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search-article2015
WMR0010.1177/0734242X14565209Waste Management & ResearchToktobaev et al.
Original Article
An innovative national health care waste management system in Kyrgyzstan
Waste Management & Research 2015, Vol. 33(2) 130–138 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0734242X14565209 wmr.sagepub.com
Nurjan Toktobaev1, Jorge Emmanuel2, Gulmira Djumalieva3, Alexei Kravtsov3 and Tobias Schüth1
Abstract A novel low-cost health care waste management system was implemented in all rural hospitals in Kyrgyzstan. The components of the Kyrgyz model include mechanical needle removers, segregation using autoclavable containers, safe transport and storage, autoclave treatment, documentation, recycling of sterilized plastic and metal parts, cement pits for anatomical waste, composting of garden wastes, training, equipment maintenance, and management by safety and quality committees. The gravity-displacement autoclaves were fitted with filters to remove pathogens from the air exhaust. Operating parameters for the autoclaves were determined by thermal and biological tests. A hospital survey showed an average 33% annual cost savings compared to previous costs for waste management. All general hospitals with >25 beds except in the capital Bishkek use the new system, corresponding to 67.3% of all hospital beds. The investment amounted to US$0.61 per capita covered. Acceptance of the new system by the staff, cost savings, revenues from recycled materials, documented improvements in occupational safety, capacity building, and institutionalization enhance the sustainability of the Kyrgyz health care waste management system. Keywords Hospital/medical waste, autoclave treatment, recycling, cost survey, sustainable healthcare waste management, Kyrgyzstan
Introduction In 2011, a report of the United Nations Special Rapporteur to the Human Rights Council of the UN General Assembly raised concern that improper management and disposal of medical waste, including the use of open burning and most small-scale incinerators, jeopardize the enjoyment of human rights (United Nations General Assembly, 2011). A few years earlier, a systematic review of health care waste management (HCWM) in 40 lowand middle-income countries found that HCWM is a serious public health challenge due to the increasing quantities of waste, improper disposal methods, lack of training, insufficient financing and infrastructure, and weak governance and administration, among others (Harhay et al., 2009). The researchers proposed focusing on alternatives for syringe waste, tools for reducing total volume, and an affordable treatment and disposal method. Kyrgyzstan, one of poorest countries of the former Soviet Union, was typical of the countries described by the UN Special Rapporteur until a few years ago. With independence in 1991, it inherited a poorly maintained medical infrastructure that also lacked proper waste management systems. This paper discusses the innovative system of HCWM that was implemented in the framework of a bilateral cooperation project throughout most of the country and that addresses the three focus areas suggested by Harhay et al. Before the new HCWM system, hospital staff had to disinfect infectious waste in hypochlorite solution. The nursing staff often
complained of exposures to hypochlorite. The lack of funds to purchase hypochlorite forced many hospitals to dispose of health care waste by open burning on the hospital premises or dumping on the hospital grounds without treatment. Health workers and neighboring residents frequently complained of the smoke. Anatomical waste was often dumped on the ground or put into overflowing cemented pits or containers. Lack of resources prevented hospitals from transporting the waste to municipal landfills resulting in considerable piles of waste scattered beyond the designated areas. In 2003, a national assessment of unintentional releases of polychlorinated dibenzo-dioxins and furans had estimated total releases to be 30.5 g TEQ, of which 14.37 g TEQ (47.11%) were
1Health
Care Waste Management Project, financed by the Swiss Agency for Development and Cooperation (SDC) and implemented by the Swiss Red Cross, Bishkek, Kyrgyz Republic 2E & ER Group, Hercules, CA, USA 3Republican Centre for Infection Control, Ministry of Health of the Kyrgyz Republic, Bishkek, Kyrgyzstan Corresponding author: Nurjan Toktobaev, Health Care Waste Management Project, financed by the Swiss Agency for Development and Cooperation (SDC) and implemented by the Swiss Red Cross, 187/1 Sydykova Street, Bishkek, Kyrgyz Republic. Email: [email protected]
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Toktobaev et al. in air, 10.87 g TEQ (35.63%) in water, and 0.16 g TEQ (0.52%) in soil (State Agency for Protection of the Environment and Forestry, 2006). Despite a high degree of uncertainty in the calculations, the preliminary inventory of unintentional releases into the air indicated that the majority were from burning medical waste (7.01 g TEQ). Kyrgyzstan ratified the Stockholm Convention on Persistent Organic Pollutants in 2005 thereby committing to the reduction and ultimate elimination, where feasible, of releases of dioxins and furans. The objective of the project was to develop and implement a HCWM system that was appropriate for rural hospitals in Kyrgyzstan. It was important that the HCWM system reduced the potential for disease transmission, enhanced the safety of health workers, protected the environment, and met the Stockholm Convention guidelines; special care was taken to develop a system with low investment and operating costs that therefore could be replicated throughout the country and sustained by facilities without further support.
Segregation of infectious waste All other infectious wastes are collected in 12-liter buckets (1.5 kg net weight) with double enamel coating. They are marked on the top and sides with the international biohazard symbol, type of waste, hospital department, and a number to keep track of each container. Regular (non-infectious) waste is placed in bins with black plastic bags. Infectious waste buckets are located only in areas where infectious waste is generated and are placed sideby-side with non-infectious waste containers. Posters are found in such areas to remind the health workers of segregation practices.
Transport of infectious waste Each bucket is covered by an enamel-coated metal lid that is held in place during transport using two standard metal binder clips. Since the buckets are labelled, have handles and lids for easy transport by hand within the facility, and are placed directly in the autoclave, the need for color-coded plastic bags is eliminated thereby significantly reducing operating costs.
Materials and methods The model was developed in 2005; its final version is described below. It was pilot tested in five facilities of the rural Naryn region in 2006. Thereafter, the model was included in the medical waste strategy of Kyrgyzstan and informed several national guidelines regarding medical waste management. In the following years, the model was further improved and expanded throughout the country. As of the end of 2013 it functions in 232 facilities, including all general treatment hospitals with 25 beds or more and all urban primary health care centers and other ambulatory services. Not covered yet are all facilities of the capital Bishkek and primary care services in villages. An external evaluation was conducted in September–October 2013. The main components of the Kyrgyz HCWM system are described next.
Syringes and needles Needles and syringes are cut and destroyed immediately after use by means of a mechanical needle remover (manufactured by BMDi Pty Ltd, India). Cutting the hub of the syringe and breaking the needle renders both unusable. The broken needle falls into a plastic container. Other sharp wastes are also collected in this container of the needle remover. When 3/4 full, a plastic lid is screwed on the needle container. The syringes are collected in a 10-liter enamel-coated metal bucket designated exclusively for syringes. When these buckets are 3/4 full, they are transported to and placed directly in an autoclave for treatment. The enamel coating protects against corrosion in the autoclave. Autoclaved syringes are sold to plastic recycling firms. The autoclaved broken needles are sold to metal recyclers. The outside surfaces of the needle removers are wiped daily with a disinfectant (2% Tetramin). Once a week, they are dismantled, soaked in the disinfectant for 10 minutes, then oiled and reassembled.
Storage The needle containers, buckets with syringes, and buckets with other infectious waste are placed on shelves in a storage room which also houses the autoclave. The buckets are weighed before they are placed on the shelves to await treatment. The room is designed to keep contaminated and decontaminated areas separate. Policies and procedures are posted on the walls of the waste storage and treatment room. A record book keeps track of the buckets and the amounts of waste generated and serves as documentation of treatment. A typical room layout is shown in Figure 1.
Autoclaving The treatment method of the HCWM system is autoclaving. The autoclave used is a top-loading gravity-displacement autoclave (two nearly identical models from two producers: the VK-75 by Tumenski Factory and the Vka-75-Pz by Kasimovski Instrument Factory). This type of vertical autoclave is widely used for medical sterilization in countries of the former Soviet Union. The vertical chamber of 75 l volume can accommodate two 10 l enamel-coated metal buckets and is ideal for a 100-bed hospital, the size of the majority of hospitals in Kyrgyzstan. To avoid releases of pathogens into the environment with the displaced air during the initial introduction of steam, the exhaust of the autoclave chamber goes through a corrosion-resistant sintered metal filter (316L stainless steel, Mott Corporation, USA) that captures 99.9% of all particles larger than 0.2 µm in the gas stream passing through the filter surface at a gas flux of 2 m3/min per m2 of filter surface area (6 actual ft3/min per ft2). A steam flow meter (Armor-Flo meter, ERDCO Engineering Corporation, USA), calibrated to 134°C at 2 bar (gauge) and density of 2.935 kg/m3, with a range of 20–200 l/min of saturated steam, was used to measure the air/steam flow rate through the
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Figure 1. Typical layout of the storage and treatment room and photos of the autoclave.
filter in order to determine the appropriate filter size. The casing for the cartridges was made locally using standard galvanized steel tubes in order to reduce costs. The autoclaving procedure entails putting two buckets with infectious waste on top of each other in the vertical autoclave. The lids are carefully removed and placed beside each bucket. A triangle of wooden bars on top of the lower bucket creates space between the two buckets to allow the contents of the lower bucket to be fully exposed to steam. Color-changing (AAMI ST-60 Class 1) thermal indicators are placed on the bucket surface and after the treatment, the indicators are placed in the record book as documentation. Once a month, a steam integrator (AAMI ST-60 Class 5 indicator) is placed with the waste and recovered after treatment. The steam integrator serves as an affordable pass/fail test of the autoclaving process.
Anatomical waste Anatomical and placenta wastes are deposited in secure cement pits to decompose. Before transport, the top surface of the waste is sprinkled with calcium hypochlorite to minimize the potential release of pathogenic aerosols during transport and disposal. Every hospital has a 2 m x 6 m x 2 m deep pit divided into three compartments, each of which has about 5 m3 and a 1 m2 slab as a lid. One compartment is used until it is filled. The lids have hooks to allow the possibility of removing and emptying them in the future after the waste has fully decomposed. These pits are located inside the fenced waste collection area along with the trailer.
Garden wastes To minimize waste, hospitals use two compost pits for garden wastes. Each compost pit is 2 m x 2 m with a depth of between
1.5 and 2 m. Stems are placed in the bottom layer along with large sticks to create air pockets for aeration. The second layer has smaller items such as grass, leaves, and other plant waste. The third layer is soil mixed with manure, ash and about 5–10 kg of compost from the previous season. Water is added to keep the waste moist and speed up decomposition. At the end of the season, the pit is covered with 4-5 cm of soil and vertical holes are created with sticks to improve aeration. The other compost pit is used for the following season. The compost area is surrounded by a wire fence.
Final disposal After treatment, autoclaved needles are collected in large metal drums while autoclaved plastic syringes are collected in large sacks or containers until sold to recyclers. Other disinfected wastes are mixed with non-infectious waste in plastic bags and stored on a trailer in the fenced area. When full, the trailer is pulled by a hospital vehicle to the dump site where the waste is discarded until such time that a sanitary landfill is constructed by the municipality. The compost from the compost pits is used as fertilizer and soil conditioner by the hospital. The overall schematic of the HCWM system is shown in Figure 2. Classes A, B1, B2, and B3 refer to the classification system used in the Kyrgyz Republic.
Training and equipment maintenance Awareness-raising workshops with all stakeholders and 1-day trainings of all hospital staff accompanied the installation of the equipment. Two autoclave operators per hospital received special training for 1 day on the operation of the autoclave, including basic maintenance. Every 2 years, the autoclaves are examined
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Figure 2. Schematic of the health care waste management system.
by licensed technicians who test and repair the parts crucial for pressure safety.
Testing the autoclaving cycle Stolze and Kühling (2009) as well as Stringer et al. (2010) have demonstrated that by using pressure pulses a gravity-displacement autoclave can safely disinfect medical waste. The disinfection of waste in both models of the gravity-displacement autoclaves was tested using thermocouples and biological indicators. Two buckets containing typical waste material were prepared for each test. The top bucket was filled only with syringes (as is done in hospitals for later recycling). The bottom bucket was filled with other typical waste material (intravenous sets, cotton swabs, bandages, gloves, etc.). Four thermocouples (TC Direct, UK; Type T, mineral insulated with pot seal, stainless steel sheath, 1.5 mm diameter, 2000 mm length) were used. A tee was added to the pipe from the autoclave chamber to the pressure gauge and one end of the tee was used for the thermocouple wires. Data were recorded with a mobile four-channel data logger (Yu Ching Technology Co., Ltd, Taiwan; Model YC-747UD, accuracy: ±0.1% of reading +0.7 °C). The biological indicators used were Geobacillus stearothermophilus spore strips (Raven Labs/Mesa Laboratories, USA) with a 104 population (D121 value of 1.6 min, D132.2 value of 0.08 min) and a 105 population (D121 value of 1.5 min, D132 value of 0.45 min). Self-contained biological indicators of 105 G. stearothermophilus spores in ampoules (ATCC 7953; D121 value of 1.5 min, D132 value of 0.45 min; ProTest, Raven Labs/Mesa Laboratories, USA) and 106 G. stearothermophilus spores on paper discs (D121 value of 1.6min,
ProLine Process Challenge Device, Raven Labs/Mesa Laboratories, USA) were also used. The thermocouples and biological indicators were placed at different levels in the waste of the two buckets. For the top bucket, the 104 and 105 spore strips and the 105 ampoules were placed inside syringes. This was done by removing the syringe plungers, inserting the biological indicators, and then putting the plungers back in place. The syringes with spore strips and the thermocouples were placed in the upper third and at the bottom of the waste load of the top bucket. Spores and thermocouples were placed in the upper and lower third of the waste load of the bottom bucket. Although it was not necessary, disinfection was also demonstrated inside intravenous tubing using 106 spore discs in process challenge devices placed in the middle of cut tubing. Figure 3 show the placement of spores and thermocouples during the tests. A total of 34 challenge tests were performed using a total of 340 biological indicators. All of these tests were done with the following cycle: pressure build up in the chamber up to 150 kPa followed by flushing of air, then two pressure pulses of 220 kPa and finally holding a pressure of 220 kPa for 10 minutes. All spore strips were incubated using tryptic soy broth with bromocresol purple indicator (Mesa Lab, USA). Incubation time was 24 hours at 60°C. With each test, spore strips were set aside and not exposed to autoclaving in order to serve as controls. Three additional tests were performed to determine if pathogens could be released during the initial flushing of air and steam. Spore strips with 104 population were placed in a Petri dish right above the exhaust port at the bottom of the autoclave chamber. Steam was introduced into the chamber until a pressure of 220
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Figure 3. Test set-up for the autoclaving cycle.
kPa was reached. After five minutes, the air-steam mixture was flushed out. The spore strips were then recovered and incubated. Also, in addition to the 34 test cycles described above, 2 cycles with 12 biological indicators (6 Log4 spore strips and 6 Log5 spore ampoules at the same locations as above) were done with this changed procedure before flushing (220 kPa held for 5 minutes before flushing, followed, as before, by two pulses of 220 kPa and 10 minutes holding at 220 kPa).
Results and Discussion Biological testing None of the 340 spore strips/containers exhibited any growth, nor did the additional 12 spore strips/containers exposed in the cycles with the adapted pre-flushing procedure; all control spore strips showed growth. Since some of the biological indicators exhibited a 5 Log and 6 Log reduction, the microbial inactivation efficacy was 10–100 times higher than the minimum requirement of 4 Log (STAATT, 1998, 2005). Based on the test results, the final autoclaving cycle is as follows. After the two buckets of waste are put in the autoclave and the lid closed, steam is introduced while keeping the exhaust steam line closed until a pressure of 220 kPa is reached. The pressure is held for 5 minutes after which the exhaust steam line is opened and the air–steam mixture released through the sintered metal filter. The autoclave pressure is again increased to 220 kPa, the steam is released, and then the pressure pulsing is repeated a third time. On the fourth time, the pressure is maintained at 220 kPa (about 132ºC) for 10 minutes and then steam is released. Figure 4 shows the temperature-pressure curve of a typical autoclaving cycle.
The process has two features that ensure that pathogens are not released during the initial flushing of air. One feature is based on tests by the UNDP GEF Project in Tanzania (Emmanuel, 2014). They inoculated paper with 105 G. stearothermophilus spores and placed it right above the exhaust port inside the autoclave. Steam was let into the chamber to a pressure of 170 kPa gauge before the steam–air mixture was released into a flask partially filled with water. When samples of the condensate were placed on trypticase soy agar plates, no G. stearothermophilus grew after 24 and 48 hours incubation. The spore strips with 104 population that were placed above the exhaust pipe showed no growth in three tests suggesting disinfection of the air. Informed by the Tanzania and Kyrgyz test results, the final Kyrgyz autoclave cycle involves an initial pressure of 220 kPa held for 5 minutes before the steam–air mixture is released. In addition, the exhaust steam line is fitted with the sintered metal filter. As the performance of the filter (99.9% capture of particles >0.2 µm) was specified for a maximum gas flow rate per square foot, various filter sizes were tested to ensure that the flow rate during flushing did not exceed the specified flow rate. A filter cartridge of 500 mm length and 63 mm diameter was found to have sufficient surface area to keep the gas flow rate during flushing below the maximum. Subsequent releases of steam during the autoclaving cycle decontaminate the filter.
Equipment maintenance and reliability The selection of the VK-75 autoclave was beneficial since it was already well-known in many hospitals for use in the sterilization of medical and surgical instruments. Many local maintenance technicians are familiar with the equipment and spare parts are readily available from local vendors. Maintenance of the autoclaves
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Figure 4. Temperature–pressure–time curves of the autoclave cycle.
involves monthly cleaning especially of the heating elements, lubrication of valves, blow down of the boiler, and checking and cleaning of gaskets. The most commonly needed spare parts are the lid gaskets, which last 3–6 months depending on use. During the pilot testing phase, refurbished autoclaves were installed, the oldest of which is 30 years old (from 1984) and still serving. However, two refurbished autoclaves had to be replaced with new ones since the testing phase. The needle removers have proven durable and reliable thus far. Since the start of the project, 3680 needle remover were installed. The hospital with the longest experience with these removers (7 years) replaced only 4 out of its 180 needle removers. This amounts to a 2% replacement rate over 7 years. The most common problems are breakage of the handle and stripping of the screw holding the cutting block. Procuring spare parts separately, in particular the cutting drum that was designed for 100,000 cuts, minimizes the need to replace the whole device. The sintered metal filters lead to formation of condensate in the hose between the autoclave and the filter; it is let out after each cycle through a tap at the bottom near the autoclave. To prevent condensate accumulating in the hose from the filter, the filter cartridge is mounted high on the wall to allow condensate to drip down to the outside of the building, generally on to a flower garden or open ground. The filters have no defined end of life. Over time the duration of one pulse increases as matter collects in the filter wall. They are therefore cleaned once a month with eight pressure pulses under reversed steam flow while running the autoclave without waste; this reduces the time for the pulses back to the baseline level and keeps the overall cycle length short.
Disposal of anatomical waste The current practice of adding calcium hypochlorite to anatomical waste as prescribed by the old guidelines is not optimal as it inhibits decomposition. Efforts are underway to change the
guidelines in order to allow the use of lime or adding no disinfection at all. It is not yet known how long the pits will take to fill up and how much time will be needed to breakdown the waste especially given the cold winters a few months of the year. At each of the hospitals that have used the pits the longest (7 years), the first of the three pits has not yet filled up. The minimum time for all three pits to fill up has been estimated at 20 years. That may be ample time for decomposition even with the cold seasons if calcium hypochlorite is not added in the future.
Extent of coverage By end of 2013, 126 hospitals were transformed through the implementation of the new system. This includes all general treatment hospitals in the country with more than 25 beds except for those in the capital city of Bishkek. The covered hospitals account for 67.3% of all hospital beds in the country. Also covered are all 45 primary care centers in towns (again except in Bishkek), as well as 32 other facilities (dental clinics, blood centers, etc.). In addition, 29 private ambulatory clinics have made arrangements with the covered hospitals to use the autoclave system for their waste treatment on a fee basis.
Costs of the HCWM system The average investment costs amounted to US$16,156 per hospital for a typical 100-bed general hospital (with surgery, gynecology/obstetrics, medicine and pediatric departments). For bigger hospitals of about 500 beds, the costs amounted to US$74,949. Table 1 gives the breakdown of these costs. The prorated investment cost is about US$0.61 per capita. Where transport costs are not an issue, a trailer need not be provided and the investment costs would be even less (US$13,776 for a 100-bed hospital). Autoclave treatment cost about US$0.59/ kg of infectious waste, consisting of labor, electricity, and bags for treated waste.
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Table 1. Costs by component of the HCWM model installation for hospitals with 100 and 500 beds. Components of the HCWM model
Price per unit (US$)
Quantity per 100-bed hospital
Mechanical needle remover Enamel-coated metal buckets Autoclaves (purchase, transport, installation, site preparation) Set of spare parts for the autoclaves Trailers for hauling regular and treated waste Weighing scale Fenced enclosure with metal roof for the trailer and waste collection area plus 3 cement pits for anatomical waste Personal protection equipment and other protective measures (coveralls, gloves, glasses, warning signs, paint, etc.) Training Total
35 10 5000 840 2380 24 5800
20 80 1 1 1 1 1
58
1
US$ per 100-bed hospital
Quantity per 500-bed hospital
US$ per 500-bed hospital
692 792 5000 840 2380 24 5800
65 260 3 3 2 3 2
2249 2574 15,000 2520 4760 72 11,600
58
3
174
570 16,156
3600 42,549
Table 2. Yearly HCWM expenses and income for Naryn Oblast Merged Hospital before and after the implementation of the new HCWM system. Annual expenses Items
Disinfectants Sharps safety boxes Waste removal fee Plastic bags for Class A waste Plastic bags for autoclaved waste Electricity Total
2005 (before)
2012 (after)
Units
US$
Units
US$
446 kg 816 boxes 416 tonnes 0 0 0 1933
1175 330 425 0 0 0
227 0 90 9125 1715 8694 kWh 1174
204 0 257 372 70 271
Annual income Items
2005 (before) Units
Sale of plastics Sale of metals Total
0 0 0
The operating costs of the HCWM system are lower on average than what the hospitals had been paying under the old system of hypochlorite treatment and/or burning. A survey of 30 hospitals showed an average annual cost savings of US$1040 or 33% savings compared with their previous costs for waste management. Those hospitals that had used chlorine disinfection in the past had the highest cost savings, those hospitals that had burned their waste (in violation of existing regulations) had little or no savings, while a few hospitals increased their expenditures. Table 2 presents an example of the costs before and after installation of the new HCWM system for a secondary-level hospital with about 500 beds. It shows that the cost savings were mainly due to reduced expenditures on chlorine disinfectant and lower waste transport costs due to composting and the trailer provided (transport costs decreased less than expected because of increased petrol prices and because the landfill began to charge fees). Revenues are generated from the sale of the sterilized
Current US$ 0 0
Units
US$
2300 kg 140 kg 595
563 31
plastic and metal parts to recyclers. On average, the HCWM costs accounted for 0.68% of the operating budgets of the hospitals.
Evaluation and staff acceptance of the new HCWM system An independent evaluation was conducted in September–October 2013 (Emmanuel, 2013) that entailed an assessment using a slightly modified version of the UNDP–GEF–WHO individualized rapid assessment tool (I-RAT). The I-RAT is an Excel-based scoring tool. Its weighted scoring system takes into account, among others, HCWM organization, policy and planning, training, occupational health and safety, monitoring, periodic evaluation and corrective action, financing, segregation, waste generation, collection, handling, labeling, posters or signage, transport inside the facility, storage, treatment, waste disposal,
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Figure 5. Needle-stick injuries and cuts documented in Naryn Oblast Merged Hospital.
and wastewater management. Six Kyrgyz hospitals covered by the evaluation had an average of 95 points (out of a maximum of 100), indicating that almost all of the aforementioned topics in the I-RAT tool had been properly addressed. Hospital directors, waste workers, autoclave operators, nurses, doctors, and other hospital staff were interviewed during the evaluation. A high level of satisfaction with the new HCWM system was found. The nursing staff consistently pointed out that the new system eliminated the time they had to spend preparing multiple hypochlorite solutions for disinfecting the waste.They also commented on the marked decrease in their exposure to hypochlorite and many felt that the use of the needle removers reduced needlestick injuries and cuts. Data from one hospital from 2005 to 2013 gave a preliminary indication of this (Figure 5). After the needle removers were introduced in 2006, there was first an increase in injury data but the hospital felt that this was due to improved documentation coupled with a shift in approach from a punitive system to one of safety improvement. Later, needle-stick injuries and cuts declined significantly. During interviews, hospital directors were especially pleased with the cost savings. Being in full compliance with state regulations was another benefit mentioned especially by hospital directors that in the past had to pay penalties for burning waste in violation of the law. Many also commented on the fact that hospital premises no longer had waste piles scattered about and that they no longer had to deal with complaints from neighbors about smoke and odors from the burning of waste.
Organization As part of the new system, each hospital created a Safety and Quality Committee that managed HCWM and related activities in the facility. The committee periodically reviews HCWM procedures, develops the budget, monitors activities, and implements training workshops. The infection control specialist and
epidemiology specialist function as HCWM advocates within the hospital. During interviews, they reported a change in the mindset of health workers and a greater appreciation of the hazards of health care waste and the importance of HCWM among the staff.
Sustainability Hospitals have been sustaining the HCWM system without further financial and technical support from the project. The first five hospitals that were the early adopters and participants of the project have successfully maintained their systems on their own for the last 7 years. The broad acceptance of the new system by the hospital staff and directors, the cost savings, improved safety for the workers, and a decreased burden on the nursing staff are important benefits that enhance the sustainability of the new system. The lessons learned from the project are being used to extend coverage to the urban hospitals in Bishkek in the near future.
Conclusions Key elements for the successful transformation of HCWM in Kyrgyzstan included an initial analysis of the problem, finding innovative solutions with stakeholder participation, pilot testing and demonstrations at a few hospitals to evaluate and refine the new system, a well-planned phased implementation, development of national regulations to support the implementation, and continuous monitoring and improvement. As a result, the new system serves 67.3% of all hospital beds in Kyrgyzstan as of end of 2013. The new HCWM system has all the major components of a good system: waste minimization (including reusable containers, recycling, and composting), segregation, use of leak-proof and puncture-proof containers, labeling and signage, safe collection and transport, use of personal protection equipment, emergency kits for accidental exposure to infectious waste, proper storage of
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waste, safe management of sharps and anatomical wastes, clear hospital policies, written HCWM guidelines, a committee and advocates to promote HCWM, regular training, documentation, record-keeping, monitoring and continuous improvement, and the allocation of human and financial resources. Low investment costs made the nationwide expansion affordable for one donor and attracted other donors to cover the gaps from 2014 on. Acceptance of the new system by the staff, its economic benefits, its improvement of occupational safety, capacity building and institutionalization bode well for the future sustainability of the Kyrgyz HCWM system.
Acknowledgement The development and installation of the HCWM model throughout Kyrgyzstan was financed by the Swiss Agency for Development and Cooperation (SDC) and was carried out by the Swiss Red Cross in collaboration with the Republican Centre for Infection Control of the Ministry of Health of the Kyrgyz Republic.
Declaration of conflicting of interests Dr Jorge Emmanuel evaluated the project that developed the model. He was hired by the Swiss Agency for Development and Cooperation (SDC) that financed the project.
Funding The research was funded by the Swiss Agency for Development and Cooperation (SDC) as part of the Health Care Waste Management Project.
References Emmanuel J (2013) Health Care Waste Management in Kyrgyz Hospitals: External Project Review. Bishkek, Kyrgyzstan: Swiss Agency for Development and Cooperation. Emmanuel J (2014) Unpublished data, United Nations Development Programme GEF Project on Healthcare Waste. Harhay MO, Halpern SD, Harhay JS and Olliaro PL (2009) Health care waste management: a neglected and growing public health problem worldwide. Tropical Medicine and International Health 14 (11), 1414–1417 Laurent E (2005) Injection Safety Healthcare Waste Management Pilot Project Needle Removing and Plastic Recycling. Ukraine Ministry of Health and World Health Organization, March 2003–February 2005. STAATT (1998) Technical Assistance Manual: State Regulatory Oversight of Medical Waste Treatment Technologies: A Report of the State and Territorial Association on Alternative Treatment Technologies (STAATT), TR-112222, EPRI Healthcare Initiative, Palo Alto, CA. STAATT (2005) STAATT III Executive Summary and Daily Decisions, Orlando, FL, December 2005, available at http://www.istaatt.org. State Agency for Protection of the Environment and Forestry (2006) National Implementation Plan for the Stockholm Convention on Persistent Organic Pollutants. Bishkek: Government of the Kyrgyz Republic, p. 23 Stolze R and Kühling J-G (2009) Treatment of infectious waste: development and testing of an add-on set for used gravity displacement autoclaves. Waste Management and Research 27: 343–353. Stringer R, Kiama J, Emmanuel J, Chenya E, Katima J and Magoma F (2010) Non-Incineration Medical Waste Treatment Pilot Project at Bagamoyo District Hospital, Tanzania. Report by Health Care Without Harm, United Nations Development Programme-Global Environment Facility Project, AGENDA, John Snow Inc. and Making Medical Injections Safer: http:// www.noharm.org/global/reports/2010/sep/rep2010–09–22.php United Nations General Assembly (2011) Report of the Special Rapporteur on the Adverse Effects of the Movement and Dumping of Toxic and Dangerous Products and Wastes on the Enjoyment of Human Rights, Calin Georgescu. Report A/HRC/18/31, Eighteenth session of the Human Rights Council, 4 July, pp. 1–2
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search-article2015
WMR0010.1177/0734242X14565209Waste Management & ResearchToktobaev et al.
Original Article
An innovative national health care waste management system in Kyrgyzstan
Waste Management & Research 2015, Vol. 33(2) 130–138 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0734242X14565209 wmr.sagepub.com
Nurjan Toktobaev1, Jorge Emmanuel2, Gulmira Djumalieva3, Alexei Kravtsov3 and Tobias Schüth1
Abstract A novel low-cost health care waste management system was implemented in all rural hospitals in Kyrgyzstan. The components of the Kyrgyz model include mechanical needle removers, segregation using autoclavable containers, safe transport and storage, autoclave treatment, documentation, recycling of sterilized plastic and metal parts, cement pits for anatomical waste, composting of garden wastes, training, equipment maintenance, and management by safety and quality committees. The gravity-displacement autoclaves were fitted with filters to remove pathogens from the air exhaust. Operating parameters for the autoclaves were determined by thermal and biological tests. A hospital survey showed an average 33% annual cost savings compared to previous costs for waste management. All general hospitals with >25 beds except in the capital Bishkek use the new system, corresponding to 67.3% of all hospital beds. The investment amounted to US$0.61 per capita covered. Acceptance of the new system by the staff, cost savings, revenues from recycled materials, documented improvements in occupational safety, capacity building, and institutionalization enhance the sustainability of the Kyrgyz health care waste management system. Keywords Hospital/medical waste, autoclave treatment, recycling, cost survey, sustainable healthcare waste management, Kyrgyzstan
Introduction In 2011, a report of the United Nations Special Rapporteur to the Human Rights Council of the UN General Assembly raised concern that improper management and disposal of medical waste, including the use of open burning and most small-scale incinerators, jeopardize the enjoyment of human rights (United Nations General Assembly, 2011). A few years earlier, a systematic review of health care waste management (HCWM) in 40 lowand middle-income countries found that HCWM is a serious public health challenge due to the increasing quantities of waste, improper disposal methods, lack of training, insufficient financing and infrastructure, and weak governance and administration, among others (Harhay et al., 2009). The researchers proposed focusing on alternatives for syringe waste, tools for reducing total volume, and an affordable treatment and disposal method. Kyrgyzstan, one of poorest countries of the former Soviet Union, was typical of the countries described by the UN Special Rapporteur until a few years ago. With independence in 1991, it inherited a poorly maintained medical infrastructure that also lacked proper waste management systems. This paper discusses the innovative system of HCWM that was implemented in the framework of a bilateral cooperation project throughout most of the country and that addresses the three focus areas suggested by Harhay et al. Before the new HCWM system, hospital staff had to disinfect infectious waste in hypochlorite solution. The nursing staff often
complained of exposures to hypochlorite. The lack of funds to purchase hypochlorite forced many hospitals to dispose of health care waste by open burning on the hospital premises or dumping on the hospital grounds without treatment. Health workers and neighboring residents frequently complained of the smoke. Anatomical waste was often dumped on the ground or put into overflowing cemented pits or containers. Lack of resources prevented hospitals from transporting the waste to municipal landfills resulting in considerable piles of waste scattered beyond the designated areas. In 2003, a national assessment of unintentional releases of polychlorinated dibenzo-dioxins and furans had estimated total releases to be 30.5 g TEQ, of which 14.37 g TEQ (47.11%) were
1Health
Care Waste Management Project, financed by the Swiss Agency for Development and Cooperation (SDC) and implemented by the Swiss Red Cross, Bishkek, Kyrgyz Republic 2E & ER Group, Hercules, CA, USA 3Republican Centre for Infection Control, Ministry of Health of the Kyrgyz Republic, Bishkek, Kyrgyzstan Corresponding author: Nurjan Toktobaev, Health Care Waste Management Project, financed by the Swiss Agency for Development and Cooperation (SDC) and implemented by the Swiss Red Cross, 187/1 Sydykova Street, Bishkek, Kyrgyz Republic. Email: [email protected]
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Toktobaev et al. in air, 10.87 g TEQ (35.63%) in water, and 0.16 g TEQ (0.52%) in soil (State Agency for Protection of the Environment and Forestry, 2006). Despite a high degree of uncertainty in the calculations, the preliminary inventory of unintentional releases into the air indicated that the majority were from burning medical waste (7.01 g TEQ). Kyrgyzstan ratified the Stockholm Convention on Persistent Organic Pollutants in 2005 thereby committing to the reduction and ultimate elimination, where feasible, of releases of dioxins and furans. The objective of the project was to develop and implement a HCWM system that was appropriate for rural hospitals in Kyrgyzstan. It was important that the HCWM system reduced the potential for disease transmission, enhanced the safety of health workers, protected the environment, and met the Stockholm Convention guidelines; special care was taken to develop a system with low investment and operating costs that therefore could be replicated throughout the country and sustained by facilities without further support.
Segregation of infectious waste All other infectious wastes are collected in 12-liter buckets (1.5 kg net weight) with double enamel coating. They are marked on the top and sides with the international biohazard symbol, type of waste, hospital department, and a number to keep track of each container. Regular (non-infectious) waste is placed in bins with black plastic bags. Infectious waste buckets are located only in areas where infectious waste is generated and are placed sideby-side with non-infectious waste containers. Posters are found in such areas to remind the health workers of segregation practices.
Transport of infectious waste Each bucket is covered by an enamel-coated metal lid that is held in place during transport using two standard metal binder clips. Since the buckets are labelled, have handles and lids for easy transport by hand within the facility, and are placed directly in the autoclave, the need for color-coded plastic bags is eliminated thereby significantly reducing operating costs.
Materials and methods The model was developed in 2005; its final version is described below. It was pilot tested in five facilities of the rural Naryn region in 2006. Thereafter, the model was included in the medical waste strategy of Kyrgyzstan and informed several national guidelines regarding medical waste management. In the following years, the model was further improved and expanded throughout the country. As of the end of 2013 it functions in 232 facilities, including all general treatment hospitals with 25 beds or more and all urban primary health care centers and other ambulatory services. Not covered yet are all facilities of the capital Bishkek and primary care services in villages. An external evaluation was conducted in September–October 2013. The main components of the Kyrgyz HCWM system are described next.
Syringes and needles Needles and syringes are cut and destroyed immediately after use by means of a mechanical needle remover (manufactured by BMDi Pty Ltd, India). Cutting the hub of the syringe and breaking the needle renders both unusable. The broken needle falls into a plastic container. Other sharp wastes are also collected in this container of the needle remover. When 3/4 full, a plastic lid is screwed on the needle container. The syringes are collected in a 10-liter enamel-coated metal bucket designated exclusively for syringes. When these buckets are 3/4 full, they are transported to and placed directly in an autoclave for treatment. The enamel coating protects against corrosion in the autoclave. Autoclaved syringes are sold to plastic recycling firms. The autoclaved broken needles are sold to metal recyclers. The outside surfaces of the needle removers are wiped daily with a disinfectant (2% Tetramin). Once a week, they are dismantled, soaked in the disinfectant for 10 minutes, then oiled and reassembled.
Storage The needle containers, buckets with syringes, and buckets with other infectious waste are placed on shelves in a storage room which also houses the autoclave. The buckets are weighed before they are placed on the shelves to await treatment. The room is designed to keep contaminated and decontaminated areas separate. Policies and procedures are posted on the walls of the waste storage and treatment room. A record book keeps track of the buckets and the amounts of waste generated and serves as documentation of treatment. A typical room layout is shown in Figure 1.
Autoclaving The treatment method of the HCWM system is autoclaving. The autoclave used is a top-loading gravity-displacement autoclave (two nearly identical models from two producers: the VK-75 by Tumenski Factory and the Vka-75-Pz by Kasimovski Instrument Factory). This type of vertical autoclave is widely used for medical sterilization in countries of the former Soviet Union. The vertical chamber of 75 l volume can accommodate two 10 l enamel-coated metal buckets and is ideal for a 100-bed hospital, the size of the majority of hospitals in Kyrgyzstan. To avoid releases of pathogens into the environment with the displaced air during the initial introduction of steam, the exhaust of the autoclave chamber goes through a corrosion-resistant sintered metal filter (316L stainless steel, Mott Corporation, USA) that captures 99.9% of all particles larger than 0.2 µm in the gas stream passing through the filter surface at a gas flux of 2 m3/min per m2 of filter surface area (6 actual ft3/min per ft2). A steam flow meter (Armor-Flo meter, ERDCO Engineering Corporation, USA), calibrated to 134°C at 2 bar (gauge) and density of 2.935 kg/m3, with a range of 20–200 l/min of saturated steam, was used to measure the air/steam flow rate through the
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Figure 1. Typical layout of the storage and treatment room and photos of the autoclave.
filter in order to determine the appropriate filter size. The casing for the cartridges was made locally using standard galvanized steel tubes in order to reduce costs. The autoclaving procedure entails putting two buckets with infectious waste on top of each other in the vertical autoclave. The lids are carefully removed and placed beside each bucket. A triangle of wooden bars on top of the lower bucket creates space between the two buckets to allow the contents of the lower bucket to be fully exposed to steam. Color-changing (AAMI ST-60 Class 1) thermal indicators are placed on the bucket surface and after the treatment, the indicators are placed in the record book as documentation. Once a month, a steam integrator (AAMI ST-60 Class 5 indicator) is placed with the waste and recovered after treatment. The steam integrator serves as an affordable pass/fail test of the autoclaving process.
Anatomical waste Anatomical and placenta wastes are deposited in secure cement pits to decompose. Before transport, the top surface of the waste is sprinkled with calcium hypochlorite to minimize the potential release of pathogenic aerosols during transport and disposal. Every hospital has a 2 m x 6 m x 2 m deep pit divided into three compartments, each of which has about 5 m3 and a 1 m2 slab as a lid. One compartment is used until it is filled. The lids have hooks to allow the possibility of removing and emptying them in the future after the waste has fully decomposed. These pits are located inside the fenced waste collection area along with the trailer.
Garden wastes To minimize waste, hospitals use two compost pits for garden wastes. Each compost pit is 2 m x 2 m with a depth of between
1.5 and 2 m. Stems are placed in the bottom layer along with large sticks to create air pockets for aeration. The second layer has smaller items such as grass, leaves, and other plant waste. The third layer is soil mixed with manure, ash and about 5–10 kg of compost from the previous season. Water is added to keep the waste moist and speed up decomposition. At the end of the season, the pit is covered with 4-5 cm of soil and vertical holes are created with sticks to improve aeration. The other compost pit is used for the following season. The compost area is surrounded by a wire fence.
Final disposal After treatment, autoclaved needles are collected in large metal drums while autoclaved plastic syringes are collected in large sacks or containers until sold to recyclers. Other disinfected wastes are mixed with non-infectious waste in plastic bags and stored on a trailer in the fenced area. When full, the trailer is pulled by a hospital vehicle to the dump site where the waste is discarded until such time that a sanitary landfill is constructed by the municipality. The compost from the compost pits is used as fertilizer and soil conditioner by the hospital. The overall schematic of the HCWM system is shown in Figure 2. Classes A, B1, B2, and B3 refer to the classification system used in the Kyrgyz Republic.
Training and equipment maintenance Awareness-raising workshops with all stakeholders and 1-day trainings of all hospital staff accompanied the installation of the equipment. Two autoclave operators per hospital received special training for 1 day on the operation of the autoclave, including basic maintenance. Every 2 years, the autoclaves are examined
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Figure 2. Schematic of the health care waste management system.
by licensed technicians who test and repair the parts crucial for pressure safety.
Testing the autoclaving cycle Stolze and Kühling (2009) as well as Stringer et al. (2010) have demonstrated that by using pressure pulses a gravity-displacement autoclave can safely disinfect medical waste. The disinfection of waste in both models of the gravity-displacement autoclaves was tested using thermocouples and biological indicators. Two buckets containing typical waste material were prepared for each test. The top bucket was filled only with syringes (as is done in hospitals for later recycling). The bottom bucket was filled with other typical waste material (intravenous sets, cotton swabs, bandages, gloves, etc.). Four thermocouples (TC Direct, UK; Type T, mineral insulated with pot seal, stainless steel sheath, 1.5 mm diameter, 2000 mm length) were used. A tee was added to the pipe from the autoclave chamber to the pressure gauge and one end of the tee was used for the thermocouple wires. Data were recorded with a mobile four-channel data logger (Yu Ching Technology Co., Ltd, Taiwan; Model YC-747UD, accuracy: ±0.1% of reading +0.7 °C). The biological indicators used were Geobacillus stearothermophilus spore strips (Raven Labs/Mesa Laboratories, USA) with a 104 population (D121 value of 1.6 min, D132.2 value of 0.08 min) and a 105 population (D121 value of 1.5 min, D132 value of 0.45 min). Self-contained biological indicators of 105 G. stearothermophilus spores in ampoules (ATCC 7953; D121 value of 1.5 min, D132 value of 0.45 min; ProTest, Raven Labs/Mesa Laboratories, USA) and 106 G. stearothermophilus spores on paper discs (D121 value of 1.6min,
ProLine Process Challenge Device, Raven Labs/Mesa Laboratories, USA) were also used. The thermocouples and biological indicators were placed at different levels in the waste of the two buckets. For the top bucket, the 104 and 105 spore strips and the 105 ampoules were placed inside syringes. This was done by removing the syringe plungers, inserting the biological indicators, and then putting the plungers back in place. The syringes with spore strips and the thermocouples were placed in the upper third and at the bottom of the waste load of the top bucket. Spores and thermocouples were placed in the upper and lower third of the waste load of the bottom bucket. Although it was not necessary, disinfection was also demonstrated inside intravenous tubing using 106 spore discs in process challenge devices placed in the middle of cut tubing. Figure 3 show the placement of spores and thermocouples during the tests. A total of 34 challenge tests were performed using a total of 340 biological indicators. All of these tests were done with the following cycle: pressure build up in the chamber up to 150 kPa followed by flushing of air, then two pressure pulses of 220 kPa and finally holding a pressure of 220 kPa for 10 minutes. All spore strips were incubated using tryptic soy broth with bromocresol purple indicator (Mesa Lab, USA). Incubation time was 24 hours at 60°C. With each test, spore strips were set aside and not exposed to autoclaving in order to serve as controls. Three additional tests were performed to determine if pathogens could be released during the initial flushing of air and steam. Spore strips with 104 population were placed in a Petri dish right above the exhaust port at the bottom of the autoclave chamber. Steam was introduced into the chamber until a pressure of 220
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Figure 3. Test set-up for the autoclaving cycle.
kPa was reached. After five minutes, the air-steam mixture was flushed out. The spore strips were then recovered and incubated. Also, in addition to the 34 test cycles described above, 2 cycles with 12 biological indicators (6 Log4 spore strips and 6 Log5 spore ampoules at the same locations as above) were done with this changed procedure before flushing (220 kPa held for 5 minutes before flushing, followed, as before, by two pulses of 220 kPa and 10 minutes holding at 220 kPa).
Results and Discussion Biological testing None of the 340 spore strips/containers exhibited any growth, nor did the additional 12 spore strips/containers exposed in the cycles with the adapted pre-flushing procedure; all control spore strips showed growth. Since some of the biological indicators exhibited a 5 Log and 6 Log reduction, the microbial inactivation efficacy was 10–100 times higher than the minimum requirement of 4 Log (STAATT, 1998, 2005). Based on the test results, the final autoclaving cycle is as follows. After the two buckets of waste are put in the autoclave and the lid closed, steam is introduced while keeping the exhaust steam line closed until a pressure of 220 kPa is reached. The pressure is held for 5 minutes after which the exhaust steam line is opened and the air–steam mixture released through the sintered metal filter. The autoclave pressure is again increased to 220 kPa, the steam is released, and then the pressure pulsing is repeated a third time. On the fourth time, the pressure is maintained at 220 kPa (about 132ºC) for 10 minutes and then steam is released. Figure 4 shows the temperature-pressure curve of a typical autoclaving cycle.
The process has two features that ensure that pathogens are not released during the initial flushing of air. One feature is based on tests by the UNDP GEF Project in Tanzania (Emmanuel, 2014). They inoculated paper with 105 G. stearothermophilus spores and placed it right above the exhaust port inside the autoclave. Steam was let into the chamber to a pressure of 170 kPa gauge before the steam–air mixture was released into a flask partially filled with water. When samples of the condensate were placed on trypticase soy agar plates, no G. stearothermophilus grew after 24 and 48 hours incubation. The spore strips with 104 population that were placed above the exhaust pipe showed no growth in three tests suggesting disinfection of the air. Informed by the Tanzania and Kyrgyz test results, the final Kyrgyz autoclave cycle involves an initial pressure of 220 kPa held for 5 minutes before the steam–air mixture is released. In addition, the exhaust steam line is fitted with the sintered metal filter. As the performance of the filter (99.9% capture of particles >0.2 µm) was specified for a maximum gas flow rate per square foot, various filter sizes were tested to ensure that the flow rate during flushing did not exceed the specified flow rate. A filter cartridge of 500 mm length and 63 mm diameter was found to have sufficient surface area to keep the gas flow rate during flushing below the maximum. Subsequent releases of steam during the autoclaving cycle decontaminate the filter.
Equipment maintenance and reliability The selection of the VK-75 autoclave was beneficial since it was already well-known in many hospitals for use in the sterilization of medical and surgical instruments. Many local maintenance technicians are familiar with the equipment and spare parts are readily available from local vendors. Maintenance of the autoclaves
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Figure 4. Temperature–pressure–time curves of the autoclave cycle.
involves monthly cleaning especially of the heating elements, lubrication of valves, blow down of the boiler, and checking and cleaning of gaskets. The most commonly needed spare parts are the lid gaskets, which last 3–6 months depending on use. During the pilot testing phase, refurbished autoclaves were installed, the oldest of which is 30 years old (from 1984) and still serving. However, two refurbished autoclaves had to be replaced with new ones since the testing phase. The needle removers have proven durable and reliable thus far. Since the start of the project, 3680 needle remover were installed. The hospital with the longest experience with these removers (7 years) replaced only 4 out of its 180 needle removers. This amounts to a 2% replacement rate over 7 years. The most common problems are breakage of the handle and stripping of the screw holding the cutting block. Procuring spare parts separately, in particular the cutting drum that was designed for 100,000 cuts, minimizes the need to replace the whole device. The sintered metal filters lead to formation of condensate in the hose between the autoclave and the filter; it is let out after each cycle through a tap at the bottom near the autoclave. To prevent condensate accumulating in the hose from the filter, the filter cartridge is mounted high on the wall to allow condensate to drip down to the outside of the building, generally on to a flower garden or open ground. The filters have no defined end of life. Over time the duration of one pulse increases as matter collects in the filter wall. They are therefore cleaned once a month with eight pressure pulses under reversed steam flow while running the autoclave without waste; this reduces the time for the pulses back to the baseline level and keeps the overall cycle length short.
Disposal of anatomical waste The current practice of adding calcium hypochlorite to anatomical waste as prescribed by the old guidelines is not optimal as it inhibits decomposition. Efforts are underway to change the
guidelines in order to allow the use of lime or adding no disinfection at all. It is not yet known how long the pits will take to fill up and how much time will be needed to breakdown the waste especially given the cold winters a few months of the year. At each of the hospitals that have used the pits the longest (7 years), the first of the three pits has not yet filled up. The minimum time for all three pits to fill up has been estimated at 20 years. That may be ample time for decomposition even with the cold seasons if calcium hypochlorite is not added in the future.
Extent of coverage By end of 2013, 126 hospitals were transformed through the implementation of the new system. This includes all general treatment hospitals in the country with more than 25 beds except for those in the capital city of Bishkek. The covered hospitals account for 67.3% of all hospital beds in the country. Also covered are all 45 primary care centers in towns (again except in Bishkek), as well as 32 other facilities (dental clinics, blood centers, etc.). In addition, 29 private ambulatory clinics have made arrangements with the covered hospitals to use the autoclave system for their waste treatment on a fee basis.
Costs of the HCWM system The average investment costs amounted to US$16,156 per hospital for a typical 100-bed general hospital (with surgery, gynecology/obstetrics, medicine and pediatric departments). For bigger hospitals of about 500 beds, the costs amounted to US$74,949. Table 1 gives the breakdown of these costs. The prorated investment cost is about US$0.61 per capita. Where transport costs are not an issue, a trailer need not be provided and the investment costs would be even less (US$13,776 for a 100-bed hospital). Autoclave treatment cost about US$0.59/ kg of infectious waste, consisting of labor, electricity, and bags for treated waste.
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Table 1. Costs by component of the HCWM model installation for hospitals with 100 and 500 beds. Components of the HCWM model
Price per unit (US$)
Quantity per 100-bed hospital
Mechanical needle remover Enamel-coated metal buckets Autoclaves (purchase, transport, installation, site preparation) Set of spare parts for the autoclaves Trailers for hauling regular and treated waste Weighing scale Fenced enclosure with metal roof for the trailer and waste collection area plus 3 cement pits for anatomical waste Personal protection equipment and other protective measures (coveralls, gloves, glasses, warning signs, paint, etc.) Training Total
35 10 5000 840 2380 24 5800
20 80 1 1 1 1 1
58
1
US$ per 100-bed hospital
Quantity per 500-bed hospital
US$ per 500-bed hospital
692 792 5000 840 2380 24 5800
65 260 3 3 2 3 2
2249 2574 15,000 2520 4760 72 11,600
58
3
174
570 16,156
3600 42,549
Table 2. Yearly HCWM expenses and income for Naryn Oblast Merged Hospital before and after the implementation of the new HCWM system. Annual expenses Items
Disinfectants Sharps safety boxes Waste removal fee Plastic bags for Class A waste Plastic bags for autoclaved waste Electricity Total
2005 (before)
2012 (after)
Units
US$
Units
US$
446 kg 816 boxes 416 tonnes 0 0 0 1933
1175 330 425 0 0 0
227 0 90 9125 1715 8694 kWh 1174
204 0 257 372 70 271
Annual income Items
2005 (before) Units
Sale of plastics Sale of metals Total
0 0 0
The operating costs of the HCWM system are lower on average than what the hospitals had been paying under the old system of hypochlorite treatment and/or burning. A survey of 30 hospitals showed an average annual cost savings of US$1040 or 33% savings compared with their previous costs for waste management. Those hospitals that had used chlorine disinfection in the past had the highest cost savings, those hospitals that had burned their waste (in violation of existing regulations) had little or no savings, while a few hospitals increased their expenditures. Table 2 presents an example of the costs before and after installation of the new HCWM system for a secondary-level hospital with about 500 beds. It shows that the cost savings were mainly due to reduced expenditures on chlorine disinfectant and lower waste transport costs due to composting and the trailer provided (transport costs decreased less than expected because of increased petrol prices and because the landfill began to charge fees). Revenues are generated from the sale of the sterilized
Current US$ 0 0
Units
US$
2300 kg 140 kg 595
563 31
plastic and metal parts to recyclers. On average, the HCWM costs accounted for 0.68% of the operating budgets of the hospitals.
Evaluation and staff acceptance of the new HCWM system An independent evaluation was conducted in September–October 2013 (Emmanuel, 2013) that entailed an assessment using a slightly modified version of the UNDP–GEF–WHO individualized rapid assessment tool (I-RAT). The I-RAT is an Excel-based scoring tool. Its weighted scoring system takes into account, among others, HCWM organization, policy and planning, training, occupational health and safety, monitoring, periodic evaluation and corrective action, financing, segregation, waste generation, collection, handling, labeling, posters or signage, transport inside the facility, storage, treatment, waste disposal,
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Figure 5. Needle-stick injuries and cuts documented in Naryn Oblast Merged Hospital.
and wastewater management. Six Kyrgyz hospitals covered by the evaluation had an average of 95 points (out of a maximum of 100), indicating that almost all of the aforementioned topics in the I-RAT tool had been properly addressed. Hospital directors, waste workers, autoclave operators, nurses, doctors, and other hospital staff were interviewed during the evaluation. A high level of satisfaction with the new HCWM system was found. The nursing staff consistently pointed out that the new system eliminated the time they had to spend preparing multiple hypochlorite solutions for disinfecting the waste.They also commented on the marked decrease in their exposure to hypochlorite and many felt that the use of the needle removers reduced needlestick injuries and cuts. Data from one hospital from 2005 to 2013 gave a preliminary indication of this (Figure 5). After the needle removers were introduced in 2006, there was first an increase in injury data but the hospital felt that this was due to improved documentation coupled with a shift in approach from a punitive system to one of safety improvement. Later, needle-stick injuries and cuts declined significantly. During interviews, hospital directors were especially pleased with the cost savings. Being in full compliance with state regulations was another benefit mentioned especially by hospital directors that in the past had to pay penalties for burning waste in violation of the law. Many also commented on the fact that hospital premises no longer had waste piles scattered about and that they no longer had to deal with complaints from neighbors about smoke and odors from the burning of waste.
Organization As part of the new system, each hospital created a Safety and Quality Committee that managed HCWM and related activities in the facility. The committee periodically reviews HCWM procedures, develops the budget, monitors activities, and implements training workshops. The infection control specialist and
epidemiology specialist function as HCWM advocates within the hospital. During interviews, they reported a change in the mindset of health workers and a greater appreciation of the hazards of health care waste and the importance of HCWM among the staff.
Sustainability Hospitals have been sustaining the HCWM system without further financial and technical support from the project. The first five hospitals that were the early adopters and participants of the project have successfully maintained their systems on their own for the last 7 years. The broad acceptance of the new system by the hospital staff and directors, the cost savings, improved safety for the workers, and a decreased burden on the nursing staff are important benefits that enhance the sustainability of the new system. The lessons learned from the project are being used to extend coverage to the urban hospitals in Bishkek in the near future.
Conclusions Key elements for the successful transformation of HCWM in Kyrgyzstan included an initial analysis of the problem, finding innovative solutions with stakeholder participation, pilot testing and demonstrations at a few hospitals to evaluate and refine the new system, a well-planned phased implementation, development of national regulations to support the implementation, and continuous monitoring and improvement. As a result, the new system serves 67.3% of all hospital beds in Kyrgyzstan as of end of 2013. The new HCWM system has all the major components of a good system: waste minimization (including reusable containers, recycling, and composting), segregation, use of leak-proof and puncture-proof containers, labeling and signage, safe collection and transport, use of personal protection equipment, emergency kits for accidental exposure to infectious waste, proper storage of
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waste, safe management of sharps and anatomical wastes, clear hospital policies, written HCWM guidelines, a committee and advocates to promote HCWM, regular training, documentation, record-keeping, monitoring and continuous improvement, and the allocation of human and financial resources. Low investment costs made the nationwide expansion affordable for one donor and attracted other donors to cover the gaps from 2014 on. Acceptance of the new system by the staff, its economic benefits, its improvement of occupational safety, capacity building and institutionalization bode well for the future sustainability of the Kyrgyz HCWM system.
Acknowledgement The development and installation of the HCWM model throughout Kyrgyzstan was financed by the Swiss Agency for Development and Cooperation (SDC) and was carried out by the Swiss Red Cross in collaboration with the Republican Centre for Infection Control of the Ministry of Health of the Kyrgyz Republic.
Declaration of conflicting of interests Dr Jorge Emmanuel evaluated the project that developed the model. He was hired by the Swiss Agency for Development and Cooperation (SDC) that financed the project.
Funding The research was funded by the Swiss Agency for Development and Cooperation (SDC) as part of the Health Care Waste Management Project.
References Emmanuel J (2013) Health Care Waste Management in Kyrgyz Hospitals: External Project Review. Bishkek, Kyrgyzstan: Swiss Agency for Development and Cooperation. Emmanuel J (2014) Unpublished data, United Nations Development Programme GEF Project on Healthcare Waste. Harhay MO, Halpern SD, Harhay JS and Olliaro PL (2009) Health care waste management: a neglected and growing public health problem worldwide. Tropical Medicine and International Health 14 (11), 1414–1417 Laurent E (2005) Injection Safety Healthcare Waste Management Pilot Project Needle Removing and Plastic Recycling. Ukraine Ministry of Health and World Health Organization, March 2003–February 2005. STAATT (1998) Technical Assistance Manual: State Regulatory Oversight of Medical Waste Treatment Technologies: A Report of the State and Territorial Association on Alternative Treatment Technologies (STAATT), TR-112222, EPRI Healthcare Initiative, Palo Alto, CA. STAATT (2005) STAATT III Executive Summary and Daily Decisions, Orlando, FL, December 2005, available at http://www.istaatt.org. State Agency for Protection of the Environment and Forestry (2006) National Implementation Plan for the Stockholm Convention on Persistent Organic Pollutants. Bishkek: Government of the Kyrgyz Republic, p. 23 Stolze R and Kühling J-G (2009) Treatment of infectious waste: development and testing of an add-on set for used gravity displacement autoclaves. Waste Management and Research 27: 343–353. Stringer R, Kiama J, Emmanuel J, Chenya E, Katima J and Magoma F (2010) Non-Incineration Medical Waste Treatment Pilot Project at Bagamoyo District Hospital, Tanzania. Report by Health Care Without Harm, United Nations Development Programme-Global Environment Facility Project, AGENDA, John Snow Inc. and Making Medical Injections Safer: http:// www.noharm.org/global/reports/2010/sep/rep2010–09–22.php United Nations General Assembly (2011) Report of the Special Rapporteur on the Adverse Effects of the Movement and Dumping of Toxic and Dangerous Products and Wastes on the Enjoyment of Human Rights, Calin Georgescu. Report A/HRC/18/31, Eighteenth session of the Human Rights Council, 4 July, pp. 1–2
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