**3. Available methods to manage healthcare waste**

The results of the formal risk assessment forms the basis of interventions. The report should detail identified risks and mitigation measures put in place. Mitigation measures should be revaluated for effectiveness. The identified risks should also inform training of the health care workers and waste handlers. Following careful consideration of the risks and the type of waste that is being produced different ways of managing it need to be described. According to the waste management hierarchy it is important minimization is the first step towards managing the waste. The management of healthcare waste is contextual and should be guided by relevant legislations, regulations, available technology, costs and environmental and occupational health and safety factors [4].

#### **3.1 Minimization**

The reduction of waste at point of production should be applied to the furthest extent possible. It includes rational and risk-based PPE's usage, choice of materials with minimal packaging, unpacking at areas of low risk of contamination with infectious agents. Use of materials that can be cleaned or disinfected can greatly reduce amount of healthcare waste [2].

#### **3.2 Segregation**

Healthcare activities produce different types of waste. It is always safe to assume that only waste produced in administrative areas is considered non-hazardous. A risk assessment however should inform how you manage the waste throughout the emergency setting. The table below shows a typical color coding of bags under normal non-emergency settings. If these waste management and treatment options are available in emergency situations they should be adopted (**Table 2**).

The three-bin system is the most commonly used and segregates waste into three categories namely general waste, infectious waste and sharp waste. This also simplifies the work of the waste handlers as they will only deal with a small number of waste types. However it is not always the case all the waste can easily be categorized into these three categories (**Figure 2**).

Based on information obtained in the risk assessment the more categories might be needed as per the first table. In emergency situation this might be adequate depending on the type of waste predominantly being produced.

#### **3.3 Collection transportation and storage**

After generation and segregation of the waste it needs to be transported from the point of generation either the final disposal point or the temporal holding place. All infectious waste should be collected in clearly labeled lined containers and sharp


#### **Table 2.**

*Color coding of waste bags.*

**Figure 2.** *Three bag waste segregation [5].*

waste in sharp boxes. In cases where people are in quarantine centers, holding centers, camps and other non-healthcare settings, waste like used masks, tissues, and other non-biodegradable waste is collected in double bagged red bags. It will be ideal to have the bags sealed and labeled with a date and time.There is no need to treat these materials with disinfectant first but tying and wiping the outside with 0.5% chlorine should be sufficient as an additional measure to reduce spread of diseases. The collection of the waste should take place at times that are least busy to prevent exposure to people from the carts that might be used to transport the waste. Full PPE should be provided to the waste handlers. Transportation of hazardous and non-hazardous waste should always be done separately using the principle of clean to dirty places with hygienically sensitive areas being the areas to start from followed by the other places.

Waste holding areas should be designated wherever possible. When new building are being built it should be incorporated in building design. The size of the holding areas should be according to the amount of waste that is anticipated to be produced. The holding areas should be totally closed off and separated from essential areas like supply areas or food preparation rooms and only authorized staff should have access to that space. The floor of the holding area should be of material that is easy to clean like vinyl.

Waste that is highly infectious like waste contaminated with blood and other bodily fluids, microbiological cultures, stocks of infectious agents from laboratory, swabs,bandages, medical devices and pathological waste must be selected sealed to allow easy disinfection and need to be identified as infectious waste area using the biohazard sign. The time from generation of waste to treating it should not exceed 24 hours in the warm climate areas in the summertime. In temperate climate 72 hours can be allowable in winter and 48 hours in summertime. Refrigerated storage if available can allow for waste to be stored for up to a week. This might be relevant where pathological waste involved. Pathological waste is considered biologically active and gas production might be expected in storage.

If pharmaceutical waste is to be stored it should be separated from other waste. In general pharmaceutical waste can be hazardous and non-hazardous in solid and liquid form. Local and international regulations should be followed to better manage this waste. If chemical waste is anticipated the characteristic of the waste need to be considered in terms of the reactivity of the chemicals. Under normal circumstances this should be a different area from the other waste. In emergency settings there might significantly differences as there might not be all these different spaces to hold waste.

The staff who handles the waste should be given the appropriate personal protective equipment like thick Gloves, boots and aprons. In addition, appropriate training should also be offered. The waste holding centers should be easy to clean, safe and locked up, well ventilated and most importantly protected away from animals, rodents and insects.

When the waste is to be transported offsite the labelling on the waste should be non-washable, the date and time of production should be clear, the name of the person sending other waste should be clearly stated, the category of the waste, and the contact details of a person in case of emergency.

#### **3.4 Treatment**

This waste should be treated on site before safe disposal. If the waste is to be moved off-site it is critical to understand where and how it be transported, treated and disposed. Waste should be treated prior to final disposal if non-combustion methods of disposal are to be used. The preferred methods include This can be useful in places where it is difficult or expensive to have an incinerator.

#### *3.4.1 Autoclaving*

Use of combination of steam, heat, and pressure to disinfect waste and equipment. The combined effect of saturated steam under pressure and heat kills microorganisms. To guarantee that the process is working well chemical and biological indicators need to be added to be process on a regular basis or with every autoclaving cycle. In combination with shredding, grinding, mixing the volume of the waste can be significantly reduced. Autoclaves can also be easily moved to sites they are needed depending on size in the process increasing access to waste treatment to the different sites for this method of disposal.

#### *3.4.2 Microwaving*

This is a recent technology in healthcare waste management. Microwaving technology heats the water in the waste. Some microwaving devices include transformation devices like shredders or blenders. It is however not suitable in waste that might contain metallic items like surgical equipment. It can be done in batches or in a continuous manner (an automated process). However microwaving might not be suitable for all types of waste like anatomical waste. Chemical disinfection should be considered depending on circumstances [6].

### *3.4.3 Chemical disinfection*

The most common and readily available method of chemical disinfection is use of hypochlorite solution. It has oxidizing properties and removes most of the microbial burden in the waste.
