**4.2 Planning HCW management**

There are basically two types of HCW management; a national level HCW management and a local level (individual healthcare institute or service provider) HCW management. In some cases, regional (provincial, prefectural) level HCW management is set between the national and local levels.

*Technical Cooperation for Enhancing Infectious Healthcare Waste Management DOI: http://dx.doi.org/10.5772/intechopen.102604*

#### *4.2.1 National/regional HCW management plan and strategy*

The purpose of planning a national/regional HCW management is to improve HCW management at the national and regional (e.g., provincial) levels, where strong political commitment is required. In the planning process, it is required to involve relevant ministries and professional organizations including academics in the HCW management field.

The goals of the national/regional HCW management plan are: to declare the government's intentions to improve HCW management, to define overall national/ regional strategies and plan for improving HCW management, to specify activities and timeline for implementation, and to define the roles and responsibilities of authorities concerned & other stakeholders.

#### 1.Assessment study

The first step for formulating a national HCW management plan is to conduct a national assessment study on HCW management, where the following four points have to be clarified: (i) an inventory of existing healthcare institutes (waste generators) and HCW treatment facilities; (ii) analysis of existing legislation, regulations, and rules; (iii) existing HCW stream and its management practices if any; and (iv) implementation agency and human resource on HCW management.

The inventory of HCW generation sources and GIS (geographical information system) map are crucial for planning HCW management, which covers all healthcare institutes including hospitals, clinics, and primary healthcare (PHC) institutions. A regression model will be applied to estimate the amount of HCW generated by them using the outpatient, inpatient, and bed numbers.

#### 2.Planning

Specific objectives toward developing a national HCW management plan should include the following five key objectives: (1) to understand the present situation and setting the purpose of the plan, (2) to develop the legal and regulatory framework, (3) to develop financial investments and resources for HCW management, (4) to develop capacity building program, and (5) to set up a monitoring plan. The expected general contents of the national HCW management plan are as shown in **Table 2**.

#### *4.2.2 Local HCW management plan*

When planning a local HCW management, the first thing that must be done is to clarify the executing agency based on the legal system, and that agency will make the plan. The local HCW management plan is created by each healthcare institute and/or service provider based on the above-mentioned national/regional plan. It is required to be specific and practical depending on given local conditions.

Specific objectives toward developing a local HCW management plan needs to include the following six key components based on the direction of the national/ regional HCW management plan: (1) designing HCW management system, (2) segregation of HCW at source, (3) HCW handling, storage, and transport, (4) treatment technologies, (5) waste disposal, (6) staff training, and (7) monitoring:


#### **Table 2.**

*General contents of the national HCW management plan.*

#### 1.Designing HCW management system

Regarding the treatment and/or sterilization of infectious HCW, there are basically two types of HCW management systems; distributed (on-site) and centralized (offsite) systems. The distributed one is a system in which a healthcare institute has its own (relatively small-scale) treatment facility and processes infectious HCW by itself. On the other hand, the centralized system is a system in which a private or public service provider collects infectious HCW and transports it from each healthcare institute based on a contract and centrally processes it in the service provider-owned treatment facility.

The advantages of the distributed system are: complete control of infectious HCW by the generator, mitigating the risk of exposure during waste collection & transportation, and reducing unknown risks in the treatment by a service provider. However the distributed system has the following disadvantages: the healthcare institute has to get a relatively high financial burden for a treatment facility, and also become responsible for meeting all regulatory requirements on infectious HCW treatment, which needs additional resources.

#### *Technical Cooperation for Enhancing Infectious Healthcare Waste Management DOI: http://dx.doi.org/10.5772/intechopen.102604*

On the other hand, the advantages of a centralized system are minimization of cost and responsibility for the treatment of infectious HCW. Each healthcare institute can concentrate only on source separation and appropriate waste discharging. The HCW generators, in particular small-scale healthcare institutes, benefit from the quality of service and the economies of scale. The disadvantages are indirect control of infectious HCW management due to outsourcing.

In the case of a centralized system, two management plans, on-site and off-site plans, are required, and coordination and cooperation between the two actors are indispensable.

These distributed and centralized systems are often combined in a country/region to act as a hybrid system for actual HCW management (**Figure 7**). As shown in the **Figure 7**, the generated HCW is first separated into non-infectious HCW and infectious HCW (sharps and infectious) at the source. Non-infectious HCW is treated in the MSW management flow, while infectious HCW is sent for on-site or off-site treatment. If there is no treatment facility or in the case of the treatment capacity is insufficient, an emergency controlled cell is installed at the landfill site for direct disposal as an emergency measure.

2.Segregation at source

Segregation at source (source separation) is one of the most important steps to successfully manage HCW. As shown in **Figure 1**, only about 15% of the HCW is hazardous, treatment and disposal costs could be greatly reduced if proper segregation were performed. Segregating hazardous from nonhazardous waste reduces also greatly the risks of infecting SWM workers.

Segregation consists in separating the different waste streams based on the hazardous properties of the waste, the type of treatment and disposal practices that are applied. A recommended way of identifying HCW categories is by sorting the waste into color-coded and well-labeled bags or containers.

#### **Figure 7.**

*Outline and options for HCW management in developing countries. Dashed parts are emergency measures under limited conditions, which is an example in Palestine.*

#### 3.Handling, storage, and transport

HCW workers have the greatest occupational risk (the Risk A in **Figure 3**), where the hazard is from direct contact with sharps and infectious waste. Sharps can cause puncture wounds, scratches, and scrapes, where infectious agents can penetrate the skin. The use of special containers for sharps is absolutely necessary. In the HCW handling process, there is also potential for exposure through inhalation of pathogencontaining aerosols or particulates [20].

The best way to minimize the risk of exposure is to ensure that the infectious waste is properly isolated. Some basic principles [20] are: packaging the infectious HCW properly; avoiding physical contact with the infectious HCW; using personal protective equipment (PPE); and handling the infectious HCW as little as possible.

Another factor to be considered is public health including informal waste pickers if the hazardous infectious waste is directly disposed without any treatment as an emergent measure under limited conditions. In that case, no one has easy access to discarded needles and syringes, so that waste sharps' containers need the following features: puncture resistance, impermeability, rigidity, tamper resistance, and proper marking [31].

#### 4.Treatment technologies

The purpose of treatment is to change the biological character of infectious HCW to eliminate, or at least to significantly reduce, its potential for causing negative impacts. The three most common techniques used to treat infectious HCW are incineration (various types are available), steam sterilization (autoclaving), and microwaving (**Table 3**). Other currently available techniques include irradiation, chemical disinfection, and so on.

#### 5.Disposal

When infectious HCW waste has been properly treated, the waste is no longer infectious. The treated HCW can be handled in the same way as normal municipal waste. However there are two exceptional cases [18]: for sharps and pathological wastes, additional processing before disposal is necessary; if other hazardous substances such as pharmaceutical, chemical, or radioactive waste are contained, there must be additional treatment before disposal.

In the case of sharps waste treated by steam sterilization, intact sharps are possibly sent to a landfill where workers are at risk for injury; therefore, they should be shredded or destroyed when be treated. Pathological waste treated by steam sterilization also requires additional processing since body parts or organs can be recognizable, which should not be directly disposed in the landfill.

In developing countries, sometimes no suitable HCW treatment facility is available and the only option is direct landfilling. In such a case, it is necessary to avoid using an open dumpsite and dispose a landfill having a shielded structure. It is necessary to immediately cover the soil at the time of waste disposal to prevent the dissipation of HCW and protect the environment.

#### 6.Staff training

HCW management training is an effective intervention for preventing infections and improving the occupational safety of the HCWs through building awareness,


**Table 3.** *Comparison of most common HCW treatment technologies and landfilling [14, 20, 32–35].*
