Disposing
Overall guidelines :
WHO's website on Healthcare Wastage Management
WHO's 25 Training Modules in Health-Care Waste Management
2014 USAID's Guide to Health Care Waste Management for the Community Health Worker
2014 WHO's Safe Management of Wastes from Health-Care Activities
Guidelines related to specific supplies :
2014 PATH's Planning for Safe Syringe Disposal
2013 UNFPA's Safe Disposal and Management of Unused, Unwanted Contraceptives
Note: Since some supplies have been in contact with blood, semen, and other body fluids, their waste should be classified as hazardous, potentially infectious. Detachable needles and syringes with needles are classified as dangerous sharps. They should be respectively collected in specific infectious/biohazard and safety containers.
Step 1. Selecting the adequate collection containers according to country and programmatic context
Note : See page sourcing supplies to source the adequate collection containers
a. Type of collection containers :
i. Carton boxes : Cheap, not bulky to transport and store (can be folded), puncture resistant, can contain a large quantity of supplies, adequate for harm reduction sites with large volume, easy to burn, minimal residual waste
Note : Sometimes need puncture resistant plastic bag to prevent leakage
ii. Large plastic containers : Expensive, bulky to transport and store, can contain a large quantity, puncture resistant, adequate for harm reduction sites with large waste, harder to burn, leave residual waste
iii. Individual plastic sharp containers : Expensive, bulky to transport and store, can only contain a small quantity of used supplies, puncture resistant, adequate for personal use, harder to burn, leave residual waste (some programs use empty shampoo bottles instead)
b. Type of collection containers and destruction methods according to supply types
Note : Different types of wastes require different methods of desinfection and then disposal.
i. Sharps potentially contaminated : Detachable needles or syringes with needle
Container : Puncture resistant plastic containers/safety box with leak proof plastic bag
Disposal method : Needle breaker, compaction, high temperature incineration, and eventually burial
Required sign on the container : Sharps, to be translated into country's language
ii. Potentially contaminated supplies : Syringes, filters, alcohol swabs, tourniquets, condoms.
Container : Infectious/biohazard containers with leak proof plastic bag
Disposal method : Compaction (and autoclave), high temperature incineration and eventually burial
Required sign on the container : Biohazard, infectious waste, to be translated into country's language
Note : To prevent scavenging and re-use, shredding/compaction would be needed if possible and not too costly.
iii. Other supplies : Filters, cookers, acidifier sachets, sterile water ampoules
Container : Non infectious containers with leak proof plastic bag
Disposal method : Compaction (and autoclave), high temperature incineration and eventually burial
Required sign on the container : non-infectious waste, to be translated into country's language
Note : To prevent scavenging and re-use, shredding/compaction would be needed if possible and not too costly.
iv. Pharmaceuticals : Ointments, naloxone
Container : Non infectious hazardous containers with leak proof plastic bag
Disposal method : Compaction, high temperature incineration and burial
Required sign : Chemical waste, to be translated into country's language
Note : To prevent scavenging and re-use, shredding/compaction would be needed if possible and not too costly.
v. Other waste : Wrapping plastic, etc.
Container : Normal
Disposal method : Normal waste
Step 2. Envisioning the supply chain of waste
Note : It is recommended to inquire about the country strategic plan and national guidelines for health waste and follow it.
a. On-site disposing
Adequate for large quantities and implementable if sites are equipped with compaction and incineration machines
Advantage : Not transportation, little cost
Inconvenient : Need investment in disposal equipment and adequate training ; not enough quantities to reach economies of scale ; perform risky operation such as incineration and burial ; sites should allocate a significant time to this non-core activity
b. Disposing to a near-by large health site (preferred option)
Adequate for small sites without waste disposal equipment
Advantage : No investment in equipment ; sites can allocate minimal time to this activity ; outsource incineration risk
Inconvenient : Need a budget to pay for the service (although it could sometimes be free of charge) ; need a transportation vehicle for drop-offs
c. Outsourcing waste collection and destruction to a private company (preferred option)
Adequate for small sites without waste disposal equipment
Advantage : No investment in equipment ; sites can allocate minimal time to this activity ; outsource incineration risk to an expert ; potentially large economies of scale ; standardization of the procedure
Inconvenient : Need a budget ; the service should be tendered and the supplier contracted ; the supplier must be compliant with the national regulation and international practice ; need monitoring and evaluation by the contracting service
Note : the company must be authorized for medical ; biohazard grade disposal
d. Collecting waste at the local level for destruction at the regional/central warehouse
Advantage : Minimal investment in equipment at the regional/central levels ; sites can allocate minimal time to this activity ; outsource risk to the regional/central level ; potentially large economies of scale ; take advantage of reverse transportation (trucks going back empty to the central/regional warehouse)
Inconvenient : Need a budget ; regional/central warehouses should have adequate equipment and trained staff
Note : It is sometimes beneficial to collect used supplies from local sites so that their number can be monitored, their content can be tested in laboratory (especially syringes)
e. Returning to supplier
Not always possible
Advantage : No investment in equipment ; minimal time allocated to this activity ; outsource risk
Inconvenient : Need a budget
Step 3 Option : Outsourcing waste collection and/or destruction
a. Estimate the main parameters
i. Locate and quantify the number of sites wastes will be collected from.
ii.Quantify the approximate number of containers (sharps, infectious biohazard, and non infectious supplies) and their volume in cubic meters or feet. Don’t forget any scale-up or scale down in service and number of sites.
Note : See 2014 PATH's Planning for Safe Syringe Disposal p. 19
Approximate Capacity of Safety Boxes 5 litres 10 litres
Number of syringes with needles 100 200
Number of syringes without needles 235 470
Weight, syringes with needles 0.5 kg 1.0 kg
Weight, syringes without needles 1 kg 2 kg
iii. Decide for a frequency (monthly or quarterly) depending on the volume stored and sites’ waste storing area's usable size. Larger sites can be serviced more frequently than smaller sites.
iv. Decide for a contract duration. If it is the initial contract, a 1 year contract with 1 additional year optional (if specific Key Performance Indicators are met such as effectiveness, price, ease to handle contract, reactivity, overall satisfaction, etc.)
b. Try to estimate the overall cost with market information and check if total cost does not exceed the available budget
c. Draft the tender according to the agency’s procurement guidelines including
i. The above parameters
ii. Clear specification that each waste type should be disposed according to national and international guidelines with reference to above documents
iii. Segregated transportation vehicles that maintain the containers dry, stack upright, loaded with their handles, without direct contact with medicines and other health supplies, are cleaned with detergent after each trip.
iv. Specific provision to prevent scavenging and re-sell by shredding/compacting (especially for expired products and unused condoms)
d. Post the tender, evaluate bids, award and contract with the supplier.
Step 4. Collecting waste and discarded needles
a. At PWUD's home or injecting places (best)
Supplies needed : Small safety containers for a small volume (also possible with empty shampoo bottles)
Advantage : Educational ; promote best practice and self safety ; easier for outreach/peer worker to pick-up during visit ; foster PWUD to drop off needle exchange sites.
b. At the needle exchange sites (mandatory)
Supplies needed : Large safety containers for large volume
c. During outreach/peer or van distribution
Supplies needed : Backpack, small or medium sized safety container.
Advantage : Makes possible one-to-one education ; enable dialogue about rate of reusage ; totally discreet ; little effort and risk for PWUD ; help monitoring returns.
Inconvenient : Outreach/peer workers can risk detention for carrying used equipment.
Note : Outreach/peer worker can also empty fixed collection boxes ; in some context, outreach/peer workers can be detained for possession of used equipment.
d. Picking on grounds of shooting sites with needle hunters
Supplies needed : Safety containers, gloves, tongs, pliers or tweezers
Advantage : Can involve neighbours and community members and enhance goodwill and support ; help to see which kind of supplies are usually consummed.
Inconvenient : Need a team of pickers and adequate equipment ; is not very educational ; foster complains from community members and neighours for safety concerns ; cannot monitor returns.
e. Via kit vending machines
Supplies needed : None
Advantage : PWUD can be access 24h/7d ; it is rather discreet ; minimize trips ; educational and somewhat teaches to return used equipment (1 for 1).
Inconvenient : Vending machines need to be built to collect used equipment, can be rapidely full and need to be emptied on a regular basis.
Note : The "honey pot" effect that might attract law enforcement near the site of collection and have an adverse impact.
f. Fixed drop/collection bins
Supplies needed : Non-openable safety bins.
Advantage : PWUD can be access 24h/7d ; it is rather discreet ; It can limit discarded needles on the ground and promote safety for neighbours ; only PWUD can know where collection boxes are located.
Inconvenient : Fixed collection boxes need to be emptied on a regular basis.
Note : The "honey pot" effect that might attract law enforcement near the site of collection and have an adverse impact.
For more details : What to do with used needles, city of Ottawa, Canada
g. At pharmacies
Supplies needed : None
Advantage : Managed by professionals ; involve pharmacies in harm reduction.
Inconvenient : Not open 24h/7d ; PWUD might face discrimination and stigma ; pharmacies might be reluctant to provide this service.
Step 5. Managing waste
Note : Some kit vending machines can collect back kits with used equipment (association SAFE in France).
a. Write sites’ guidelines and Standard Operating Procedures for waste management that are aligned with the national guidelines with reference to the above documents and the above setting of the supply chain for waste
b. Train all sites’ staff
c. On a daily basis, segregate waste with the adequate container for
i. Sharps
ii. Infectious biohazard supplies
iii. Non infectious biohazard supplies
Ensure wastes are minimized by disassembling components (when possible)
Note : Consider using a mechanical needle remover to minimize waste. See 2014 PATH's Planning for Safe Syringe Disposal p. 8
d. Always use gloves, tongs, pliers or tweezers when picking up and handling detachable needles and syringes with needles.
e. Never overfill safety boxes more than ¾.
f. Always close all containers and describe the contents on the label.
g. Make sure good labels are used on the containers and on the waste storage area.
h. Store safety boxes, infectious and non infectious biohazard waste containers in a segregated and locked place clearly indicated “Caution: Infectious Waste Storage Area. Unauthorized Persons Keep Out.” This place should be safe, secure, dry place, out of the reach of children and stray animals such as a locked closet or room.
i. Store until the date for collection/picks-up or drop-offs.
j. In case of transportation, segregated transportation vehicles should be used, containers should be dry (covered trunk), stack upright, loaded with their handles, without direct contact with medicines and other health supplies. Trunks are cleaned with detergent after each trip.
k. If not outsourced, treat, incinerate, and burry the waste.
Note : see 2014 USAID's Guide to Health Care Waste Management for the Community Health Worker
Step 6. Monitoring and evaluating
a. Monitor the number of containers for each site for annual Key Performance Indicators
Note : This number might help to improve the parameters for the next tender of waste management service.
Indicators linked to needles retrieved per month/quarter/year :
- Drop Boxes
- PWUD Waste Depots
- Needles/crack pipes retrieved by City staff
- Needles/crack pipes picked up by Needle Hunters
- Needle Exchange Programs & partner agencies
- Total
b. Think about analysing syringes’ content for information about blood borne disease and type of drug used. This information can inform changing trends and support changes in harm reduction strategies.