Medical Waste Management Plan 1. Introduction and Project Context The objective of this plan is to provide guidance to control the medical waste of [HAMREEN PHC] in [Diyala] governorate and the location of HAMREEN PHC is [3405’47.22â€?N 4503’33.90â€?E], this PHC provides healthcare service for [population of 16500] and the number of outpatients who took advantage form these services roughly per month is [3000] and this number will be increased if: - the rehabilitation of the PHC is completed which will provide all required healthcare services. - when the IDP’s in this area return to their homes. The planned healthcare services are: - Outpatient service; - Laboratory; - Dental services; 2. Regulatory Framework and Technical Standards The standards/Regulations that MoH use for the Medical Waste Management is (Regulation No. 1 for 2015 – Hazardous Waste Management – issued by Ministry of Health/Environment) and (EPA Medical Waste Management Guidelines. The current practice of the MWM is through contracting between the health directorate with a local contractor which cleaning and waste management of the PHC is his responsibility. 3. Review of current Waste Management System The current procedure of treatment of the medical waste is through the segregation, collection and storage of these waste to be transported to the nearest healthcare facility (containing incinerator). The procedure starts by collecting the waste from the sections of the PHC and placed in (yellow bags for non-sharp waste and special plastic containers for sharp waste) to be weight measured in the PHC and then placed in larger containers with a 1 cubic meter capacity for temporary storage until it is transferred to [Al ZAHRAA PHC] to be treated using the incinerator in the PHC this process is done according to the regulations issued by the Ministry of Health / Environment In collaboration with the World Health Organization and the supervision from the health directorate. The current waste volumes is by (kg/month) where the medical waste weight for the PHC It Ranges (15 - 18) kg/month and the municipal waste weight it ranges 35 kg/month collected in a 2 colored coded waste plastic bags with capacity of 4 kg for each bag (5 yellow bags for the medical waste & 9 black bags for the municipal waste) ;there is no specific facility for the collection of the medical waste which is collected by 2 large containers (1 m3) as mentioned earlier, the transport to incinerators is done by the local contractor once a week to Al ZAHRAA PHC (18 km distance from the PHC) by loading the plastic bags to the truck and cover it with thick fabric cover, the type of the incinerator is Mediburn model 2010 and the work condition of it is acceptable to the needs of the medical waste management, the disposal of ashesand other non- incinerated waste types is in the landfill site. (see checklist in Annex 1) 4. Demand and Gap Analysis The expected quantity of each medical waste type resulting from different activities is clarified in attachment 1. The characteristics and specifications of collection boxes, safety of temporary storage containers are following the Determinants of National Emission Activities No.3 of 2012 Annex C. The transportation of medical waste of Hamreen PHC to Al ZAHRAA PHC incinerator will follow strict rules according to medical waste transport protocol in Annex D. 5. Compliance and Operational Management Plan 5.1 Mitigation Plans Mitigation plans are presented in Tables 5.1. The mitigation plans describe the potential impacts and associated mitigation measures, and also assigns implementation and monitoring responsibilities. Table 5.1: Mitigation Plan for Medical Waste Management Potential Responsibility Activity Impact Mitigation Measures Mitigation Monitoring Waste Health and Use ofMedical Management Waste Waste segregation safety risks for Waste instructions No.1, 2015 Management Manage staff and Comply with article 1; Officer ment patients (see Annex A) Officer Use of PPEs; /Health Capacity building and Care training of staff including Center waste handlers; Director Awareness raising of patients and their attendants. Sharps Health and Use ofMedical Management Waste Waste Management safety Waste instructions No.1, 2015 Management Manage risks for staff Comply with article4 of the Officer ment and patients Management of Medical Officer Waste instruction, 2015 (see /Health Annex A) Care Center Director Infectious waste Health and Use ofMedical Management Waste Waste collection and safety risks for Waste instructions No.1, 2015; Management Management transportation waste handlers Comply with articles1, 4 and 8; Officer Officer (Annex A); /Health Care Use of PPEs; Center Ensuring that waste bags are Director in not opened or punctured coordination during transportation; with Ensuring that bags are not Environment punctured (disinfection of al Directorate the trolleys/area to be carried out in case of leakage from bags); Proper documentation and handover-takeover protocol along with „chain of custody‟ protocol; Capacity building of staff including waste handlers; Implement measures to forestall any pilferage of medical waste for recycling. Use of Medical Management Waste Infectious waste Health and Waste Management storage safety risks for Waste instructions No.1, 2015; Managem Officer /Health waste Comply with article 5 (Annex A); ent Care Center handlers Officer Director Proper controlled-access storage; Ensuring that waste bags are not opened or punctured in the storage; Ensuring that bags are not punctured (disinfection of the trolleys /area to be carried out in case of leakage from bags); Use of PPEs; Weighing of waste; Proper documentation and handover-takeover protocol; Capacity building of staff including waste handlers; Security arrangements to avoid theft/pilferage. Use of Medical Management Waste Infectious waste Health and Waste Management Waste instructions No.1, 2015; disposal safety risks for Managem Officer /Health waste Comply with article9 ent Care Center handlers, , 2015 (Annex A); Officer waste pickers; Proper documentation Soil and and handover-takeover water protocol; contamina Comply with tion Determinants of National Emission Activities No. 3 of year 2012, article 8 and 9 and (see Annex B) Incineration Use properly designed for medical waste treatment, double chamber incinerators with wet scrubbers; Ensure that incineration is carried out at 1200 °C; Properly operate and maintain incinerators particularly to avoid leakage of gases from the first chamber; Ensure that dioxins are not released, and exhaust gases comply with NEQS; Maintain complete record of the key incinerator operation parameters (waste quantity incinerated, temperature in first chamber, temperature in second chamber, resident time, and others); Capacity building of operators; Use of PPEs. Availability of Non Availability of supplies and Waste Waste supplies and implementati consumables for WMP Manage Management Officer consumables on of WMP implementation will be ment /Health Care for WMP ensured Officer Center implementation Non-risk waste Contaminatio Non-risk waste will be Waste Waste n of soil and disposed with the municipal Manage Management Officer water, odour, waste; ment /Health Care proliferation Proper storage arrangements Officer Center of vectors Director (such as dumpsters) avoiding (rodents, flies, any spill-over/over-flowing; others) Regular transportation of waste from healthcare facility to the municipal waste disposal site. Water supply Health hazard Ensure that drinking Waste Waste for staff and water complies with Manage Management Officer patients NEQS; ment /Health Care Carry out water analysis Officer Center Director periodically. Sewage Health hazard Ensure that the Waste Waste disposal for staff and treatment system (eg, Manage Management Officer patients septic tank) is properly ment /Health Care working Officer Center Director 5.2Waste Management Plan In accordance with the Health Waste Management of 2015 and Determinants of National Emission Activities 0f 2012, the mobile health care center facility is required to prepare its facility-specific medical waste management plan. The Plan will include: • a plan/layout of the healthcare facility showing waste disposal points for every ward and department, indicating whether each point is for risk waste or non-risk waste, and showing the sites for central storage facility for risk waste and central storage facility/arrangements for non- risk waste • details of the types, numbers, and estimated cost of containers, waste bags, and trolleys required annually • timetable including frequency of waste collection from each ward and department • duties and responsibilities of each category of healthcare facility staff involved in waste generation and management • an estimate of number of staff required for waste management • procedures for the management of waste requiring treatment such as autoclaving before final disposal • Planned waste disposal sites/methods • contingency plans for storage or disposal of risk waste in the event of breakdown of incinerators • training courses and program on waste management • emergency procedures. • Comprehensive documentation will be maintained for the implementation of each element of the WMP. • The waste management plan will be regularly monitored, reviewed, revised, and updated. Attachment 1: Waste Management System Review(Amount of medical Waste expected from (Mojema,a Himreen ) health center and integrated management. ‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ 1 - Current waste volumes Waste type Estd. volume/month Collection system Transport Final disposal (m3) Infectious type 5kg Containers and Cars Incineration bags Sharps &needles 7 kg Containers and Cars Incineration bags Bottles & glass(municipal 3kg Containers and Cars Landfill wastes) bags Food waste( municipal 4 kg Containers and Cars Landfill wastes) bags Other waste(placenta) - - - - 2- Incinerators / disposal facilities Type Weekly capacity Auxiliary fuel / Condition Remarks (m3) incineration method Mediburn USA 10 kg / hour Automatic / Its failed now and the incineration done at AL –Zahraa PHC . 3- Current waste volumes Component / issues Identified measures Remarks (e.g time compliance Rectification gaps description and cost requirement Condition & functionality of little Increase no. of collection non collection boxes boxes Safety of temporary storage No facilities, containers Need room(facilities) for containers / facilities only storage the medical waste Transport to incinerators deposits There is private vehicle Provide box vehicle to the safety and functionality of route transports medical waste health center and equipment to the nearly incinerator Incinerators: completeness of There is no incinerator Need incinerator in health incineration process; quality of flue near with sensitive center must be friendly gases prevailing wind directions, receptor environmentally. existence of sensitive receptor ? (e.g gardens fields residences schools, hospital facilities , patient’s wards ) Quality and dimension of There is no receptacles for Need receptacles for receptacles for incineration residue incineration residue incinerations ashes with (ashes ) protection against rain and (ashes) (just plastic bags high Quality leaching currently existing. Quality and dimensions of There is no receptacles Need receptacles with high receptacles for non incinerated for non-incinerated Quality medical waste (e.g placentas ) medical waste (e.g. placentas Annex A ‫‪Annex B‬‬ ‫((محددات االنبعاث الوطنية لالنشطة واالعمال))‬ ‫رقم (‪ )3‬لسنة ‪2012‬‬ ‫المادة ‪-8-‬يسمح للجهات المولدة للنÙ?ايات الطبية أن تنشئ محرقة خاصة بها للتخلص من النÙ?ايات‬ ‫الطبية وذلك بترخيص من السلطة المختصة وبالتنسيق مع الوزارة على أن تتوÙ?ر‬ ‫Ù?يها الشروط التالية ‪-:‬‬ ‫اوال‪-‬أن ال تقل درجة حرارة االحتراق Ù?يها عن ( ‪ ) 1200‬ألÙ?ا Ù? ومئتا درجة مئوية‪.‬‬ ‫ثانيا‪-‬أن تكون سعة المحرقة كاÙ?ية لحرق النÙ?ايات المنقولة إليها خالل ( ‪ ) 24‬أربع وعشرون‬ ‫ساعة ‪.‬‬ ‫ثالثا‪-‬أن تستخدم المحرقة للتخلص من النÙ?ايات الطبية العائدة للجهة المالكة لها Ù?قط وال‬ ‫يسمحب استخدامها للتخلص من النÙ?ايات الطبية لجهات أخرى إال بمواÙ?قة السلطة المختصة‬ ‫وبالتنسيق مع الوزارة ‪.‬‬ ‫رابعا Ù‹ ‪ -‬يمنع استخدام المحرقة لحرق النÙ?ايات التالية ‪:‬‬ ‫أ‪ .‬النÙ?ايات الخطرة المحددة من قبل الوزارة والجهات المختصة‪.‬‬ ‫العبوات المضغوطة ‪.‬‬ ‫ب‪.‬‬ ‫النÙ?ايات والمواد البالستيكية والمطاط ‪.‬‬ ‫ج‪.‬‬ ‫د‪ .‬النÙ?ايات ذات المحتوى العالي من المعادن الثقيلة ( رصاص ‪ ،‬كادميوم ‪ ،‬زئبق ‪ ...‬الخ ) ‪.‬‬ ‫ه‪ .‬أمالح الÙ?ضة والنÙ?ايات المتولدة من أشرطة التصوير ‪.‬‬ ‫المواد السامة للجينات‪.‬‬ ‫و‪.‬‬ ‫خامسا ً‪-‬أن ال تتجاوز ملوثات الهواء المنبعثة عنها الحدود القصوى المسموح بها وكما هو وارد‬ ‫Ù?ÙŠ المالحق الخاصة بها من هذه التعليمات‪.‬‬ ‫المادة ‪ -9-‬تحرق النÙ?ايات الخطرة Ù?ÙŠ محطات حرق تخضع لألحكام والشروط الواردة Ù?ÙŠ المادة‬ ‫( ‪ ) 6‬من هذه التعليمات على أن ال تقل درجة حرارة االحتراق Ù?ÙŠ المحرقة عن (‬ ‫‪ ) 1200‬ألÙ? ومائتان درجة مئوية وان ال تتجاوز ملوثات الهواء المنبعثة عن الحدود‬ ‫القصوى المسموح بها كما هو منصوص عليه Ù?ÙŠ الملحق رقم (‪ )4‬الخاصبها‬ ‫المرÙ?قبهذه التعليمات ومن الممكن حرق النÙ?ايات الطبية Ù?ÙŠ هذه المحارق مع مراعاة‬ ‫أحكام الÙ?قرة (‪ )4‬من المادة( ‪ ) 7‬من هذه التعليمات ‪.‬‬ ‫ملحق رقم (‪)4‬‬ ‫الحدود القصوى المسموح بها من ملوثات الهواء المنبعثة من محارق النÙ?ايات‬ ‫الخطرة والنÙ?ايات الطبية‪.‬‬ ‫الحد األقصى المسموح به بـ (ملغرام‪/‬المتر‬ ‫ملوثات الهواء ورمزه‬ ‫المكعب القياسي)‬ ‫‪( 10‬معدل يومي)‬ ‫مجموع الدقائق العالقة (‪)TSP‬‬ ‫‪( 30‬معدل نصÙ? ساعة)‬ ‫‪( 50‬معدل يومي)‬ ‫آحادي اوكسيد الكربون (‪)CO‬‬ ‫‪( 100‬معدل نصÙ? ساعة)‬ ‫‪( 200‬معدل يومي)‬ ‫اكاسيد النتروجين (‪)NOx‬‬ ‫‪( 400‬معدل نصÙ? ساعة)‬ ‫(تقاس كثنائي اوكسيد النتروجين)‬ ‫‪( 50‬معدل يومي)‬ ‫ثنائي اوكسيد الكبريت (‪)SO2‬‬ ‫‪( 200‬معدل نصÙ? ساعة)‬ ‫‪( 10‬معدل يومي)‬ ‫حامض الهيدروكلوريك (‪)HCl‬‬ ‫‪( 60‬معدل نصÙ? ساعة)‬ ‫‪( 1‬معدل يومي)‬ ‫حامض الهيدروÙ?لوريك (‪)HF‬‬ ‫‪( 4‬معدل نصÙ? ساعة)‬ ‫مجموع الهيدروكربونات المتطايرة (‪)VOC‬‬ ‫‪( 10‬معدل يومي)‬ ‫(تقاس كمحتوى كلي من الكربون العضوي‬ ‫‪( 20‬معدل نصÙ? ساعة)‬ ‫(‪))TOC‬‬ ‫‪( 1‬مجموع كلي)‬ ‫‪( 1‬مجموع كلي)‬ ‫‪ ( 1‬مجموع كلي)‬ ‫االنتيمون (‪ )Sb‬ومركباته (تقاس كانتيمون)‬ ‫الزرنيخ (‪ )As‬ومركباته (تقاس كزرنيخ)‬ ‫‪( 1‬مجموع كلي)‬ ‫الكروم (‪ )Cr‬ومركباته (تقاس ككروم)‬ ‫الكوبلت (‪ )Co‬ومركباته (تقاس ككوبلت)‬ ‫‪( 1‬مجموع كلي)‬ ‫النحاس (‪ )Cu‬ومركباته (تقاس كنحاس)‬ ‫الرصاص (‪ )Pb‬ومركباته (تقاس كرصاص)‬ ‫‪( 1‬مجموع كلي)‬ ‫المنغنيز (‪ )Mn‬ومركباته (تقاس كمنغنيز)‬ ‫النيكل (‪ )Ni‬ومركباته (تقاس كنيكل)‬ ‫‪( 1‬مجموع كلي)‬ ‫القصدير (‪ )Sn‬ومركباته (تقاس كقصدير)‬ ‫الÙ?ناديوم (‪ )V‬ومركباته (تقاس ÙƒÙ?ناديوم)‬ ‫‪ ( 1‬مجموع كلي)‬ ‫‪ ( 1‬مجموع كلي)‬ ‫‪ ( 1‬مجموع كلي)‬ ‫‪( 0.1‬نانوغرام(‪ TEQ‬مكاÙ?ئ‬ ‫الدايوكسينات والÙ?يورانات‬ ‫سمية)‪/‬المتر المكعب القياسي)‬ ‫الكادميوم (‪ )Cd‬ومركباته (تقاس ككادميوم)‬ ‫‪( 0.1‬كمجموع كلي)‬ ‫الثاليوم (‪ )Tl‬ومركباته (تقاس كثاليوم)‬ ‫‪0.1‬‬ ‫الزئبق (‪ )Hg‬ومركباته (تقاس كزئبق)‬ ‫مالحظات‪-:‬‬ ‫‪ -1‬يجبب ان ال تتجباوز تراكيز أيبة مبادة محبددة Ù?ÙŠ العمود اعول‪ ،‬عنبد قيباسببببهبا من المحبارق Ù?ÙŠ أيبة نقطبة‬ ‫قبل حدوث المزج والخلط مع الهواء‪ ،‬الدخان والغازات اعخرى‪ ،‬الحدود القصوى المحددة‪.‬‬ ‫‪ -2‬المتر المكعبب القيباسببببي = تعني متر مكعبب من غباز جباي Ù?ÙŠ Ù?روي ‪25‬م˚ وضببببغط ‪ 760‬مليمتر‬ ‫زئبق‪.‬‬ ‫‪ -3‬محددات االنبعاث لببببببب ‪ ØŒSn ØŒNi ØŒMn ØŒPb ØŒCu ØŒCo ØŒCr ØŒAs ØŒSb ØŒHg ØŒTl ØŒCd‬و ‪ V‬تقاس‬ ‫كمعدل قيم ضمن Ù?ترة نمذجة من ‪ 30‬دقيقة كحد أدنى إلى ‪ 8‬ساعات كحد أقصى‪.‬‬ ‫‪ -4‬معدالت قيم الدايوكسبينات والÙ?يورانات يجب ان تقاس ضبمن Ù?ترة نمذجة ‪ 6‬سباعات كحد أدنى إلى ‪8‬‬ ‫سباعات كحد أقصبى‪ .‬قيمة محدد االنبعاث تعتبر التركيز الكلي من الدايوكسبينات والÙ?ورانات وتحسبب‬ ‫كمكاÙ?ئ السمية (‪ )TEQ‬وكما هو موضح Ù?ÙŠ ملحق رقم (‪.)5‬‬ ‫‪ -5‬تعتمد Ù?ÙŠ قياس تراكيز اي مادة محددة Ù?ÙŠ العمود االول الطريقة المعتمدة من قبل وكالة البيئة االمريكية‬ ‫كطريقة قياس مرجعية او ما يعادلها من طرق القياس المرجعية العالمية‪.‬‬ ‫‪Annex C‬‬ Annex D