are no colour coded bins and pedal operated bins therefore segregation of waste using colour coded bins is not being practiced. Some facilities do not have the bins and they end up improvising with cardboard boxes. Furthermore, there are no well- trained incinerator operators to operate the incinerators, to diagnose and conduct minor repairs when an incinerator breaks down. There is also a challenge with the maintenance and servicing of the incinerators which is generally not conducted once the incinerator is installed. The unit is usually used until it breaks down. The Department of Public Works under the Ministry of Local Government and Public Works is responsible for the operation and maintenance of waste management facilities including incinerators, at government institutions. The department has skilled technicians and workers who monitor and maintain these facilities. Through the Results Based Financing (RBF) approach, the PIE will continue to support health facilities to plan and invest in health care waste management facilities and equipment. There is need for the country to revamp and improve service delivery on healthcare waste management in the country and develop appropriate legislation for healthcare waste management. 1.5 Health Care Waste Situation in Zimbabwe A situational analysis was conducted to assess the national status with respect to infection control and waste management by visiting select health care facilities. Six Face-to-face focus group discussion and 2 email questionnaires were for key informant interviews were completed from the 10-30th of September 2020. Also, some key informant questionnaires with other non- governmental organizations like OXFAM and a service provider who manufactures incinerators, FENCRAFT, were completed and they gave their input to the development of this ICWMP. However, 5 email questionnaires were not responded to. Healthcare facilities of different categories were selected for assessment on infection control and health care management practices. The healthcare facilities selected were those which are being supported by the HSDSP AF-V. These were as follows: • 2 central hospitals one in Harare and one in Bulawayo • 2 provinces Mashonaland East and Matabeleland South (provincial, district hospitals, and rural health centre 17 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) • 2 metropolitan cities Harare and Bulawayo isolation facilities and urban clinics. A March 2016 independent assessment, Review of the Implementation of the Health Care Waste Management Plan in 18 Rural Districts under the Results Based Financing Programme in Zimbabwe found that HSDSP brought about an improvement in participating facility waste management, However, this ICWMP review of project facilities in 2020 revealed that there has been a deterioration in the management of health care waste in facilities as evidenced by broken down incinerators and an inadequate supply of bins and bin liners. During the assessment it was that 90% of the facilities visited had no functional incinerators and segregation of waste is not being achieved due to inadequate supply of bins and bin liners. There are no waste storage areas in 75% of facilities visited, and those that have the storage area it is inadequate. It was also observed that there is shortage of vehicles to transport waste to its final disposal. 1.6 National Institutional, Organisational and Technical Capacity of Zimbabwe to Manage Non- Hazardous and non-Infectious Waste The national capacity to manage health care waste in Zimbabwe is enhanced by availability of pieces of legislation that provides for the regulation and management of health care waste. The Environmental Management Act Chapter 20:27 and its Statutory Instruments such as Environmental Management (Atmospheric Pollution Control) regulations of 2009, Environmental Management (Environmental Impact Assessment and Ecosystems Protection) Regulations of 2007, Environmental Management (Effluent and Solid Waste Disposal) Regulations of 2007 and the Public Health Act (Chapter 15:17). The Environmental Management Act requires that every generator of waste prepare a waste management plan specifying the quantity and type of waste being produced. The HCF, by using this plan in developing its own facility ICWMP will meet the requirements of the EM Act. Together all these acts prohibit open dumping and open burning of waste. The Environmental management Act is administered by the Environmental Management Agency (EMA) and the Public Health Act is being administered by the Ministry of Health and Child Care (MOHCC). EMA has competent staff at all from National level to district level to support the implementation of the Environmental management Act and MOHCC through the department of Environmental Health Services has Environmental Health Officers and Environmental Health Technicians up to primary health care facility level. Through their trainings they provide guidance and support the implementation of the ICWMP and take a lead in the development of individual health facility infection control and waste management plan. The responsibility of managing this waste lies with the local authorities which are being affected by shortages of financial, human, and material resources. Zimbabwe lacks appropriate and effective technologies in waste management, due to the country's old infrastructure and this has resulted in the accumulation of waste and outbreaks of diseases. Service delivery has collapsed in most Municipalities as they fail to collect the waste regularly, among the reasons are 18 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) inadequate machinery which frequently breaks down. The standard of waste management continues to fall way below accepted standards with town councils failing to collect waste regularly. 2 INFECTION CONTROL AND WASTE MANAGEMENT 2.1 Overview of Infection Control and Waste Management in HCF Management of health-care waste is an integral part of health care facility hygiene and infection control. Health care waste should be considered as a reservoir of pathogenic microorganisms, which can cause contamination and give rise to infection. If waste is inadequately managed, these microorganisms can be transmitted by direct contact, in the air, or by a variety of vectors. Infectious waste contributes in this way to the risk of nosocomial infections, putting the health of hospital personnel, and patients, at risk. The practices described in Chapters 2 and 3 of this ICWMP for the proper management of health-care waste should therefore be strictly followed as part of a comprehensive and systematic approach to hospital hygiene and infection control. This chapter outlines the basic principles of prevention and control of the infections that may be acquired in health-care facilities (but does not address other aspects of hospital hygiene and safety such as pressure sores and the risk of falls). It should be stressed here that other environmental health considerations, such as adequate water-supply and sanitation facilities for patients, visitors, and health-care staff, are of prime importance. The project will follow WHO guidance and GIIP to reduce the risk of spreading COVID-19 among project implementors and patients. In addition to the standard Covid-19 prevention protocols, these IPC practices will be carried out in vaccination centres under ZCERP as appropriate and required. Patients gathered for vaccination are at risk for COVID-19 infection. MoHCC will establish and maintain an appropriate EHS risk management system for monitoring and surveillance of AEFIs; safe injections; for proper collection, transportation, and disposal of all hazardous medical wastes (including from this project); and for minimization of occupational health and safety risks. According to the WHO, about 15-25% of total health-care waste is infectious waste, and improper handling of health care waste can cause serious health problems for workers, community, and environment. WHO reports showed that worldwide, about 5.2 million people (including 4 million children) die each year from waste related diseases. The hazards of exposure to health care waste can range from gastro-enteric, respiratory, and skin infections to more deadly diseases such as HIV/AIDS, and Hepatitis. WHO reported that globally, injections with contaminated syringes caused 21 million hepatitis B infections (32% of all new infections), 2 million hepatitis C infections (40% of all new infections) and 260,000 HIV infections (5% of all new infections). More specifically medical waste has a high potential of carrying micro-organisms that can infect people who are 19 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) exposed to it, as well as the community at large if it is not properly disposed of. Many of these infections were avoidable if the wastes had been disposed of safely (WHO 2004)8. Although treatment and proper disposal of health-care waste reduces risks, indirect health risks may occur through the release of toxic pollutants into the environment through treatment or disposal. For instance, landfills can contaminate drinking-water if they are not properly constructed. Occupational risks exist at disposal facilities that are not well designed, run, or maintained. Furthermore, incineration of waste has been widely practiced but inadequate incineration or the incineration of unsuitable materials results in the release of pollutants into the air and generate ash residue. Incinerated materials containing chlorine can generate dioxins and furans, which are human carcinogens and have been associated with a range of adverse health effects. Incineration of heavy metals or materials with high metal content (in particular lead, mercury and cadmium) can lead to the spread of toxic metals in the environment. Dioxins, furans and metals are persistent, and bio accumulate in the environment. Materials containing chlorine or metal should therefore not be incinerated. The beneficiary health-care activities in the vaccination centres will protect and restore health and save lives however, the amount of infectious waste and by-products being generated may cause adverse potential health and environmental impacts. The average distribution on types of medical waste for purposes of waste management planning is approximately 80% non-infectious and 20% infectious such as biological/pathological waste, chemical/pharmaceutical waste and sharp materials. The quantity of infectious wastes generated will increase due to infectious nature of COVID-19. According to WHO guidelines, all the waste generated in and around the care of COVID-19 patients is treated as infectious waste. For adequate implementation and management of infection control and waste management, health facilities need to incorporate the following in their individual ICWMPs: • Waste minimisation o Source reduction measures o Waste toxicity reduction measures o Efficient stock management practices and monitoring o Maximisation of safe equipment use • Waste segregation strategies • On-site handling, storage and transportation • Off-site transportation 8 https://www.who.int/water_sanitation_health/medicalwaste/en/hcwmpolicye.pdf 20 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) • Treatment and disposal options o Incineration ▪ Pollution prevention measures o Chemical disinfection o Wet thermal treatment o Microwave irradiation o Land disposal o Inertisation • Wastewater management • Treatment and disposal methods for categories of waste • Activity implementation plan with timeframes and responsibilities assigned per activity • Budget 2.1.1 Importance of Infection Prevention and Control (IPC) Infection prevention and control protects: • Patients from hospital acquired infections which are costly to deal with as they increase length of stay in the hospital, require treatment with expensive broad-spectrum antibiotics and increase use of other interventions like laboratory and surgery. • Healthcare workers from occupational exposures bloody borne infections like HIV and Hepatitis B and C. • Communities and the environment from pollution 2.1.2 National infection Prevention and Control Guidance The Public Health Act makes provision for the control of activities and situations that have potential to affect public health. It establishes powers of health officials, local authorities and has several regulations made subservient to it, including the Public Health (Effluent) Regulations 1972 (SI.639 of 1972) serve to control the disposal of effluent into the environment. In view of this legal requirement, all work areas should have proper provision for management of human excreta and general waste from project sites. The Act also provides for the formulation of regulations regarding formidable epidemic diseases and conditions or events of public health concern. These regulations may be on imposition and enforcement of quarantine and the regulation and restriction of public traffic and of the movement of persons, the closing of public places such as schools, churches, cinemas, establishment of isolation facilities/ hospitals among other this necessary for the control of infectious diseases. In this regard the MOHCC, formulated 21 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) the Public Health (COVID 19 prevention, containment, and treatment) (amendment) regulations, 2020, Statutory Instrument 103 of 2020. The Statutory Instrument makes screening and testing mandatory and must remain in force even after expiry of the national lockdown. For all workers who were on lockdown and are coming to work should screened and tested for the virus. The use of Rapid Diagnostic Tests (RDT) in Zimbabwe according to the World Health Organisation guidelines is in place. Persons who are essential services should be tested regularly. Sanitizers and hand washers should be put on all office entrances. A law enforcement officer can randomly visit any workplaces without notice. The officer can close any premise as they see fit, by writing or other formal means. Persons who fail to comply will be fined. Depending on the location of work areas, the Project Implementing Entity (PIE), MOHCC and designated health care facilities will ensure that there are toilets and waste collection bins in all qualifying work areas. The project will also ensure that provisions are made for potable water supply, and adequate and proper sanitation facilities, and waste collection bins at all vaccination sites especially mobile outreach centres that will have many people at the same place. The country developed the National Infection Prevention and Control Guidelines of 2019 which promote safe practices in all health care settings and facilities (that is ZCERP settings) providing health care workers, managers and communities with standards and criteria to implement and measure safe practices in infection prevention and control. In addition, due to the infectious nature of COVID-19, the MoHCC has developed the Infection Prevention and Control (IPC) Guidelines and Standard Operating Procedures in Health care Facilities for COVID-19 which is an addendum to the National Infection Prevention and Control Guidelines of 2019. The document provides technical measures required to reduce the risk of COVID-19 transmission. 2.1.3 Infection Prevention and Control Programmes According to the National infection prevention and control guidelines and policy each healthcare facility should have infection prevention and control programme. 2.1.4 Management and Organisation Organisational Structures for effective implementation of IPC activities at the various levels of health care delivery include: • Ministry of Health and Child Care- National Infection Prevention and Control Committee (NIPCC) -Central Hospitals -Province & City Health Directorate levels -District Level 22 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) -Health Facility level -Community Representatives • Other sectors to be involved in IPC service development (Local Government, Housing & Public Works) 2.1.5 Components of an Infection Prevention and Control Programme • A focal IPC Coordinator • Infection Control Team Plus Infection Prevention and Control Committee • An IPC Plan with timelines • Infection Prevention and Control Guidelines, Policies and Standard Operating Procedures (SOPs). • Standard Precautions and Transmission Based Precautions • System of Monitoring of IPC practice includes risk assessment • Surveillance of Healthcare Associated Infections (HAI) and Multi-drug resistant organisms • Training 2.1.6 Principles and practices of infection prevention and control IPC is the responsibility of all health care providers as part of duty of care aimed at prevention of the transmission of pathogens (microorganisms that can cause disease) where healthcare is being delivered. It is an active, on-going quality assurance process that develops, implements, supports and monitors IPC standards also involves all aspects of healthcare delivery. Figure 2-1 below shows that infection control is everyone’s responsibility in healthcare delivery. 23 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) FIGURE 2-1 DIVERSE ROLES IN INFECTION PREVENTION AND CONTROL FOR HEALTH CARE DELIVERY 2.1.7 Main Functions of an IPC Program 1. Develop and maintain IPC policies and procedures based on best practice standards -Policies must be appropriate for the healthcare context (level of care and cost-effective) 2. Educate and train healthcare workers, patients, and support staff in IPC 3. Obtain and manage IPC data: -Surveillance data of healthcare-associated infection (HAI) -Other relevant data, e.g. staff exposure to blood and body fluids 4. Implement isolation precautions and monitor clinical practice 5. Identify and manage outbreaks 6. Conduct IPC risk assessments (audits) and risk management 7. Advise and support procurement of capital equipment and supplies 8. Active participation in healthcare facility design and reconstruction to improve workflow 9. Research in IPC – collect, interpret, and share data and experiences 24 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.1.8 Roles of the IPC Focal Person Each healthcare facility generally has an IPC Focal Person for the following tasks: -Conducting surveillance activities such as investigating outbreaks of hospital infections. -Monitoring infection prevention and control practices -Collecting, recording, storing, and reporting relevant infection control data. -Advising on the management of ‘at risk’ patients relating to isolation categories and prevention and control measures -Conducting learning needs assessment on infection prevention and control for all categories and levels of health workers. -Planning, conducting training and/or participating in orientation and education programs on infection prevention and control. -The Infection Prevention Control Focal Person (IPCFP) also keeps a record of all staff that has completed such trainings and programs. -Serving as the secretary of the Infection Prevention and Control Committee. -Facilitating availability of vaccines e.g. Hepatitis B vaccines for all HCW including waste handlers. The IPC Focal Person should be a healthcare worker trained in basic IPC or holding a Postgraduate diploma in IPC and her/his condition of employment is generally on a full-time basis. 2.1.9 Essential IPC Structures Central, provincial and district hospitals should have multidisciplinary IPC committee and at rural healthcare centres, urban and rural clinics there should be IPC teams which report all their IPC issues to the district and the district reports to the province. IPC teams for hospitals to include link nurses/person who will be coordinating IPC issues within their departments. Link Nurses/Persons Definition • Link Nurses (LNs)/persons are defined as ‘practicing nurses or persons with an expressed interest in a specialty and a formal link to specialist team members’ (MacArthur, 1998) in this case IPC teamThese nurses/persons link between ward/unit/clinic/departments and IPC team. They are the “Eyes and ears� of IPC, they are an advocacy for good IPC practices Their role is to increase awareness of infection control issues in their ward or departments and motivate staff to improve IPC practice. 2.1.10 IPC Committee/Team Should be a multidisciplinary team with the following responsibilities • Link with hospital management 25 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) • Set standards and establish IPC policies • Identify and deal with IPC priorities • Monitor antibiotic usage • Initiate IPC policies • Surveillance and monitoring of IPC practice • Training & development of local IEC material • Management of outbreaks 2.1.11 IPC Guidelines Policies and guidelines should easily be accessible to all healthcare workers, and to be user- friendly, and these are: • IPC policies, standard operating procedures • National and other IPC guidelines 2.1.12 Example of a Clinic IPC Committee/Team • Nurse in charge of the clinic • Environmental health technician • Nurse aid • General hand • Health Centre Committee (HCC) representative • Community based organizations representative The above is a multidisciplinary team which handles IPC and waste management issues at facility level and these issues include water and sanitation, waste collection and disposal and also environmental cleanliness. 2.1.13 The Infectious Disease Transmission Cycle Transmission of infectious agents within a healthcare setting requires three elements: a source (or reservoir) of infectious agents, a susceptible host with a portal of entry receptive to the agent, and mode of transmission for the agent as shown in Error! Reference source not found.. 26 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) FIGURE 2-2 THE CHAIN OF INFECTION What is the chain of infection? For infection to develop the following are needed: 1. An infectious agent (the disease causing or pathogenic microorganism) 2. A susceptible host (a human with poor immune defences against the micro-organisms) 3. The right environment (the ideal conditions under which infection can be spread). The sequence of infection transmission is sometimes called the “chain of infection�. It is the step- wise manner in which a micro-organism can be transmitted to a susceptible host. The following steps are required to spread an infectious agent or micro-organism 1. It leaves its reservoir. A reservoir is the environment where the micro-organism is usually found, e.g. Staphylococcus aureus is commonly found in the nose; Mycobacterium tuberculosis (TB) is commonly found in the lungs. 2. It leaves through a portal of exit. For example, SARS-COV-2 viruses are coughed up from the lungs (respiratory tract) into the air. 3. . It is transmitted by a route of infection. For example, SARS-COV-2 virus droplets in the air). 27 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 4. It gets into another person through a portal of entry. For example, SARS-COV-2 droplets may be breathed into the lungs of a person closer to the COVID-19 patient. Transmission: For infection transmission to occur there must be enough of the pathogen and the pathogen must be virulent enough to cause disease. The pathogen moves through a route of transmission and reaches a “portal of entry� to enter the susceptible host. Common portals of entry include respiratory tract, gastrointestinal tract, mucosa (e.g. nose, conjunctiva, and mouth), genitourinary tract, breach of skin integrity. Chain of infection can be prevented by breaking one or more of the links in the chain of infection transmission between the source or reservoir of infecting organisms which cause the infection and the susceptible host. Standard precautions when adhered to breaks the chain of infection transmission. 2.1.14 Standard Precautions In 1985 Universal Precautions, a system of Infection Prevention and Control which assumed that every contact with body fluids is potentially infectious was developed. In 1987 universal precautions were updated when body substance isolation was added to include the use of gloves when coming in contact with all body fluids, mucus membranes and moist skin. However, in 1995 a synthesis of universal precautions and body substance isolation was carried out which established the now standard precautions. 2.1.15 Objectives of Standard Precautions Objectives of Standard Precautions are the following: • Employee protection against occupational exposure and infection from blood borne pathogens or other body fluids. • Reduction of the risk of transmission of micro-organisms from both recognized and unrecognized sources of infection in a health facility. • Creation of a safe environment for both patients and personnel. The number of patients colonized or infected with pathogens that we know about may only be a small portion of the true picture. Also, the patients not identified or not suspected of being colonized or infected with pathogens represent a substantial risk to other patients; therefore, we must treat all patients as if they have a potential infection. Body fluids classified as infectious are blood, amniotic fluid, vaginal secretions, seminal fluid, peritoneal fluid, pericardial fluid, pleural fluid, and synovial fluid. 28 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.1.16 Healthcare Associated Infections Delivery of healthcare is associated with a risk of transmission of infectious agents through other patients, healthcare workers and in association with medical devices. Risk of transmission of infectious agents is determined by susceptibility, route of transmission, duration and intensity of exposure, and availability and behaviour of healthcare workers with hands-on patient contact. Every year large numbers of patients acquire healthcare associated infections due to poor adherence to standard precautions. Some of these infections are directly related to surgical and other invasive procedures. However, standard precautions are the basic level of infection control precautions which are to be used, as a minimum, in the care of all patients. These are also routine precautions that apply to all patients, health workers and visitors in all health care settings. The aim of standard precautions is to reduce the risk of transmission of infections in all healthcare settings. Use of one or a combination depends on the anticipated contact with the patient. 2.1.17 Components of Standard Precautions • Hand hygiene • Appropriate use of PPE • Safe injection practices • Health care waste management • Sharps management • Spillage management • Environmental cleanliness • Handling of linen • Decontamination and sterilization • Patient’s placement • Cough etiquette • Occupational health 29 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) FIGURE 2-3 STANDARD PRECAUTIONS 2.1.18 Standard Precaution Practices • Consider every person (patient or staff) as potentially infectious and susceptible to infection • Wash hands before and after using gloves, or after accidentally touching blood, body fluids and between patient contacts, or use alcohol hand rub when hands are not visibly soiled. • Wear gloves (both hands) before touching anything wet—broken skin, mucous membranes, blood, or body fluids, soiled instruments, or contaminated waste materials and before performing invasive procedures • Use physical barriers PPEs (protective goggles, face masks and aprons) if splashes and spills of blood or body fluids (secretions and excretions) are likely. • Use antiseptic agents for cleansing the skin or mucous membrane prior to surgery, cleaning wounds, or doing hand rubs or surgical hand scrubs with an alcohol-based antiseptic product. • Use safe work practices such as not recapping or bending needles, safely passing sharp instruments and suturing, when appropriate, with blunt needles. • Safely dispose of infectious waste materials to protect those who handle them and prevent injury or spread of infection to the community • Process instruments and other items after use by thoroughly cleaning first and then either sterilizing or high-level disinfecting them using recommended procedures. 30 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.1.19 Common Challenges to Implementing Standard Precautions Implementation and adherence to standard precautions are a global challenge resulting in Healthcare Associated Infections (HAIs). Some of the common challenges faced worldwide are: 1. Standard precautions are not being applied all the times for all patients by healthcare providers due to complacence. 2. Health institutions do not routinely train staff in IPC to provide an understanding in the rationale application of standard precautions. However, these challenges in implementation and adherence to standard precautions are more pronounced to Zimbabwe because of lack of human capital with the necessary expertise and worsened by brain drain as they look for greener pastures, constrained resources and inadequate supplies for IPC activities and poor economic structures. In addition, these are challenges peculiar to Zimbabwe: 1. Shortages of supplies for IPC activities e.g. PPEs, colour coded bins, colour coded bin liners, detergents and disinfectants 2. Lack of supervision and monitoring of IPC practices to ensure compliance 3. Broken down facilities e.g. hand washing basins, incinerators and window latches 4. Delays in repairs due to limited funding. Despite the challenges where resources are limited recommendations will need to be modified according to what is possible, practical, and affordable. 2.1.20 Transmission Based Precautions These are required to contain highly infectious and/or epidemiologically important pathogens; they are used in addition to Standard Precautions. Transmission based precautions are based on the mode of transmission of the specific pathogen hence Contact Precautions Droplet Precautions Airborne Precautions Application of Transmission-Based Precautions While mostly used for diagnosed infection they are useful when a specific diagnosis is suspected. Goal of this 2-tier system is to minimise risk of infection and maximise safety levels within the healthcare facility environment. Transmission based precautions must be applied by all health workers or visitors into the COVID- 19 care areas. 31 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.2 Generation of Health Care Waste Knowing the types and quantities of waste produced in a health-care facility is an important first step in safe disposal. Waste-generation data are used in estimating the required capacities for containers, storage areas, transportation and treatment technologies. Waste-generation data can be used to establish baseline data on rates of production in different medical areas and for procurement specifications, planning, budgeting, calculating revenues from recycling, optimization of waste-management systems, and environmental impact assessments. 2.2.1 Categories of Health Care Waste The table below explains the different categories of waste as defined by the World Health Organisation. TABLE 2--1 CATEGORIES OF HEALTH CARE WASTE Infectious Infectious wastes: Waste suspected to contain pathogens e.g. Cultures Waste and stocks of infectious agents from diagnostic and research laboratories and items contaminated with such agents; wastes from infectious patients (excreta, dressings from infected or surgical wounds, clothes and bedding heavily soiled with human blood or other body fluids, and other contaminated waste infected with human pathogens e.g. food residues); discarded live and attenuated vaccines; contaminated waste that has been in contact with infected patients undergoing haemodialysis (e.g. dialysis equipment such as tubing and filters, disposable towels, gowns, aprons, gloves, and laboratory coats); infected animals from laboratories. Pathological waste: Human tissues, organs or fluids e.g. body parts; blood and other body fluids; fetuses, animal carcasses infected with human pathogens. Recognizable body parts are also referred to as anatomical waste. Sharps wastes (used or unused): Needles, syringes, scalpel blades, suture needles, razors, infusion sets, contaminated broken glass, specimen tubes and other similar material. Chemical Wastes: Solid, liquid, or gaseous chemicals such as solvents, reagents, film developer, ethylene oxide and other chemicals that may be toxic, corrosive, flammable, explosive or carcinogenic. The types of hazardous chemicals used most commonly in the maintenance of health care facilities and are most likely to be found in waste include: · Formaldehyde · Photographic chemicals · Solvents · Organic chemicals · Inorganic chemicals 32 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Pharmaceutical Wastes: Outdated medications of all kinds, as well as residuals of drugs used in chemotherapy that may be cytotoxic, genotoxic, mutagenic, teratogenic or carcinogenic. Items contaminated by or containing pharmaceutical bottles, boxes. Radioactive Wastes: Any solid, liquid, or pathological waste contaminated with radioactive isotopes of any kind. e.g. unused liquids from radiotherapy or laboratory research, contaminated glassware, packages, or absorbent paper; urine and excreta from patients treated or tested with unsealed radionuclides; sealed sources Genotoxic Wastes: Genotoxic waste is highly hazardous and may have mutagenic or carcinogenic properties. It may include certain cytostatic drugs, vomit, urine, or feaces from patients treated with cytostatic drugs, chemical and radioactive material. Pressurized Containers: Cylinders containing gases or aerosols which when accidentally punctured or incinerated could explode. Waste with High content of Heavy metals: Batteries, broken thermometers, blood pressure gauges etc. Non- Communal Wastes: All solid waste that does not contain hazardous waste Hazardous types). Communal waste from medical treatment or research centres Waste includes uncontaminated wastes such as bottles, office paper, boxes and packaging materials. Source: Safe management of wastes from health-care activities. Edited Pruss A, Giroult E, Rushbrook P. World Health Organization 1999 2.2.2 Liquid Waste Effluents that are a non-chemical liquid wastes but considered infectious, that comes out of laundry, kitchen, toilet, shower, and laboratory rooms which may be contaminated by pathogenic micro-organisms. Effluents from isolation wards, treatment centres and medical diagnostic laboratories contain chemical and are considered as hazardous liquid waste that should receive specific treatment (thermal, chemical and irradiation) before being discharged into the sewer/drainage system, if such a system exists. At rural health facilities (primary care facilities), there are on-site wastewater treatment facilities composed of a lined septic tank which drains treated wastewater into soakaway pit. Larger secondary facilities (hospitals) use off-site wastewater treatment facilities which can be either a waste stabilisation pond or municipal wastewater reticulation system. however, the facility would pre-treat its wastewater before discharging into the municipal system. there are no separate sewer lines for collection of wastewater. During operation of the laboratory activities, all wastes generated in the laboratories of the facility (including sample packaging materials, culture materials, petri dishes, PPE, and associated process wastes) would leave the laboratories only after decontamination 33 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) using the facility’s autoclave, after being chemically sterilized or released effluent from the labs and isolation area directed to a pre-treatment chamber before release to public sewers. Currently, proposed laboratories to be used to manage the large-scale testing for COVID-19 cases also provide several laboratory services for community and public health management including referral laboratory services for whole country. The inclusion of COVID-19 testing in the operation of these laboratories will increase the amount of contaminated liquid waste. The contaminated wastewater will be disposed of in a septic tank as it cannot go through the local drainage. Septic tanks are constructed to facilitate sedimentation and decomposition of small solid particles. The septic tank is an enclosed cement lined tank for the collection of wastewaters from primary health care facilities. The treated water from the septic tank will drain into a soakaway pit. Because of the low volumes of wastewater generated from primary health facilities the septic tank will take long to fill up over (over 30 years). Hazardous wastewater can only be discharged into the public sewer system only after it has been treated. If it cannot be treated, then septic tanks must be used for disposal. However, in most facilities especially in rural areas where they have no access to reticulated sewer systems, they rely on septic tanks. NB: Given the infectious nature of the novel coronavirus, some wastes that are traditionally classified as non-hazardous may be considered hazardous, the volume of waste will increase considerably given the number of admitted patients during COVID-19 outbreak. Special attention should be given to the identification, classification and quantification of the healthcare wastes. 34 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) TABLE 2-2 ZCERP HEALTH CARE WASTE STREAM Source Sharps Infectious and Chemical, Non-Hazardous and Pathological Waste pharmaceutical and General waste cytotoxic waste Laboratory Needles, broken glass, Petri Blood and body fluids, Fixatives; formalin; Packaging, paper, dishes, slides and cover slips, microbiological xylene, toluene, plastic containers broken pipettes cultures and stocks, methanol, methylene tissue, infected animal chloride and other carcasses, tubes and solvents; broken lab containers thermometers; contaminated with reagents blood or body fluids Vaccination Campaigns Needles and syringes Bulk vaccine waste, Packaging Needles and syringes vials, gloves Environmental Services Broken glass Disinfectants Packaging, flowers, Broken glass (glutaraldehyde, newspapers, phenols, etc.), magazines, cardboard, cleaners, spilt plastic and glass mercury, pesticides containers, yard and plant waste Engineering services Cleaning solvents, oils, Food scraps; plastic, lubricants, thinners, metal and glass asbestos, broken containers; packaging mercury devices, batteries 35 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Source Sharps Infectious and Chemical, Non-Hazardous and Pathological Waste pharmaceutical and General waste cytotoxic waste Food Services Food scraps; plastic, metal and glass containers; packaging Source: Excerpted and adapted from Safe management of wastes from health-care activities, World Health Organisation / edited by Y. Chartier et al. – 2nd ed. as cited by the HSDSP ICWMP (2022). 36 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.3 Management Measures 2.3.1 Waste Management Guiding Principles Improper management of health care waste can cause serious health problem for health workers and other workers along the waste management chain, community, and the environment. Medical wastes have a high potential of carrying micro-organisms that can infect people who are exposed to it, as well as the community at large if it is not properly disposed of. Wastes that may be generated from laboratories and vaccination centres to be supported by the COVID-19 vaccination efforts could include solid and liquid contaminated waste (e.g., blood, other bodily and contaminated fluid) and infected materials (used water, lab solutions and reagents, syringes. Most of the waste from labs and vaccine centres requires special handling and awareness as it may pose an infectious risk to healthcare workers in contact with or handling the waste. It is also important to ensure that sharps are properly disposed of. This section provides background information for reference and basis for development of facility specific ICWMP. This plan has considered the four internationally accepted principles that guide systems development and maintenance to safeguard public health and protect environment. These are the precautionary principle, polluter pay principles, duty of care and proximity principle. Precautionary Principle: Health facilities (blood service centres, laboratories, COVID-19 vaccination centres) administrators or managers are required to prepare and be responsible for the protection, preservation, and restoration of the environment. Medical practitioners should be cautious when handling medical waste to ensure that they protect themselves, those around them and the environment. Polluter Pays Principle: Health facilities (laboratories, COVID-19 vaccination centres) administrators or managers shall be legally and financially responsible for safe handling of waste, environmentally sound disposal of waste and creating an incentive to produce less waste. Duty of Care Principles: Health facilities (laboratories, COVID-19 vaccination centres) administrators or managers handling or managing substances or related equipment are ethically responsible for applying the utmost care. Proximity Principle: The treatment and disposal health care waste from the health facilities (laboratories, COVID-19 vaccination centres) should take place as near as possible to the point of production as is technically and environmentally possible to minimize risks involved in transportation. Infectious waste if not managed properly has the potential to endanger the health of patients, health-care workers, waste-handlers, waste-pickers, and the general population. To manage the 37 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) waste generated from the health facilities (laboratories, COVID-19 vaccination centres), the following waste mitigation strategies (Figure 2-41) usually referred to as key steps in management of HCWM shall be implemented: FIGURE 2-4 INFECTIOUS HEALTHCARE WASTE MANAGEMENT In achieving sound management of waste, a hierarchy of waste management should always be applied. This is a ranking of waste management methods in terms of their ‘desirability’. The hierarchy is based largely on the concept of the 3R’s – reduce, reuse, recycle. The most preferable approach is that which produces as little waste as possible, thus minimizing the amount entering the waste stream, taking cautious and very careful attention the risks involved. Therefore, while 38 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) applying this to HCWM, ensuring safety of the workers and protection of the environment at every level of control is very critical (see Figure 2-5): FIGURE 2-5 WASTE MINIMIZATION STAGES 2.3.2 Minimisation of Waste, Reuse and Recycling Effective waste reduction programs require commitment of top management and effective communication among hospital staff. Physicians, managers, and other medical staff must be made aware of waste generation and associated hazards. Source reduction requires involvement of purchasing staff and periodic reassessment. These programs require staff and moderate infrastructure support, planning and organization, assessment, feasibility analysis, implementation, training, and periodic evaluation. Facilities should consider practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety considerations, including source reduction measures, waste toxicity reduction measures, use of efficient stock management practices and monitoring (e.g for chemical and pharmaceutical stocks), maximisation of safe equipment reuse practices including reuse of equipment after sterilisation. 2.3.3 Waste Segregation Waste should be segregated at the point of generation using appropriately colour-coded bags and labelled containers. Segregation is the responsibility of the one who generates the waste. There is a need to be vigilant to avoid intermixing of different categories of waste by patients, attendants, or visitors. The three-bin system to be instituted in all healthcare settings and the containers for collection should be strategically located at all points of generation. Given the fact that only about 10-25% of the HCW is hazardous, treatment and disposal costs could be greatly reduced if thorough segregation is to be performed. Segregating hazardous from non-hazardous waste also significantly reduces risks of infecting workers handling HCW. Generally, the part of the HCW that is hazardous and requires special treatment could be reduced to about 2-5% if the hazardous part was immediately separated from the other waste. Vaccination centres (both 39 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) static and mobile/ outreach centres) will ensure segregation of waste at point of generation. Appropriately colour coded containers or bin liners will be used at each point of generation. a) Collection of waste during the COVID-19 vaccination activity i. Collection of vaccine vials • Any used or discarded COVID-19 vaccine vials MUST be collected safely and separately from the rest of the waste. Both the empty vials and those with remaining vaccine doses discarded at the end of the daily vaccination activity shall be collected and safely stored until they are collected for final treatment and disposal. These vials must be counted and recorded by the responsible team for the purpose of vaccination activity analysis (e.g., utilisation, coverage, wastage, etc.). • Used vials should be collected in leak proof bag, preferably with no less than 40-50 microns and not bigger than 15L to fit in the dimension of the main chamber of incinerators available in the field. If only normal bags (waste bags) are available, it is recommended to place the waste in double bag and place any absorbent material (e.g., paper tissue, absorbent pad or similar) to retain any possible leakage from the waste materials. ii. Collection of syringes and sharp waste • In parallel, all sharp wastes (e.g., needles, auto-block syringes, scalpels, etc.) MUST be collected inside the appropriate and dedicated container, such as sharps container or safety box. iii. Collection of other waste materials: used PPE, cottons, wrap, etc. Used PPE, cottons and wrap should be collected in leak proof bag, preferably with no less than 40-50 microns and not bigger than 15L to fit in the dimension of the main chamber of incinerators available in the field. iv. Interim waste disposal at lower facility • At the end of the day, upon return to the health facility and after counting and recording the number of vials and syringes used, the waste may be transferred to a centralized dedicated container for potentially infectious materials. This container should have a secured lid cover, safe, and made of rigid plastic and clearly labelled as Infectious Wastes. Clean and disinfect “field� waste containers to make them available for the following days. • Keep all generated waste (discarded COVID-19 vaccine vials, used sharps and the rest of the solid waste) in an enclosed and securely locked place in the base until they are collected for treatment and final disposal. The waste storage should be placed under supervision and with limited access only to the responsible personnel. 40 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) TABLE 2-3 RECOMMENDED WASTE SEGREGATION AND COLLECTION SCHEME Waste Colour of Type of Container Collection Frequency Categories Container and Markings Infectious waste Yellow with Leak-proof strong When three-quarters filled biohazard symbol plastic bag placed in or at least once a day. and Red (highly a container (bags for infectious waste highly infectious should be waste should be additionally capable of being marked HIGHLY autoclaved) INFECTIOUS Sharp waste Yellow, marked Puncture-proof When three-quarters filled. SHARPS with container. biohazard symbol. Pathological Yellow with Yellow with When three-quarters filled waste biohazard symbol. biohazard symbol. or at least once a day. Chemical and Brown, labelled Plastic bag or rigid On demand. pharmaceutical with appropriate container. waste hazard symbol. Radioactive Labelled with Lead box. On demand. waste radiation symbol. General health- Black. Plastic bag inside a When three-quarters filled care waste container or or at least once a day. container which is disinfected after use. Adopted from Safe management of Wastes from Healthcare Activities, WHO (2017) 41 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) TABLE 2-4 COLOUR CODING FOR WASTE SEGREGATION Colour code Category Examples Black Domestic or general waste Food scraps, paper Red/Yellow Clinical waste Used bandages, gloves Red/Yellow Sharps Needles Red/Yellow Pathological/infectious waste Placentas, amputations Red/Yellow Pharmaceutical waste Uncompleted medication from wards, expired drugs Red with ‘’radioactive� Radioactive waste Body fluids from patient on label radiotherapy Adapted from National Infection Prevention and Control Guidelines, Zimbabwe, March (2020) If either the red or yellow bag is not available in stock, the yellow or red bags can be used for both clinical and pathological/infectious waste. However, if pathological waste is placed in yellow bag, it must be labelled ‘Pathological or Infectious waste’. The colour-coded bags must be strong and leak-proof. Pedal operated bins must be used in all departments as an infection prevention and control practice. TABLE 2-5 RESPONSIBILITY AND REQUIREMENTS FOR WASTE MANAGEMENT Site Container Responsibilities Wards Pedal bins for patients with Doctors, charge nurse, Sluice room black liners. nurses, nurse aides and Patient bins Two large bins with general hands Nurse station yellow/red and black color- coded liners Casualty and treatment Pedal bins with yellow liners Doctors, charge nurse, rooms Two large black bins with nurses, nurses’ aides and Doctor’s consulting rooms yellow /red and black color- general hands coded liners in sluice room for collection of waste from the different rooms 42 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Theatres and ICUs Two bins with yellow/red Doctors, charge nurse, nurses and black color-coded liners or nurse aide to segregate the waste upon generation Office/ administration Pedal operated bins lined Housekeeper with black liners Kitchen Large bins lined with black Housekeeper bin liners 2.3.4 Handling, Transportation, Storage and Treatment of Waste Health care facility staff must handle medical waste as little as possible before storage and disposal. The more often waste is handled, is the greater the chance for accidents. Special attention must be paid when handling used needles and other sharps which pose the greater risk of accidental injuries and infections. Information related to bulk items such as refrigerators and the like are discussed in the ZCERP ESMF and its general ESMP. a) Storage of the collected waste All wastes must be stored in the following condition until they are collected for delivery in an appropriate waste treatment and disposal facility: i. Protected from the sun to ensure the integrity of the packaging. ii. Protected from rain and water, to ensure the integrity of the packaging and the avoid leakage and spread of the products due to contact with water. The water in contact with waste should be collected and managed as the rest of the wastes. iii. Protect from rodents and other plagues to ensure the integrity of the packaging and avoid the spread of the waste. iv. Isolated from food and water sources to avoid contamination. v. Protected from other staff to avoid improper manipulation and accidental exposure to reagents and other infectious/toxic products. 2.3.5 Transportation and Storage of Waste in Clinical Areas The house keeping staff will be responsible for transporting the different coloured polythene bags of waste from the sluice room, nursing station and treatment room of each ward on garbage trolleys to the waste designated collection points. Waste is stored temporarily in the secure place or holding bins to control access before being transported to the incinerator or final disposal site. When bags are three-quarters full they should be tied securely, removed from the large bin and kept in ward sluice room. Waste can only be kept in the holding bins overnight and removed 43 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) twice daily according to schedule and send to the final disposal site. All waste generated the previous day and during the night must be removed from the holding binds and transported to the incinerator or final disposal area. If there is no on-site incineration, the waste will be stored in a designated temporary storage facility awaiting transportation to off-site incinerator, otherwise waste will be transported directly to the incinerator. Each ward must have a wheelie bin or trolley designated for transportation of waste to designated areas, including waste that must be transported directly to the incinerator. The trolley can not be used for other procedures such as carrying clean linen, medications, and other items. To avoid waste accumulation, collection must be on a regular basis and waste transportation to a central storage area or temporal holding area within the health care facility. Collection must follow specific routes through the HF, to reduce the passage of loaded wheelie bins or trolley through wards and other clean areas. If there are no wheelie bins the trolleys used to transport waste to the temporal holding area should be easy to load, have no sharp edges that can damage waste bags or containers and should be easy to clean. Great care should be taken when handling healthcare waste as most serious risks are associated with injuries from sharps. When handling healthcare waste, sanitary staff and cleaners should always wear protective clothing including (as a minimum) overalls or industrial aprons, boots and heavy-duty gloves. In the health-care facilities, health care waste is temporarily stored before being treated or disposed of on-site or transported to a disposal facility off-site. Non-hazardous health care waste should always be stored in a separate location from the infectious/ hazardous healthcare waste to avoid cross-contamination. 2.3.6 Transportation to External Facilities Transportation of waste destined for off-site facilities will proceed according to the guidelines for transport of hazardous wastes / dangerous goods in the General EHS Guidelines and in the WB EHS Guideline for Health Care Facilities as they are more stringent than national guidance. • Transport packaging for infectious waste should include an inner, watertight layer of metal or plastic with a leak-proof seal. Outer packaging should be of adequate strength and capacity for the specific type and volume of waste, • Packaging containers for sharps should be puncture-proof, • Waste should be labelled appropriately, noting the substance class, packaging symbol (e.g., infectious waste, radioactive waste), waste category, mass / volume, place of origin within hospital, and final destination, 44 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) • Transport vehicles should be dedicated to waste and the vehicle compartments carrying waste sealed. The transporter of hazardous waste must get permission from the Environmental Management Agency and to be issued with a red license which allows transportation of hazardous waste. However, EMA will also assess if the incinerator and transportation has been approved and will issue Residue and Incineration Certificate. Drivers and handlers of infectious waste should be informed of what their cargo is and receive any necessary training. Necessary EHS clauses are to be included in the Waste Transporter’s Site specifics. Labelling of the transport vehicle: The transport vehicle should be labelled according to the type of waste that is being transported. The label that is displayed will depend on the United Nations classification of the waste. Before sending hazardous health-care wastes off-site, transport documentation (commonly called a “waste tracking note�) should be prepared and carried by the driver with the following information: i) waste classes ii) waste sources iii) pick-up date iv) destination v) driver name vi) number of containers or volume vii) Receipt of load received from responsible person at pick-up areas; On completion of a journey, the transporter should complete a consignment note and return it to the waste producer for filing. 2.3.7 Temporary Waste Holding Areas Each healthcare facility has a waste holding area where different type of wastes are stored after collection from the wards and will be awaiting incineration or to be transported to an off-site incinerator. Waste temporary storage area should meet the following parameters: i. Be protected from water, rain, or wind, i.e., placed in a shed. ii. Minimize the impact of odours, or putrescent waste (waste that can decompose and produce odours after several days). iii. Do not store for more than three days; putrescent waste should be transported to the incinerator immediately. However, during COVID-19 outbreak, infectious waste should be removed from any HCF’s storage area for disposal within 24 hours to an on-site incinerator or disposal area within the HCF . iv. Be accessible to authorized employees and should be locked to prevent unauthorized access. v. All waste containers to have lids to protect from animals and not provide a breeding place or food source for insects and rodents. vi. Should have a concrete floor which is cleanable and to be kept clean and free from any loose debris and always standing water. 45 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) vii. To be fenced right round (completely) and locked so that no unauthorized or scavengers can enter. viii. It should be disinfected weekly and whenever a spill occurs. 2.3.8 Health Care Waste Treatment It is illegal to send infectious waste to any dumpsite or landfill in Zimbabwe, therefore health care infectious waste requires treatment. HCW treatment systems should be efficient, environmentally sound, and have access controls, to protect persons from voluntary or accidental exposure to waste during the treatment process. Technological choices should be made according to the following criteria: a) Performance and efficiency of treatment b) Environmental viability c) Easiness and simplicity in the setting up, the operating and maintenance d) The spare parts should be available, easy to acquire e) Costs of investments and operating f) Social acceptability TABLE 2-6- DEFINITIONS USED IN TREATMENT AND DISPOSAL OF WASTE9 Treatment Any method, technique, or process (usually thermal or chemical) designed to change the biological character or composition of a health care risk waste to reduce or eliminate its potential for causing disease. The treatment may/not physically destroy the waste and render it unrecognizable. Destruction The process whereby wastes are rendered unrecognizable, such as grinding or shredding. Destruction may be part of the treatment process or follow treatment. Disposal Final placement of health care facility waste, or its residue, following treatment to eliminate its original risk. 9 Source: Safe Management of Wastes from Health-care Activities. Edited Pruss A, Giroult E, Rushbrook P. World Health Organization (1999) 46 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) In addition to this, the waste treatment system should be close to the waste generating point. The following is an outline of available technologies for treating COVID-19 vaccine HCW: a) Treatment of the discarded COVID-19 vaccine vials before final disposal: • Before performing the following procedures, you must first wash your hands and put on surgical gloves for your personal protection. • Before subjecting the vaccine vials to any treatment procedures, remove all vial caps (with the aluminium seal) and labels – if any to ensure effective treatment. Collect all caps in a plastic bag and set aside for latter incineration. Once done, vials are ready for treatment. b) Treatment by disinfection with chlorine solution: • Disinfection of used vials with 0.5% chlorine solution is often the quick and easy method at the field level. This can be done with any available chlorine-containing products (e.g., (Sodium Hypochlorite) HTH, Dichloroisocyanurates (NaDCC), bleach, bleach powder, etc.). • Prepare the 0.5% disinfection solution in quantity enough to completely fill the plastic container with discarded vials. • Using heavy-duty gloves, submerge the vials in the chlorine solution making sure the disinfecting solution gets inside each of them and reaching all surfaces. Let them react for at least 30 minutes. • After the 30-minute reaction time, remove all vials from the disinfecting solution. Make sure you are wearing heavy-duty gloves and all vials are emptied. Collect the vials for their final disposal. • Used disinfecting solution (0.5% Chlorine) MUST be disposed in a safe and appropriate manner to protect the environment and bodies of water. Note: Discharge used chlorine solution into the toilets / latrines, when not possible. If not, leave the solution exposed to sunlight for several hours prior discharging in a controlled place, far from water sources and/or food gardens c) Treatment by sterilisation through autoclaving process: If an autoclave is available, use it to effectively sterilize discarded COVID-19 vaccine vials before final disposal. • First wash your hands and put on surgical gloves. • Place the vials inside of the autoclave, following specified instructions for using the equipment. 47 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) • Turn on the autoclave and allow sterilization process to complete. Then, collect the sterilized vials from the autoclave for their final’s disposal. d) Treatment of other associated waste: Collect all sharp wastes (e.g., needles, scalpels, etc.) in a dedicated “sharps container� (safety box). Dispose used sharps inside the “sharps pit� without removing them from the safety box. There is no need to sterilize before disposal. Non-hazardous waste will not be incinerated but will be collected by the municipality for disposal at a designed sanitary landfill. e) Incineration Waste incineration is a thermal treatment, which aims at destroying organic waste parts by oxidation. Various types of equipment are used: • Pyrolytic incinerator: This has a treatment capacity ranging from 500 to 30000 kg wastes daily, at a combustion temperature of 1200° or 1600° C; its initial cost is very high. It also needs highly qualified staff. The remnants of wastes are sent to lined landfill disposal sites or ash-pits. • Pyrolytic incinerator (Standard /modern incinerator): its treatment capacity is from 200 to 10,000 kg/daily, with a combustion temperature ranging from 800 to 900° C; its requirements in terms of investment and care taking are somewhat high; it needs qualified staff; the remnants of wastes are sent to the landfill disposal sites or ash-pits. • Incinerator with combustion room (artisanal construction, with local materials): Its investment and maintenance costs are relatively low; it can work effectively, even with low-qualification staff. Pyrolytic incinerators, also known as standard/modern incinerators are the kind mainly used in Zimbabwe health care settings because of these properties. Incineration provides very high disinfection efficiency and drastic reduction of weight and volume of waste. It is relatively low in cost and does not need highly qualified staff to operate, however it requires qualified maintenance officers to maintain the incinerator. On the other hand, it generates pollutant emissions. Due diligence of existing incinerators in facilities participating in the project should be conducted to examine their technical adequacy, process capacity, performance record, and operators’ capacities. This includes implementation of operational controls including combustion and flue gas outlet temperatures (combustion temperatures should be above 850°C while flue gases need to be quenched very quickly to avoid formation and 48 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) reformation of Persistent Organic Pollutants (POPs) as well as use of flue gas cleaning devices meeting international standards). 10 Persistent Organic Pollutants are hazardous organic compounds that are resistant to environmental degradation through chemical, biological, or photolytic processes. This resistance means that they bioaccumulate in humans and wildlife with potential adverse impacts on human health and the environment. In case any gaps are discovered, corrective measures should be recommended and pursued. Most rural health centres participating in the project use low-cost single chamber static grates and most are not working properly. Their volume of waste is low. Unfortunately, there is not much operation and maintenance of them. All urban, district and provincial healthcare facilities’ incinerators have broken down and are not working. Consultations for this ICWMP found that there were no working incinerators in the provinces. Most of the few functioning incinerators in the country fail to reach the 850°C that is required to treat or destroy sharps. In the 2011 HCWM assessment most of urban, district and provincial healthcare facilities supported by the project had functional incinerators compared to the assessment completed in September 2020 for this ICWMP that found that most of them are no longer functional. Historically HCF incinerators would use coal but since they usually do not have the money to buy coal, they use the general waste they generate to support combustion leaving some of the infectious waste not totally burnt. In accordance with the project’s Exclusionary List, coal and wood for incinerators will not be extracted from any fragile or sensitive ecosystems, protected areas, forests or other such sources (consult the Exclusionary List in the ESMF). In terms of emissions control technologies, most of the incinerators in Zimbabwe do not have wet scrubbers which is a device that is used for pollution control. Incinerators can be fitted with dry gas scrubbers to reduce acidic gasses. Incinerators should have permits issued by authorized regulatory agencies (i.e., EMA) and be operated and maintained by trained employees. EMA will issue a red licence according to SI10 of 2007 in respect of disposal of waste that is considered to present a high risk to the environment. Private healthcare facilities with incinerators are required to have this red licence and incinerator manufacturers to provide standard and checklists on how to operate and maintain the incinerator. Project Implementing Entity to monitor and evaluate the standards which the incinerator will be operating biannually for any private facilities. Most project facilities will likely be governmental since the project does not support private facilities. 10 Refer to Guidelines on BAT/BEP practices relevant to Article 5 and Annex C of the Stockholm Convention on Persistent Organic Pollutants, Section V. 49 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Given the malfunctioning incinerators, the project will examine use of private facilities and specialized companies for collection and treatment of hazardous and medical waste and other possibilities such as use of hub incinerators to treat waste from multiple HF. This will be done before or during project implementation after the incinerators for off-site medical waste treatment have been identified. Currently there are 2 main private companies that incinerate waste; one in Harare and one in Bulawayo. The one in Bulawayo also has intercity operations—transporting health care waste from other cities for incineration in Bulawayo. The second company also has capacity to treat project waste, however further due diligence is required before contracting them. Waste disposal facilities should be integrated into the overall design and ESIA developed for any new HCFs to be constructed. However, the project is not building new health care facilities and so there is no need for ESIAs. Good design, operational practices and internationally adopted emission standards for healthcare waste incinerators can be found in pertaining EHS Guidelines and GIIP (i.e. the 2007 Health Care Facility EHS). 2.3.9 Onsite Incinerator i. All incinerators in public HCF are owned, operated and maintained by the Public Works Department under the Ministry of Local Government, Public Works and National Housing. ii. After the waste (in yellow and red coloured bags) is deposited in the custody of the supervisor, the waste handlers’ staff should obtain a proper receipt, and the entire process should be documented. iii. All incinerators to be monitored to ensure they are properly licenced by EMA, being operated according to manufacturer operating criteria and in accordance with WB EHS guidelines iv. It is the responsibility of the supervisor to ensure that waste-pickers and other unwanted elements are stored in closed locked area. The functioning of the incinerator and the number of cycles operated per day should be documented and recorded in a logbook. v. Regular monitoring of the process should be carried out by the engineers. vi. The ash produced by incineration should be sent for final disposal at the landfill or disposed in a watertight brick or concrete lined ash pit fitted with a waterproof covered lid (where access to engineered sanitary landfills is limited especially small incinerator operations) to prevent uncontrolled disposal of the ash, which can allow the contaminants it contains to enter the environment or the food chain. . When the incinerator ash is sent to the landfill it must tested first to confirm no hazardous wastes e.g heavy metals exits. 50 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) vii. Incinerator operators to be provided with appropriate PPE which includes a regular air purifying respirator, and to be vaccinated against blood-borne disease e.g. hepatitis B and tetanus. Incinerator emissions should comply with national standards and in accordance with the Stockholm Convention BAT and best environmental practices (BEP) guidance in those countries that have signed the convention and emissions for this Project must comply with applicable Zimbabwe limits and WB EHS Guideline for Health Care Facilities. Pollutants potentially emitted from health care waste incinerators (HWIs) include: • Heavy metals, • Organics in the flue gas, which can be present in the vapor phase or condensed or absorbed on fine particulates, • Various organic compounds (e.g. polychlorinated dibenzo-p-dioxins and furans [PCDD/Fs], chlorobenzenes, chloroethylenes, and polycyclic aromatic hydrocarbons [PAHs]), which are generally present in hospital waste or can be generated during combustion and post-combustion processes, • Hydrogen chloride (HCl) and fluorides, and potentially other halogens-hydrides (e.g. bromine and iodine); Typical combustion products such as sulphur oxides (SOx), nitrogen oxides (NOx), volatile organic compounds (including non-methane VOCs) and methane (CH4), carbon monoxide (CO), carbon dioxide (CO2), and nitrous oxide (N2O).11 Pollution prevention and control measures include: • Application of waste segregation and selection including removal of the following items from waste destined for incineration: halogenated plastics (e.g. PVC), pressurized gas containers, large amounts of active chemical waste, silver salts and photographic / radiographic waste, waste with high heavy metal content (e.g. broken thermometers, batteries), and sealed ampoules or ampoules containing heavy metals;12 • Incinerators should have permits issued by authorized regulatory agencies and be operated and maintained by trained employees to ensure proper combustion temperature, time, and turbulence specifications necessary for adequate combustion of 11 WB EHS Guidelines for Health Care Facilities, 2007 12 WB (2007) Health Care Facility EHSG, p6. 51 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) waste.13 This includes implementation of operational controls including combustion and flue gas outlet temperatures (combustion temperatures should be above 850 °C while flue gases need to be quenched very quickly to avoid formation and reformation of POPs) as well as use of flue gas cleaning devices meeting international standards.14,15 Secondary air pollution control measures for hospital waste incinerators (HWI) include the following: • Wet scrubbers to control acid gas emissions (e.g. hydrochloric acid [HCl)], sulphur dioxide [SO2, and fluoride compounds]). A caustic scrubbing solution will increase the efficiency for SO2 control, • Control of particulate matter may be achieved through use of cyclones, fabric filters, and / or electrostatic precipitators (ESP). Efficiencies depend on the particle size distribution of the particulate matter from the combustion chamber. Particulate matter from hospital incinerators is commonly between 1.0 to 10 micrometres (µm). ESPs are generally less efficient than baghouses in controlling fine particulates and metals from HWI, • Control of volatile heavy metals depends on the temperature at which the control device operates. Fabric filters and ESP typically operate at relatively high temperatures and may be less effective than those that operate at lower temperatures. Venturi quenches and venturi scrubbers are also used to control heavy metal emissions. The volatile heavy metals usually condense to form a fume (less than 2 µm) that is only partially collected by pollution control equipment, Management of incineration residues such as fly ash, bottom ash and liquid effluents from flue gas cleaning as a hazardous waste (see General EHS Guidelines) as they may contain high concentrations of POPs.16 It is important to note that since sharps will not be disinfected with chlorine solutions, POPs are not expected to be formed during incineration. 2.3.10 Off-Site Incinerator 13 Technical information on the proper operation and maintenance of hospital waste incinerators may be obtained from WHO (1999) Chapter 8 and the US EPA Handbook on the Operation and Maintenance of Medical Waste Incinerators (2002). 14 Refer to Guidelines on BAT/BEP practices relevant to Article 5 and Annex C of the Stockholm Convention on Persistent Organic Pollutants, Section V. 15 WB (2007) Health Care Facility EHSG, p9. 16 WB (2007) Health Care Facility EHSG, p9. 52 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) If a HF has no incinerator or their incinerator is not working, they will outsource services from other institutions that have functional incinerators or private companies who incinerate waste. In such case, the Infection Control Team and other relevant parties should visit and assess off- site incinerators and ascertain the following: • If they are licensed by the Environmental Management Agency to operate as a private waste disposal entity and to accept health care waste, and are properly operated and maintained. • If they have covered trucks to collect and transport waste to the incinerator. • If the area is secured from scavengers • A stack sufficiently tall to eliminate odour nuisances and optimize dispersion should be used. Stack heights for all waste treatment facilities should be determined in accordance with guidance provided in the General EHS Guidelines. • Is operated and maintained by trained employees to ensure proper combustion temperature, time, and turbulence specifications necessary for adequate combustion of waste. This includes implementation of operational controls including combustion and flue gas outlet temperatures (combustion temperatures should be above 850oC while flue gases need to be quenched very quickly to avoid formation and reformation of POPs) as well as use of flue gas cleaning devices meeting international standards If the above is in place, a service level agreement can be signed. 2.3.11 Sharps Management A sharp object is defined as anything that can puncture the skin. Examples of sharp objects are hypodermic needles, blades, glass ampoules, bone fragments and jagged metal. In a clinical environment, a sharp may be contaminated with blood or other body fluids and expose healthcare workers to blood-borne infections. Safe disposal of sharps is the responsibility of the person who has used it. To minimize risk of exposure the following must be adhered to: • Discard sharps, needles and syringe as one unit. • Discard sharps in a rigid sharps container immediately after use. • Do not recap needles • Sharps boxes to be located close to point of use. • Make sure sharps bins are always in stock. • Do not transfer used sharp from one person to another by hand. • Sharps bins to be labelled. • Sharps bins not to be overfilled, to be sealed and sent for incineration when ¾ full. • Sharps to be disposed of as clinical waste thus requiring incineration. 53 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) • When needle prick injury occurs, to be handled in accordance with the healthcare facility post exposure prophylaxis protocols. • Sharps are not disinfected before incineration therefore production of POPs from chlorinated disinfection solution residues during incineration is avoided. 2.3.12 Final Disposal of the Waste from COVID-19 Vaccine • All used syringes and sharp wastes: MUST be treated by incineration (using an appropriate incinerator that is able to reach high temperatures, with double chamber to reduce emissions of toxic gases). Follow recommended methods for proper final disposal of resulting ashes. • After incineration, dispose “solid waste fraction� inside the dedicated “ash pit� previously identified in the selected Health Structure. • Neutralised COVID-19 vaccine vials can be safety disposed in a manner that is not accessible or reusable, and neither being an environmental nor a health threat. • COVID-19 vaccine vials (preferably not crushed) MUST be properly disposed inside the dedicated “ash pit� previously identified in the selected Health Structure. Make sure the “ash pit� capacity is adequate and compliant with national standards. • In absence of any dedicated structure (e.g., “Sharps pit�), used sharps may be encapsulated17 (preferably not crushed). This will prevent them from being reused and accessible, and no longer pose a risk to both the population and environment. TABLE 2-7 RECOMMENDATIONS FOR MANAGEMENT OF HEALTHCARE WASTE Waste Examples Types of Handling Disposal** Special Category Containers to be Considerations used* Infectious Blood, products, Impervious Disinfect with 3- Bags should be ¾ wastewater body fluids, container with lid 3.5% chlorine-based full, sealed, marked dialysis water compound prior to with site of origin discharging in sewer and removed. 17 Encapsulation is done by placing already treated COVID-19 vaccine vials in a container, mixing them within cement, lime and water mixture (3:3:1 part by weight) in a sealed metallic drum. Once mixture solidified, the whole block is buried within a secured area (either inside the waste zone of the hospital or health centre, in a dedicated dumping area, or any proper identified place) 54 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Waste Examples Types of Handling Disposal** Special Category Containers to be Considerations used* Pathological Tissues, organs Suitable Incineration, burn Bags should be ¾ waste/ body parts, impervious full, sealed, marked anatomical foetus, containers or with site of origin waste placenta, waste storage and removed. Mark surgical waste bags placed in container with etc. rigid containers biohazard label with lids Isolation Viral National approved Incineration Follow national waste haemorrhagic sealed, impervious guidelines for VHF fever containers with lid Animal waste From research Impervious Incineration, burn Bag sealed and laboratory container with lid marked with site of origin Laboratory Culture plates Impervious Autoclave if possible Bags should be ¾ waste (highly and bottles. container with lid before disposal then full, sealed, marked infectious) Diagnostic lined with a plastic incinerate or burn with site of origin specimens, disposal bag and removed. vaccines and reagents. Double red bags labelled biohazard Cartridges waste Incineration Bags to be ¾ full double bagged and labelled biohazard. To be sent to an incinerator of temperatures 1200- 1600℃ for complete combustion. 55 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Waste Examples Types of Handling Disposal** Special Category Containers to be Considerations used* Sharps Needles, Special puncture Incineration, burn Empty ash pit or scalpels, blades, resistant sharps disposal site razors, other container Container ¾ full for sharps, clinical disposal glass Medical Gloves, Impervious waste Incineration, burn or Empty ash in ash pit waste sponges, holding bag or landfill or disposal site dressings, double plastic bag sanitary pads, surgical drapes Container ¾ full for soiled or soaked disposal with blood, body fluids, secretions Food waste Milk, Meat, fish Lined plastic bins Incineration, burn or When ¾ full seal bag chicken, covered with tight landfill and take to disposal vegetables etc. lid site Other Empty bulk Lined bins with lid Incineration or Place separately kitchen cartons, Food landfill from food. When ¾ waste containers, full seal and dispose Food wrappers Healthcare Old SDD vaccine No containers Transfer to another When equipment is obsolete fridges, ordinary department with or obsolete it is equipment fridges, solar without financial boarded and panels, adjustment, sale by removed from the batteries solar public tender, sale inventory register inverters at the by auction, then its either end of their destruction, auctioned or useful life etc. dumping, or burial, donated. trade in or any other 56 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Waste Examples Types of Handling Disposal** Special Category Containers to be Considerations used* method recommended by the Procurement Regulatory Authority of Zimbabwe18 (PRAZ). 2.4 Types of Incinerators Incineration is controlled burning of solid, liquid, or gaseous combustible wastes to produce gases and residues containing little or no burnable material and will be safe to handle. Incineration is a high temperature dry oxidation process that reduces the volume and weight of waste. This process is usually selected to treat waste that cannot be recycled, reused, or disposed of in a landfill, thus healthcare waste. Health-care waste includes all waste generated by health care facilities, research facilities, laboratories and that produced in the course of health care undertaking in the home e.g. dialysis, insulin injections and home based care (needles, syringes, soiled bandages, disposable sheets, medical gloves, dialysis machine filters, plastic catheters and drip set, glass waste, urinary bags, expired medicines, medicine containers, pesticide containers, sanitary napkins, liquid waste and placenta) (WHO, 1998). Pyrolytic incinerator (Standard /modern incinerator): This is a standard incinerator consist of a primary combustion chamber, which has a treatment capacity of 200 to 10,000 kg/daily, with a maximum combustion temperature ranging from 800 to 900° C. Its requirements in terms of investment and maintenance is not very high; it needs trained staff to operate it hence found in most rural healthcare facilities. This is fuelled by firewood or coal; the residues of wastes are sent to the landfill disposal sites or ash-pits. Pyrolytic incinerator (Advanced): An advanced incinerator with two combustion chambers, primary and secondary combustion chambers. It has a treatment capacity ranging from 500 to 30,000 kg wastes daily, at a combustion temperature of 1200° or 1600° C. This incinerates even 18The Procurement Regulatory Authority of Zimbabwe (PRAZ) was created through an Act of Parliament, Public Procurement and Disposal of Public assets Act (Chapter, 22:23) with the mandate to supervise public procurement proceedings and disposal of obsolete or unserviceable public equipment to ensure transparency, fairness, honesty, cost-effectiveness and competition. 57 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) expired medicines, but its initial cost is very high. The incinerator is highly controlled with air pollution equipment and operational practice is specifically designed to reduce formation of dioxins. It needs fuel or electricity to function and highly qualified staff to operate it hence found in central hospitals. The residues of wastes are sent to landfill disposal sites or ash-pits. To install and operate an incinerator, a red licence is required from the Environmental Management Agency (EMA). This is because treatment, disposal of hazardous waste and discharge is a high environmental hazard. Each facility with an incinerator pays a fee of 16574.58 USD annually which includes environmental monitoring and emission fees. Small-Scale Low-Cost Incinerators: Small-scale incinerators are designed to meet an immediate need for public health protection where there is no access to more sophisticated technologies. This involves a compromise between the environmental impacts from controlled combustion and an overriding need to protect public health if the only alternative is indiscriminate dumping. These circumstances exist in many developing situations, and small-scale incineration can be a realistic response to an immediate requirement (WHO, 2014, citing Batterman, 2004). As far as possible, a small-scale facility should avoid burning PVC plastics and other chlorinated waste. If small-scale incinerators are the only option available, the best practices possible should be used, to minimize operational impacts on the environment. Best practices in this context are (WHO, 2014 , citing Batterman, 2004): • effective waste reduction and segregation, ensuring only the smallest quantities of combustible waste types are incinerated, • an engineered design with sufficient residence time and temperatures to minimize products of incomplete combustion, • siting incinerators away from health-care buildings and residential areas or where food is grown, • construction using detailed engineering plans and materials to minimize flaws that may lead to incomplete destruction of waste and premature failures of the incinerator, • a clearly described method of operation to achieve the desired combustion conditions and emissions; for example, appropriate start-up and cool-down procedures, achievement and maintenance of a minimum temperature before waste is burned, use of appropriate loading/charging rates (both fuel and waste) to maintain appropriate temperatures, proper disposal of ash and equipment to safeguard workers, • periodic maintenance to replace or repair defective components (including inspection, spare parts inventory and daily record keeping), • improved training and management, possibly promoted by certification and inspection programmes for operators, the availability of an operating and maintenance manual, visible management oversight, and regular maintenance schedules. In 2004, WHO commissioned a screening-level health risk assessment for exposure to dioxins and furans from small-scale incinerators. The study found that the expected practice with small-scale 58 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) incinerators resulted in unacceptable cancer risks under medium usage (two hours per week) or higher (WHO, 2014). The report concluded that small-scale incineration should be viewed as a transitional means of disposal for health-care waste. Single-chamber, drum and brick incinerators do not meet the Best Available Technology (BAT) requirements of the Stockholm Convention guidelines (Secretariat of the Stockholm Convention, 2006). 2.4.1 Emissions Incinerator emissions should comply with national standards and in accordance with the Stockholm Convention BAT and best environmental practices (BEP) guidance in those countries that have signed the convention and emissions for this Project must comply with applicable Zimbabwe limits and WB EHS Guideline for Health Care Facilities. Pollutants potentially emitted from health care waste incinerators (HWIs) include: • Heavy metals, • Organics in the flue gas, which can be present in the vapor phase or condensed or absorbed on fine particulates, • Various organic compounds (e.g. polychlorinated dibenzo-p-dioxins and furans [PCDD/Fs], chlorobenzenes, chloroethylenes, and polycyclic aromatic hydrocarbons [PAHs]), which are generally present in hospital waste or can be generated during combustion and post-combustion processes, • Hydrogen chloride (HCl) and fluorides, and potentially other halogens-hydrides (e.g. bromine and iodine); • Typical combustion products such as sulphur oxides (SOx), nitrogen oxides (NOx), volatile organic compounds (including non-methane VOCs) and methane (CH4), carbon monoxide (CO), carbon dioxide (CO2), and nitrous oxide (N2O).19 2.4.2 Pollution Prevention and Control Pollution prevention and control measures include: • Application of waste segregation and selection including removal of the following items from waste destined for incineration: halogenated plastics (e.g. PVC), pressurized gas containers, large amounts of active chemical waste, silver salts and photographic / 19 WB (2007) Health Care Facility EHSG, p6. 59 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) radiographic waste, waste with high heavy metal content (e.g. broken thermometers, batteries), and sealed ampoules or ampoules containing heavy metals;20 • Incinerators should have permits issued by authorized regulatory agencies and be operated and maintained by trained employees to ensure proper combustion temperature, time, and turbulence specifications necessary for adequate combustion of waste.21 This includes implementation of operational controls including combustion and flue gas outlet temperatures (combustion temperatures should be above 850 °C while flue gases need to be quenched very quickly to avoid formation and reformation of POPs) as well as use of flue gas cleaning devices meeting international standards.22,23 Secondary air pollution control measures for hospital waste incinerators (HWI) include the following: • Wet scrubbers to control acid gas emissions (e.g. hydrochloric acid [HCl)], sulphur dioxide [SO2, and fluoride compounds]). A caustic scrubbing solution will increase the efficiency for SO2 control, • Control of particulate matter may be achieved through use of cyclones, fabric filters, and / or electrostatic precipitators (ESP). Efficiencies depend on the particle size distribution of the particulate matter from the combustion chamber. Particulate matter from hospital incinerators is commonly between 1.0 to 10 micrometres (µm). ESPs are generally less efficient than baghouses in controlling fine particulates and metals from HWI, • Control of volatile heavy metals depends on the temperature at which the control device operates. Fabric filters and ESP typically operate at relatively high temperatures and may be less effective than those that operate at lower temperatures. Venturi quenches and venturi scrubbers are also used to control heavy metal emissions. The volatile heavy metals usually condense to form a fume (less than 2 µm) that is only partially collected by pollution control equipment, • Management of incineration residues such as fly ash, bottom ash and liquid effluents from flue gas cleaning as a hazardous waste (see General EHS Guidelines) as they may contain 20 WB (2007) Health Care Facility EHSG, p6. 21 Technical information on the proper operation and maintenance of hospital waste incinerators may be obtained from WHO (1999) Chapter 8 and the US EPA Handbook on the Operation and Maintenance of Medical Waste Incinerators (2002). 22 Refer to Guidelines on BAT/BEP practices relevant to Article 5 and Annex C of the Stockholm Convention on Persistent Organic Pollutants, Section V. 23 WB (2007) Health Care Facility EHSG, p9. 60 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) high concentrations of POPs. 24 It is important to note that since sharps will not be disinfected with chlorine solutions, POPs are not expected to be formed during incineration. 2.4.3 Emission Standards The Stockholm Convention on Persistent Organic Pollutants (POPs) is a global treaty to protect human health and the environment from chemicals that remain intact in the environment for long periods, become widely distributed geographically, accumulate in the fatty tissue of humans and wildlife, and have harmful impacts on human health or on the environment. The Convention specifically targets incinerators. Among other actions, it will require countries to develop and implement actions to address the release of dioxins and furans; Article 5 will require measures to reduce dioxin/furan releases from incinerators with the goal of their “ultimate elimination;� and countries are required to promote the use of alternatives including the use of the best available techniques/technologies. Under the Stockholm Convention, standard incinerators are not a preferred technique due to their potential to emit POPs. Only highly controlled incinerators with air pollution control equipment and operational practice specifically designed to minimize dioxin formation and release could be considered the best available technology. Zimbabwe emission standards are regulated by the Environmental Management Agency SI.72 of 2009 (Atmospheric Pollution Control Regulation 2009. These standards are monitored by the Standards Association of Zimbabwe (SAZ) which test the air to assess the amount of pollutants. Table 2-8 shows a comparison of WB EHS Guidelines for Health Care Facilities to Zimbabwean Emission Standards, however the EHS Emission Guidelines are generally more stringent and therefore will be used for this project. Zimbabwean standards will be used when they are more stringent, such as for NOx. TABLE 2-8 COMPARISON OF EHS GUIDELINES AND ZIMBABWEAN EMISSION STANDARDS EHS ZIMBABWE POLLUTANTS UNITS GUIDELINE EMISSION VALUE STANDARD Total Particulate matter (PM) mg/Nm3 10 100 Total organic carbon (TOC) mg/Nm3 10 30 24 WB (2007) Health Care Facility EHSG, p9. 61 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) EHS ZIMBABWE POLLUTANTS UNITS GUIDELINE EMISSION VALUE STANDARD Hydrogen Chloride (HCl) mg/Nm3 10 30 Hydrogen Fluoride (HF) mg/Nm3 1 ---- Sulphur dioxide (SO2) mg/Nm3 50 50 Carbon Monoxide (CO) mg/Nm3 50 100 NOX mg/Nm3 200-400a 150 Mercury (Hg) mg/Nm3 0.05 ---- Cadmium + Thallium (Cd + Tl) mg/Nm3 0.05 ---- Sb, As, Pb, Cr, Co, Cu, Mn, Ni and V mg/Nm3 0.5 ---- Polychlorinated dibenzodioxin and ng/Nm3TEQ 0.1 ---- dibenzofuran (PCDD/F) 2.4.4 Management of Air Pollution and Incinerator Residue In accordance with the WB EHS for Health Care Facilities, secondary air pollution control measures for hospital waste incinerators should include the following where technically and financially feasible: • Wet scrubbers to control acid gas emissions (e.g. hydrochloric acid [HCl)], sulphur dioxide [SO2, and fluoride compounds]). A caustic scrubbing solution will increase the efficiency for SO2 control, • Control of particulate matter may be achieved through use of cyclones, fabric filters, and / or electrostatic precipitators (ESP). Efficiencies depend on the particle size distribution of the particulate matter from the combustion chamber. Particulate matter from hospital incinerators is commonly between 1.0 to 10 micrometres (µm). ESPs are generally less efficient than bag houses in controlling fine particulates and metals from HWI. • Control of volatile heavy metals depends on the temperature at which the control device operates. Fabric filters and ESP typically operate at relatively high temperatures and may 62 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) be less effective than those that operate at lower temperatures. Venturi quenches and venturi scrubbers are also used to control heavy metal emissions. The volatile heavy metals usually condense to form a fume (less than 2 µm) that is only partially collected by pollution control equipment. • Management of incineration residues such as fly ash, bottom ash, and liquid effluents from flue gas cleaning as a hazardous waste as they may contain high concentrations of POPs. • Incineration residues (including those which may contain POPs) will be disposed in an ash pit to control emissions to the environment. Installing new ash pits is not the goal of the project but refurbishing the ones already in existence is possible. However, Zimbabwe is a low-income country and the standard incinerators which are used in healthcare facilities generally do not have pollution control devices. They adhere to air emission standards prescribed by EMA. For this project, participating facilities will need to install or use an air pollution control measures in accordance with the national environmental laws and WB EHS Guidelines for Health Care Facilities. 2.5 Management of Health Care Workers’ Health and Safety HCF health and safety hazards may affect health care providers, cleaning and maintenance personnel, and workers involved in waste management handling, treatment, and disposal. Industry specific hazards include exposure to infections and diseases, exposure to hazardous materials / waste, exposure to radiation, fire safety. 2.5.1 Exposure to Infections and Diseases • Health care providers and personnel may be exposed to general infections, blood-borne pathogens, and other potential infectious materials (OPIM) during care and treatment, as well as during collection, handling, treatment, and disposal of health care waste. the Following measures are recommended: • Formulate an exposure control plan for blood-borne pathogens, • Provide staff members and visitors with information on infection control policies and procedures, • Establish Universal / Standard Precautions to treat all blood and other potentially infectious materials with appropriate precautions, including: o Immunization for staff members as necessary (e.g. vaccination for hepatitis B virus) o Use of gloves, masks, and gowns, o Adequate facilities for hand washing. Hand washing is the single most important procedure for preventing infections (e.g. nosocomial and community). Hand washing should involve use of soap / detergent, rubbing to cause friction, and placing hands under running water. Washings of hands should be undertaken before and after direct patient contacts and contact with patient blood, body 63 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) fluids, secretions, excretions, or contact with equipment or articles contaminated by patients. Washing of hands should also be undertaken before and after work shifts; eating; smoking; use of personal protective equipment (PPE); and use of bathrooms. If hand washing is not possible, appropriate antiseptic hand cleanser and clean cloths / antiseptic towelettes should be provided. Hands should then be washed with soap and running water as soon as practical, o Procedures and facilities for handling dirty linen and contaminated clothing, and preparing and handling food o Appropriate cleaning and waste disposal practices for the health care workplace • Healthcare personnel should not report to work if they have a febrile respiratory illness. • In communities where transmission is occurring, healthcare personnel who develop a febrile respiratory illness should be excluded from work and should be tested for COVID- 19. If negative, then they should stay away from work until symptoms resolve. If positive, then they should proceed to isolation for 14 days, and • Healthcare personnel, who develop a febrile respiratory illness and have been working in areas of the hospital where COVID-19 patients are present, should be excluded from work for 7 days or until symptoms have resolved, whichever is longer. 2.5.2 Exposure to hazardous materials HCF workers may be exposed to hazardous materials and wastes, including glutaraldehyde (toxic chemical used to sterilize heat sensitive medical equipment), ethylene oxide gas (a sterilant for medical equipment), formaldehyde, mercury (exposure from broken thermometers), chemotherapy and antineoplastic chemicals, solvents, and photographic chemicals, among others. In addition to the guidance provided above, hazardous materials and wastes should be handled according to occupational health and safety guidance provided in the General EHS Guidelines. 2.5.3 Fire Safety The risk of fire in health care facilities is significant due to the storage, handling, and presence of chemicals, pressurized gases, boards, plastics, and other flammable substrates. Fire safety recommendations applicable to occupational areas are presented under ‘Occupational Health and Safety’ in the General EHS Guidelines. Recommendations applicab le to buildings accessible to the public, including health care facilities, are presented under ‘Life and Fire Safety’ in the General EHS Guidelines. Additional recommendations for fire safety include: • Installation of smoke alarms and sprinkler systems, • Maintenance of all fire safety systems in proper working order, including self-closing doors in escape routes and ventilation ducts with fire safety flaps, • Training of staff for operation of fire extinguishers and evacuation procedures, • Development of facility fire prevention or emergency response and evacuation plans with adequate guest information (this information should be displayed in obvious locations and clearly written in relevant languages). 64 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.5.4 Exposure to Radiation Occupational radiation exposure may result from equipment emitting X-rays and gamma rays (e.g. CT scanners), radiotherapy machines, and equipment for nuclear medicine activities but these activities will not be supported by the ZCERP which focusses on Covid vaccines. In any case, HCF operators should develop a comprehensive plan to control radiation exposure in consultation with the affected workforce. This plan should be refined and revised as soon as practicable on the basis of assessments of actual radiation exposure conditions, and radiation control measures should be designed and implemented accordingly. 2.5.5 Environmental and Engineering Infection Control Routine cleaning and disinfection strategies should be applied to the environmental management of COVID-19. Management of laundry, utensils and medical waste should be performed in accordance with procedures for infectious waste management (refer to the National Guidelines for the Management of COVID-19 (2020). 2.6 Safely Disposing of Grey Water or Water from Washing PPE, Surfaces and Floors WHO Water, sanitation, hygiene and waste management for COVID-19 technical guidance (https://apps.who.int/iris/handle/10665/331305) recommends cleaning of utility gloves or heavy duty, reusable plastic aprons with soap and water and then decontaminate them with 0.5% sodium hypochlorite solution after each use. Single-use gloves (nitrile or latex) and gowns should be discarded after each use and not reused; hand hygiene should be performed after PPE is removed. If grey water includes disinfectant used in prior cleaning, it does not need to be chlorinated or treated again. However, it is important that such water is disposed of in drains connected to a septic system or sewer or in a soak away pit. If grey water is disposed of in a soak away pit, which is designed to allow for percolation of wastewater from a septic tank into the surrounding subsoil. The soak away pit should be sufficiently large enough to avoid flooding or overflow with the minimum capacity being able to accommodate all wastewater produced in one day. Percolation tests should be performed to determine the absorption capacity of the soil. The pit should be fenced off within the health facility grounds to prevent tampering and to avoid possible exposure in the case of overflow. The soak away pit or trench should be located sufficiently away from building foundations, watercourses and wells, in order to safeguard public health and maintain the structural integrity of nearby buildings. A safe distance is generally 30 metres away from watercourses and wells and 3 metres from structures. Maintenance required is period removal of the sludge. 65 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 2.7 Roles and Responsibilities for ICWMP According to the national HCWMP of 2011, the ICWMP falls directly under the responsibility of the Environmental Health Department of MoHCC. The department was given the role to implement and apply the multi-stakeholder approach so that all relevant players take part. The key targeted stakeholders included Ministry of Environment, Water and Climate and its Environmental Management Agency, local authorities, non-governmental organizations, and the private sector. The Environmental Health Department was chosen because the responsibility is part of its mission, it has competent staff cascading to ward level and it has capacity to offer health education services, public information and raising awareness. The department was thus tasked with the responsibility to procure consumables, maintain existing incinerators, build capacity among health care workers, and coordinate the whole HCWMP process. The Environmental Management Agency had the responsibility of monitoring the implementation of the HCWMP as it was considered to have the overall responsibility of protecting the environment. Therefore, the Environmental Health Department’s activities would have to conform to the requirements of the Environmental Management Act. The EMA had to oversee the whole chain of the health care waste from generation to final disposal. The HCWMP neglects to mention the need for facilities to register with EMA as waste generators, and hence inadvertently misses the need to submit reports on waste management to EMA on an annual basis as required by Statutory Instruments 6 and 10 both of 2007. Local authorities have the responsibility to ensure that their sanitary landfills (currently dumpsites) are designed to take in non-hazardous health care waste. To this end, the landfills should have separate designated sections devoted to the disposal of health care waste followings norms and standards defined by the Environmental Management Act to avoid possible environmental pollution. The coordination of the activities was to be done by the local authorities’ Environmental Health Departments. It was suggested that this could be strengthened if the local authorities were to put in place regulations to refuse any mixed waste from health facilities, forbid uncontrolled health care waste disposal and set up deterrent penalties for offenders. Most of the legislation to achieve these requirements are in place but are not being implemented. For example, currently there is no properly lined landfill in Zimbabwe although Statutory Instrument (S.I) 6 of 2007 and S.I 10 of 2007 both required the lining of general and hazardous waste landfills, respectively by 2012. Therefore, project facilities rely on incineration and disposing of the ash in ash pits while those without an ash pit will take their ashes to the unlined landfill. Local authorities have failed to meet this requirement because of the pertaining 66 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) macro-economic environment. It was out of the scope of the assessments to check what was happening at the landfills of the visited urban local authorities. Another role of the local authorities noted during the visits was that they collected the general health care waste from the hospitals visited. However, it was clear that they sometimes collect mixed hazardous and non-hazardous health care waste as there were no mechanisms in place for them to check the waste designated as non-hazardous waste at the health institutions before transportation. Use of color-coded bins, spot checks and audits on waste segregation is a solution which can be put in place to minimize mixing of waste as well as training or information sessions for local authorities to educate them on the logic of waste segregation and the dangers of mixing. At the health facility level, the Infection Control Focal Person and the Environmental Health Officer are responsible for the health care waste management. They ensure that HCWM plans are in place, and that they met the national policy, regulations, and standard operating procedures. Infection Control Focal Person and Environmental Health Officer are responsible for the segregation, collection, transportation, and treatment of health care waste. They ensure that HCWM plans are in place, and that they meet the national policy, regulations, and standard operating procedures. 67 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 3 EMERGENCY PREPAREDNESS AND RESPONSE An emergency event is an unanticipated incident, arising from both natural and man-made hazards, typically in the form of fire, explosions, leaks, spills or injuries from needle pricks. This may occur for a variety of different reasons, including failure to implement operating procedures that are designed to prevent their occurrence, extreme weather or lack of early warning. Emergency preparedness and response are measures designed to address the emergency event in a coordinated and expeditious manner, to prevent it from injuring the health and safety of the community, and to minimize, mitigate and compensate for any impacts that may occur. See the project ESMF for further details on project arrangements for emergencies. 3.1 Management of Spillages What are spillages? In a hospital, hazardous substances such as body fluids, drugs, cleaning fluids and other chemicals are in very close proximity to hundreds of people each day. Thus, in hospital spillage of blood, body fluids or chemicals can occur at any time due to broken or faulty equipment or human error. Any such spill poses risk to the staff, visitors and patients who are extremely susceptible to infection It is important to determine the type of infectious agent because immediate evacuation of the area may be necessary in some cases. In general, the most hazardous spillages occur in laboratories rather than in medical care departments. Procedures for dealing with spillages should specify safe handling operations and appropriate protective clothing. An example of such a procedure is provided in Box 11.2. Appropriate equipment for collecting the waste and new containers should be available, as should means for disinfection. Table 3-1 provides a typical list of required items. In case of skin and eye contact with hazardous substances, there should be immediate decontamination. An exposed person should be removed from the area of the incident for decontamination, generally with copious amounts of water. Special attention should be paid to the eyes and any open wounds. In case of eye contact with corrosive chemicals, the eyes should be irrigated continuously with clean water for 10–30 minutes; the entire face should be washed in a basin, with the eyes being continuously opened and closed. TABLE 3-1- EXAMPLE OF A LIST OF ITEMS FOR SPILLAGE CLEANING Action Tools or items Approaching the spillage Protective equipment (to secure the area) Containing the spillage Absorbent material (e.g. absorbent paper, towels, gauze pads) 68 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Action Tools or items Neutralizing or disinfecting the spillage (if For infectious material: disinfectant25. For necessary) acids: sodium carbonate, calcium carbonate or other base For bases: citric acid powder or other acid For cytotoxic material: special chemical degradation substances Collecting the spillage For liquids: absorbent paper, gauze pads, wood shavings, calcium bentonite, diatomaceous earth For solids: forceps, broom, dustpan or shovel For mercury: mercury sponge or vacuum pump Organizing containment for disposal Plastic bag (red, yellow, or brown, as appropriate), sharps container Decontaminating or disinfecting the area For infectious material: disinfectants For hazardous chemicals: suitable solvent or water Documenting the spillage Report of incident to the superior 25 Such as bleaching powder, which is a mixture of calcium hydroxide, calcium chloride and sodium hypochlorite, used in the powder form or in solution of varying dilution (1:1 to 1:100) depending on the nature of the spilled material Source: adapted from Reinhardt & Gordon (1991) 69 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Box 3-1 Example of general procedure for dealing with spillages Evacuate the contaminated area. Decontaminate the eyes and skin of exposed personnel immediately. Inform the designated person (usually the waste-management officer or infection-control officer), who should coordinate the necessary actions. Determine the nature of the spill. Evacuate all the people not involved in cleaning up if the spillage involves a particularly hazardous substance. Provide first aid and medical care to injured individuals. Secure the area to prevent exposure of additional individuals. Provide adequate protective clothing to personnel involved in cleaning up. Limit the spread of the spill. Neutralize or disinfect the spilled or contaminated material, if indicated. Collect all spilled and contaminated material. (Sharps should never be picked up by hand; brushes and pans or other suitable tools should be used.) Spilled material and disposable contaminated items used for cleaning should be placed in the appropriate waste bags or containers. Decontaminate or disinfect the area, wiping up with absorbent cloth. The cloth (or other absorbent material) should never be turned during this process, because this will spread the contamination. The decontamination should be carried out by working from the least to the most contaminated part, with a change of cloth at each stage. Dry cloths should be used in the case of liquid spillage; for spillages of solids, cloth impregnated with water (acidic, basic or neutral, as appropriate) should be used. Rinse the area, and wipe dry with absorbent cloth. Decontaminate or disinfect any tools that were used. Remove protective clothing and decontaminate or disinfect it, if necessary. Seek medical attention if exposure to hazardous material has occurred during the operation. Report the incident and document the response. 3.2 Occupational Post-Exposure prophylaxis Post-exposure prophylaxis (PEP) is short-term antiretroviral treatment (for HIV) or immunization (for hepatitis B) to reduce the likelihood of infection after potential exposure, either occupationally or through sexual intercourse. Within the health sector, PEP should be provided as part of a comprehensive universal precautions package that reduces staff exposure to infectious hazards at work. PEP for HIV comprises a set of services to prevent development of the infection in the exposed person. These include first-aid care; counselling and risk assessment; HIV blood testing; and, depending on the risk assessment, the provision of short-term (28 days) antiretroviral drugs, with follow-up and support. Most incidents linked to occupational exposure to bloodborne pathogens 70 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) occur in health-care facilities. The guidelines should be printed in large font and displayed in all departments where its accessible to all personnel. PEP kit should be available all the time. The World Health Organization (WHO) and the International Labour Organization have published guidelines on PEP to prevent HIV infection.26 TABLE 3-2 MANAGEMENT OF HEALTH CARE WORKER FOLLOWING BLOOD/BODY FLUID EXPOSURE Antiretroviral medicines to be used in PEP • In line with Guidelines on Antiretroviral Therapy for the Prevention and Treatment of HIV in Zimbabwe • Tenofovir 300mg orally once daily Plus • Lamivudine 300mg orally once daily Plus • Atazanavir 300mg/ritonavir 100mg orally once daily • This regimen is continued until HIV results for HCW and the patient are known or for • one month. 26 See http://whqlibdoc.who.int/publications/2007/9789241596374_eng.pdf 71 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Flow chart for HIV post exposure prophylaxis Flow chart for HBV post exposure prophylaxis FIGURE 3-1 FLOW CHARTS FOR HIV &HBV POST EXPOSURE PROPHYLAXIS 3.3 Reporting Accidents and Incidents All waste-management staff should be trained in emergency response and made aware of the correct procedure for prompt reporting. Accidents or incidents, including near misses, spillages, damaged containers, inappropriate segregation and any incidents involving sharps, should be reported to the Environmental Health Practitioner/ Infection Prevention and Control Focal Person (if waste is involved) or to another designated person. The cause of the accident or incident should be investigated by the Environmental Health practitioner and Infection Prevention and Control focal person. In turn, all accidents, incidents and fatalities are to be reported to the PIE and then to the WB within 48 hours of learning of the incident. The incident report should include details of: • the nature of the accident or incident • the place and time of the accident or incident • the staff who were directly involved • any other relevant circumstances. • Any mitigatory measures employed 72 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) The cause of the accident or incident should be investigated by the Environmental Health Officer (in case of waste) or other responsible officer, who should also take action to prevent recurrence. The records of the investigation and subsequent remedial measures should be kept. 3.4 Personal Protective Equipment PPE is used in healthcare settings to create a barrier between healthcare workers and an infectious agent from the patient and to reduce the risk of transmitting micro-organisms from healthcare workers to patient(s). In addition, PPE may sometimes be used by the patient’s family / visitors, particularly if they are providing direct patient care e.g. assisting patient with toileting. In these circumstances carers must be fully inducted in the use of PPE and Hand Hygiene. The choice of PPE should be based on a risk assessment of potential exposure to blood / body fluids / infectious agents. PPE should be available at the point of use in both community and acute healthcare settings and staff should receive training on the correct use and disposal of PPE. If used inappropriately PPE can increase the risk of transmitting infections and put people at risk of acquiring an infection. Stewardship of personal protective equipment, antivirals, medical equipment and supplies: Health Facilities should implement plans to ensure appropriate allocation of personal protective equipment, including gloves, masks, N95 respirators, and antiviral medications. Referral isolation centres should be adequately staffed, equipped with functional mechanical ventilators, oxygen, patient monitors and consumables. Gloves, aprons, long sleeved gowns, surgical masks, eye goggles, face visors and respirator masks are all examples of PPE that may be worn in the provision of healthcare. Industrial boots and heavy-duty gloves are particularly important for waste workers. The thick soles of the boots offer protection in the storage area, as a precaution from spilt sharps, and where floors are slippery. If segregation is inadequate, needles or other sharps items may have been placed in plastic bags; such items may also pierce thin-walled or weak plastic containers. If it is likely that health-care waste bags will come into contact with workers’ legs during handling, leg protectors may also need to be worn. 3.5 Dilution of Sodium Hypochlorite Chlorine in liquid bleach comes in different concentrations. • You can use any concentration to make a dilute chlorine solution by using the following formula: [% chlorine in liquid bleach] divided by [% chlorine desired] -1 = Total parts of water for each part bleach* Example: To make a 0.5% chlorine solution from 3.5%** bleach: 73 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) • [ 3.5%/0.5%] – 1 = [7] – 1 = 6 parts water for each part bleach Therefore, you must add 1 part bleach to 6 parts water to make a 0.5% chlorine solution. • Parts� can be used for any unit of measure (e.g. liter, or gallon) or any container used for measuring, such as a measuring jug or a bottle TABLE 3-3 SODIUM HYPOCHLORITE DILUTIONS Product Chlorine How to make How to make How to make 1% How to make available 0.1% 0.5% 2% Sodium 3.5% 1 part bleach 1 part bleach to 1 part bleach to 2.5 4 parts bleach hypochlorite to 34 parts 6 parts water. parts water to 3 parts liquid water water (bleach) Sodium 5% 1 part bleach 1 part bleach 1 part bleach to 4 1 part bleach hypochlorite to 49 parts to 9 parts parts water to 1.5 parts liquid water water water (bleach) 74 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 4 INSTITUTIONAL ARRANGEMENTS AND CAPACITY BUILDING 4.1 Zimbabwe COVID-19 Emergency Response Project (ZCERP) Level The project PIE has a qualified Environmental and Social Specialists who will work with MoHCC at all levels to ensure that this ICWMP and the project ESMF are being implemented. The Environmental Specialist together with the Social Safeguards Specialist, will also compile relevant performance and compliance data on all participating facilities providing guidance as necessary. The Environmental Specialist, in coordination with any other necessary parties, will report on ICWMP implementation, compliance and other relevant project performance matters to the PIE as required and to the World Bank on a biannual basis. All accidents, fatalities and incidents are to be reported to the Bank within 48 hours after learning of them. Among other duties, the PIE Environmental Specialist will ensure that each participating project HF will establish an ICWMP tailored to its needs providing guidance to the facility through MOHCC national and subnational levels as necessary before such facility begins project funded activities that generate infectious waste, check that required trained, and qualified staff are in place (including those in charge of infection control and biosafety and waste management), check that IPC measures are funded and in place, that there is use of appropriate PPE for waste handlers, appropriate bins, colour-coded bin liners and transportation to the waste disposal area if onsite or off site. He/ She will also provide guidance on individual facility ICWMP development, review and clear individual facility ICWMPs. The PIE Environmental, Social and Communications Specialists will be available to support the facilities in reporting any risks and dangers associated with infectious and hazardous wastes to the public appropriately. Consultations and disclosures will be carried out during project implementation. Consult the ESMF for further details. 4.2 National (Central) Level According to the 2011 Healthcare Waste Management Plan (HCWMP), which is being updated, the coordination structure for the national HCWMP would be designed by the MoHCC Environmental Health Services Department (EHSD) ensuring that responsibilities are clearly defined. An Environmental Health Technician ensures that the environment is fully protected and that any health risks posed by the risks posed by the environment are dealt with quickly and properly. EHT roles include among other activities, food quality monitoring, premises inspections, water quality monitoring, disease prevention and control. They are appointed upon completion 75 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) of a three-year course after which they are awarded a diploma certificate in environmental health. The EMA and EHSD will lead in developing the health care waste regulations and technical guidelines at national level. According to the Environmental Management Act, each facility is required to develop a waste management plan and report to EMA annually on its waste management activities and these reports will feed into the state of the environment report which EMA is required to produce by the same Act. Although waste management plans are required, facilities usually do not generate them. Zimbabwe emission standards are regulated by the SI.72 of 2009, Environmental Management (Atmospheric Pollution Control) Regulation 2009. These standards are monitored by the Standards Association of Zimbabwe (SAZ) which does the testing of the air to assess amount of pollutants. The PIE Environmental Specialist will verify if each participating facility has the required licensing (for example incinerator licences) and support the facilities in developing appropriate health care waste management plans. The PIE Environmental Specialist working in collaboration with MOHCC will check that facilities with incinerators are adhering to the emission and pollutants standards required by EMA and SAZ. All participating HCF in the project are required to adhere to national laws and policies maintaining or obtaining mandatory licences as necessary. SAZ empowers EMA to do regular inspections and monitoring incinerators. EMA is also responsible for monitoring disposal of both solid and liquid waste. 4.3 Provincial Level The Provincial Development Committee will ensure that healthcare waste is being managed properly without causing harm to the community and the environment. The committee is also responsible for ensuring that healthcare waste treatment infrastructure is available and being maintained well and infection control measures are being followed. This is done by reviewing facility performance. Provincial Environmental Health Officer and Provincial IPC Focal Person are also responsible for training all healthcare workers on IPC and waste management and their implementation. 4.4 District Level The District Development Committee headed by the District Development Coordinator is responsible for ensuring that there is appropriate and enough infrastructure in the district for healthcare waste management. The committee provides oversight to government ministries including MOHCC. The committee also ensures infection control measures for COVID-19, like social distancing, hand hygiene, mandatory masking, respiratory hygiene and environmental cleanliness are being adhered to in healthcare facilities and the community. The committee with the District Environmental Health Officer (DEHO) and District IPC Focal Person conduct monthly inspections in public areas, raise awareness and educate the community to reinforce these 76 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) practices. The DEHO and District IPC Focal Person are also responsible for implementing IPC and waste management in districts health care facilities. The DEHO reports to the PEHO and the District IPC Focal Person reports to the Provincial Nursing Officer. 4.5 Facility Level (Urban and Rural Clinics) All relevant departments in an HCF must be involved in waste and hazardous materials management. An independent team which is not part of the healthcare facility management the Health Centre Committee (HCC), manages, coordinates, and regularly reviews issues and performance. In the urban and rural clinics, the clinic management which includes the HCC and Community Based Organizations (CBOs) are responsible for raising public awareness and health by educating the patients and the community on healthcare waste management and infection control measures to prevent spread of disease. In response to COVID-19, they are responsible for ensuring social distancing, hand hygiene, mandatory masking and respiratory hygiene within healthcare facilities and the community. Infection Control Focal Person also monitors the incidences of needle pricks, other injuries and ensure that Post Exposure Protocol and appropriate reporting internally and externally has been adhered to. In any case, the District Medical Officer, District Nursing Officer or Charge Nurse of a HCF takes overall responsibility for infection control and waste management, leading an intra-departmental HCC team which includes doctors, nurses, cleaners, lab personnel including the microscopist and EHTs of the facility which regularly reviews issues and performance of the facility infection control and waste management practices. Each facility generally has an Infection Control Focal Person who is trained in IPC and waste management. Together with the MoHCC EHSD, this Infection Control Focal Person is supervised by the Nursing Department and is responsible for ensuring any necessary IPC and waste management training of health facility workers (including waste handlers known as general hands or cleaners). At each health facility, the EHT are responsible for HCWM in close collaboration with the facility Infection Control Focal Person. Provincial Health Executives and DHEs under the guidance of Environmental Health Department and Infection Control Focal Persons take responsibility for day-to-day management of health care waste. Infection Control Focal Person to ensure that facility has appropriate bins, color-coded bin liners and PPE for the waste handlers and an on–site or another incinerator is available. If incinerator is off- site to ensure that it meets all the standards and regulatory requirements, and the waste handlers are trained to carry out the job. 77 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) The facility should establish an information management system to track and record the waste streams in HCFs and monitor and report on performance, budget and other arrangements for environmental and social risk management related to infection control and medical waste management. 4.6 Trainings Capacity building and training is mainly structured around seven key areas, focusing on required Infectious Control Waste Management baseline mitigation measures at all levels of the benefiting healthcare facilities (hospitals, and laboratories). The focus will be but not limited to: 1. Infection prevention and control measures, 2. Standard precautions for COVID-19 patients, 3. Infectious HCW management procedures, 4. Environment, Safety and Health while handling COVID-19 cases including handling the dead, 5. Specimen collection and shipment, and Laboratory biosafety guidance for the labs carrying out analysis of COVID-19 samples, 6. Training on emergency preparedness and response 7. Community health and safety in relation to hygiene and other standard precautions for COVID-19 at the community level through community health workers. The targeted audience for the ICWMP is the PIE, all healthcare workers (hospitals, isolation, quarantine, PoE and laboratories) waste handlers, local communities near the healthcare facility, stakeholders and personnel from private sector operators of the waste transportation and disposal service providers. The MOHCC’s training activities shall be oriented towards the quality of healthcare services and prevention of infections from COVID-19. Whilst it is necessary to reinforce the knowledge of medical professionals in these sectors, it is also important to improve their practices in infection prevention and control as well as on HCW handling and management. Training should also involve medical waste transporters, medical waste disposal workers, private operators and technicians active in maintenance work, cleaning, and the management of solid wastes. Promotion of the appropriate handling and disposal of medical waste is important for community health, and every member of the community should have the right to be informed about potential health hazards. The objectives of training on health-care waste and infection control are as follows: a. To prevent exposure to COVID-19 health-care waste and related health hazards; this exposure may be voluntary or accidental, because of unsafe disposal methods. 78 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) b. To create awareness and foster responsibility among hospital patients and visitors to healthcare establishments regarding hygiene and health-care waste management. c. To inform the public about the risks related to COVID-19 health-care waste, focusing on people living or working near, or visiting, health-care establishments and scavengers on waste dumps. It is necessary to develop awareness-raising programs for populations providing healthcare, as well as people using recycled objects or living in proximity of garbage dumps as well, as garbage collectors. There is a need to educate the public in general about community health and safety on the risks associated with improper management of HCWM and the use of recycled objects. Initiating a poster campaign in healthcare structures directed towards visitors, and patient caretakers; making information and awareness raising banners; and holding monthly neighbourhood public information sessions. Particular attention will be towards leaving no one behind including those not able to access such common communication channels. In order to implement the ICWMP, all relevant parties in the MoHCC participating in the COVID19 ERP (as identified above) would be trained to be aware of good practices and procedures of infection control and waste management that are stipulated under this plan. The technical support and capacity building training plan Trainings on implementation of Infection Prevention and Healthcare Waste Management are currently being conducted under the Health Sector Development support Project Additional Financing V all healthcare workers in the 18 rural districts and 2 urban districts, that is from the highest level to the lowest level of personnel on orientation, refresher annually and as when there is need. The District Medical Officer (DMO) /Medical –Superintendent, IPC Focal Person or facility manager will be leading in the implementation of this ICWMP at the facility level. Each facility EHT and IPC Focal Person will lead in the development and implementation of facility specific ICWMP which will have many of the basic elements of the EMA required waste management plan. Under ZCERP trainings on vaccine waste management and infection prevention and control are going to be conducted. The MOHCC, EHD and Nursing Directorate Infection Control Department are responsible for training healthcare workers on infection prevention and healthcare waste management at provincial level through the Provincial Environmental Health Officer (PEHO) and Provincial IPC Department. The PEHO and IPC Department are responsible for training districts and the districts will cascade training to urban and rural healthcare facilities. The IPC and the EH departments will keep the record of the trainings and feed to the health information systems on the number of trained 79 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) healthcare workers in IPC and waste management. IPC and EH departments are also responsible for writing training reports. 4.7 External Supervision and Support Implementation 4.7.1 The Role of the Environmental Management Agency The Environment Management Agency (EMA) is the oversight authority on environmental issues in Zimbabwe. Its role will be of monitoring environment indicators as identified in this ICWMP. The role of EMA includes: - regulatory oversight monitoring as the regulatory agency responsible for the protection of environment in Zimbabwe, EMA plays the leading regulatory role of monitoring for compliance of the project activities according to the EMA ACT (Chapter 20:17) and its functions. - Site inspection visits: EMA as mandated in the EMA Act will undertake site visits to inspect project activities the nature and extent of the impacts and the extent to which the mitigation measures proposed in this ICWMP are being complied. They will then be expected to make viable recommendations based on their findings to the PIE and MOHCC. 4.7.2 Project Implementation Support by World Bank The Bank will conduct regular support implementation missions to support and monitor implementation of compliance with the requirements of the ICWMP. The World Bank’s Task Team will also provide regular Project implementation support to the PIE and other relevant implementing partners as follows: a) Monitor progress in all substantive aspects of the Project implementation against the targets, development objectives, and performance monitoring indicators/targets for the ICWMP, b) Monitor procurement implementation and disbursement, recommending ways to ensure that procurement activities and financing disbursements for components related to waste management proceed smoothly in line with the planned schedule; and c) Ascertain the extent of compliance with financing covenants, including those related to environmental and social due diligence compliance commitments in the ICWMP, d) Support the development of individual facility ICWMPs through PIE and MOHCC. 80 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 5 MONITORING AND REPORTING 5.1 Monitoring and Reporting Arrangements MoHCC will standardize data collection tools for waste management to enable data flow from facilities to the National Health Information Management System and therefore existing tools will be adapted and/ or adopted. Thus, the project would not seek to create parallel tools for reporting. Each HF generally has an Infection Committee responsible for monitoring and reporting IPC and waste management practices monthly, quarterly, and annually. The main duties of the IPC Committee include: • Observation of segregation of waste in all departments within a healthcare facility recording those who are not complying and reinforce practice. • Auditing of infection control and waste management practices to be done to improve practices. • Weighing of waste should be done to monitor amount of waste generated per healthcare facility. • Ensure compliance with all EHS Project requirements related to HCF EHS management including medical waste management • Ensure that all Project-related infectious medical waste is disposed at facilities that meet all EHS requirements established by EMA and this Project (including this ICWMP and ESMF) HFs should track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities. Zimbabwe emission standards are regulated by the Environmental Management Agency SI.72 of 2009 (Atmospheric Pollution Control) Regulation 2009. These standards are monitored by the Standards Association of Zimbabwe (SAZ) which test the air to assess the amount of pollutants. 5.1.1 Indicators to be Monitored at Each Facility These indicators were formulated incorporating feedback from the stakeholder consultation meetings. 81 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) TABLE 5-1 INFECTION CONTROL AND WASTE MANAGEMENT PLAN INDICATORS BASELINE FREQUENCY OF KEY RESULT AREA OUTCOME/OUTPUT INDICATORS INDICATOR DEFINITION DATA SOURCE TARGET (2023) (YEAR) COLLECTION OUTCOME PERCENTAGE OF FACILITIES THAT HAVE ADOPTED HCWM PLAN OR FACILITY WITH A CURRENT IMPROVED ENABLING HCWM PLAN THAT MEETS THE PROPORTION OF HF THAT HAVE AT START OF THE ENVIRONMENT FOR UNKNOWN PROJECT REQUIREMENTS HCWM PLANS INSTITUTIONALISED THE HCWM PROJECT AND THE 80% HEALTH CARE WASTE (2021) (INCLUDING THIS ICWMP) FOLDER PLAN QUARTERLY MANAGEMENT NUMERATOR NUMBER OF FACILITIES THAT HAVE ADOPTED HCWM PLAN/DENOMINATOR ALL FACILITIES OUTPUTS ENABLING ENVIRONMENT FOR HEALTH CARE WASTE NUMBER OF COMMUNITY REPORTS MANAGEMENT MEETINGS NUMBER OF MEETINGS CONDUCTED UNKNOWN MEETINGS CONDUCTED ON WASTE MONTHLY CONDUCTED ON HCWM (2021) MANAGEMENT WITH MINUTES PROVIDED ATTENDANCE REGISTERS HCWM A PERFORMANCE REPORT ON HCWM ANNUAL NUMBER OF HCWM ANNUAL UNKNOWN ANNUAL HCWM FOR THE YEAR UNDER ANNUALLY REPORT PRODUCED REPORTS PRODUCED (2021) REPORTS REVIEW. FOLDER PERCENTAGE OF FACILITIES WHO HCWM BUDGET % OF FACILITIES WITH A BUDGET UNKNOWN HAVE A BUDGET ALLOCATED IN OPERATIONAL ANNUALLY ALLOCATED ALLOCATION ON HCWM (2021) THE CURRENT YEAR PLANS NUMERATOR NUMBER OF 82 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) FACILITIES WITH A BUDGET ALLOCATED FOR HCWM/DENOMINATOR ALL FACILITIES HCWM OVERSIGHT NUMBER OF SUPPORT, NUMBER OF HCWM SUPPORT AND MANAGEMENT ACTIVITIES 4 (2021) SUPERVISION VISITS CONDUCTED QUARTERLY SUPERVISION VISITS CONDUCTED BOOK CONDUCTED WITH ACTIVITY (SSVS) REPORT PROCESS HCWM PROCESS NUMBER OF HCWM PROCESS NUMBER OF PROCESS 0 (2021) 2 YEARS EVALUATION EVALUATION EVALUATIONS CONDUCTED EVALUATIONS CONDUCTED REPORTS NUMBER OF HEALTH CARE WASTE ATTENDANCE HCW TRAINED ON NUMBER OF HCW TRAINED ON 1200 MANAGEMENT 3 DAY PHYSICAL QUARTERLY REGISTERS WASTE MANAGEMENT WASTE MANAGEMENT (2021) TRAININGS CONDUCTED REPORTS PROPORTION OF FACILITIES WITH PROPORTION OF HF WITH HCWM UNKNOWN MANAGEMENT INSTITUTIONALISED HEALTH CARE QUARTERLY PLAN (2021) BOOK WASTE MANAGEMENT PLAN PROPORTION OF FACILITIES WITH INSTITUTIONALISED STANDARD OPERATING PROCEDURES ON HCWM PLAN AND HEALTH CARE WASTE SOPS PROVIDED PROPORTION OF HF WITH HCWM UNKNOWN MANAGEMENT MANAGEMENT ANNUALLY SOPS (2021) NUMERATOR NUMBER OF BOOK FACILITIES WITH INSTITUTIONALISED SOPS/DENOMINATOR ALL FACILITIES QUALITY HEALTH OUTCOMES CARE WASTE WASTE DESTINED FOR THE RBF MANAGEMENT IMPROVED QUALITY 54% INCINERATOR CORRECTLY CHECKLIST/DHI IN HEALTH CARE VOLUME OF WASTE SEGREGATED HOSPITALS ANNUALLY SEPARATED IN VARIOUS S RBF WASTE MANAGEMENT (Q2 2022) DEPARTMENTS INSTANCE OUTPUTS 83 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) HEALTH CARE WASTE MANAGEMENT ZONES PROVIDED NUMBER OF INCINERATORS: FUNCTIONAL REACHING MINIMUM NUMBER OF FACILITIES USING A UNKNOWN RECOMMENDED TEMPERATURE 0F MANAGEMENT QUARTERLY LICENCED INCINERATOR (2021) 800 TO 1200 DEGREE CELSIUS BOOK LICENCED BY ENVIRONMENTAL MANAGEMENT AGENCY (EMA). UNKNOWN ASHPITS:3M DEEP AND LINED % OF HFS WITH PROPER ASHPIT QUARTERLY (2021) (RURAL HEALTH CENTRES) PROPORTION OF FACILITIES WITH % OF FACILITIES WITH WASTE AREA CYNTHIA A FENCED AND LOCKABLE WASTE QUARTERLY FENCED AND LOCKABLE (2021) AREA % OF HFS WITH FUNCTIONAL UNKNOWN BOTTLE CRUSHER: 3M DEEP AND QUARTERLY BOTTLE PITS WITH BOTTLE CRUSHERS (2021) LINED (RURAL HEALTH CENTRES) OTTO WAY PIT WITH LID, NOT % OF HF WITH FUNCTIONAL 81% (Q2 FULL AND FUNCTIONAL (RURAL QUARTERLY OTTAWAY PIT 2022) HEALTH CENTRES) LINED, VENTILATION, FLYSCREEN, 84 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) % OF HF WITH HEALTH CARE WATE FENCED WITH LOCKABLE GATES, UNKNOWN MANAGEMENT TEMPORARY ROOFED, ANIMAL PROOF, QUARTERLY (2021) HOLDING BAY RODENTS’ PROOF, NUMBER OF FACILITIES WITH STANDARD WASTEWATER NUMBER OF FACILITIES WITH MANAGEMENT FACILITIES WHICH UNKNOWN STANDARD WASTEWATER INCLUDES SEPTIC TANK, QUARTERLY (2021) MANAGEMENT FACILITIES SOAKAWAYS, STABILISATION PONDS, CONVECTIONAL TREATMENT NUMBER OF FACILITIES WITH AT LEAST TWO BINS WITH A LID PER NUMBER OF FACILITIES WITH UNKNOWN POINT OF CARE AND 3 LID BINS QUARTERLY WASTE ADEQUATE PEDAL OPERATED BINS (2021) WHERE THERE IS PATHOLOGICAL MANAGEMENT WASTE COMMODITIES NUMBER OF FACILITIES WITH AT PROVIDED NUMBER OF FACILITIES WITH 64% IN LEAST 2 COLOUR CODED BINS: ADEQUATE COLOUR CODED WHEELIE HOSPITALS QUARTERLY -RED/YELLOW FOR NON-SHARP BINS (Q2 2022) INFECTIOUS WASTE PERCENTAGE OF HEALTH FACILITIES WITH WASTE HANDLERS THAT HAVE HEAVY DUTY GLOVES, UNIFORMS, DUST COATS, HEAVY 90% IN DUTY APRONS, GUMBOOTS, FACE % OF WASTE HANDLERS WITH CLINICS PPE FOR WASTE MASKS, HELMET, HEAT RESISTANT APPROPRIATE PERSONAL 100% IN QUARTERLY 100% HANDLERS PROVIDED GOOGLES AND GLOVES PROTECTIVE EQUIPMENT HOSPITALS NUMERATOR: HEALTH FACILITIES (Q2 2022) WITH WASTE HANDLERS WITH ADEQUATE PROTECTIVE CLOTHING/DENOMINATOR ALL FACILITIES 85 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) NUMBER OF NEEDLE STICK INJURIES NUMBER OF NEEDLE STICK UNKNOWN FROM HEALTHCARE WASTE INJURIES FROM HEALTHCARE QUARTERLY (2021) MANAGEMENT WASTE MANAGEMENT PROPORTION OF FACILITIES WHICH COLLECT AND DISPOSE DAILY OR WITHIN 4 TO 5 HOURS WASTE COLLECTED PROPORTION OF FACILITIES WHICH 100% IN NUMERATOR NUMBER OF AND DISPOSED COLLECT AND DISPOSE DAILY OR HOSPITALS QUARTERLY 100% FACILITIES WHICH COLLECT AND TIMEOUSLY WITHIN 4 TO 5 HOURS (Q2 2022) DISPOSE DAILY OR WITHIN 4 TO 5 HOURS/ DENOMINATOR ALL FACILITIES OUTCOMES WASTE IMPROVED PROPORTION OF HEALTH MANAGEMENT AWARENESS AND FACILITIES IN COMPLIANCE WITH AWARENESS AND ADHERENCE TO BASIC STANDARDS OF COMPLIANCE HEALTH CARE WASTE SEGREGATION AND WASTE AREA PROPORTION OF HEALTH FACILITIES CULTURE MANAGEMENT UNKNOWN NUMERATOR NUMBER OF MANAGEMENT IN COMPLIANCE WITH BASIC ANNUALLY STANDARDS (2021) HEALTH FACILITIES IN COMPLIANCE BOOK STANDARDS (LEGISLATION AND WITH BASIC STANDARDS OF SOPS) OF WASTE SEGREGATION AND WASTE SEGREGATION AND AREA/DENOMINATOR ALL AREA FACILITIES OUTPUTS 86 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) NUMBER OF AWARENESS NUMBER OF AWARENESS CAMPAIGNS CAMPAIGNS CONDUCTED ON IPC 12 CAMPAIGNS CONDUCTED ON IPC MONTHLY REPORTS CONDUCTED AND WASTE MANAGEMENT AND WASTE MANAGEMENT NUMBER OF A MINIMUM OF 2- DAY MONITORING AND M&E TRAININGS NUMBER OF M&E TRAININGS ON UNKNOWN TRAINING EVALUATION TRAININGS QUARTERLY CONDUCTED CONDUCTED (2021) REPORTS CONDUCTED ON HEALTH CARE MANAGEMENT. PROPORTION OF HEALTH FACILITIES WITH AT LEAST ONE POSTER ON HEALTH CARE WASTE MANAGEMENT DISPLAYED, EVEN IEC ON HEALTH CARE % OF HF WITH HCWM IEC UNKNOWN IMPROVISED WASTE MATERIALS QUARTERLY REPORTS MATERIAL DISPLAYED (2021) NUMERATOR HEALTH FACILITIES PROVIDED WITH AT LEAST ONE POSTER ON HEALTH CARE WASTE MANAGEMENT DISPLAYED/ DENOMINATOR ALL FACILITIES CLIENTS’ PROPORTION OF GRIEVANCES SATISFACTION RESOLVED /ADDRESSED WITHIN 4 ANALYSIS WEEKS OF COMPLAINT AND COMPLAINTS AND REPORTS PROPORTION OF COMPLAINTS 47.6% FEEDBACK GIVEN TO CLIENT COMPLIMENTS MONTHLY COMPLAINTS RESOLVED (Q2 2022) NUMERATOR NUMBER OF HANDLED REPORT GRIEVANCES RESOLVED/ CLIENTS’ DENOMINATOR NUMBER OF ALL COMMENTS GRIEVANCES LOGGED IN BOOK 87 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) CLIENTS COMMENT GRIEVANCE ADDRESSED WITHIN 4 BOOK NUMBER OF GRIEVANCES HANDLED 0 MONTHLY WEEKS OF COMPLAINT INVESTIGATION MINUTES 88 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 5.1.2 Records i. Training records on waste management and disposal. ii. Reports on routine IPC rounds checking on waste segregation. iii. Costs for waste disposal materials and for occupational health activities such as needle stick injuries and post exposure treatments. iv. Registers of waste generated and sent for disposal. v. Summaries (minutes) from any public consultations held for the projects. 5.2 Estimating Amount of Health Care Waste Generated Per Facility Assess your facility for: • Number of wards, or department or offices • Number of beds per wards • Distance from central storage place • Number of staffs or health workers • Amount of waste generated per day To establish the amount of waste generated per day, multiply the generation rate factor (0.41 kg/occupied bed per day) by the number of beds for referral, regional and district hospitals or 0.03 kg/patient per day for health centres and dispensaries. Weighing of healthcare waste is key in waste management as the information generated will enable authorities to assess if waste segregation at source is being implemented and if they want to build an incinerator, the data will assist on determining the size of incinerator required. 5.3 Reporting The Environmental Specialist will also compile relevant performance and compliance data on all participating facilities providing guidance as necessary to facilities. The Environmental Specialist, in coordination with any other necessary parties, will report on ICWMP implementation, compliance and other relevant project performance matters to the PIE as required and to the World Bank on a biannual basis. All accidents, fatalities and incidents are to be reported to the Bank within 48 hours after learning of them. Facilities must register with EMA as medical/hazardous waste generators or waste handlers including private sector companies and thereafter, submit reports on waste generated and/ or handled to EMA on an annual basis as required by Statutory Instruments 6 and 10, both of 2007. EMA will also submit an annual report to the MOHCC on facilities performance on healthcare waste management. 89 INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) Externally, reporting should be conducted per government and World Bank requirements. The PIE will submit a report on ESMF and ICWMP project implementation to the Bank biannually on the project as described in the Environmental and Social Commitment Plan (ESCP). These reports will include statistics on national project implementation, management of grievances received, screening of HCFs, site-specific ESMPs and ICWMPs, monitoring and reporting on ESMF and ICWMP implementation. 5.4 Implementation of Infection Control and Waste Management Plan (ICWMP) At the national level, the HCWMP, which is being updated, is part of the Government’s Environmental Health Strategy, of which this is an important component. Implementation will be coordinated by the EHD of the MOHCC, in collaboration with other stakeholders (NIPCC, EMA, Ministry of Local Government and Public Works) who will participate in a range of activities – from implementation to supervision. Trainings and awareness are some of the activities which will be executed, and each facility will develop its own budget. Many HCFs in developing countries face the challenge of inadequate monitoring and records of healthcare waste streams. HCFs should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities. The HCF is encouraged to develop an IT based information management system should their technical and financial capacity allow. As discussed above, the HCF chief takes overall responsibility, leads an intra-departmental team and regularly reviews issues and performance of the infection control and waste management practices in the HCF. Internal reporting and filing systems should be in place. Externally, reporting should be conducted per government and World Bank requirements. 90 COVID-19 Response ESMF – ICWMP TABLE 5-2 INFECTION CONTROL AND WASTE MANAGEMENT PLAN Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks General HCF Non-hazardous -Use of waste receptacles that encourage segregation to hold MOHCC, PIE, As needed operation – waste waste on site before its collection, Health Facility Environment -Use of durable, long-lasting materials that will not need to be replaced often, -Contract registered waste handler to dispose of hazardous waste and have waste destruction certificate and waste transfer notes. -Designate temporal waste / garbage holding areas at site. -General waste in the case of handling COVID-19 patients should be treated as infectious waste Wastewater -All infectious effluents should be discharged into the public MOHCC, PIE, Continuous sewer system or soak pits only after being pre-treated according Health Facility to WHO standards / EMA (Effluent and Solid Waste Disposal) Regulations, 2007 and WB EHS Guideline for Health Care Facilities. -Wastewater from primary care facilities will be discharged into septic tanks connected to soakaway pits -Wastewater from secondary facilities will be discharged into waste stabilisation ponds, -Wastewater from laboratories to be pre-treated before discharge into municipal sewer. Air Emissions Controlled procurement process to ensure quality and efficient MOHCC, PIE, Quarterly incinerators, Health Facility -Prohibit open burning of medical waste on site, - Siting of the incinerators should be away from the health facilities wards, residential areas and farms 91 COVID-19 Response ESMF – ICWMP Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks -Ensure the incinerators used in the health facilities are fitted with scrubbers to reduce on release of pollutants to be in compliance with Environmental Management (Atmospheric Pollution Control) Regulations, 2009. -Incinerator chimney installed should be of the recommended height as stipulated in the Environmental Management (Atmospheric Pollution Control) Regulations, 2009 -Improved operation, process monitoring, and emission controls will be necessary to meet standards for dioxins, furans and particulate matter release to the environment. -Adequate training of incinerator operators on proper operation and maintenance of incinerators. -Regular monitoring of the process should be carried out by the engineers. -The ash produced by incineration should be sent for final disposal at the landfill or disposed in a watertight brick or concrete lined ash pit fitted with a waterproof covered lid When the incinerator ash is sent to the landfill it must tested first to confirm no hazardous wastes e.g heavy metals exits. -Incinerator operators to be provided with appropriate PPE which includes a regular air purifying respirator, and to be vaccinated against blood-borne disease e.g. hepatitis B and tetanus. 92 COVID-19 Response ESMF – ICWMP Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks General HCF - Physical -All workers should be provided with appropriate PPE against MOHCC, PIE, Quarterly operation – OHS hazards exposure to hazards, Health Facility issues - Chemical -Training for all staff should be given on safe work practices use /OHS and guidelines and ensure that they adhere to it, - Ergonomic -The medical facilities and equipment should be regularly hazards maintained to correct any electrical faults, -Strategic display on Infection Prevention and Control Policy and regular review of the policy by the management/ team, -Proper maintenance of PPE, including cleaning when dirty and replacement when damaged or worn out, -Proper use of PPE should be part of the recurrent training programs for employees, -Emergency eye-wash and shower facilities should be equipped with audible and visible alarms to summon aid whenever the eye-wash or shower is activated by the worker and without intervention by the worker, -Ensure adequate provision of safety systems which should cover fire, electrical emergencies with First-aid areas or rooms suitably equipped and readily accessible should be available, Provision of first aid kits and first aiders trained the relevant personnel on first aid, and -Materials safety data sheet for all chemicals used especially at the lab should be hanged on notice boards -Incinerator operators to be provided with appropriate PPE which includes a regular air purifying respirator - Electrical -All electrical repair activities should be done by competent MOHCC, PIE, Quarterly and electrician, Health Facility 93 COVID-19 Response ESMF – ICWMP Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks explosive -Ensure the Biomedical department in the health facility has a hazards qualified electrician to address the electrical faults, -Prepare and implement Emergency response plan -Emergency Contacts, Periodic maintenance of electrical equipment, and -Consider safe storage of supplies and undertake precaution with respect to explosives. - Fire -Prepare and implement Fire prevention or emergency response MOHCC, PIE, Quarterly and evacuation plans [with adequate guest information (this Health Facility information should be displayed in obvious locations and clearly written in relevant languages)]. -Training of fire marshals in the facilities, -Early identification of risks (Job Risk Assessment) and instituting proactive measures to avoid. -Provide fire extinguishers to healthcare facilities during their renovation -Ensure servicing and inspection of the firefighting equipment -Fire emergency telephone numbers should be displaced in communal areas. Undertake fire drills at healthcare facility, at a minimum once quarterly. -Installation of smoke alarms and sprinkler systems (should be installed prior to project support), -Maintenance of all fire safety systems in proper working order, including self-closing doors in escape routes and ventilation ducts with fire safety flaps, -Training of staff for operation of fire extinguishers and evacuation procedures, (indicator is percentage of staff trained per year) 94 COVID-19 Response ESMF – ICWMP Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks - Radioactive -All radioactive materials should be handled safely to prevent MOHCC, PIE, Quarterly hazard harm to people and environment. Health Facility -HCF operators should develop a comprehensive plan to control radiation exposure in consultation with the affected workforce, -Radioactive waste should be stored in containers that prevent dispersion behind lead shielding. -Waste that is stored during radioactive decay should be labelled with the type of radionuclide, the date and details of the required storage conditions, -Radioactive hazard plan should be refined and revised as soon as practicable on the basis of assessments of actual radiation exposure conditions, and radiation control measures should be designed and implemented accordingly, and -Places of work involving occupational exposure to ionizing radiation should be provided with requisite protection (PPE) in accordance with recognized international safety standards and guidelines27 Waste -Potential -Procure medical supplies & equipment from accredited MOHCC, PIE, On need minimization, reuse increased suppliers preferably in small quantities, Health Facility basis and recycling generation of -Waste generated from care of COVID-19 patient should not be waste -Risk in re-used spread of COVID-19 HCF operation - Possible risks of MOHCC, PIE, Quarterly Infection control infection Health Facility 27 International Basic Safety Standard for protection against Ionizing Radiation and for the Safety of Radiation Sources and its three interrelated Safety Guides. Taken from WB (2007) General EHSG: Occupational Health & Safety, p73. 95 COVID-19 Response ESMF – ICWMP Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks and waste -Orientation for all staff would be given on safe work practices management plan and guidelines and ensure that they adhere to it (indicator is Delivery and Infection to percentage of staff trained per quarter). MOHCC, PIE, Daily storage of laboratory -Provide relevant vaccine program for all health workers and Health Facility specimen, samples, attendants - supportive staffs Adopt or utilize WHO guidelines, MOHCC reagents, Expiry of standards, practice and procedures especially WHO Laboratory pharmaceuticals medical biosafety guidance related to coronavirus disease 2019 (COVID- and medical supplies and 19). supplies pharmaceutical -Initial processing of all specimens should take place in a Storage and -Infection to lab validated biological safety cabinet (BSC) or primary containment MOHCC, PIE, Daily handling of attendants device. Health Facility specimen, samples, -All technical procedures should be performed in a way that reagents, and minimizes the generation of aerosols and droplets. infectious materials -Use of appropriate disinfectants with proven activity against enveloped viruses should be used (for example, hypochlorite [bleach], alcohol, hydrogen peroxide, quaternary ammonium compounds, and phenolic compounds). Waste segregation, -Increased - Segregation is the responsibility of the one who generates the MOHCC, PIE, Weekly packaging, colour generation of waste. Health Facility coding and infectious - The three-bin system to be instituted in all healthcare settings labelling waste due to and the containers for collection should be strategically located poor at all points of generation. segregation -Segregation of wastes into different categories—for control of practices quantities and disposal methods -Waste containers should be of the same colour as the bags and fitted with lids 96 COVID-19 Response ESMF – ICWMP Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks -All sharp wastes (e.g., needles, auto-block syringes, scalpels, etc.) MUST be collected inside the appropriate and dedicated container, such as sharps container or safety box. -Any used or discarded COVID-19 vaccine vials MUST be collected safely and separately from the rest of the waste. Onsite collection -Infection to -Ensure proper waste management practices as recommended MOHCC, PIE, Weekly and transport the waste by the WBG EHS guidelines, WHO Safe waste management Health Facility handlers -Non guidelines for improvement waste management and this segregation of ICWMP waste -Waste handlers responsible for on-site waste transportation -Increased must be adequately trained on safely handling and generation of transportation of medical waste (indicator is percentage of staff infectious trained per quarter). waste due to -The collection of waste would be made at least once in 24 contamination hours or when they are ¾ full to an on-site incinerator or temporary storage facility for off-site incineration, -Waste collection and transportation should be done in such a way to minimize nuisance of smell and dust during collection and all the waste collected must be carried away from the storage site to an approved disposal point. -Each HCF department must be provided with colour-coded wheelie bins for or trolley for transportation of waste to designated areas including waste that must be transported directly to the incinerator. -HCF waste supervisors must monitor waste transportation to ensure they follow designated routes for waste transportation, 97 COVID-19 Response ESMF – ICWMP Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks -Provide appropriate waste bins for the different types of waste generated in the HCF departments to allow segregation and collection at the point of generation. Waste storage -Littering of -Segregation of wastes into different categories for control of MOHCC, PIE, Weekly waste quantities and disposal methods. Health Facility -Contamination -Provision of colour coded waste bins with lid, of surfaces -Provision of appropriate PPEs for waste handlers and incinerator operators -Decontamination of surfaces Onsite waste -Pollution to -Adopt the suggested design for the waste treatment facility, if MOHCC, PIE, Quarterly treatment and environment an incinerator, see section 2. Health Facility disposal discharges of -Waste segregation at point of origin to reduce on waste contaminated generated, wastewater -Ensure operator of incineration unit is adequately trained to -Emissions from ensure efficient operation. the incinerator -All incinerators to be monitored to ensure they are properly licenced by EMA, being operated according to manufacturer operating criteria and in accordance with WB EHS guidelines - The functioning of the incinerator and the number of cycles operated per day should be documented and recorded in a logbook. -The ash produced by incineration should be sent for final disposal at the landfill or disposed in a watertight brick or concrete lined ash pit fitted with a waterproof covered lid (where access to engineered sanitary landfills is limited especially small incinerator operations) to prevent uncontrolled disposal of the ash, which can allow the contaminants it contains to enter the environment or the food chain. When the 98 COVID-19 Response ESMF – ICWMP Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks incinerator ash is sent to the landfill it must tested first to confirm no hazardous wastes e.g., heavy metals exist, -Provide the required PPE to operators and waste handlers -Periodic maintenance of the incinerator through cleaning of combustion chamber and de-clogging the air flows -Routine inspection of furnace and air pollution system by the regulatory authority have a well-established audit and reporting system on waste treatment operations Waste -Littering of -Offsite transportation of waste should comply with the national MOHCC, PIE, Weekly transportation to wastes regulations Environmental Management (Control of Hazardous Health Facility and disposal in -Disposal in Substances) (General) Regulations, 2018 offsite treatment non- permitted -Use of EMA licensed Waste transporters, and disposal waste sites -Keeping record of waste transfer notes as well as waste facilities destruction certificates at the point of disposal facility. -Use the appropriate vehicle type for transportation of HCW off site Staff should be aware of emergency procedures for dealing with accidents and incidents of spillage during transportation on public roads -Due diligence should be undertaken for all the waste treated off site to ensure waste is transported through the required routes (non-busy route) and safely treated and disposed -Ensure waste incinerators are operating according to manufacturer operating criteria, and according to WB EHS guidelines 99 COVID-19 Response ESMF – ICWMP Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks HCF operation – -Importation of -Procure medical supplies & equipment from accredited supplier MOHCC, PIE, On need transboundary substandard -Proper handling of equipment use, and methods of storage Health Facility basis movement of medical from cradle to crave, specimen, samples, supplies and -Cross-boundary transport of specimens of the virus responsible reagents, medical equipment for COVID-19 should follow the United Nations model equipment, and -Illegal regulations, technical instructions for the safe transport of infectious materials importation dangerous goods by air (Doc 9284) of the International Civil -Classes of Aviation Organization. dangerous goods without clear G -Improper handling and stowage Emergency events -Spillage, Fire -Emergency response plan(s) for specific emergencies MOHCC, PIE, Quarterly and others Regular drills would constantly follow on various possible Health Facility incidences. This will test the response of the involved stakeholders. Such drills will keep them alert and they will become more responsive to in the case of incidences -Train relevant staff on response in risk management and emergency procedures in case of accidents (indicator is percentage of staff trained per year) -Occupational -Ensure the provision of safe water, sanitation, and hygienic MOHCC, PIE, Weekly exposure to conditions, which is essential to protecting human health during Health Facility infectious all infectious disease outbreaks, -Health facilities shall establish and apply good practices line with WHO guidance on water, sanitation and waste 100 COVID-19 Response ESMF – ICWMP Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks management for COVID-19 and National guidelines for Infection -Prevention and Control in the healthcare facilities. -Exposure to -Refer to earlier section above on radiation MOHCC, PIE, Weekly radiation Health Facility -Accidental -Train relevant staff on response in risk management and MOHCC, PIE, Annually releases of emergency procedures in-case of accidental releases of Health Facility infectious or infectious or hazardous substances (indicator is percentage of hazardous staff trained per year), and substances to -Provision of receptacles for timely response of accidental the releases environment -Medical -Provide requisite training during equipment installation MOHCC, PIE, Annually equipment (indicator is percentage of staff trained per year). Health Facility failure -Carry out regular supervision, ensure only trained authorized personnel operate equipment, -The manual containing information on how the medical facilities and equipment should be safely handled should be made available to the relevant staff, and -Equipment should be sanitized and disinfected before use to minimize risks of infections. 101 COVID-19 Response ESMF – ICWMP Activities Potential E&S Proposed Mitigation Measures Responsibilities Timeline Issues and Risks -Failure of solid -All HCFs should prepare waste management procedures in MOHCC, PIE, waste and accordance with the national requirements that outline waste Health Facility wastewater segregation procedures, on site handling, collection, transport, treatment treatment and disposal, and training of the staff facilities Operation of Non-use of the Ensure equipment purchased is of the required standard and MOHCC, PIE, Quarterly acquired assets for equipment due specifications, Health Facility holding potential to lack of Ensure good control measures in purchase of medical COVID-19 patients technical know equipment, how Equipment should be disinfected before use to minimize risk of -Risk of misuse infections Provide requisite training during equipment of the installation, equipment The equipment’s manual should be made available to the -Poor medical workers for safe routine procedures Prepare maintenance maintenance plan for all equipment leading to breakdown 102 COVID-19 Response ESMF – ICWMP The PIE will work in collaboration with the MOHCC and HCFs to implement the ICWMP. Below is the estimated budget for implementation. TABLE 5-3 TRAINING PLAN AND BUDGET FOR STAFF AND SUPPORT STAFF Capacity Needs Target Participants Cost (USD) Training on Infection control -Professionals and non-professional staff working 15,000 and waste management in the HCF (hospitals, rural health facilities and in procedures and the roles and the Laboratories tasks for all actors from -Cleaners, morgue attendants waste transporters cradle to grave and handlers, incinerator operators, liquid waste treatment facility operators and other staff of the laboratories. -Staff for waste reporters service providers Training on Environment, -Professionals and non-professional staff working 10,000 Health and Safety, Material in the HCF (hospitals, vaccination centres, Safety Data Sheets (MSDS) isolation and in the Laboratories, and emergency preparedness -Cleaners, waste transporters and handlers, and response incinerator operators, liquid waste treatment facility operators and other staff of the laboratories. Training on biosafety and -Professionals working in the Laboratory and staff 20,000 biosecurity -Cleaners, waste transporters and handlers, incinerator operators, liquid waste treatment facility operators and other staff of the laboratories Community health and safety -Community members and community health 10,000 in relation to hygiene and workers within the HCF zone of influence. other standard precautions for infectious disease (i.e. COVID 19). Training of HCF on proper -Professionals working at vaccination centres, implementation of their Laboratory, HCF, Isolation, treatment Centre, specific ICWMP and ESMP blood services. during operations 103 COVID-19 Response ESMF – ICWMP Capacity Needs Target Participants Cost (USD) Training of the medical waste Professionals working in the Laboratory, HCF, 10,000 handlers on their HCF specific Isolation and treatment Centre, blood services. ICWMP during operations Training of transporters on Drivers transporting medical waste, waste 11,000 safe handling and handlers responsible loading and offloading transportation of medical medical waste for off-site incineration waste Total 86,000 TABLE 5-4- ESTIMATED IMPLEMENTATION BUDGET Activity Amount (USD) Printing of documents (ICWMP) -2000 copies $20,000 Training $86,000 Information, Education Communication (IEC) material $5,000 (posters)- Printing (10000 copies) Total $111,000 104 COVID-19 Response ESMF – ICWMP 6 STAKEHOLDER CONSULTATIONS On 7 April 2022 a stakeholder consultation meeting was held to solicit for feedback on the ZCERP ICWMP. The stakeholders were drawn from the MOHCC, local NGOs, Ministry of Local Government, Public Works and National Housing, Environmental Management Agency. The meeting was held virtually where the ICWMP draft contents were reviewed and discussed. The outline and feedback from the consultation meeting is presented in Appendix 8. The stakeholder consultations were built on the HSDSP AFV consultations which were conducted in 2020/2021 as outlined in the table below. The stakeholder consultations added value to the ICWMP as it assisted in getting stakeholder buy-in to own the document from MOHCC. Stakeholders especially MOHCC became enlightened about the requirements of the ESMF, ICWMP and the LMP. Feedback from the participants made some sections of the document clearer and aligned to other MOHCC working documents. Specifically, changes were made to indicators to be tracked. Additionally, the consultations confirmed many of the issues which were also highlighted during the consultations for the HSDSP AF ICWMP consultations which included the need for capacity building on infection control and waste management among waste handlers and health care workers, refurbishment of waste incinerators and regular maintenance of the same. FIGURE 6-1 STAKEHOLDER CONSULTATIONS FOR HSDSP AFV ICWMP # Stakeholder Method Used Dates Who Was Consulted Consultation 1 Field Public Field Visits and 19- Provincial Health Executives Consultation Focus Group 27/08/2020 of Mashonaland East, Meetings Matabeleland South, Matabeleland North Provinces, and selected District Health Executives, Health Centre Committees and Community Based organisations from the mentioned provinces. Provincial Development Committees and District Development Committees. Covid-19 Isolation Facilities 2 Consultation with Key Informant 19- Fencraft Investments Pvt NGOs Interviews 27/08/2020 Ltd, Oxfam, UNICEF. Only through email Fencraft Investments Pvt Ltd responded. 105 COVID-19 Response ESMF – ICWMP 3 Consultation with Key Informant 31/08/2020 Environmental Environmental Interviews Management Agency. Management through email Agency 4 ESMF and ICWMP Workshop 7-8/06/2021 MOHCC structures from Validation national to district levels Workshop Ministry of Local Government and National Housing. Environmental Management Agency 5 Stakeholder Workshop 7/04/2022 MOHCC structures from Consultation national to district levels Ministry of Local Government and National Housing. Environmental Management Agency 6 ICWMP Validation28 Workshop 1-2/09/2022 MOHCC structures from national to district levels Ministry of Local Government and National Housing. Environmental Management Agency 28 The details of the validation meeting are found in the project ESMF page 298 (APP9.7 to APP 9.8) 106 COVID-19 Response ESMF – ICWMP 7 RESOURCE LIST: COVID-19 GUIDANCE WHO Guidance a) Advice for the public • WHO advice for the public, including on social distancing, respiratory hygiene, self- quarantine, and seeking medical advice, can be consulted on this WHO website: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public b) Technical guidance • Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected, issued on March 19, 2020 • Recommendations to Member States to Improve Hygiene Practices, issued on April 1, 2020 • Severe Acute Respiratory Infections Treatment Center, issued on March 28, 2020 • Infection prevention and control at health care facilities (with a focus on settings with limited resources), issued in 2018 • Laboratory biosafety guidance related to coronavirus disease 2019 (COVID-19), issued on March 18, 2020 • Laboratory Biosafety Manual, 3rd edition, issued in 2014 • Laboratory testing for COVID-19, including specimen collection and shipment, issued on March 19, 2020 • Prioritized Laboratory Testing Strategy According to 4Cs Transmission Scenarios, issued on March 21, 2020 • Infection Prevention and Control for the safe management of a dead body in the context of COVID-19, issued on March 24, 2020 • Key considerations for repatriation and quarantine of travellers in relation to the outbreak COVID-19, issued on February 11, 2020 • Preparedness, prevention and control of COVID-19 for refugees and migrants in non-camp settings, issued on April 17, 2020 • Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health, issued on March 18, 2020 • Oxygen sources and distribution for COVID-19 treatment centres, issued on April 4, 2020 • Risk Communication and Community Engagement (RCCE) Action Plan Guidance COVID-19 Preparedness and Response, issued on March 16, 2020 • Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19), issued on March 19, 2020 • Operational considerations for case management of COVID-19 in health facility and community, issued on March 19, 2020 • Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19), issued on February 27, 2020 • Getting your workplace ready for COVID-19, issued on March 19, 2020 • Water, sanitation, hygiene and waste management for COVID-19, issued on March 19, 2020 107 COVID-19 Response ESMF – ICWMP • Safe management of wastes from health-care activities, issued in 2014 • Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (COVID-19) outbreak, issued on March 19, 2020 • Disability Considerations during the COVID-19 outbreak, issued on March 26, 2020 • Global manual on Surveillance of adverse events following immunization, issued 2016 • How to monitor temperature in the vaccine supply chain, issued July 2015 • HSDSP AVF Infection Control and Waste Management Plan, April 2022 c) WORLD BANK GROUP GUIDANCE • Technical Note: Public Consultations and Stakeholder Engagement in WB-supported operations when there are constraints on conducting public meetings, issued on March 20, 2020 • Technical Note: Use of Military Forces to Assist in COVID-19 Operations, issued on March 25, 2020 • ESF/Safeguards Interim Note: COVID-19 Considerations in Construction/Civil Works Projects, issued on April 7, 2020 • Technical Note on SEA/H for HNP COVID Response Operations, issued in March 2020 • Interim Advice for IFC Clients on Preventing and Managing Health Risks of COVID-19 in the Workplace, issued on April 6, 2020 • Interim Advice for IFC Clients on Supporting Workers in the Context of COVID-19, issued on April 6, 2020 • IFC Tip Sheet for Company Leadership on Crisis Response: Facing the COVID-19 Pandemic, issued on April 6, 2020 • WBG EHS Guidelines for Healthcare Facilities, issued on April 30, 2007 d) MFI GUIDANCE • EBRD COVID-19 resources (includes list of websites providing information on Covid-1(and guidance materials and resources provided by IFIs) • ADB Managing Infectious Medical Waste during the COVID-19 Pandemic • IDB Invest Guidance for Infrastructure Projects on COVID-19: A Rapid Risk Profile and Decision Framework • KfW DEG COVID-19 Guidance for employers, issued on March 31, 2020 • CDC Group COVID-19 Guidance for Employers, issued on March 23, 2020 • CDC Vaccine Storage and Handling Toolkit, issued 2020 108 COVID-19 Response ESMF – ICWMP APPENDICES Appendix 1: Infection Control and Waste Management Plan for MOHCC Infection control and waste management plan and reporting Objective Timing/Period Responsible Parties Awareness of the project At the beginning of the project MOHCC/EHD in ICWMP collaboration with PIE Planning activities for IPC At the beginning of the program MOHCC, Nursing Services and waste management Department IPC FP Approved Medical waste Before infectious waste Each participating facility to Management Plan for each generating project activities generate; HCF begin PIE/Environmental Specialist to provide guidance, review and clear Implementation of Continuous MOHCC /Healthcare Facility Infection Control and IPC Focal Person Waste Management plan at health facility Control and follow up of Daily Health facilities the execution of infection Control and Waste Management Plan Monthly PEHD/Provincial IPC focal activities at healthcare Person/Environmental facilities Specialist 109 COVID-19 Response ESMF – ICWMP Quarterly Implementation: MOHCC EHSD Monitoring PIE Environmental Specialist Training Every quarter PEHD/Nursing services Department MOHCC Awareness Biannually PEHD/Nursing Services MOHCC and NGOs, CBOs Supervision Quarterly PEHD/Nursing Services Department MOHCC Evaluation of facility annually MOHCC/EHD/Nursing Medical Waste Services Management Plan PIE Environmental Specialist 110 COVID-19 Response ESMF – ICWMP Appendix 2: Medical Waste Management Plan Template An Infection Control Waste Management Plan adequate for the scale and type of activities and identified hazards must be developed for each ZCERP supported HCF and such plan must meet the EHS requirements established in this ICWMP and the ESMF. The plan will address medical waste generated by the project and other waste that become co-mingled with project related waste during collection, transportation and disposal. Medical Waste Management Plan 1. Introduction 4 Describe the project context and components 5 Describe the targeted healthcare facility (HCF): - Type: E.g. general hospital, clinics, inpatient/outpatient facility, medical laboratory, quarantine or isolation centers; - Special type of HCF in response to COVID-19: E.g. existing assets may be acquired to hold yet- to-confirm cases for medical observation or isolation; - Functions and requirement for the level infection control, e.g. biosafety levels; - Location and associated facilities, including access, water supply, power supply; - Capacity: beds 6 Describe the design requirements of the HCF, which may include specifications for general design and safety, separation of wards, heating, ventilation and air conditioning (HVAC), autoclave, and waste management facilities. 2. Infection Control and Waste Management 2.1 Overview of infection control and waste management in the HCF - Type, source and volume of healthcare waste (HCW) generated in the HCF, including solid, liquid and air emissions (if significant) - Classify and quantify the HCW (infectious waste, pathological waste, sharps, liquid and non- hazardous) following WBG EHS Guidelines for Healthcare Facilities and pertaining GIIP. - Given the infectious nature of the novel coronavirus, some wastes that are traditionally classified as non-hazardous may be considered hazardous. Special attention should be given to the identification, classification and quantification of the healthcare wastes. 111 COVID-19 Response ESMF – ICWMP - Describe the healthcare waste management system in the HCF, including material delivery, waste generation, handling, disinfection and sterilization, collection, storage, transport, and disposal and treatment works - Provide a flow chart of waste streams in the HCF if available - Describe applicable performance levels and/or standards - Describe institutional arrangement, roles and responsibilities in the HCF for infection control and waste management 2.2 Management Measures - Waste minimization, reuse and recycling: HCF should consider practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety considerations. - Delivery and storage of specimen, samples, reagents, pharmaceuticals and medical supplies: HCF should adopt practice and procedures to minimize risks associated with delivering, receiving and storage of hazardous medical goods. - Waste segregation, packaging, color coding and labeling: HCF should strictly conduct waste segregation at the point of generation. Internationally adopted method for packaging, color coding and labeling the wastes should be followed. - Onsite collection and transport: HCF should adopt practices and procedures to timely remove properly packaged and labelled wastes using designated trolleys/carts and routes. Disinfection of pertaining tools and spaces should be routinely conducted. Hygiene and safety of involved supporting medical workers such as cleaners should be ensured. - Waste storage: A HCF should have multiple waste storage areas designed for different types of wastes. Their functions and sizes are determined at design stage. Proper maintenance and disinfection of the storage areas should be carried out. Existing reports suggest that during the COVID-19 outbreak, infectious wastes should be removed from HCF’s storage area for disposal within 24 hours. - Onsite waste treatment and disposal (e.g. an incinerator): Many HCFs have their own waste incineration facilities installed onsite. Due diligence of an existing incinerator should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. Detail the source of the incinerator’s power. If charcoal or wood, detail where that wood is extracted from or obtained. This project does not permit wood or charcoal extraction from protected areas, forests, national parks or any fragile or sensitive ecosystems. In case any gaps are discovered, corrective measures should be recommended. Although there will not be any new construction of HCF under the project, a new HCF would require waste disposal facilities to be integrated into the overall design and ESIA developed. 112 COVID-19 Response ESMF – ICWMP Good design, operational practices and internationally adopted emission standards for healthcare waste incinerators can be found in pertaining EHS Guidelines and GIIP. - Transportation and disposal at offsite waste management facilities: Not all HCF has adequate or well-performed incinerator onsite. Not all healthcare wastes are suitable for incineration. An onsite incinerator produces residuals after incineration. Hence offsite waste disposal facilities provided by local government or the private sector are probably needed. These offsite waste management facilities may include incinerators, hazardous wastes landfill. In the same vein, due diligence of such external waste management facilities should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended and agreed with the government or the private sector operators. - Wastewater treatment: HCF wastewater is related to hazardous waste management practices. Proper waste segregation and handling as discussed above should be conducted to minimize entry of solid waste into the wastewater stream. In case wastewater is discharged into municipal sewer sewerage system, the HCF should ensure that wastewater effluent comply with all applicable permits and standards, and the municipal wastewater treatment plant (WWTP) is capable of handling the type of effluent discharged. In cases where municipal sewage system is not in place, HCF should build and properly operate onsite primary and secondary wastewater treatment works, including disinfection. Residuals of the onsite wastewater treatment works, such as sludge, should be properly disposed of as well. There’re also cases where HCF wastewater is transported by trucks to a municipal wastewater treatment plant for treatment. Requirements on safe transportation, due diligence of WWTP in terms of its capacity and performance should be conducted. 3. Emergency Preparedness and Response Emergency incidents occurring in a HCF may include spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, and fire. These emergency events are likely to seriously affect medical workers, communities, the HCF’s operation and the environment. Thus, an Emergency Response Plan (ERP) that is commensurate with the risk levels is recommended to be developed. The key elements of an ERP are defined in ESS 4 Community Health and Safety (para. 21). 4. Institutional Arrangements and Capacity Building 113 COVID-19 Response ESMF – ICWMP Clearly defined institutional arrangements, roles and responsibilities should be included. A training plan with recurring training programs should be developed. The following aspects are recommended: - Define roles and responsibilities along each link of the chain along the cradle-to-crave infection control and waste management process, - Ensure adequate and qualified staff are in place, including those in charge of infection control and biosafety and waste management facility operation, - Stress the chief of a HCF takes overall responsibility for infection control and waste management, - Involve all relevant departments in a HCF, and build an intra-departmental team to manage, coordinate and regularly review issues and performance, - Establish an information management system to track and record the waste streams in HCF; and - Capacity building and training should involve medical workers, waste management workers and cleaners. Third-party waste management service providers should be provided with relevant training as well. 5. Monitoring and Reporting Many HCFs in developing countries face the challenge of inadequate monitoring and records of healthcare waste streams. HCF should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities. The HCF is encouraged to develop an IT based information management system should their technical and financial capacity allow. As discussed above, the HCF chief takes overall responsibility, leads an intra-departmental team and regularly reviews issues and performance of the infection control and waste management practices in the HCF. Internal reporting and filing systems should be in place. Externally, reporting should be conducted per government and World Bank requirements. 114 COVID-19 Response ESMF – ICWMP Appendix 3: Infection Control and Waste Management Checklist Management of health care waste at HCF from the point of generation to final disposal is of paramount importance. Due care must be taken to ensure that those involved in health care waste are adequately protected during handling, transportation and disposal of health care waste. this checklist will be used by the District Health Teams to collect data (during facility monitoring activities), that will be used to support health care facilities in managing their waste. Additionally, health care facilities can use the checklist as a self-audit tool in assessing in identifying and managing health care waste related hazards. Name of facility------------------ Type of facility-------------- Bed capacity ------------- Categories of waste generated---------- A) General Waste/ Non-hazardous waste B) Infectious waste C)Pathological waste D) Sharps E) Radioactive waste F) Chemical and Pharmaceutical waste Amount of healthcare waste generated by category General Waste/ Non-hazardous waste……………… Infectious waste………… Pathological waste……… Sharps……………… Radioactive waste……… Chemical and Pharmaceutical waste…………………………. Standard Yes No Policies and legislation Policies and legislation requirements met National legislation waste and effluent disposal, Pollution prevention and atmospheric air pollution control regulations, WB EHS Guidelines for HCF, Occupational Health and Safety, Labour Act, Chapter 28.01, and National Social Security Authority (Accident Prevention) (Workers Compensation Scheme) Notice No. 68 of 1990 Required Licenses/Permits secured? List here: contract 115 COVID-19 Response ESMF – ICWMP Minimization of waste Segregation of waste at source Use of colour coded bins Bins and sharp tins ¾ full and sealed properly Use of pedal operated bins Labelling of bins Transportation and labelling of waste Designated tools for transportation of labelled waste Use of carts /trolleys/wheelie bins with lids Temporary holding area Biohazard warning sign on the area Secured from scavengers Storage area clean and tidy Cleanable area with concrete Source of water near the temporal holding area Adequate drainage Time waste is kept in the temporal holding area Area well ventilated Disposal of waste On-site incinerator Weighing of waste generated 116 COVID-19 Response ESMF – ICWMP Recording of waste generated Off-site incinerator Labelling of waste Weighing of waste Designated vehicle covered Record of waste send for incineration Permit to transport waste (Red Licence) PPE Work suite /scrub suite Heat resistant visor Gown Surgical mask N95 mask Heavy duty heat resistant gloves Heavy duty heat resistant apron Helmet Heat resistant industrial shoes Safety goggles Training Categories of waste Segregation of waste Collection Transport Storage Disposal 117 COVID-19 Response ESMF – ICWMP Personnel Protective Equipment (PPE) Hand Hygiene Incineration and standard temperatures Cleaning of the incineration site and surrounding areas Maintenance of the incinerator Monitoring and evaluation Weighing of waste Recording of waste Designing a waste data base Support and supervision visits Health care waste management process evaluation HCWM trainings Health care waste management facilities and equipment repair/ rehabilitated Occupational health Vaccination Post exposure prophylaxis Reporting of incidence/accident internally and externally Hand Hygiene Basic hand hygiene facility 118 COVID-19 Response ESMF – ICWMP Hand washing Hand sanitizing Budgetary needs Trainings Waste management supplies PPE Permit and licenses 119 COVID-19 Response ESMF – ICWMP Appendix 4: Incinerator Operation Checklist and Safety Guidelines The first source for the operation and maintenance of the incinerator should be the Manufacturer Operation and Maintenance Manual for the specific incinerator. In addition, to the manufacturer operation and maintenance manual, the checklist adapted from WHO guidelines on operation and maintenance of medical waste incinerators will be used. This will provide periodic guidance on incinerator operation and maintenance. Personal protective equipment (PPE) must be selected to protect against risks specific to incinerator operators. The major risks to these staff are encountered either during direct contact with medical waste or when incinerator operators are exposed to heat or fumes emitted by the incinerator while burning health care waste. Wearing PPE reduces risk from sharps, germs, exposure to blood and other bodily fluids, splashes from chemicals, inhalation of exhaust, and sparks from the incinerator. PPE FOR INCINERATOR OPERATORS INCLUDES: Work suit Heat resistant visor Helmet Safety goggles Respirator mask Heavy-duty, heat resistant gloves Heavy duty heat resistant apron Clothes that cover the body Heavy-duty, heat resistant industrial shoes. INSTRUCTIONS FOR OPERATING THE INCINERATOR The following are key steps that incinerator operators should follow: -Wear personal protective equipment such as helmet, goggles, respirator, overcoat/overalls, heavy-duty gloves, apron, and boots. -Ensure fuel is available for operating the incinerator. 120 COVID-19 Response ESMF – ICWMP -Record the number of safety boxes and bags to be burned. -Check and record incinerator operation temperatures. -Clean the incinerator. -Remove the ash and deposit it safely in the ash pit. -The incinerator operator should always: -Follow the incinerator operations procedure. -Use protective equipment when handling waste. -Ensure an adequate supply of fuel is available. -Record the weight and type of waste received. -Follow the regular maintenance schedule for incinerator. To reduce risk of infection: -Wash hands after working with waste or infected material. -Handle all waste with care to minimize needle stick injury. -Do not sort waste or open waste containers to sort waste. - Know the procedures for treatment of injuries and cleaning of contaminated areas. SECURITY AT THE WASTE DISPOSAL SITE -Entry to the waste disposal site should be restricted. -Keep the incinerator site locked at all times. -Do not allow unauthorized persons to enter the incinerator area during periods of incineration. Immediately report any vandalism, theft, or unauthorized entry to the waste management supervisor. INCINERATOR MAINTENANCE CHECKLISTS All incineration equipment requires regular service and preventive maintenance. Unscheduled maintenance is also required in the event of failures. The provided service schedule should be 121 COVID-19 Response ESMF – ICWMP used, and well-trained and qualified technicians are required to regularly visit the incineration sites to inspect and service the equipment. DAILY MAINTENANCE -The incinerator operator should inspect the incinerator daily and do the following: -Check for evidence of cracks on the refractory lining -Check and record incinerator operation temperatures. -Remove the secondary chamber particulate matter through the ash door - Keep the incinerator house floor areas clean and disinfected. -Carefully sweep the area around the incinerator to ensure that all the non-combustible waste is placed in the ash pit. -Clean tools and equipment. -Store safety boxes and other non-infectious health care waste in an orderly manner in the incinerator waste store. - Maintain fuel stock levels for the incinerator (Coal). -Keep tools, records, and protective clothing in the storage room or box provided at the Incinerator. -Immediately report to the waste-management supervisor any damage to the incinerator that affects operation or performance. WEEKLY MAINTENANCE -Remove any lumps of melted glass/plastics and clean grates (to improve aeration). -Properly install the grates where required. -Maintain good housekeeping of the Waste disposal site by clearing the grass around the incinerator house. -Check the operational responsiveness of all the combustion control equipment -Maintain good house-keeping on the ash pit and its perimeter to comply. 122 COVID-19 Response ESMF – ICWMP -Ensure the fencing is intact -Check the refractory for evidence of cracking MONTHLY MAINTENANCE -Ensure the fence of the site is intact. -Check the vertical fixings of the chimney. -Check the refractory and incinerator case for evidence of thermal damage. -Check the ash door for corrosion. Check the ash door for damaged hinges. -Take an inventory of condition of tools and equipment. YEARLY MAINTENANCE -Inspect and replace metal parts, refractory and consumable parts where necessary. -Overhaul the incinerator or its components where necessary. -Check the status of the ash pit. Empty it when full or decommission it. -Perform annual audit/inspection of all the components and equipment. -Report when incinerator is no longer effective and/or the ash pit is full, and take appropriate action -Ensure environmental audits and licenses are obtained. RECORD KEEPING IMPORTANCE OF RECORDS Records help to plan for events and expansion; budgets for the incineration, monitoring, and evaluation of the incineration process; and for organizing waste audits. RECORDS The following records/tracking documents are: 123 COVID-19 Response ESMF – ICWMP - Waste Incineration Log: This documents the amount of waste incinerated daily and the events (i.e., failure of equipment, accidents/injuries) and records of visitors. -Supervisor’s checklist. Responsibility of the operator in recording The operator is responsible for maintaining the records and to ensure that these records are always available for inspection at the site. Responsibility of the supervisor in recording The supervisor is responsible for ensuring the records are maintained correctly. The supervisor should also ensure that he/she duly fills in the supervision checklists as required. SUPERVISION CHECKLIST Health facility: ........................................................... Date: Type of Incinerator... Activity Yes No Remarks Incinerator licence SAFETY 1. Is there adequate personal protective equipment (PPE)? 2. Is the PPE being used? 3. Is the PPE in good condition? 4. Is there restricted entry to the waste disposal site? Is there functional fire safety equipment? 5. Do the operators know how to use the equipment? 6. Is there adequate first aid kit? 7. Are the operators conversant with use of the kit? 8. Is flammable material stored away from the incinerator? 124 COVID-19 Response ESMF – ICWMP 9. Is there adequate water at the waste disposal area? 10. Are warning signs distinctly displayed? Additional comments on safety: ...................................................................................................................................................... .......................................................................................................................................................... ................................................................................................................................................. OPERATION -Is the ash properly disposed into the ash pit? Are the following tools and equipment available? - Ash rakes, Shovel, Hand brush/dustpan, hard broom, wheel barrow, weighing scales, fire resistant gloves, eye protection/face mask, overalls or suitable clothing to cover the upper body, including the lower arms and safety first aid kit Additional comments on operation: ...................................................................................................................................................... ...................................................................................................................................................... ............................................................................................................................................... ...................................................................................................................................................... Signature of the supervisor …………………………………….. 125 COVID-19 Response ESMF – ICWMP Appendix 5: Establishing a New Healthcare Waste Incinerator in Zimbabwe 1.0. THE EIA PROCESS According to the EMA Act, it is mandatory for any organization or individual who intends to construct and operate a hazardous waste incinerator to obtain the mandatory environmental authorisations and licenses that are required to construct and operate the hazardous waste incinerator. In order to comply with the provisions of the EMA Act as amended, the first stage is for the project proponent to embark on an Environmental impact assessment process as follows: 1.1. FIRST STAGE: THE PROSPECTUS PHASE The proponent of the project is first required at law to identify potential issues and select the preferred alternatives to focus on in the impact assessment phase. During this time, interested and affected persons can assist the project proponent by ensuring that all possible impacts of the project are being identified. The outcome of this phase is the Prospectus Report and Approval from EMA to proceed with the EIA. 1.2. SECOND STAGE: IMPACT ASSESSMENT PHASE At this stage the EMA Act requires that the project proponent engages a registered and EMA approved air quality analysis specialist to carry out detailed studies of potential positive and negative impacts associated with the project. Findings are then consolidated into the Environmental impact Report and the Environmental Management Report and forwarded to EMA for consideration and approval. 1.3. THIRD STAGE: DECISION MAKING PHASE At this stage, EMA uses the EIA findings to decide if the project should be authorized. If authorized, EMA will then issue a positive Environmental Authorization with certain conditions covering the incinerator expected performance standards, operation conditions, running test required, waste analysis, monitoring and inspections required. 2. PERFORMANCE STANDARDS The EMA Act that deals specifically with air pollution control set performance standards which limit the quantity of gaseous emissions an incinerator may release. Specifically, the regulations set limits on the emission of organics, HCl, and PM. • ORGANICS To obtain an EMA permit to operate an incinerator, an owner/operator is required to demonstrate that emission levels set for various hazardous organic constituents are not exceeded. In line with international best practice, the principle measure of incinerator performance is its destruction and removal efficiency (DRE). A 99.99 percent DRE means that one 126 COVID-19 Response ESMF – ICWMP molecule of an organic compound is released to the air for every 10,000 molecules entering the incinerator. A 99.9999 percent DRE means that one molecule of an organic compound is released to the air for every million molecules entering the incinerator. Since it would be impossible to monitor the DRE results for every organic constituent contained in a waste, certain principal organic hazardous constituents (POHCs) are selected for monitoring and are designated in the permit. POHCs are selected based on high concentration in the waste feed and difficulty in burning compared to other organic compounds. For healthcare waste, the main POHCs that are considered are human tissues, sharps, laboratory waste and pharmaceutical waste. If the incinerator achieves the required DRE for the selected POHCs, then it is presumed that the incinerator should achieve the same or better DRE for organic compounds that are easier to incinerate. In line with best international practice, performance standards require a minimum DRE of 99.99 percent for POHCs designated in the permit and a minimum destruction and removal efficiency of 99.9999 percent for dioxin-bearing wastes. EMA is yet to mandatorily enforce these provisions. • HYDROGEN CHLORIDE HCl is an acidic gas that forms when chlorinated organic compounds in hazardous Wastes are burned. In line with international best practice, an incinerator burning hazardous waste is required not to emit more than 1.8 kg of HCl per hour or more than 1 percent of the total HCl in the stack gas prior to entering any pollution control equipment, whichever is larger • PARTICULATE MATTER PM is tiny particles of ash that are carried along with the combustion gases to the incinerator's stack. The incinerator regulations control metal emissions through the performance standard for particulates, since metals are often contained in or attached to the particulate matter. A limit of 180 milligrams of particulate matter per dry standard cubic meter of gas emitted through the stack has been established 3. OPERATING CONDITIONS The goal of setting operating conditions for hazardous waste incinerators is to ensure compliance with the performance standards discussed above. (i.e., for organics, HCl, and PM). Within the permit, the law requires EMA to clearly specify the operating conditions that will have been established in a trial burn to result in the incinerator meeting these performance standards. A very important aspect of the regulations is that compliance with the operating conditions specified in the permit is deemed to be compliance with the performance standards for organics, HCl, and PM. The EMA permit for a hazardous waste incinerator will set operating conditions that specify allowable ranges for, and requires continuous monitoring of, certain critical parameters. Operation within these parameters ensures that combustion is performed in the most protective manner and the performance standards are achieved. These parameters, or operating conditions, include: • Maximum allowable carbon monoxide levels in stack emissions 127 COVID-19 Response ESMF – ICWMP • Allowable ranges for temperature • Maximum waste feed rates • Combustion gas velocity limits on variations of system design and operating procedures. At law, the permit requires that, during incinerator the startup and shut down, hazardous waste must not be fed into the unit unless it is operating within the conditions specified in the permit. The law further stipulates that an incinerator must cease operations when changes in waste feed, incinerator design, or operating conditions exceed limits designated in its permit 3.1 FUGITIVE EMISSIONS The EMA Act requires incinerator owners to also control fugitive emissions during the operation of the incinerator. Fugitive emissions are gases that escape from the combustion chamber (for example, gases may escape through the opening where wastes are fed into the combustion chamber) and do not pass through pollution control devices. Fugitive emission control methods are (1) maintaining negative pressure in the combustion zone so that air will be pulled into the APCD rather than escaping into the ambient air, or (2) totally sealing the combustion chamber so that no emissions can escape to the environment. 4. PERMIT PHASES The EMA Act requires an owner/operator wishing to operate a new hazardous waste incinerator to obtain a permit before construction of the unit commences. The purpose of a hazardous waste incinerator permit is to allow a new hazardous incinerator to establish conditions including, but not limited to, allowable waste feeds and operating conditions that will ensure adequate protection of human health and the environment. The incinerator permit covers four phases of operation: pre-trial burn, trial burn, post-trial burn, and final operating conditions 4.1. PRE-TRIAL BURN In line with international best practice, the pre-trial burn phase of the permit allows the incinerator to achieve a state of operational readiness necessary to conduct the trial burn. The pre-trial burn permit conditions are effective for the minimum time (not to exceed 720 hours) required to bring the incinerator to a point of operational readiness to conduct a trial burn. This phase is often referred to as the shakedown period. 4.2. TRIAL BURN The trial burn can be seen as the "test drive" of the incinerator. It is the time when the owner/operator will bring the unit up to operational readiness, monitor the key operating conditions and measure the emissions. The trial burn test conditions are based on the operating conditions proposed by the permit applicant in the trial burn plan submitted to EMA for evaluation. In line with international best practice, EMA is responsible for establishing conditions in the permit necessary to conduct an effective trial burn, meaning that the burn will be representational of the incinerator's intended day-to-day operation and will 128 COVID-19 Response ESMF – ICWMP yield meaningful data for analysis. It should be noted that currently in Zimbabwe today, these trial burns are not being mandatorily enforced by EMA although covered in the relevant regulations. 4.3. POST-TRIAL BURN The post-trial burn period is the time for EMA to evaluate all of the data that was recorded during the incinerators trial burn. To allow the operation of a hazardous waste incinerator following the completion of the trial burn, EMA is required to establish permit conditions sufficient to ensure that the unit will meet the incinerator performance standards. This post-trial burn period is limited to the minimum time required to complete the sampling, analysis, data computation of trial burn results, and the submission of these results to EMA. 4.4. FINAL OPERATING CONDITIONS After reviewing the results of the trial burn, EMA will modify the permit conditions again, as necessary, to ensure that the operating conditions of the incinerator are sufficient to ensure compliance with incinerator standards and protection of human health and the environment. Owners/operators of incinerators are required to comply with the final permit conditions for the duration of the permit, or until the permit is modified. 5. WASTE ANALYSIS During operation, the owner/operator of an incinerator is required to conduct sufficient waste analyses to verify that the waste feed is within the physical and chemical composition limits specified in the permit. This analysis may include a determination of a waste's heat value, viscosity, and content of hazardous constituents, including POHCs. Waste analysis also comprises part of the trial burn permit application. EMA stresses the importance of proper waste analysis to ensure compliance with emission limits. 6. MONITORING AND INSPECTIONS The EMA Act requires the owner/operator of an incinerator to perform, at a minimum, the following functions while incinerating hazardous waste: ✓ Monitor the combustion temperature, waste feed rate, and indicator of combustion gas velocity on a continuous basis ✓ Monitor carbon monoxide on a continuous basis at a point downstream of the combustion zone and prior to release into the atmosphere ✓ Sample and analyze the waste and exhaust emissions once every four months to verify that the operating requirements established in the permit achieve the performance standards and submit results to EMA for a review of the permit. ✓ Conduct daily visual inspections of the incinerator and associated equipment ✓ Record monitoring and inspection data in the operating log. 7. MANAGEMENT OF RESIDUES 129 COVID-19 Response ESMF – ICWMP According to WHO, if an incinerator burns a listed hazardous waste, the ash is also considered a listed waste. The derived-from rule states that any solid waste generated from the treatment, storage, or disposal of a listed hazardous waste, including any sludge, spill residue, ash, emission control dust, or leachate, remains a hazardous waste unless and until delisted. The owner/ operator of a hazardous waste incinerator must manage the residual ash as a hazardous waste. 8. CLOSURE At closure, the owner/operator must remove all hazardous waste and hazardous Residues from the incinerator equipment site. In addition, as throughout the operating period, if the residue removed from the incinerator is a hazardous waste, the owner or operator becomes a generator of hazardous waste and must manage the residue in accordance with the applicable requirements of the EMA Act. 130 COVID-19 Response ESMF – ICWMP Appendix 6: PPE Requirements Facility PPE requirements should be calculated based on bed capacity, number of staff (by category of staff) and procedures or services offered. CDC and WHO have calculators to estimate PPE requirements. Management and the procurement department should work together to calculate and procure adequate PPE. Provision for different sizes to fit the different personnel at the facility, estimations for short term (2 weeks) and long term (3 months), necessary arrangements to stock up and considering the imminent surge in cases should be made. PPE must be of good quality for it to offer the intended protection and to minimize wastage. Ensure all staff are trained on rational use of PPE and are competent in donning and doffing PPE safely. The recommended PPE for COVID-19 is outlined in the National PPE guidelines for COVID-19 which have been adapted from the WHO guidelines the Rational Use of Personal Protective Equipment March (2020). REQUIRED PPE For healthcare workers • Gown • Plastic apron • N95 mask • Surgical mask • Gloves • Head cape • Overshoes • Heavy duty gloves • Face shields • Goggles PPE for incinerator operator • Work suite /scrubs • Helmet • Safety goggles • Heat resistant visor • N95 mask • Heavy duty heat resistant apron • Heat resistant gloves 131 COVID-19 Response ESMF – ICWMP • Heat resistant industrial shoes/boots • Respirators (for spills or waste involving toxic dust or incinerator residue) as necessary • PPE for waste handlers29 • Heavy duty gloves • Gumboots • Overalls / industrial aprons • Leg protectors, • Helmets, • Visors / face masks and • Eye protection (especially for cleaning of hazardous spills), and • Respirators (for spills or waste involving toxic dust or incinerator residue) as necessary Table A-1: Extracted from the draft national PPE guidelines adopted from the WHO rationale use of PPE, 2020 29 WB EHSG for HCF (2007), p 12. 132 COVID-19 Response ESMF – ICWMP 133 COVID-19 Response ESMF – ICWMP Appendix 7: Stakeholder Consultations 1. Stakeholder Feedback # Thematic area Section and Issue raised Comment/ Response 1 Thematic topic 2. Health care waste The project is only going Infection control and incinerators in most to support with logistics waste management facilities are not functioning for off site waste for the proper treatment of transportation and waste especially treatment considering that waste there is going to be an increase in the amount waste from vaccination activities. Does the project or MOHCC has plans to install new incinerators or rehabilitate non-functional incinerators. 2 Thematic topic 3. Nil Emergency Preparedness and Response (EPR) 3 Thematic topic 4. General: The section has This is noted and during Institutional highlighted all the critical implementation all arrangements and players in the participants will be capacity building implementation of this engaged as necessary, and ICWMP. However, it is feedback given. important that during implementation all the players mentioned are continuously engaged and participate in project implementation. 4 Thematic Topic 5. Section 5.1 The proposed change has Monitoring and The following phrase need been accepted reporting to be changed “HCFs are to be encouraged to develop an information technology (IT)-based information management system should their technical and financial capacity allow� and 134 COVID-19 Response ESMF – ICWMP replaced with “There is need for development of information technology system to monitor waste management system in HCF� Section 5.1 Change the following phrase, “These standards are monitored by the Standards Association of Zimbabwe (SAZ) which test the air to assess the amount of pollutants.’ And replace with “Voluntary organisation such as SAZ are also critical stakeholders which can also assist with quality assurance�. Section 5.1.1 The proposed changes The following changes to were shared and agreed. indicators were proposed 1. Number of facilities with approved HCWMP by DHEs or Hospital Management. 2. Number of facilities with adequate waste management supplies and consumables for waste management (pedal operated bins, color coded bin liners). 3. Number of HCFs with proper wastewater disposal facilities (septic and soak 135 COVID-19 Response ESMF – ICWMP away tanks, stabilising ponds, convectional treatment (municipal). 4. Number of facilities with properly functioning – Incinerators. 5. Number of rural health facilities with properly functioning otto-way pits. 6. Number of rural health facilities with properly functioning bottle crushers. 7. Number of rural health facilities with properly functioning ash pits. 8. Number of HCF with proper secured waste management zones. 9. Number of health facilities with Waste Management Policy documents available all relevant departments, units and operational areas (wards, departments). 2. Agenda for the stakeholder Consultation meeting Date: Thursday April 7, 2022 136 COVID-19 Response ESMF – ICWMP Time Activity Presenter Chairperson 09:00-09:20 Welcome Remarks and Introductions MOHCC Env. Director Env. Health Health 09:20-09:30 Opening Remarks and Meeting Mr. Nyamandi Objectives 09:30-10:00 Presentation on the ZCERP project- Dr Endris Project activities and overview, (objectives, background, scope and expected outcome) 10:00-10:10 Plenary All 10:10-10:20 Health Break 10:20-10:35 Presentation: Outline ESMF Bloodwell Environmental Issues 10:35-10:50 Presentation: Outline ESMF Social Zvisineyi/ Issues (GBV, SEA-H, GRM, etc) Paida 10:50-11:10 Break aways groups- All Review different sections of the ESMF 11:10-11:40 Plenary 11:40-12:00 Break aways groups- All Review different sections of the ICWMP 12:00-12:30 Plenary 12:30-12:40 Summary of group presentations Bloodwell 12:40-12:50 Way forward MOHCC 12:50-13:00 Closing Remarks Director Environmental Health 3. Guide to Group work ICWMP Duration of the second group assignment: 20 minutes # THEMATIC AREA WHERE TO FOCUS ON Group Coordinators 1 Thematic topic 2. Are the infection control Bloodwell Infection control and measures adequate and waste management appropriate? 137 COVID-19 Response ESMF – ICWMP Are the waste management measures appropriate and adequate? 2 Thematic topic 3. Are the EPR measures sufficient? Musara Emergency Preparedness and Response (EPR) 3 Thematic topic 4. Are the implementation Paida, Zvisineyi Institutional arrangements appropriate and arrangements and sufficient for capacity building 4 Thematic Topic 5. Is the monitoring plan adequate Rumbi, Chivasa Monitoring and reporting for the intended purpose? Are the monitoring indicators sufficient? Is the proposed capacity building 138 COVID-19 Response ESMF – ICWMP 4. List of Participants LIST OF PARTICIPANTS ZCERP ESMF STAKEHOLDER CONSULTATION MEETING APRIL 7, 2022 VIRTUAL Mobile Phone # Full Name Organization Department Station Position Number Email Address 1 Chivasa Milliton MOHCC Env Health MOHCC-HQ PHSO 0772524858 millysibs@gmail.com 160 Baines Vuyelwa T. Sidile- Avenue 2 Chitimbire ZACH FBO Harare Executive Direcotr 0712608659 chitimbire@zach.org.zw 3 Victor Nyamandi MOHCC Env Health MOHCC-HQ Director 0772809365 Environmental 4 Abigail Musara MOHCC Health MOHCC-HQ Manager Waste 0773621413 musaraabigail@gmail.com Rumbidzai Health Promotion 5 Chimukangara MOHCC Health Promotion MOHCC-HQ Manager 0773468834 rchimu@gmail.com Environmental 6 Chipo Makwezwa MOHCC Health MOHCC-HQ Programme Assistant 0772130609 7 Paul Chinakidzwa MoHCC Health Promotion MoHCC HQ Deputy Director 0772737046 pchinakidzwa@gmail.com Dhliwayo Malaria 8 Patience MoHCC Programme MoHCC HQ Deputy Director 0772284704 pdhliwayo@nmcpzim.co.zw Winfilder Environmental 9 Dhambure MoHCC Health MoHCC HQ E.H.O 0775475883 windeeds5@gmail.com Nesbert National WASH 10 SHIRIHURU MLAFWRD Coordination HQ A/Director 0773290358 nshirihuru@gmail.com Nyaradzo Health Promotion 11 Mandizvidza MOHCC health Promotion MOHCC HQ Officer 0783898432 nyaradzomandizvidza@gmail.com MOHCC - Programme 12 Nyathi Khulamuzi Cordaid Coordination Unit MOHCC HQ RBF Health Specialist 0776248128 kny@cordaid.org Health Promotion 13 Privilege Tsorai MOHCC Health Promotion MOHCC HQ Officer 0719992539 simbanitsorai@gmail.com 139 COVID-19 Response ESMF – ICWMP Environmental 14 Nzenza Theotia MOHCC Health MOHCC HQ DD 0772818782 Ransom 15 Machacha MOHCC EPI MOHCC HQ M and E officer EPI 0779528526 ransommachacha@gmail.com Nursing 16 Clara Mashiringo MOHCC Services/EPI MOHCC HQ National EPI Officer 0774376037 claramashiringo@gmail.com Women's Loveness T Action Group WAG Harare Finance and Admin 17 Rukuni (WAG) Health Promotion office Manager 0773847964 loveness@wag.org.zw Musasa 18 Tinashe Chitunhu Musasa Program Harare office Program Officer 0778036359 tinashet@musasa.co.zw Environmental 19 Rodney Mapfumo MOHCC Health MOHCC HQ P 0777063774 mapfumorodney@gmail.com Environmental PMD MASH 20 Renwick Ngandu MOHCC Health CENTRAL PEHO 0772917265 renyngandu@gmail.com Environmental PMD MASH 21 Letwin Kanyama MOHCC Health CENTRAL EHO 0775299502 letwinkanyama@gmail.com Constance 22 Mandengenda MOHCC E.P.I MOHCC HQ Public Health Officer 0773204408 mandengendac@gmail.com Bloodwell Cordaid Environmental 23 Tarume Cordaid Environmental Harare Specialist 0718449164 btr@cordaid.org Paidamoyo Cordaid Communication 24 Magaya Cordaid Communication Harare Specialist 0782702274 pai@cordaid.org Nembawaew Environmental Environmental Health 25 Notmah Nyaradza MOHCC health MOHCC HQ Officer 0783013891 notinembs@gmail.com environmental Environmental Health 26 kefas Chanana MOHCC health MOHCC Technician 0773748692 kckchanana@gmail.com 27 Mangeya Miriam MOHCC Nursing mohcc-hq IPC FP 0719836374 28 E, S Tshuma MOHCC nursing services MOHCC -HQ DD Community 0772476925 emmasibusisotshuma@yahoo.com NCUBE 29 DUMISANI MOHCC ENV HEALTH MAT NORTH PEHO 0773281753 Fusire Memory 30 Punha MOHCC env health manicaland EHO -WASH FO 0774032382 140 COVID-19 Response ESMF – ICWMP 141