Hcwm guidelines ethiopia final

Health Care Waste Management for Ethiopia
Guidelines
Prepared by:
Fikru Tessema (BSc, MSc), Senior Public Health Professional
M&E Specialist
May 2006

Table of contents Page
Abbreviations 4
Preface 5
Section 1
1.1 Introduction 6
1.1.1 Overview of Health Facilities (HFs) Hazards and Infections 6
1.1.2 Overview of HCWM Programmes for HCFs 7
1.1.3 Overview of the Need for Developing Comprehensive HCWM
Programmes 8
1.2 Objectives 12
1.3 How to use these guide lines 13
Section 2. Definition 14
Section 3. Public Health Importance, Risks and Management of
Health-Care Wastes
3.1 Public Health Importance 19
3.2 Risks of Health-Care Wastes 19
3.3 HCW Management 21
Section 4. Health-Care Waste Management Guidelines
4.1 Segregation of Health-Care Waste Guidelines 23
4.2 Guidelines for Colour coding system 25
4.3 Guidelines for HCW recycling and reusing 26
4.4 Guidelines for Recycling of non-contaminated plastic items 26
4.5 Guidelines for Packaging 28
4.6 Waste storage guidelines 29
4.7 Waste handling guidelines 31
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4.8 Waste transportation guidelines 31
4.9 Waste treatment guidelines 34
4.10 Guidelines for steam sterilization 36
4.11 Guidelines for incineration 37
4.12 Guidelines for thermal inactivation 38
4.13 Guidelines for gas/vapor sterilization 39
4.14 Guidelines for chemical disinfection 40
4.15 Guidelines for accidents and spillage 41
4.16 Guidelines for Ultimate Disposal 41
4.17 Guidelines for maintenance workers 42
4.18 Guidelines for occupational risks 42
4.19 Guidelines for Training 43
Section 5. Specific Guidelines Associated With HCW Categories
5.1 Class 1: non-risk health-care waste 44
5.2 Class 2: clinical waste 44
5.3 Class 3: sharps 45
5.4 Class 4: anatomical waste and placentas 46
5.5 Class 5: hazardous pharmaceutical waste and cytotoxic waste 46
5.6 Class 6: highly infectious waste 47
5.7 Class 7: radioactive waste 48
5.8 Class 9: Waste with high contents of heavy metals 48
5.9 Class 10: Effluents 50
Section 6. Guidelines for Implementation of HCWM Plan in HCFs
6.1 Guidelines for waste management plan 52
6.2 Guidelines for duties and responsibilities 53
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6.3 Guidelines for allocation of resources and equipment for
health-care waste handling 59
6.4 Guidelines for Awareness and Training 61
6.5 Guidelines for monitoring system and reporting
procedures for HCWM at all levels 62
6.6 Guidelines for private sector involvement 63
References 64
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Abbreviations
HCF : Health-Care Facility
HCW : Health-Care Waste
HCWM : Health-Care Waste Management
WHO : World Health Organization
EPA : Environment Protection Authority
MoH : Ministry of Health
DHEH : Department of Hygiene & Environmental Health
RHB : Regional Health Bureau

PREFACE
The purpose of the health-care waste management guidelines is to
ensure safe and healthful working conditions for every working
man and woman in the health-care facility by providing guidelines
that will ensure, insofar as practicable, that no workers will suffer
diminished health, functional capacity, or life expectancy as a
result of their work experience.
This document does present guidelines for reducing the incidence
of injury and disease among health care workers of health care
facilities and the population at large.
Every effort was made to address all major health and safety
hazards that might be encountered in hospitals or other health
care centers.
The document is not intended to affect patients directly, but
implementing the guidelines will generally benefit patient care.
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Section 1 Introduction
1.1 Overview of Health Facilities (HFs) Hazards and Infections
Safe management of Health-Care Waste (HCW) is a key issue to control
and reduce nosocomial infections inside a hospital, health centres,
clinics and health posts and to ensure that the environment outside is
well protected. Health-Care Waste Management (HCWM) should be part
of the overall management system of a Health-Care Facility (HCF) and
reflect the quality of the services provided by the facilities.
Ethiopia has poor health status relative to other low-income countries,
even within Sub-Saharan African countries. This is largely attributed to
preventable infections and nutritional problems. Infectious and
communicable diseases account for about 60-80% of the health
problems in the country. Therefore, the recommendations that are
contained in this document should be applied in all the HCFs of
Ethiopia. In case these recommendations cannot be rapidly applied in
certain HCFs, due to financial or institutional constraints, a minimum
HCWM programme should always be set up.
According to the Ministry of Health report, there are a total of 126
hospitals, 519 health centers, 1797 health stations, and 2899 health
posts run by the government (over 90%), private institutions, and NGOs.
5627 public health service facilities that include hospitals, health
centers, health stations, health posts, and clinics; and 2489
pharmaceutical retail outlets are owned by the government, private
owners, OGA and NGOS. Health-care services inevitably generate wastes
that may be hazardous and infectious to health as well as have harmful
environment. Some of them, such as sharps and pathogenical wastes,
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carry a higher potential for infection and injury than any other type of
wastes. An integrated effort is necessary in Ethiopia to set-up safe
health-care waste management practices.
1.2 Overview of HCWM Programmes for HCFs
Health-care waste is a management issue (and not only a technical one)
that should become and integral feature of health-care services. It is
essential that clear individual and group responsibilities and monitoring
procedures should be established at each level of the health-care
establishments. Additionally, awareness and training programmes for
medical and ancillary staff should be strengthened in health-care
establishments. Specific administrative procedures should be defined
and adequate resources allocated at all levels to ensure a proper
management of health-care waste. Appropriate, environmental-friendly
and affordable technologies should be selected for the treatment and the
disposal of health-care waste, taking into consideration the resources of
each health-care facility.
A policy statement on hazardous waste exist at the national level,
specifics that deal with hazardous waste management, in general, and
health care waste, in particular, does not exist at the national level.
Given the rapid expansion of health-related infrastructures, which
implies a rapid growth of hazardous waste generation, the need for
policies, directives, and a strategic plan as well as their implementation
based on prioritized problems is a forthcoming challenge. Studies that
are contributing to the appreciation of the depth and breadth of health
care waste management problems currently become important.
National Guidelines for Health-Care Waste Management 8

This document is prepared to provide guidelines for the persons involved
in health-care waste management at central, regional, district and local
levels. Some HCFs have started to establish safety and health care waste
management committees. The committees have made important
contributions by identifying safety and health problems and by educating
the workforce about safety and health issues. Such committees can help
to ensure safe work environments in HCFs.
1.3 Overview of the Need for Developing Comprehensive HCWM
Programmes
A comprehensive HCWM programmes are needed to:
1.3.1 Address Diverse Needs: The diverse HCWM concerns in HCFs are
traditionally divided into HCW that pose an immediate threat and
HCW that cause long-term health problems. These conditions may
result in an immediate illness or in the long-term development of
disease.
Developing an appropriate and useful safety and health program
for a health care facility requires the involvement of a safety and
HCWM committee that represents workers and supervisors from
all departments in the HCFs. To be effective, committee members
should be knowledgeable in HCWM and have explicit
responsibilities and appropriate authorities.
1.3.2 Identify Hazards and interventions: Hazard and infections
identification involves not only recognizing the hazards and
infections themselves but also learning their specific
characteristics and identifying the population at risk so that
control programs can be designed.

The HCFs safety and health committee should assist with this in
consultation with workers from each department. The most
important step in identifying hazards is usually a physical
inspection called a walk-through survey. Persons conducting the
survey actually walk through the unit and note as many hazards
as possible.
1.3.3 Conduct Medical Evaluations: Medical evaluation is usually on
the extent of exposure to the agent, the severity of the adverse
effects, the complexity of the work process, and protective
measures. Complex work procedures (e.g. operating-room
practices) should be analyzed carefully, noting products and
byproducts formed during the procedures.
The signs and symptoms that workers experience should be
evaluated medically, taking care to avoid preconceptions about
which ones are work related. An occupational history should also
be maintained for each worker to help evaluate the long-term
effects of exposures. This history should contain at least the
worker’s prior occupations and job titles, the duration of
employment at each job, and the name of any substance or agent
to which the worker may have been exposed.
1.3.4 Provide Personal Protective Equipment: Personal protective
equipment for health woprkers includes gloves, goggles, aprons,
respirators (not surgical masks), and boots. Although the use of
such equipment is generally the least and last desirable way to
control workplace hazards and infections because it places the
burden of protection on the worker, the equipment should be
available for situations when an unexpected exposure to chemical

substances physical agents, or biologic materials could have
serious consequences.
1.3.5 Keep Records: No sufficient data is available on the amount of
health care waste generated and how that waste is handled.
Adequate recordkeeping is very important:
(1) To track the safety and health of individual workers and work
groups over time,
(2) To provide documentation on quantity of waste generated and
disposed off for future evaluations, planning for management,
(3) To help the HCFs’ administrations and the safety and health
committee identify problem areas, and
(4) To measure the effectiveness of safety and health programs.
The employer must maintain these records and provide access to
concerned body. Workers and their representatives also have the
right to access these records.

1.4 Objectives
1.4.1 The overall aim is at providing guidelines for HCWM methods that
can be applied in the HCFs of Ethiopia.
More specifically, it attempts to:
o Provide a better knowledge of the fundamentals of HCWM planning
and a better understanding of the hazards linked to HCW;
o Develop HCWM plans and standards which are protective for both
the human health and the environment, in compliance with the
current environmental and public health legislations of Ethiopia
taking into consideration the financial possibilities of each
institution;
o Set priority actions in order to tackle the most sensitive problems
related to HCWM (e.g. disposal of sharps) and to present these
actions as part of a more global framework;
o Review appropriate and sustainable technologies to treat and
dispose of HCW;
o Facilitate the analysis of HCWM problems and develop strategies for
the safe management of HCW at district level.

1.4.2 It is also targeting the provision of both conceptual and practical
information on HCWM.
More specifically for:
o The medical staff members having a "duty of care" at all levels in
public or private HCFs, namely: Medical Directors in Charge, Heads
of all Hospital Departments, Administrators, Doctors, Matrons,
Nurses, Medical attendants and all other staffs;
o National policy makers, regional and district health management
teams in charge of developing, implementing and devaluating HCWM
plans at central, regional and district levels as well as health officers
in charge of their implementation monitoring;
o Members of the health training institutions;
o International Organisations or NGOs involved in the backstopping of
health care services delivered in Ethiopia.

1.5 How to use these guide lines
These guidelines are divided into five sections and have bee structured to
be as practical as possible.
o The two first sections have been written for all people involved in
health-care waste management at any level. They provide key
information on HCW and the potential harmful effects that can
result from its mismanagement;
o The third section gives the procedures for health-care waste
manipulation and disposal that should be applied and followed in
all the HCFs of the country;
o The instructions contained in the fourth section have been written
for personnel involved in the organisation of HCWM plans in major
hospitals and minor HCFs;
o The fifth section has been written for personnel of central, regional
and district Health Services that should deal with HCWM to ensure
a smooth implementation of the instructions contained in this
document;

Section 2 Definition
The definitions and the classification hereafter are adapted from the
international classification provided by the World Health Organisation.
2.1 Health-Care Waste
Health-Care Waste (HCW) includes all the waste, hazardous or not,
generated during medical activities. It embraces activities of diagnosis as
well as preventive, curative and palliative treatments in the field of
human medicine. In other words, are considered as health-care waste,
all the waste produced by a medical institution (public or private), a
medical research facility or a laboratory.
2.2 Non-Risk Health-Care Waste
Non-risk Health-Care Waste comprises all the waste that has not been
infected. They are similar to normal household or municipal waste and
can be managed by the municipal waste services. They represent the
biggest part of the HCW generated by a medical institution. It includes
paper, cardboard, non-contaminated plastic or metal, cans or glass, left
over food, etc... and can also be included in this category of waste, all
items that have been used for medical care but are visually not
contaminated with blood or body fluids of the patient, this only being
applicable if the patient is not confined in an isolation ward.

2.3 Pathological Waste
Pathological Waste groups all organs (including placentas), tissues as
well as blood and body fluids and follows the precautionary principle
stipulated by WHO.
2.4 Anatomical Waste
Anatomical waste comprises recognizable body parts. It is primarily for
ethical reasons that special requirement must be placed on the
management of human body parts. They can be considered as a
subcategory of Pathological Waste.
2.5 Infectious Waste
Infectious waste comprises of all biomedical and health-care waste
known or clinically assessed by a medical practitioner to have the
potential of transmitting infectious agents to humans or animals. Waste
of this kind is typically generated in the following places: Isolation wards
of hospitals; centres caring for patients infected with hepatitis viruses;
pathology departments, operating theatres and laboratories.
2.6 Highly Infectious Waste
Highly infectious waste includes all viable biological and pathological
agents artificially cultivated in significant elevated numbers. Cultures
and stocks, dishes and devices used to transfer, inoculate and mix
cultures of infectious agents belong to this category of waste. They are
generated mainly in Diagnostic Medical Laboratories.

2.7 Sharps
Sharps are all objects and materials that pose a potential risk of injury
and infection due to their puncture or cutting properties (e.g. syringes
with needles, blades, broken glass...). For this reason, sharps are
considered as one of the most hazardous categories of waste generated
during medical activities.
2.8 Pharmaceutical Waste
Pharmaceutical Waste embraces a multitude of active ingredients and
types of preparations. This category of waste comprises expired
pharmaceuticals or pharmaceuticals that ate unusable for other reasons
2.9 Cytotoxic Waste
Cytotoxic Waste may be considered as a sub-group of hazardous
Pharmaceutical Waste, due to its high degree of toxicity. The potential
health risks for people who handle cytotoxic Pharmaceuticals results
above all from the mutagenic, carcinogenic and teratogenic properties of
these substances, which can be split into six main groups: alkylated
substances, antimetabolites, antibiotics, plant alkaloids, hormones and
others.
2.10 Radioactive Waste
Radioactive Waste includes liquids, gas and solids contaminated with
radio nuclides whose ionizing radiations have genotoxic effects. The
ionizing radiations of interest in medicine include X-any. An important

difference between these types of radiations is the X-rays are emitted
from X-ray tubes only when generating equipment is switched on.
2.11 Special Hazardous Waste (Waste with high contents of heavy
metals)
Waste with high contents of heavy metals should normally be treated in
specific recovering industries. Alternatively, as for chemical waste, it
may be encapsulated. Waste with high contents of mercury or cadmium
shall never be incinerated because of the risk of atmospheric pollution
with toxic vapours.
Special Hazardous Waste includes gaseous, liquid and solid chemicals,
waste with a high contents of heavy metals such as batteries,
pressurized containers, out of order thermometers, blood-pressure
gauges, photographic fixing and developing solutions in X-ray
departments, halogenated or non-halogenated solvents... this category of
waste is not exclusive to the health-care sector. They can have toxic,
corrosive, flammable, reactive, explosive, shock sensitive, genotoxic
properties.
2.12 Effluents
Effluents and more particularly, effluents from isolation wards and
medical diagnostic laboratories should be considered as hazardous liquid
waste that should receive specific treatment before being discharged into
the sewerage/drainage system, if such a system exists.
2.13 Miscellaneous wastes
These types of wastes are wastes include those from surgery and
autopsies, contaminated laboratory wastes, dialysis unit wastes and
contaminated equipment.

2.13.1 Wastes from surgery and autopsies include soiled dressings,
sponges, drapes, lavage tubes, drainage sets, under pads, and
surgical gloves.
2.13.2 Contaminated laboratory wastes include specimen containers,
slides and cover slips, disposable gloves, laboratory coats, and
aprons.
2.13.3 Dialysis unit wastes include contaminated disposable equipment
and supplies such as tubing, filters, disposable sheets, towels,
gloves, aprons, and laboratory coats.
2.13.4 Contaminated equipment refers to discarded equipment and
parts that are used in patient care, medical research, and the
production and testing of certain pharmaceuticals.

Section 3 Public Health Importance, Risks and
Management of Health-Care Wastes
3.1 Public Health Importance
Nowadays, health care wastes generation is significantly large amounts
by volume and diverse by types that require proper handling and
disposal. Much of the waste is hazardous and must therefore be
packaged, transferred, and disposed of properly to protect both the
persons handling it and the environment
All individuals exposed to hazardous HCW are potentially at risk of being
injured or infected. They include:
1. Medical staff: doctors, nurses, sanitary staff and hospital
maintenance personnel
2. In-and out-patients receiving treatment in HCFs as well as their
visitors;
3. Workers in support services linked to HCFs such as laundries,
waste handling and transportation services;
4. Workers in waste disposal facilities, including scavengers;
5. The general public and more specifically the children playing with
the items they can find in the waste outside the HCFs when it is
directly accessible to them.
3.2 Risks of Health-Care Wastes
3.2.1 Occupational Risks
HCFs’ work environment, during handling of wastes, the medical and
ancillary staff as well as the sanitary laborers can be injured if HCW has
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not been handled safely. In this respect, sharps are considered as one of
the most dangerous categories of waste. Many injuries occur because
syringe and needles or other sharps have not been collected in safety
boxes or because these have been overfilled.
On dumpsites, scavengers during their reusing or recycling activities
may also come in contact with infectious waste if it has not been properly
treated or disposed of.
Maintenance workers serve in all patient and non-patient areas and are
thus potentially exposed to all of the health hazards found in drainage
system, chemical stores, etc of the HCFs’ environment. Maintenance
personnel are frequently exposed to pathogens.
3.2.2 Risks to the Population
The general public can be infected by HCW either directly or indirectly
through several routes of contamination. Dumping HCW in open areas is
a practice that can have major adverse effects on the population.
The ''recycling'' practices, the reuse of syringes are certainly the most
serious problem in some of the developing countries. The WHO estimates
that some millions infections of Hepatitis B, C and HIV occur yearly from
the reuse of discarded syringes needles without prior disinfection.
3.3 HCW Management
It is not often understood why HCW should be managed in a different
way than the other categories of wastes, and particularly why HCW
should be segregated on the spot, where it is generated. Furthermore, the
constraints related to their management as well as the funds required to

set up a proper management system discourage many medical
institutions to undertake the necessary steps to improve their current
HCWM practices.
However, HCWM is an integral part of hygiene and infection control
within a HCF and proper management should help control of nosocomial
infections.
HCWM is not only compliance with Federal and local regulations, but it
should carefully consider the development of an infectious waste
management plan to minimize the overall risks of HCWs. Each HCF
should develop an infectious waste management plan that provides for:
(1) Designation of the waste that should be managed as HCWs,
(2) Segregation of infectious waste from the noninfectious waste,
(3) Packaging of infectious waste to reduce contacts and exposure,
(4) Storage of HCW for proper transport,
(5) Treatment of infectious waste to avoid contaminations,
(6) Disposal of infectious waste to eliminate risks,
(7) Measures for emergency situations, and
(8) Staff training on HCWM.
Implementing adequate procedures to minimize the overall risks
associated with HCWM remains the prior objective of these National
Guidelines. Waste management and treatment options should first
protect the health-care workers and the population and minimizes
indirect impacts from environmental exposures to HCW.

The instruction contained in theses guidelines for the handling and the
disposal of sharps, and more specifically used syringes, attempt first to
minimize the risks of cuts or needle stick injuries that may occur after
an injection:
Some treatment options - such as low-cost incinerators that emit
pollutants - may be used in certain situations (e.g. low density populated
areas) where the overall health benefits from preventing infections are
likely to outweigh the risks from exposure to toxic pollutants in the air.
Nevertheless, environmental-friendly practices, like the recycling of
plastics are recommended when they are in accordance with the
precautionary principle.

Section 4 Health-Care Waste Management Guidelines
The implementation of safe HCWM guidelines aims at containing
infections and reducing public health risks both within and outside the
HCF. The guidelines should always contain the following measures:
1. Segregation and identification of hazardous HCW from non-risk
HCW;
2. Recyclingof HCW to minimize the quantity of HCW generated by
the HCF;
3. Adequate packaging and safe storage of the different categories of
HCW;
4. Proper treatment and disposal of hazardous and non-risk HCW.
4.1 Guidelines for Segregation of Health-Care Waste
A proper segregation must follow rigorous and standardized procedures
to enable and reduce the risks of infecting workers and control the
economical incidence of hazardous HCW disposal by decreasing the
treatment costs. It must be:
1. Simple to implement for medical and ancillary staff;
2. Safe and guaranty the absence of infectious HCW in the domestic
waste flow;
3. Stable and homogeneously applied in all the HCFs;
4. Regularly monitored to ensure that the procedures are respected.
The following guidelines should be included in HCW Segregation:
1. Segregation of HCW should consist in separating the different
waste streams based on the type of treatment and disposal
required at economical cost.
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2. The segregation should identify waste according to source and
type of disposal or disinfections.
3. Segregation of HCW practices should provide coloured waste
receptacles specifically suited for each category of waste.
4. Segregation shall take place at the source or at the site, that is
at the ward bedside, Operation Theatre, Medical Diagnostic
Laboratory, or any other room or ward in the hospital and
health center where the waste is generated.
5. Seven categories of waste shall be considered in the segregation
of HCW: HCW of classes 1, 2, 3, 4 and 9 are commonly
generated in major and minor medical institutions. HCW of
classes 5, 6, 7 and 8 are generated only in some institutions
and in small quantities.
Class1: non-risk waste comprises the non-hazardous waste generated
within the medical institutions as defined in section 2, as well as the
non-hazardous pharmaceutical waste;
Class 2: clinical waste comprises pathological waste and infectious waste
as defined in section 2. It includes also all items that are visually
contaminated with blood or body fluids;
Class 3: sharp waste includes all items that can case cuts or puncture
wounds as defined in section 2 sharps shall be considered as highly
hazardous waste and collected in rigid safety boxes;
Class 4: anatomical waste and placenta comprises recognizable body
parts as specified in section 2. Due to their physical characteristics,
similar to anatomical waste, placentas are grouped in the same class;

Class 5: Hazardous pharmaceutical and cytotoxic waste include
pharmaceuticals (cytotoxic drugs and toxic chemicals), which pose a
potential hazard when used improperly by unauthorized persons, and
unidentifiable pharmaceuticals heavy-metal-containing disinfectants,
which owing to their composition require special management and
cytotoxic waste as defined in section 2.
Class 6: highly infections waste comprises waste as defined in section 2.
This category of waste is generated in medical Diagnostic laboratories or
in isolation wards;
Class 7: radioactive waste includes waste as defined in section 2.
Class 8: Wastes with high contents of heavy metals include wastes as
defined in section 2. This category of wastes is wastes with high contents
of heavy metals such as mercury or cadmium.
Class 9: Effluents comprises waste as defined in section 2. This category
of waste is non-solid waste of all liquid infectious waste.
4.2 Guidelines for Colour coding system
The colour coding system aims at ensuring an immediate and non-
equivocal identification and segregation of the hazards associated with
the type of HCW that is handled or treated. In this respect, the colour
coding system shall remain simple and be applied uniformly throughout
the country.

All health- care facilities shall apply the following colour coding system:
1. Black: all bins or bags containing non-risk HCW of class 1;
2. Yellow: any kind of container filled with HCW from class 2 – 7;
3. Red: any kind of container filled with HCW from class 8 and 9.
4.3 Guidelines for HCW Recycling and Reusing
The implementation of recycling procedures in HCFs to minimize the
quantity of HCW generated is highly sensitive. Recycling procedures
complicate the overall segregation scheme by increasing the segregation
criteria and multiplying the number of waste streams in the HCF. It is a
potential source of error.
However, considering the specific recycling practices in Ethiopia, the
necessity to implement an environmental-friendly process of HCW
disposal and the financial resources of each HCF, a simple and safe
recycling practice should be implemented whenever it is possible. In
these situations the instructions hereafter should be followed.
4.3.1 Guidelines for Recycling of non-contaminated plastic
items
The following guidelines should be included in recycling of non-
contaminated plastic items:
1. All non-contaminated plastic items (e.g. bags of sodium chlorine,
etc) should be collected, packed in separate boxes.
2. They should be delivered to or picked-up local collectors capable of
recycling them with environmental-friendly techniques.

4.3.2 Guidelines for Recycling of glassware inside the
Diagnostic Laboratories
The following guidelines should be included in glassware inside the
Diagnostic Laboratories:
7 All non-contaminated and non-broken glassware (flasks of inject able
penicillin for instance) should be collected separately.
8 They should be put in a disinfectant solution not less than 30
minutes, carefully washed, rinsed and dried before being reused.
9 The disinfected glassware should be reused only for specific medical
Diagnostic (blood, urine) carried out inside the Diagnostic laboratory.
10 After having been used once, they shall be considered as
contaminated and infectious.
11 Broken glassware shall always follow the stream of sharp waste (class
3) while non-broken glass flasks shall be reused only after
disinfections in a disinfectant solution, carefully washed with a brush
and soap, rinsed.
12 During the disinfection process, hands shall always be protected with
gloves. It is further recommended to autoclave the glassware after
washing at 1210
C for at least 30 minutes to ensure complete
disinfection.
4.3.3 Guidelines for Reuse of specific equipment
The following guidelines should be included in recycling of non- specific
equipment:
1. In general, to encourage reuse, each hospital and health center
shall collect separately, wash and sterilize, either thermally or
chemically in accordance with approved procedures, surgical

equipment and other items which are designed for reuse and are
resistant to the sterilization, disinfection or disinfection process.
2. Pressurized materials as cylinders shall be returned to suppliers
for refilling and reuse.
4.4 Guidelines for pharmaceuticals management
The following guidelines should be included in pharmaceuticals
management:
1. Drug stores in each HCF shall be rigorously managed on a base of
first in first out to avoid wastage.
2. Stock positions should be recorded on a regular basis.
4.5 Guidelines for Packaging
The following guidelines should be included in packaging:
1. Infectious wastes should be contained from the point of origin to the
point at which they are not longer infectious.
2. The packaging should be appropriate for the type of waste involved
3. It should consider tear-resistant packaging materials in the process of
handling, storage, transportation, and treatment.
4. Liquid infectious wastes should be placed in capped or tightly stopper
bottles or flasks and large quantities may be placed in containment
tanks.
5. Solid or semisolid wastes should be placed in plastic bags, but the
following recommendations should be observed:

5.1 Selection of tear-resistant bags: use plastic bags that are
judged by their thickness or durability and the most
important considerations are tear-resistance.
5.2 Placement of sharps (sharp items, or items with sharp
corners) in the bags: place sharps in impervious rigid,
puncture-resistant containers made of glass, metal, rigid
plastic, or wood.
5.3 Loading a bag beyond its weight or volume capacity: load
bags up to its limit.
5.4 Keeping bags from coming into contact with sharp external
objects: keep away bags from contacts with sharp objects.
5.5 Double bagging: Consider double bagging to ensure tear-
resistance.
6. There should be special packaging characteristics for some treatment
techniques: incineration required combustible containers, and steam
sterilization requires packaging materials such as low-density plastics
that allow steam penetration and evacuation of air.
4.6 Waste storage guidelines
The following guidelines should be included in waste storage:
1. In each room where HCW is generated, an adequate place shall be
dedicated for storing HCW bag-holders, bins or containers.
2. Waste storing places in each room of HCF should be easily
accessible for the sanitary staff and instruction shall be displayed.
3. In all HCFs, separate central storage facilities shall be provided for
hazardous HCW, except radioactive waste that shall be stored
specifically.
4. It shall clearly be mentioned that the facility stores hazardous
HCW and no materials other than yellow bag waste.

5. No waste shall be stored for more than two days before being
treated or disposed of.
6. The designated central storage facility shall be located within the
hospital premises close to the treatment unit but away from food
storage or food preparation areas.
7. The designated central storage facility should be large enough to
contain all the hazardous HCW produced by the hospital during
one week, with spare capacity to cope with any maintenance or
breakdown of the treatment unit.
8. The designated central storage facility shall be totally enclosed and
secured from unauthorized access.
9. The designated central storage facility shall be inaccessible to
animals, insects and birds.
10. The designated central storage facility shall be easy to clean and
disinfect with an impermeable hard-standing base, good water
supply, drainage and ventilation: The following procedures area
recommended:
10.1 Infectious waste should be stored for a minimum amount of
time and should be packaged securely enough to ensure
containment of the waste and to prevent penetration by
rodents and vermin.
10.2 Limited access to the storage area is recommended.
10.3 The universal biological hazard symbol should be posted on
the storage area door, waste containers, freezers, or
refrigerators.
10.4 Containers for bio-hazardous material should be a
distinctive red or orange color.

4.7 Waste Handling guidelines
The following guidelines should be included in Waste Handling:
1. All HCW or disposal of medical equipment shall be discarded at the
point of use by the person who used the item to be disposed off in
case any such used equipment or supplies are found or are
handed over to another person, it should be discarded by that
person.
2. All the specific procedures of HCW segregation, packaging and
labeling shall be explained to the medical and ancillary staff and
displayed in each department on charts located on the walls
nearby the HCW containers.
3. When handling waste, sanitary staff and sweepers shall wear
protective clothing at all times including face masks, aprons and
boots, heavy duty gloves, as required.
4. Carts and recyclable containers that are used repeatedly for
transport should be disinfected after each use. Single-use
containers should be destroyed as part of the treatment process.
4.8 Waste Transportation guidelines
4.8.1 Transport to Central Storage
4.8.1.1 The waste collection trolley should be easy to load, unload and.
The trolley shall not be used for any other purpose. It shall be

cleaned regularly, and especially before any maintenance work
is performed on it.
4.8.1.2 Yellow bags of hazardous HCW and black bags of non-risk HCW
shall be collected on separate trolleys that shall be painted
marked with the corresponding colours and washed regularly.
4.8.1.3 The collection route shall be the most direct one from the
collection point to the central storage.
4.8.1.4 The collected waste shall not be left even temporarily anywhere
other than at the designated central storage.
4.8.1.5 Containers should be covered with lids during storage.
4.8.1.6 Instead of chutes or dumbwaiters, carts should be used for
transporting bags of infectious waste within the facility.
4.8.2 Transport to Final Disposal Site
4.8.2.1 When the waste is to be moved about for treatment or storage,
special handling or packaging may be necessary to keep bags
intact and to ensure containment of the waste. The following
procedures are recommended:
1. Single-bagged waste and containers of sharps and liquids
should be placed within a rigid or semi-rigid container such
as a bucket, box, or carton lined with plastic bags.
2. Containers should be covered with lids during
transportation.
3. When transporting plastic bags of infectious waste, care
should be taken to prevent tearing the bags.
4. Infectious waste should not be compacted before treatment.
This process could damage the packaging and disperse the
contents, or it could interfere with the effectiveness of
treatment.

5. Outside the hospital and health centers or all HCFs,
infectious waste should be transported in closed, leak-proof
dumpsters or trucks.
6. The waste should be placed in rigid or semi-rigid, leak-proof
containers before being loaded onto trucks.
7. In case off-site transportation is required to treat hazardous
HCW at treatment facilities, the local Government shall
approve the off-site transportation plan before any transit
occurs.
8. All yellow bags shall be collected and transported at least
every second day.
9. The transportation shall be properly documented, and all
vehicles shall carry a consignment note from the point of
collection to the treatment facility.
10.Vehicles used for the carriage of yellow bags shall not be
used for any other purpose.
11.The vehicles shall be free of sharp edges, easy, to load and
unload by hand, easy to clean/disinfect, and fully enclosed
to prevent any spillage in the HCF premises or on the road
during transportation.
12.All vehicles shall be cleaned and disinfected after use.
13.The vehicles shall carry adequate supply of plastic bags,
protective clothing, cleaning tools and disinfectants to clean
and disinfect in case of any spillage.
14.All staffs handling yellow bags shall wear protective clothing.
15.Staffs shall be properly trained in the handling, loading and
unloading, transportation and disposal of the yellow bags.
16.Staffs shall be fully aware of emergency procedures for
dealing with accidents and spillage.

4.9 Waste treatment guidelines
The following guidelines should be included in waste treatment:
1. Amongst all the current existing technologies for treating and
disposing of HCW, the most appropriate technology shall be
applied, that is:
.1 The most reliable, affordable and sustainable technology in
accordance with the technical, human and financial
resources of each HCF;
.2 The technology that minimizes the immediate public health
risks associated with HCWM with the lowest impact on the
environment.
2. Incineration may be considered as the technology that most
reliable disposal of hazardous and properly buried in an
appropriate pit. Nevertheless, in highly densely populated areas
large quantities of hazardous HCW shall not be incinerated at
temperatures lower than 12000
C.
3. Several methods are used for infectious waste treatment,
depending on the type of waste material. These treatment methods
shall include one of the following options or combination of
options: steam sterilization, incineration, thermal inactivation,
gas/vapor sterilization, chemical disinfection, or sterilization by
irradiation.
4. After treatment, the wastes or their ashes should be disposed of
by discharge into sanitary sewer systems (for liquid or ground-up
waste) or burial in sanitary landfills.
5. Acceptable treatment methods for the various types of wastes are
listed in Table 3-1.

Recommended techniques for treatment of infectious wastes
Type of
infectious
waste
Recommended treatment techniques
Steam
sterilization
Incineration
Thermal
inactivation
Chemical
disinfection
Other
Isolation wastes X X
Cultures and
stocks of
infectious
agents and
associated
biologicals
X X X X
Human blood
and blood
products
X X X X
Pathological
wastes
X X X
Contaminated
sharps
X X
Carcasses and
parts
X X
Bedding X

4.9.1 Guidelines for Steam Sterilization (Autoclaving)
Steam sterilization, autoclaving, involves the use of saturated steam
within a pressure vessel at temperatures high enough to kill infectious
agents in the waste. Sterilization is accomplished primarily by steam
penetration. Steam sterilization is most effective with low-density
material such as plastics.
The following guidelines should be included in Steam Sterilization
(Autoclaving):
1. An alternative treatment method, e.g. incineration, should be used
on high-density wastes such as large body parts or large
quantities of animal bedding or fluids because they inhibit direct
steam penetration and require longer sterilization times.
2. Containers that should be used effectively in steam sterilization
are plastic bags, metal pans, bottles, and flasks. High-density
polyethylene and polypropylene plastic should not be used in this
process because they do not facilitate steam penetration to the
waste load.
3. Heat-labile plastic bags allow steam penetration of the waste, but
they may crumble and melt. If heat-labile plastic bags are used,
they should be placed in another heat-stable container that allows
steam penetration, such as a strong paper bag, or they should be
treated with gas/vapor sterilization.
4. The following precautions should be taken when using steam
sterilization:
4.1 Plastic bags should be placed in a rigid container before
steam treatment to prevent spillage and drain clogging.

4.2 To facilitate steam penetration, bags should be opened and
caps and stoppers should be loosened immediately before
they are place in the steam sterilizer.
4.3 Care should be taken to separate infectious wastes from
other hazardous wastes.
4.4 Infectious waste that contains noninfectious hazards should
not be steam-sterilized because of the possibility that the
equipment operator will be exposed to toxic, radioactive, or
other hazardous chemicals.
4.5 Waste that contains drugs, toxic chemicals, or chemicals
that would be volatilized by steam should not be steam-
sterilized.
4.6 Persons involved in steam sterilizing should be trained in
handling techniques to minimize personal exposure to
hazards from infectious wastes. Some of these techniques
include:
4.6.1 Use of protective equipment
4.6.2 Minimization of aerosol formation
4.6.3 Prevention of waste spillage during autoclave loading
and unloading
4.6.4 Prevention of burns from handling hot containers
4.6.5 Management of spills
4.7 The autoclave temperature should be checked with a recording
thermometer to ensure that the proper temperature is being
maintained for a long enough periods during the cycle.
4.8 Steam sterilizers should be routinely inspected and serviced,
and the process should be routinely monitored to ensure that
the equipment is functioning properly.
4.9.2 Guidelines for Incineration

Incineration converts combustible materials into noncombustible residue
or ash. Gases are ventilated through the incinerator stacks, and the
residue or ash is disposed of in a sanitary landfill. If incinerators are
properly designed, maintained, and operated, they are effective in killing
organisms present in infectious waste.
The following guidelines should be included in Incineration:
1. Incineration should be used for anesthetic disposal of pathological
wastes such as tissues and body parts.
2. Incineration should be used to render contaminated sharps
unusable.
3. The principal factors affecting incineration like variations in waste
composition, the waste feed rate, and the combustion temperature
should be considered to maintain efficiency of incinerating
infectious wastes.
4. Infectious wastes containing drugs should be disposed of in an
incinerator that provides high temperatures and enough time for
the complete destruction of these compounds.
5. The incinerator’s effectiveness in disposing of chemical wastes
should be documented before such use.
6. Persons involved in Incineration should be trained in handling
techniques to minimize personal exposure to hazards from
infectious wastes. Some of these techniques include:
6.1 Use of protective equipment
6.2 Prevention of waste spillage during incinerators loading
6.3 Management of spills

4.9.3 Guidelines for Thermal Inactivation
Thermal inactivation involves the treatment of waste with high
temperatures to eliminate the presence of infectious agents. This method
is usually used for large volumes of infectious waste.
Liquid waste is collected in a vessel and heated by heat exchangers or a
steam jacket surrounds the vessel. The types of pathogens in the waste
determine the temperature and duration of treatment. This method
requires higher temperatures and longer treatment cycles than steam
treatment.
The following guidelines should be included in Thermal Inactivation:
1. After treatment, the contents should be discharged into the sewer
or landfills in a manner that complies with Federal and local
requirements.
2. Solid infectious waste should be treated with dry heat in an oven,
which is usually electric.
3. Persons involved in Thermal Inactivation should be trained in
handling techniques to minimize personal exposure to hazards
from infectious wastes. Some of these techniques include:
3.2 Prevention of waste spillage during Thermal Inactivation
loading and unloading
3.3 Prevention of burns from handling hot containers
4.9.4 Guidelines for Gas/Vapor Sterilization

Gas/vapor sterilization uses gaseous or vaporized chemicals as the
sterilizing agents. Ethylene oxide is the most commonly used agent.
The following guidelines should be included in Gas/Vapor Sterilization:
1. Gas/Vapor Sterilization should be used with caution since it is a
suspected human carcinogen, because ethylene oxide may be
adsorbed on the surface of treated materials, the potential exists
for worker exposure when sterilized materials are handled.
2. Persons involved in Gas/Vapor Sterilization should be trained in
from infectious wastes and handling of sterilized materials. Some
of these techniques include:
2.2 Prevention of waste spillage during Gas/Vapor Sterilization
4.9.5 Guidelines for Chemical Disinfection
Chemical disinfection is the preferred treatment for liquid infectious
wastes, but it can also be used in treating solid infectious waste.
The following guidelines should be included in Chemical Disinfection:
1. The following factors should be considered and labeled with
wastes to be treated when using chemical disinfection:
1.1 Type of microorganism
1.2 Type of disinfectant
1.3 Contact time

1.4 Other relevant factors such as temperature, pH, mixing
requirements, and the biology of the microorganism
2. Ultimate disposal of chemically treated waste should be in
accordance with Federal and local requirements.
3. Persons involved in Chemical Disinfection should be trained in
from infectious wastes and handling of sterilized materials. Some
of these techniques include:
3.2 Infections from exposure to pathogenic organism
3.3 Prevention of waste spillage during Chemical Disinfection
4.9.6 Guidelines for Accidents (emergency) and spillage
The following guidelines should be included in Accidents and spillage:
1. All HCF staff members shall be properly trained and prepared for
emergency response, including procedures for treatment of
injuries, cleanup of the contaminated area and prompt reporting of
all incidents of accidents.
2. The following actions shall be taken:
2.1 Evacuation of the contaminated area if required;
2.2 Decontamination or disinfection, rinsing and wiping dry
with absorbent cloth by personnel wearing adequate
protective clothing;
2.3 Decontamination or disinfection of the protective clothing
if necessary;
2.4 Cuts with sharps or needle stick injuries shall be
immediately disinfected;

2.5 Accident shall be reported to the infection control
officer/staff;
2.6 All cases shall be registered by the management Team of
the HCF and annually reported to the District Health
Authorities.
2.7 It is highly recommended to perform blood tests following
such an injury to ensure that the injured staff has not
been contaminated by any pathogen.
4.10 Guidelines for Ultimate Disposal
The following guidelines should be included in Ultimate Disposal:
1. The recommended types of disposal options in accordance with
the type of HCW are:
1.1 Conventional sewer system for discharge of treated liquids
and grounded solids.
1.2 Landfill disposal of treated solids and incinerator ash.
2. EPA and MoH shall control that only treated infectious wastes are
buried in landfills.
3. Facilities should secure the services of reputable waste handlers
to ensure, to the extent possible, that ultimate disposal of
hazardous wastes is performed according to applicable Federal
and local regulations.
4.11 Guidelines for Maintenance Workers
The following specific guidelines should be included in a HCWM for
maintenance workers:

1. Workers should be instructed to use gloves during working in
contaminated areas and materials, and wash their hands
thoroughly after removing work gloves.
2. Workers should be aware that other persons may not have followed
proper procedures for disposing of needles, knives, and glassware.
4.12 Guidelines for occupational risks
The following guidelines should be included in HCWM for central store,
food, laundry & other services and office workers:
1. Desks and countertops should be free of sharp.
2. Needles and other sharp instruments should be discarded in
designated puncture-resistant containers and not in trash cans or
plastic bags.
3. There should be no recapping of needles.
4. Rules for safe disposal and collection of sharp instruments or other
hazardous materials should be reviewed regularly.
5. Workers should examine and handle soiled linens and similar
items as if they contained hazardous items.
6. Workers should receive periodic instruction to keep them aware of
the specific hazards of HCW of HCFs.
7. Worker should follow instructions issued by the infection control
personnel for reporting infections.
8. Workers should take appropriate measures to limit further
contagion from HCWs by practicing universal precautions of self-
protection from exposure to infectious wastes.
4.13 Guidelines for Training
All workers who handle infectious waste should receive infectious waste
management training that includes:

(1) Explanation of the infectious waste management plan.
(2) Assignment of roles and responsibilities for implementation of the
plan.
(3) Refresher courses should also be given periodically.

Section 5 Specific Guidelines Associated With HCW Categories
Class 1: non-risk health-care waste
1. Non-risk HCW of class 1 shall be placed in black containers.
2. Non-contaminated items that are designated for recycling shall be
packed in specific black containers marked ''Non-contaminated
plastic, to be recycled'' or ''Non-contaminated glassware, to be
recycled''.
3. All non-risk HCW not designated for recycling shall be collected
with the other municipal waste.
Class 2: clinical waste
1. All class 2 clinical waste shall be placed in yellow polyethylene
bags of minimum 300 microns gauge marked ''Danger! Hazardous
medical waste'' and indicated with the international Biohazard
symbol.
2. Preferably, the bags shall be placed in bag-holders.
3. Bags shall be sealed with appropriate adhesive tape, removed and
replaced immediately when they are no more than three-quarters
full.
4. If not available, yellow bins or containers shall be used; they must
nevertheless be systematically disinfected in a solution of 10% of
sodium hypochlorite or Lysol once emptied.
5. All class 2 clinical HCW shall be incinerated in double chamber
incinerators.
6. In highly densely populated areas centralized pyrolytic incinerator,
reaching 1'2000
C shall be preferably used.
46

7. In minor HCFs, i.e. in health centers and Dispensaries, class 2
clinical HCW may be incinerated in a simple pit hole land disposal
is an alternative solution when there is no risk of contaminating
underground water.
Class 3: sharps
1. All class 3 sharps shall be placed in specific cardboard or plastic
safety boxes, resistant to punctures and leak-proof, designed so
that items can be dropped in using one hand and no item can be
removed.
2. The safety box shall be coloured yellow, marked ''Denger!
Contaminated sharps''.
3. It shall be closed when three-quarters full and then placed in a
yellow plastic bag or containers with the other hazardous HCW of
class 2.
4. In particular all disposable syringes and needles shall be
discarded immediately following use.
5. The needle shall not be recapped or removed from the syringe; the
whole combination shall be inserted in to the safety box.
6. Under no circumstances are used syringes or needles, or safety
boxes, to be disposed of in normal garbage or dumped randomly
without prior treatment.
7. Sharps are destroyed together with the hazardous HCW of class 2.
The method of choice for destruction of full safety boxes is
incineration, preferably in an appropriate double-chamber
incinerator.
8. If such an incinerator is unavailable, alternative methods may be
used like the use of sharp pits.

9. Under exceptional circumstance, full safety boxes may be
incinerated in small numbers by open burning in a pit hole.
10. The residues of incineration shall be safety buried at sufficient
depth (> 1m).
Class 4: anatomical waste and placentas
13 In operation theatres, all class 4 anatomical waste and placentas
shall be collected separately.
14 When a centralized incinerator is available they shall be incinerated.
15 Nevertheless, when low-cost incinerators are used, anatomical waste
or large number of placentas can be difficult to incinerate and will
reduce drastically the performance of the system.
16 If incineration cannot be performed, class 4 anatomical waste and
placentas shall be dropped into a concrete lined pit or buried at a
sufficient depth (> 1m) inside the HCF compound1
.
17 If transportation and disposal cannot be immediately ensured,
anatomical waste should be stored in the mortuary.
Class 5: hazardous pharmaceutical and cytotoxic waste
1. Hazardous pharmaceutical waste and cytotoxic waste shall be
repacked in specific cardboard boxes marked ''Danger! Hazardous
pharmaceutical and cytotoxic waste'' they shall be sent to the
medical store Department that shall ensure their disposal at
central level.
2. Class 5 wastes shall be incinerated in a pyrolytic incinerator at a
minimum of 1'2000
C.
1
The area around the pit should be totally enclosed and secured from unauthorized
access and at least 100 m away from any underground fresh water borehole or well.

3. Class 5 hazardous pharmaceutical wastes and cytotoxic waste
containing heavy metals shall not be incinerated.
4. For this specific category of waste, inertization2
may be foreseen.
Class 6: highly infectious waste
1. Highly infectious waste from the medical Diagnostic laboratory of
the HCF, such as media and culture plates, shall be collected
preferably in leak proof yellow bags suitable for autoclaving and
properly sealed.
2. It shall be autoclaved at a temperature of 1210C at 1 bars for at
least 20 minutes at source, i.e. in the medical Diagnostic
laboratory itself.
3. Disinfected waste shall be collected and treated with the hazardous
HCW of class 2.
4. If a distinct autoclave is not available at the medical Diagnostic
laboratory to ensure a thermal treatment, highly infectious waste
shall be disinfected in a solution of sodium hypochlorite in
concentrated form and left overnight.
5. It shall than be discarded in a specific yellow bag properly sealed
and itself discarded with the hazardous HCW of class 2.
6. If none of the above treatment options can be ensured, ensured,
highly infectious waste should at least be packed in a specific
yellow bag that shall be sealed and directly discarded with the
hazardous HCW of class 2 and this option shall remain
exceptional.
2
Inertization consists in mixing pharmaceutical waste with cement and lime before
burying too minimize the risk that toxic substance migrate in to the surface water or
groundwater. The packaging should previously be removed.

7. Class 6 wastes from isolation wards or permanent treatment
centers (cholera) shall always be incinerated on-site.

Class 7: radioactive waste
1. All radioactive waste of class 7 shall be stored to allow decay to
background level.
2. They shall be placed in a large container or drum and labelled with
the radiation symbol showing the radio-nuclide's activity on a
given date, the period of storage required, and marked "Caution!
Radioactive waste".
3. Containers or tanks with radioactive waste that has not decayed to
background level shall be stored in a specific marked area, with
concrete walls 25 cm thick.
4. Non-infectious radioactive waste, which has decayed to
background level, shall follow the non-risk HCM stream (class 1)
while infectious radioactive waste which has decayed to
background level shall follow the clinical HCW stream (class 2).
5. Liquid radioactive waste shall be discharged into the sewerage
system or into a septic tank only after it has decayed to
background level in adequate tanks.
Class 8: Waste with high contents of heavy metals
1. Wastes with high contents of heavy metals should normally be
treated in specific recovering industries.
2. Alternatively, as for chemical waste, it should be encapsulated for
handling and disposal.
3. Wastes with high contents of mercury or cadmium shall never be
incinerated because of the risk of atmospheric pollution with toxic
vapours.

Class 9: Effluents
1. All liquid infectious waste shall be discharged into the sewerage
system only after being treated according to WHO standards.
2. Wastewater from HCFs should not be released to the environment
with out treatment because they may contain various potentially
hazardous components such as microbiological pathogens,
hazardous chemicals, pharmaceuticals and radioactive isotopes.
3. The proper treatment of wastewater from HCFs is very expensive
and cannot be currently foreseen in every HCF of Ethiopia,
however, basic steps described above (1 & 2) should be applied to
contributes to the reduction of the public health risk associated
with liquid waste and wastewater.

Section 6. Guidelines for Implementation of HCWM Plan in HCFs
6.1 Guidelines for waste management plan
The following guidelines should be included in HCWM plan:
6.1.1 Each HCW generating organizations should have a
comprehensive waste plan as part of an overall health care
strategy.
6.1.2 Implementation of HCWM plan shall be coordinated by the
DHEH of the MoH, in concordance with other stakeholders who
will participate in a range of activities - from implementation to
supervision.
6.1.3 There should be a designated individual and/or waste
management committee responsible for HCWM plan
implementation.
6.1.4 The HCWM plan shall contain:
a) Duties and responsibilities for each of management level and
different categories of HCF staff members.
b) An estimation of the quantities of HCW generated and the
annual needs for the implementation of the HCWM
procedures/plan.
c) A manual describing all the procedures for the management of
HCW in the premises with special explanation for those HCWs
requiring specific management.
d) Monitoring procedure to track and a day-to-day activities
inside the HCF and ensure that HCWM rules are respected.

e) Information on procedures, display and location of HCF staffs,
receptacles, storage at strategic points.
f) Training courses and programmes for all categories of HCF
staff members.
g) A plan for storage and disposal of hazardous HCW in cases of
emergency in the events of a breakdown of the incinerators or
autoclave, and emergency procedures.
6.2 Guidelines for duties and responsibilities:
6.2.1 HCWM in HFs shall involve clarifying who is responsible for
what functions and identifying the fields of competencies of
each actor involved in this process.
6.2.2 The following guidelines should be included in Duties and
Responsibilities at National level:
a) The Federal MoH, Department Hygiene and Environmental
Health (DHEH), shall take the lead in coordinating
implementation of the HCWM plan.
b) The Federal government, DHEH, shall ensure that Regional
Health Bureaus (RHB) prepare and implement a proper
HCWM plan.
c) The DHEH shall support the RHB in the definition and the
implementation of the HCWM plan by providing technical
advice.
d) The DHEH shall set up periodic training programmes review
in all the training institutions to ensure that adequate
training on HCWM is given.

e) The DHEH shall be responsible give supportive supervision
on HCWM activities at all levels and Federal EPA at local
landfills to ensure that treatment and disposal facilities
comply with guidance and regulations.
f) The DHEH and Federal EPA shall watch over the means of
collection, transportation, destruction and disposal of the
wastes.
g) The Federal MoH, Health Extension and Education
Department, shall play a role with activities of public
information and awareness raising on HCWM.
h) EPA shall watch over the respect of environmental norms
and procedures, particularly as they are contained in the
Environmental Impact Assessment guidelines for hazardous
wastes and health-care wastes.
i) EPA shall be responsible for developing norms and
standards for soil, water and air protection, mainly as they
relate to the use of landfill sites for HCW disposal. In these
conditions, the EPA should develop norms and standards for
landfills so that they could receive HCW in a safe manner.
Responsibilities at regional/district level:
6.2.3.1 The local (regional/district) governments shall:
a) Design their landfills according to the norms and standards
defined by Federal EPA, in order to avoid soil, water and air
pollution in case of reception of HCW.
b) Ensure that safe disposal of HCW accomplishment by
reserving specific areas.

c) Enact regulations to refuse receiving mixed HCW with non
infectious wastes at local landfills; forbid uncontrolled HCW
disposal; and set up strong waste management controls in
their landfills (materials for covering, restriction for non
authorized public access, equipment protection, etc.)
6.2.3.2 The Regional/District health and environmental
bureaus/offices shall:
a) Need to put in place arrangements to make sure that HCW
are not mixed with general wastes in their public landfills.
b) Give their opinion about the HCWM plan activities proposed
for health facilities in their jurisdiction, in case some may
have negative impacts on the local population's health.
c) Ensure that coordination of the monitoring and reporting on
implementation of the HCWM should be exercised by the
HCWM Committee.
d) Prepare and implement a proper HCWM plan.
e) Support the HCFs in the definition and the implementation
of the HCWM plan by providing technical advice.
f) Set up periodic training programmes in all the HCfs to
ensure that adequate training on HCWM is given to their
staffs.
Responsibilities at health facility level:
1. The medical director of the health facility shall:
a) Be responsible for HCWM plan in his/her HF.

b) Ensure that a HCWM plan is prepared and then watch to
ensure that procedures and regulations are respected.
c) Designate a committee in charge with supervising HCW
segregation, storage, collection, transportation, treatment
and disposal.
d) Assign duties and responsibilities to all medical and non-
medical staff.
e) Allocate sufficient financial and manpower resources for
the implementation of HCWM plan.
f) Ensure adequate training and refresher courses for the
concerned hospital staff members.
2. The HCWM committees shall:
a) Make important contributions by identifying safety and
health problems and by educating the workforce about
safety and health issues.
b) Get a full support and commitment of the hospital
administration to have a strong and effective HCWM in the
HCFs.
c) Be a committee with no informal tasks for the members but
a regular part of their job responsibilities.
d) Represent workers and supervisors from all departments in
the HCFs.
e) Comprise the following members:
i) Medical director or Deputy, who shall be the chairperson.
ii) The Head of administration
iii) The Head of units/nurses
iv) The Matron
v) The HCWM officer/expert
vi) The Head of operation and maintenance

vii) The Head of pharmacy
f) Include the following major functions:
i) Inspecting workplaces regularly to identify safety and
health hazards and infections
ii) Regularly reviewing needle injury rates and results from
prevention activities, and other relevant workplace data
iii) Preparing information for workers on identified hazards
and infections
iv) Organizing educational classes
v) Reviewing safety and health aspects when planning new
construction or renovating facilities
vi) Establishing motivational programs (e.g. recognition,
awards, and dinners) to stimulate worker participation
in HCWM activities.
3. The HCWM officer/expert shall:
a) Be responsible for the daily implementation and monitoring
of the HCWM plan.
b) Ensure internal collection of bags and waste containers and
their transport to the central storage facility of the HF on a
daily basis.
c) Liaise with the medical and supply units to ensure that an
adequate supply of waste bags, containers, protective
clothing and collection trolleys are available at all level.
d) Ensure that cleaners and sweepers immediately replace used
bags/containers with a new bag/ container of the same type
and where a waste bin is removed from one container, that
the container is properly cleaned before a new bag is fitted
in.

e) Ensure that cleaners and sweepers are not involved in waste
segregation and that they only handle waste bags and
containers, in the correct manners.
f) Ensure correct use of the central storage facility and that it
is kept secured from unauthorised access. He should also
prevent unsupervised dumping of waste nags and waste
containers on the hospital premises, even for short periods of
time
g) Coordinate and monitor all disposal operations, and for this
purpose meet regularly with the concerned representative of
the local council.
h) Ensure that the correct methods of transportation and
disposal of waste are used.
i) Ensure the emergency procedures exist and can be taken.
He shall investigate record and review all incidents reported
regarding hospital waste management.
4. The Heads of administration shall:
a) Ensure that all the logistics and human resources needs are
adequately fulfilled to implement the HCWM plan.
b) Ensure that a proper budget to the implementation of the
HCWM plan.
c) Liaise with the medical director and the HCWM
officer/expert to estimate the specific costs and to request
the proper budget to the waste storage, treatment and
disposal facilities and health services.
5. The Matron shall:
a) Liaise with the medical director and HCWM committee.

b) Be responsible for the application of HCWM procedures by
the nursing and the cleaning staffs.
c) Be responsible for the recording and the reporting of all cuts
or puncture wounds associated with sharps and
manipulations such as needle stick injuries of medical and
non-medical staff members.
d) Ensure that the staff members know the immediate
disinfection measures to be taken during spilling
emergencies.
6. The Head of units/nurses shall:
a) Be responsible for the proper management of the HCW
generated in their respective units.
b) Head of units/nurses shall:
c) Ensure that al, the medical and ancillary staff working in
their unit respect the HCWM procedures.
d) Ensure that the HCWM procedures are clearly displayed at
strategic locations.
e) Liaise with the HCWM officer/ expert for effective monitoring
reporting of mistakes and errors in the implementation of
the HCWM plan.
7. The Head of operation and maintenance shall:
a) Liaise with the head administration and HCWM
officer/expert.
b) Be responsible for the application of HCWM procedures by
the maintenance staffs.

c) Be responsible for the recording and the reporting of all cuts
or puncture wounds associated with sharps and needle stick
injuries of maintenance staffs.
d) Ensure that the maintenance staff members know the
immediate reporting of all cuts or puncture wounds
associated with sharps and needle stick injuries.
e) Ensure that the maintenance staff members know the
immediate corrective maintenance measures to be taken
during spilling emergencies wastes from drainage lines.
f) Be responsible for the installation, maintenance and safe
operation of waste storage facilities as well as the waste
handling and treatment equipment.
g) Ensure that the concerned HF staff members are properly
trained for these purposes.
8. The Pharmacist shall:
a) Ensure that all logistics and pharmaceutical commodities
are stored properly to minimize wastage due mishandling.
b) Ensure that a proper records for logistics and
pharmaceutical commodities.
c) Ensure that the application of first-in first-out dispensary for
pharmaceutical commodities.
d) Liaise with the medical director and the HCWM
officer/expert to handle expired pharmaceutical commodities
and to request the proper method of handling and disposing
off.
6.3 Guidelines for allocation of resources and equipment for
health-care waste handling
6.3.1 Guidelines for waste audits and needs estimate

a) A waste management baseline audit and needs estimate
should be conducted before developing a waste management
plan of the HCF.
b) The following information HCW for waste audit should be
collected and assessed in accordance with the guidelines:
i) Types, volume and/or weight, quantities and composition
of waste generated;
ii) Incidence and severity of waste handling injuries;
iii) Incidence and nature of spills and leakages of hazardous
wastes;
iv) Sources of solid and liquid wastes;
v) Points of generation, collection and storage sites;
vi) Types and number of waste containers;
vii)Loading, transport and disposal methods;
viii) Transportation and disposal records;
ix) Costs of waste handling, transport, treatment and
disposal;
c) The number of safety boxes, yellow, black and red bags as well
as bag-holders, containers, collection trolleys and protective
clothing annually required for HCW handling shall be
estimated.
d) A contingency margin of 5% shall always be applied for safety
boxes, yellow, black and red bags.
e) The quantities of disinfectants, necessary spare parts for HCW
treatment and disposal shall be estimated.
f) The number of staff members required for HCW collection and
disposal.

6.3.2 Guidelines for selection of the technology for HCW
treatment/disposal
The technology for HCW treatment /disposal shall:
a) Be selected according to the types of HCW generated in the
HCF.
b) Be sized according to the quantities of HCW generated in the
HCF.
c) The operation and maintenance procedures shall be carefully
estimated and documented in the HCWM plan.
d) A contingency plan shall be included in the HCWM plan in
case of breakdown of the disposal/treatment facility.
6.3.3 Guidelines for allocation of resources and provision of
equipment
a) Equipment and materials (safety box, bags, disinfectant,
protective clothing) should be supplied regularly with out
any shortage in stock.
b) Health facility heads should promote material recovery for
reuse under supervision from national, regional and district
health offices.
c) Sufficient annual running costs shall be dedicated in the
budget for the safe management of the HCW.
6.4 Guidelines for Awareness and Training
Training and awareness efforts with regards to HCWM shall be made at
all levels:
6.4.1 To raise awareness amongst the public about HCW health risks
and safe practices.

6.4.2 To make sure that medical staff refresher training is given on
HCWM.
6.4.3 To make sure that the new staff member is familiarized with
HCWM of the HCF.
6.4.4 To ensure that of waste management is included in the
curricula of health-care personnel in the National training
package.
6.4.5 To ensure that waste management operators (transporters,
treatment plant and landfill operators…) get appropriate
training and support.
6.4.6 For public education on risks, waste segregation, or waste
disposal practices by using the following methods:
a) Displaying posters at strategic points in HCFs such as waste
bin locations, giving instructions on waste segregation. Posters
should be explicit, using diagrams and illustrations to convey
the message to as broad an audience as possible, including
illiterate people.
b) Conveying simple messages outside HCFs through schools,
radio or television programmes, raising awareness about the
risks involved in scavenging discarded syringes and
hypodermic needles, etc…
c) Applying attractive manner for all information displayed or
communicated to be at a maximum effectiveness in holding
people’s attention.
6.5 Guidelines for monitoring system and reporting procedures
for HCWM at all levels:

6.5.1 Monitoring system shall be set up to track hazardous HCW and
sharps along the waste stream until final disposal.
6.5.2 Monitoring should include incident and accident reporting and
recording.
6.5.3 Monitoring data should be analyzed and reviewed at regular
intervals and compared with the host country regulatory limits
so that any necessary corrective actions can be taken.
6.5.4 Records of monitoring results should be kept in an acceptable
format.
6.5.5 Periodic survey shall be performed in waste generators, storages
and transportation, treatment and disposal facilities.
6.5.6 All responsible bodies should submit annual HCWM
performance monitoring reports to their respective bodies.
6.5.7 The annual reports shall contain quantitative data of the
performance of the facility illustrating compliance with national
guidelines.
6.6 Guidelines for private sector involvement
6.6.1 All contracts with private contractors for collection, on-site or
off-site transportation, treatment or disposal of HCW shall be
approved by regional health and environment bureaus.
6.6.2 A private contractor shall be licensed for HCWM operation by
regional health bureaus for competency and regional
environment bureaus for operation.
6.6.3 The MoU with private contractor shall include duties and
responsibilities of ach party regarding HCWM procedures and
handling, transportation and final disposal of HCW.
6.6.4 All workers of the private enterprise dealing with HCW shall be
supplied adequate protection clothes and equipment.

REFERENCES
1. Federal Democratic Republic of Ethiopia, Ministry of Health. Health
Related Indicators, 1996 EC.
2. EPA (1986). EPA guide for infectious waste management.
Washington, DC: U.S. Environmental Protection Agency, Office of
Solid Waste.
3. Garner JS, Favero MS (1985). Guideline for handwashing and
hospital environmental control, Atlanta, GA: U.S. Department of
Health and Human Services, Public Health Service, Centers for
Disease Control, Center for Infectious Diseases, Hospital Infections
Program.
4. Federal Democratic republic of Ethiopia. Environmental Pollution
control. Federal Negarit Gazeta, 9th
year, Proclamation No 300/2002,
Addis Ababa 3rd
December 2002.
5. Hauri A, Armstrong G, Hutin Y. The Global burden of diseases from
contaminated injections given in health care settings. Presentation
at the 2001 meeting of the Infectious disease Society of America,
San Francisco, October 2001.
6. World health organization. Safe management of wastes from health-
care activities. Edited by Pruss A and Girout A, 1999.
7. Fikru Tesfaye. Assessment of injection safety at health facilities in
four pilot Weredas of Oromia Region and SNNPR. A report submitted
to JSI – Injection Safety Project. August 2004, Addis Ababa
(Unpublished).

8. World Health Organization. Management of Solid Health care Waste
at Primary Health centers: a decision making guide. WHO, Geneva,
2005.
9. WHO and the WB. Better health care waste management, an integral
component of health investment. WHO/WB, Amman 2005.
10. Environmental Health department, Ministry of Health of Ethiopia.
An assessment of the status of four Federal hospitals Infectious
waste management system and hygiene practice. July 2004, Addis
Ababa (Unpublished).
11. Federal Democratic Republic of Ethiopia, Ministry of Health.. Report
on the assessment of situations of water supply and sanitation
facilities in selected health centers and health stations. Hygiene and
Environmental Health Department, December 1997 (Unpublished).
12. JSI-making Medical Injections Safer Project. Assessment of injection
practices in Ethiopia: a case of six Woredas of Harari, Tigrai,
Amhara Regions and Dire Dawa Administration. January 2006
(Unpublished).
13. Federal Ministry of Health. AIDS in Ethiopia: 5th
report. Addis
Ababa, June 2004.
14. Federal Democratic Republic of Ethiopia, Ministry of Health. Making
medical injections safer, Ethiopia. Country strategic plans, 2005-
2009, Final draft. December 2004, Addis Ababa (Unpublished).
15. Yemane Berhane and Millogo, J. Report of injection safety survey in
Ethiopia. Geneva, Switzerland, 2000 (unpublished).
16. WHO. Preparation of national health care waste management plans
in Sub-Saharan Countries, Guidance manual. WHO, UNEP, Geneva
2005.
17. USAID. Treatment alternatives for medical waste disposal.
Programme for appropriate technology in health (PATH), October
2005.

18. JOHN SNOW INCORPORATED – MAKING MEDICAL INJECTIONS
SAFER, Assessment of Health Care Waste Management Status in
Health Facilities of Ethiopia, February 2006 (unpublished).
19. The World Bank, Final Report - National Health-Care Waste
Management Plan of the United Republic of Tanzania, March 2003.
20. Michael Reid, NSWHEALTH, Waste Management Guidelines for
Health Care Facilities – August 1998.
21. California Polytechnic State University, MEDICAL WASTE
MANAGEMENT PLAN, Risk Management, June, 1996
22. National Health and Medical Research Council, National Guidelines
for Waste Management in Health Industry, March 1999.
23. REPUBLIC OF MALAWI MINISTRY OF HEALTH AND POPULATION
In conjunction with UNICEF, WORLD BANK and WHO, HEALTH
CARE WASTE MANAGEMENT PLAN OF ACTION, May 2003.
24. Board of Public Works HTM Office, City of Los Angeles Fact Sheet:
Medical Waste Management, November 1995
25. Recommendations of CDC and the Healthcare Infection Control
Practices Advisory Committee (HICPAC), Guidelines for
Environmental Infection Control in Health-Care Facilities, May 2003
26. USEPA, Publication on Pollution Prevention for Selected Hospital
Waste Streams, Environmental and Social Guidelines for Health
Care Facilities, May, 2003

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