5.0 guidelines for setting up a biomedical waste management training ...

Biomedical Waste Management in the Organization of Eastern Caribbean States (OECS)

Prepared for: Pan American Health and Education Foundation

By: Dr. Martin Forde Health Promotion Research Program Windward Islands Research & Education Foundation (WINDREF) Department of Public Health & Preventive Medicine School of Medicine St. George's University P.O. Box 7, St. George’s Grenada, W.I. Phone: (473) 444-4175 Fax: (473) 444-1219 Email: [email protected]

Date submitted: December 2007

This report was made possible through a small grant from the Pan American Health and Education Foundation (SGP06-Grenada-IC-Biomedical Waste Management in OECS Countries). The author alone is responsible for the views expressed in this publication, which may not necessarily reflect the views of the Pan American Health and Education Foundation.

ii

TABLE OF CONTENTS List of Tables Acknowledgements Executive Summary 1.0

Introduction 1.1 1.2 1.3 1.4 1.5

2.0

1

Background Goal and Objectives Definition and Characterization of Medical Waste Rationale for Establishing a Biomedical Waste Management System Management of Biomedical Waste in the Caribbean

Methodology 2.1 2.2 2.3

3.0

vi vii viii

1 2 3 4 6

8

Methodology Outlined Countries Visited Study Limitations

8 8 9

Country Reports

10

3.1

Anguilla 3.1.1 General Background 3.1.2 General Organization of the Health care System 3.1.3 Facilities Visited and Persons Interviewed 3.1.4 Review of Biomedical Waste Management Practices

10 10 11 11 11

3.2

Antigua 3.2.1 General Background 3.2.2 General Organization of the Health care System 3.2.3 Facilities Visited and Persons Interviewed 3.2.4 Review of Biomedical Waste Management Practices: Antigua 3.2.5 Review of Biomedical Waste Management Practices: Barbuda

18 18 19 19

British Virgin Islands 3.3.1 General Background 3.3.2 General Organization of the Health care System 3.3.3 Facilities Visited and Persons Interviewed 3.3.4 Review of Biomedical Waste Management Practices

28 28 29 29 30

3.3

iii

20 27

4.0

3.4

Dominica 3.4.1 General Background 3.4.2 General Organization of the Health care System 3.4.3 Facilities Visited and Persons Interviewed 3.4.4 Review of Biomedical Waste Management Practices

36 36 37 37 38

3.5

Grenada 3.5.1 General Background 3.5.2 General Organization of the Health care System 3.5.3 Facilities Visited and Persons Interviewed 3.5.4 Review of Biomedical Waste Management Practices

43 43 44 44 45

3.6

Montserrat 3.6.1 General Background 3.6.2 General Organization of the Health care System 3.6.3 Facilities Visited and Persons Interviewed 3.6.4 Review of Biomedical Waste Management Practices

52 52 53 53 54

3.7

St. Kitts (Christopher) & Nevis 3.7.1 General Background 3.7.2 General Organization of the Health care System 3.7.3 Facilities Visited and Persons Interviewed 3.7.4 Review of Biomedical Waste Management Practices: St. Kitts (Christopher) 3.7.5 Review of Biomedical Waste Management Practices: Nevis

58 58 59 60

3.8

St. Lucia 3.8.1 General Background 3.8.2 General Organization of the Health care System 3.8.3 Facilities Visited and Persons Interviewed 3.8.4 Review of Biomedical Waste Management Practices

70 70 71 72 72

3.9

St. Vincent & the Grenadines 3.9.1 General Background 3.9.2 General Organization of the Health care System 3.9.3 Facilities Visited and Persons Interviewed 3.9.4 Review of Biomedical Waste Management Practices

79 79 80 81 81

Regional Summary 4.1 4.2 4.3

60 65

86

General Overview Recommendations Conclusions

86 93 97

iv

5.0

Guidelines for setting up a Biomedical Waste Management Training Program

99

5.1 General Overview 5.2 Target Audience 5.2.1 Training Administrators 5.2.2 Training Doctors 5.2.3 Training Nurses 5.2.4 Training Housekeeping Staff 5.3 Training Tools 5.4 Sample BMW Training Program

99 99 99 100 100 101 102 102

Appendices

104

A1 Letter to Permanent Secretaries in the Ministries of Health A2 Proposed Biomedical Waste Management Standards for OECS Region A2 Pictures of BMW Practices in each OECS Country

105 107 108

v

LIST OF TABLES Table 1

Selected demographic and mortality data for Anguilla

10

Table 2

Summary of Biomedical Waste Management Practices Audit in Anguilla, 2007

17

Table 3

Selected demographic and mortality data for Antigua and Barbuda

18

Table 4

Summary of Biomedical Waste Management Practices Audit in Antigua &

26

Barbuda, 2007 Table 5

Selected demographic and mortality data for the British Virgin Islands

28

Table 6

Summary of Biomedical Waste Management Practices Audit in BVI, 2007

35

Table 7

Selected demographic and mortality data for Dominica

36

Table 8

Summary of Biomedical Waste Management Practices Audit in the

42

Commonwealth of Dominica, 2007 Table 9

Some demographic and mortality data for Grenada

43

Table 10

Summary of Biomedical Waste Management Practices Audit in Grenada, 2007

51

Table 11

Selected demographic and mortality data for Montserrat

53

Table 12

Summary of Biomedical Waste Management Practices Audit in Montserrat, 2007

57

Table 13

Selected demographic and mortality data for St. Kitts (Christopher) & Nevis

59

Table 14

Summary of Biomedical Waste Management Practices Audit in St. Kitts

64

(Christopher), 2007 Table 15

Summary of Biomedical Waste Management Practices Audit in Nevis, 2007

69

Table 16

Selected demographic and mortality data for St. Lucia

71

Table 17

Summary of Biomedical Waste Management Practices Audit in St. Lucia, 2007

79

Table 18

Selected demographic and mortality data for St. Vincent & the Grenadines

81

Table 19

Summary of Biomedical Waste Management Practices Audit in St. Vincent & the

86

Grenadines, 2007 Table 20

Summarized Regional Findings of Biomedical Waste Management Practices in

93

the OECS, 2007 Table 21

Summary of Biomedical Waste Management Practices Audit in OECS Member

99

Countries, 2007 Table 22

Sample Biomedical Waste Management Training Program

vi

103

ACKNOWLEGEMENTS Firstly, I wish to express my thanks to the Pan American Health and Education Foundation (PAHEF) for giving me the opportunity to do this very important piece of research.

In

particular, I would also like to express my sincerest gratitude and appreciation to Ms. Pilar Torres, who played a pivotal role in helping me secure this grant.

Secondly, I wish to thank all the governmental officials, and in particular those at the Ministries of Health and those working in solid waste management authorities, that graciously permitted me to meet with them and facilitated my on-site visits. Ms. Consuela Parker in Antigua, Ms. Sharon Gillard in St. Kitts, and Mrs. Auguste in St. Lucia were extremely helpful in arranging my itineraries so as to make my brief visits as productive and enjoyable as possible.

I am most grateful to all the health care personnel—both in the public and private sectors— who, despite their very busy schedules, allowed me to interview them and facilitated my tours of their facilities. Their frank and candid interviews have gone a long way in making this report reflect what is really happening out there in the trenches.

I wish to personally extend my gratitude to my parents and wife. Firstly, to my father, Dr. St. Clair Forde, I am most grateful that when I lost my initial project administrative assistant, he graciously responded at very short notice to my request to come and help with the scheduling of my many islands visits and then later, with the formatting and editing of this report. I wish to thank my mother, Marianne Forde, who used her expertise as a Foreign Language Translator, to edit this report and greatly increase its grammatical correctness. Finally, but by no means least, to my dear wife, Laura, I would like to express my heartfelt thanks for her help in designing the cover and back pages of this report.

vii

EXECUTIVE SUMMARY This report presents the results of a situational audit of the current status of biomedical waste management practices in the Eastern Caribbean islands. All nine Caribbean islands that form the Organization of Eastern Caribbean States (OECS) were visited and data collected. This project was made possible by a small grant obtained from the Pan American Health and Education Foundation.

The Permanent Secretaries in the Ministry of Health of each island were contacted and approval sought to visit their islands, conduct interviews with health care personnel and solid waste managers, tour health care facilities—both public and private—as well as waste disposal sites, and collect pertinent documents. Island visits and data collection took place over the period July to November 2007.

The results presented in this document are,

therefore based on information received from face-to-face interviews, personal observations made on tours of various facilities and sites, photo-documentation, and information obtained from other documents and telephone interviews.

While there are some laws and regulations that specifically address the issue of biomedical waste management, by and large, the OECS region lacks a clear and consistent legislative framework to effectively manage this issue. As a result of such a legislative vacuum, each island has developed on an ad hoc basis, its own way of handling biomedical waste. Several positives were noted. In almost all the health care facilities visited, some degree of waste segregation is taking place, particularly with respect to sharps. Most health care personnel are at least aware of and appreciate the importance of proper biomedical waste management. Further, they are familiar with the most common ways (e.g., using sharp containers, color-coded bags, etc.) to effect such.

Several notable deficiencies were observed as well.

For example, formal, regular, and

specific training in best biomedical waste management practices is not common. Systems to quantify and track biomedical waste from cradle (source) to grave (final disposal) are, by and large, non-existent.

Internal and external auditing procedures and mechanisms to

viii

monitor how well health care institutions are managing their biomedical waste are also not found in most health care institutions operating in the OECS region.

With respect to the methods most commonly employed to dispose of biomedical waste, the two most prevalent methods used in the region were incineration and burial in landfill sites. Both approaches are problematic and come with significant drawbacks.

The use of

incinerators is being steadily phased out in developed countries and replaced by treatment modalities that are less harmful to the environment and public health.

The burial of

biomedical waste in landfills is not being done consistently and properly in most OECS member islands, thereby increasing the risk to those who work in this environment. Additionally, besides landfill operators, several OECS landfill sites permit waste pickers to scavenge for items and so these, too, are exposed to potentially significant health and safety hazards arising out of non- or poorly-buried biomedical waste.

This report concludes with a number of recommendations—short and long-term—which, if implemented, can dramatically improve the management of biomedical waste in the OECS region. Guidelines on how to set up a training program are also provided to assist those governments in the region, which may wish to start developing a training program for those involved in generating, handling, and disposing of biomedical waste on how to adopt industry-developed best practices.

ix

1.0 INTRODUCTION

1.1

Background

The term biomedical waste (BMW) refers to any waste from health care, research, and laboratory facilities that pose a hazard to the environment and human health. According to the Caribbean Environmental Health Institute (CEHI), the challenge of ensuring effective management of biomedical waste in the Caribbean is a major source of concern to the policy makers and operatives who have been charged with the responsibility for environmental management and the protection of human health. Caribbean island states are very much aware that there are potential negative impacts related to workers’ occupational health and safety, environmental contamination, and the spread of contagious diseases if such waste is not managed properly.

With the added burden of a growing HIV and AIDS epidemic in the region, there is an even greater sense of urgency to have proper and efficient BMW management systems in place. Some islands within the region have commenced development of BMW management strategies and policies.

In others, however, there exist no clear policies, legislation, or

appropriate regulations and management systems to address and effect proper biomedical waste management.

One consequence of this vacuum is that a variety of BMW

management systems obtain throughout the Caribbean region. Most seem to have been developed merely on the basis of available resources, the level of expertise of health care personnel chosen to deal with biomedical waste, and/or convenience rather than on the most

appropriate

thing

to

do.

Furthermore,

it

is

uncertain

whether

the

classification/characterization and treatment of a specific type of waste is the same throughout the region.

Under the Caribbean Cooperation in Health Phase Two (CCH-II—A New Vision for Caribbean Health, page 109), solid waste management has been identified as a priority issue for Environmental Health. Biomedical waste is included in the classification of solid waste, and as such is a priority area in the region. The CARICOM institution responsible for environmental management and environmental health in the Caribbean, the Caribbean

2 Environmental Health Institute (CEHI), has received multiple requests from agencies within its member states for assistance to address the issue of biomedical waste disposal. The most common and immediate request from CARICOM Member States is for firstly, a workshop or training program and secondly, assistance in developing a policy and a longterm program. As CARICOM countries embrace the reality of a Common Single Market and Economy, regional governments are working to develop a unified and structured approach to deal with the many challenges facing the different sectors in the region. In this context, biomedical waste management should be included.

1.2

Goal and Objectives

The overarching goal of this situational audit was to provide a clear picture of biomedical waste (BMW) management practices in member countries of the Organization of Eastern Caribbean States (OECS). Among other things, such baseline data can then be useful for the development of a regional biomedical waste management policy; attendant legislation, regulations, and infrastructure; the adoption of a standardized color classification system for biomedical waste; and uniform training programs for all health care personnel in the OECS.

The above-mentioned goal was achieved by meeting the following project objectives:  Conducting an assessment of existing biomedical waste management practices at all major health care facilities in each OECS country  Reviewing what legislation, if any, exists that addresses issues connected with proper handling and disposal of biomedical waste  After consultation with all stakeholders, proposing a unified color-coding scheme that could be adopted by all OECS countries  Proposing a standardized BMW management-training program for health care personnel in the OECS.

3 1.3

Definition and Characterization of Biomedical Waste

For the purpose of this report, Biohazardous Waste (BHW) can be defined as:  Laboratory waste, cultures and stocks of infectious agents from research laboratories, wastes from the production of biological agents, discarded live and attenuated vaccines, and culture dishes and devices used to transfer, inoculate and mix cultures or material which may contain infectious agents and may pose a substantial threat to health. All non-sterilized cultures shall be presumed to be biohazardous.  Any specimen sent to a laboratory for microbiologic analysis shall be presumed to be biohazardous.  Surgical specimens including animal parts or tissues removed surgically or by autopsy shall be presumed to be biohazardous.  Sharps, including any objects or devices having acute rigid corners, edges, or protuberances capable of cutting or piercing, and including, but not limited to, hypodermic needles, blades, microscope slides and slip covers.

All of the above listed items, except sharps, are considered putrefying waste and should be stored in the waste freezer.

Biomedical Waste (BMW) can be broadly defined as waste generated in the health care industry as a result of diagnosis, treatment, and immunization of humans or animals. Biomedical Waste, therefore, is a subset of biohazardous waste. Specifically, biomedical waste includes the following:  Human blood, blood products, body fluids, tissues, organs and anatomical parts  Waste saturated with human blood, blood products, or body fluids  Discarded "sharps" used in patient, animal, or cadaver care, or in medical or biomedical research laboratories  Cultures and stocks of infectious agents and devices used to transfer, inoculate, and mix cultures  Discarded clinical specimens and the associated containers or vials  Discarded biologicals and waste from the production of biologicals

4  Recombinant DNA waste  Carcasses, body parts, bedding, or other waste generated by research facilities from animals containing organisms or agents not usual to the normal animal environment and which are pathogenic or hazardous to humans  Cytotoxic drugs not identified as hazardous waste  Material that has come in contact with and has no more than a trace of cytotoxic agents.

It should be noted that the term biomedical waste does not include the following:  Urine or feces  Wastewater treatment sludge and septage  Water samples used for and waste from routine screening  Animal carcasses, anatomical parts, bedding, or other waste generated in the routine handling of animals containing organisms or agents normally found in the animal environment  Band-Aids and other blood spotted items such as feminine hygiene products.

1.4

Rationale for Establishing a Biomedical Waste Management System

Locally, regionally, and internationally, there are many pressures being brought to bear on organizations in order to ensure that they are operating in an environmentally sound manner. They are being asked to do this while at the same time having to ensure that they provide their services/products in an economically efficient manner. Particularly in recent years, governmental and external agencies are requiring that all types of enterprises— including health care institutions—actively plan and ensure that they minimize the harm they cause to the environment.

One area that has received much attention is the whole issue of waste—who generates it, how much, of what type, the hazards associated with it, and where and how is it ultimately disposed of.

Any organization, which generates waste can no longer think of it as

something to just get rid of; rather, it needs to implement waste management systems (if it has not already started to) that respond to the pressures mentioned above.

5 A Waste Management System is a structured process for monitoring, collecting, sorting, storing, transporting, and disposing of waste generated by an organization. A key ingredient to the overall success of such a system is that it must be approached with the emphasis on waste minimization rather than what has been termed "end-of-pipe" controls. This has many benefits to the organization, as well as to the community and the environment. One of the more obvious benefits is the reduction in costs associated with waste disposal.

Concern about the environmental and health risks of medical waste has increased in recent years as a number of studies have shown that such waste is ubiquitous in the waste stream and poses unique risks. Facilities that generate such biomedical waste have special moral and social responsibilities to ensure that their waste is properly handled and disposed of. In addition to these responsibilities, there is also the distinct likelihood that legal responsibilities will soon be added. Several Caribbean governments have begun the process of drafting and enacting legislation that would extensively regulate the manner in which biomedical waste can be handled and disposed of. As can be expected, any such legislation would impose requirements that biomedical waste be properly managed with the potential for punitive fines and penalties if this is not done.

Regardless of whether legal requirements currently exist or not, facilities that generate biomedical waste should at all times give careful consideration to the environment and any person who may come into contact with such waste during the packaging, transport and disposal phases. Even when legal requirements are created, these should be viewed as minimum standards to be achieved.

As the core of a waste management system, all biomedical waste generating organizations should recognize waste management as a hierarchy of:  Reducing the amount of waste generated  Reusing waste materials wherever possible  Recycling waste.

This means that in order to minimize the impact of waste on the environment, as well as to reduce costs, all possibilities for reducing the amount of waste generated should be explored.

6 1.5

Management of Biomedical Waste in the Caribbean

In 2003, the OECS Solid and Ship–Generated Waste Management Project ended. Under the aegis of the World Bank, international and regional agencies were mobilized to fund the project, which brought together six OECS member countries (Antigua & Barbuda, Dominica, Grenada, St. Kitts & Nevis, St. Lucia, and St. Vincent & the Grenadines) to jointly address some of the important environmental problems facing these island states.

The original

objective of the project was aimed at reducing public health risks and protecting the environmental integrity of the islands and their coastal and marine systems.

While one of the national components was aimed on investments and improvements in systems for solid waste management storage, collection and disposal, and the rationalization of the existing framework for ship and land-based solid waste management to enable these countries to enforce the MARPOL 73/78 Convention, there was provision for the procurement of equipment and treatment of biomedical/hospital waste in Antigua & Barbuda, St. Lucia, and St. Kitts & Nevis.

During the second phase of the project, attention was given to the implementation of a biomedical waste management program. From project status reports, the following major achievements were noted:

o

Work had commenced on the development and implementation of a Biomedical Waste Management Plan in Dominica with contracts issued to two consultants for similar activity in St. Kitts & Nevis, Grenada, and St. Vincent & the Grenadines.

o

In St. Lucia, technical specifications and tender documents for an autoclave were submitted to the Natural Resources Management Unit of the OECS. For the other participating countries, steam sterilization (autoclaving) with shredding was expected to be the chosen treatment technology.

o

A regional technical workshop on Biomedical Waste management was to be convened.

7 In another report, presented by the E & ER Group based in Rodeo, California, USA, an audit of biomedical waste management practices was done in St. Kitts & Nevis.* The report gave the status of practices in the Joseph Nathanael France (JNF) and Alexandria hospitals. It was noted that the incinerators at both hospitals were of obsolete design and did not meet the generally accepted criteria for good combustion.

It was recommended that these

incinerators be replaced with treatment technologies that are more efficient.

* Source: Accessed November 23, 2007 http://wwwwds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2003/02/15/000094946_03013004020110/Rendered/IN DEX/multi0page.txt

8

2.0 METHODOLOGY

2.1

Methodology Outlined

Information for this report was primarily gleaned from personal interviews and on-site observations of current biomedical waste handling practices at both public and private health care facilities in each island.

Specifically, the following major activities were

undertaken:

1. Face-to-face interviews with the person(s) most knowledgeable about biomedical waste management procedures of each major hospital and health care provider facility in each OECS member country 2. On-site observations of biomedical waste management and handling practices at each major hospital and health care provider facility 3. Review of available reports/manuals on biomedical waste management in the OECS member countries 4. Review of available and existing biomedical waste management laws and legislation in the Caribbean region 5. Observation of biomedical waste treatment and disposal sites in the OECS member countries.

These activities were conducted primarily over a five-month period, July to November 2007. All project activities were conducted by the Principal Investigator, Dr. Martin Forde, who traveled to each island to collect the data, interview health care and solid waste management personnel, and tour both health care and waste disposal sites.

2.2

Countries Visited

The OECS is a nine member grouping comprising seven full members—Antigua & Barbuda, Commonwealth of Dominica, Grenada, Montserrat, St Kitts (Christopher) & Nevis, St. Lucia,

9 and St Vincent & the Grenadines—and two associate members, Anguilla and the British Virgin Islands. All nine islands were visited between the period July to November, 2007.

2.3

Study Limitations

Some potential factors that could have inhibited the completeness of the information detailed in this report are:

o

Lack of full support from relevant Ministries of Health and/or Ministries of the Environment in providing required information

o

Unwillingness of private health care institutions in providing the necessary information and on-site access to document their current biomedical waste management practices

o

Unwillingness and/or unavailability of key personnel to provide key information

However, these inhibitory factors were, to a large extent, mitigated by providing information well in advance to all the key stakeholders on the importance and many benefits that this proposed project could bring. Letters were written to all OECS Ministry of Health Permanent Secretaries soliciting their government’s support (see Appendix A1). Stakeholders were informed on how the data collected would be used.

Before the report on each island was made final, draft copies were sent to all those interviewed in that island with a request that they review the report for accuracy and completeness. Corrections and suggested additions/modifications were then incorporated into each island’s report before compiling this final report.

Additionally, besides the above primary data collection efforts, secondary data sources, where available, were obtained and reviewed to corroborate and back up personal interviewee and observational data.

10

3.0 COUNTRY REPORTS 3.1

Anguilla

Date visited: November 13, 2007

3.1.1

General Background

Anguilla is a British overseas territory in the Caribbean, the most northerly of the Leeward Islands in the Lesser Antilles. It consists of the main island of Anguilla itself, approximately 26 km (16 miles) long by 5 km (3 miles) wide at its widest point, together with a number of much smaller islands and cays with no permanent population. The island's capital is The Valley. The total land area of the territory is 102 km² (39.4 square miles), with a population of approximately 13,500 (2006 estimate). Some selected demographic and mortality data, sourced from the Pan American Health Organization (PAHO), are provided in Table 1.

Table 1

Selected demographic and mortality data for Anguilla demographic indicators—2006*

total population (thousands)

crude birth rate (1,000 pop)

annual deaths average (thousands)

13

14.2

0.1

life expectancy at birth (years) 2006 ______________________________________ total male female 77.3

74.4

80.3

mortality indicators maternal mortality ratio (100,000) lb

infant mortality rate (1,000 lb)

____________ ratio No. year


general mortality rates (100,000 pop) (2000–2004) ______________________________________________________ total male female _________________________________________________________ estimated adjusted estimated adjusted estimated adjusted

- 2005 n/a 2 2005 533.9 516.4 568.9 587.8 498.9 449.5 * Adapted from Health situation in the Americas Basic Indicators 2006, Pan American Health Organization (PAHO).

11 3.1.2

General Organization of the Health Care System

All public health care facilities are managed and run by the Health Authority of Anguilla, a statutory body, created in 2004.

There is one (1) main public hospital, the Princess

Alexandra Hospital, a 36-bed facility located at Pope Hill. This hospital is supported by one (1) polyclinic and four (4) health care centers distributed throughout the island.

Health care is also available through several private medical and dental clinics. There is one (1) major private hospital, the Hughes Medical Centre.

There are two (2) main

laboratories; one located at the Princess Alexandra Hospital and the other at Hughes Medical Centre.

There are approximately 18 doctors actively practicing medicine on the island.

3.1.3

Facilities Visited and Persons Interviewed

Facility/Institution Visited Ministry of Social Development, Department of Health Protection, Environmental Health Unit

Persons Interviewed  Mr. Lynrod Brooks, Health Planner  Ms. Jane Rogers, Director  Mr. Oliver Hodge, Ag. Principle Environmental Health Officer  Mr. Leroy Richardson, Ag Senior Environmental Health Officer, Solid Waste Management

Princess Alexandra Hospital



Mr. James Richardson, Facilities Manager

3.1.4

Review of Biomedical Waste Management Practices

1.

Biomedical Waste Policies, Legislation, and Regulations Currently, there is no Solid Waste Management Act, but rather only an Environmental Health Act. This particular legislation does not specifically deal with solid waste or BMW issues. The Department of Environment within the Ministry of Home Affairs is now drafting an Environmental Protection Act, which can cover solid waste management issues. In its current version, this proposed Act does mention ‘Hazardous waste.’

The Department of Health Protection, which comes

12 under the Ministry of Social Development, is drafting a Solid Waste Management Act.

This Act does specifically mention ‘Biomedical waste’ and defines it as

including ‘any solid waste containing human or animal fluids, flesh, bones, or other body parts except hair.’ No specific BMW policy, legislation, and regulations are being planned for at this time.

2.

Current Biomedical Waste Management Practices at Public Facilities At the two facilities visited—Princess Alexandra Hospital (PAH) (see Picture 1) and The Valley Health Centre—the hospital administration was unable to supply a copy of a written BMW policy and/or guidelines. The Facilities Manager at PAH reported that during 2007 this institution sought and obtained accreditation from the Canadian Council on Health Services Accreditation. One of the conditions attached to this accreditation was the requirement that a BMW policy be created. It is reported that a draft BMW policy does exist and will soon be implemented at all government controlled health care facilities.

Although hospital administrators were not able to produce any internal BMW management policy documents (i.e., written BMW management manuals specifying standard operating procedures), on walk-through of the facility, attempts at waste segregation were observed. For example, in all the wards and laboratories toured, sharp containers were observed and appeared to be actively used for collecting and separating sharps from the other types of biomedical waste.

Other BMW management practices and procedures reported to be standard operating procedure at PAH were:  Red biohazardous bags were observed but used inconsistently and inappropriately (see Picture 2). o

It appears that bags are just simply placed where there is a need without regard being paid to their color. Therefore, both general and biomedical waste streams are effectively co-mingled and would have to be considered hazardous.

 Clear bags are used to collect supposedly non-biomedical waste. However, on walk-through and interviews with nursing staff, it is evident

13 that biomedical waste (with the exception of sharps) is being placed in these bags.  In the hospital’s laboratory, a brand new autoclave exists, but it has never been used as the laboratory technicians were never trained on how to use it (see Picture 3).

Discarded clinical specimens and the associated

containers or vials are therefore placed directly in red bags and subsequently taken out to the incinerator.  Biomedical waste from the hospital’s dialysis unit is collected in red bags and sent to the incinerator. Liquid waste is sent down the sanitary sewer system.  There is an isolation ward. Biomedical waste from this ward, however, is combined with all other biomedical waste and sent to the incinerator.  Body parts are put in a freezer and then taken to the incinerator when the next burning takes place.  Workers with the job title of ‘House Keeper’ are the designated personnel assigned to collect and remove waste bags—clear and red—to the main collection skips located at the back of the facility (see Picture 4).  The hospital’s incinerator is located at the back of the facility and is currently run and operated for the hospital by a private contractor (see Picture 5). The hospital is planning, however, to take over its operation shortly.  Some expired and used drugs are disposed off in the incinerator; most, however, are taken to the Corito Landfill for burial. o

The hospital’s pharmacist reported that very few cytotoxic drugs are used at PAH.

o

The hospital does not have a policy on how spent or expired drugs should be disposed of.

 Signage on BMW hospital policy and/or best practices was not observed in any part of the facilities that were toured.  Used chemicals for developing and fixing X-ray films are routinely disposed of down the drain.

One government-run health care center—The Valley Health Center—was visited and the facility toured. Red biohazardous bags were observed, but used inconsistently

14 and inappropriately (see Picture 6). Both biomedical and general waste, however, are stored in the same location (see Picture 7) where it is picked up by a private waste hauler contractor and taken to the PAH’s incinerator for disposal.

Thus,

significant amounts of non-hazardous waste are unnecessarily being sent to the incinerator.

3.

Current Biomedical Waste Management Practices at Private Facilities No private health care facility was visited. However, based on information obtained from those interviewed, the following BMW management practices and procedures were reported.  Private health care facilities are required to hire waste haulers to collect and take their biomedical waste to the Corito landfill disposal site (see Picture 8).  There is no governmental agency or independent body that audits these facilities to determine if proper waste segregation is being done. Therefore, although compliance is reported to be high, it is not possible to verify such or the degree to which this is taking place.

With respect to biomedical waste management practices by doctors operating single practice clinics, it was reported that very few doctors have such clinics. Rather, most doctors are attached to one of several medium- to large-size medical centers operating on the island. These health care centers use the contractual arrangement described above to handle their biomedical waste. Since the contractors responsible for handling general (municipal) waste (i.e., non-biomedical), do not report seeing any biomedical waste, this would lend further support to the conclusion that biomedical waste from such facilities is not getting into the regular waste stream.

4.

Biomedical Waste Treatment and Disposal Technology Used There is one incinerator on the island, a single chamber, double-burner incinerator located at the Princess Alexandra Hospital. This incinerator is used to dispose of all biomedical waste generated by the Health Authority of Anguilla health care facilities (see Picture 5). This incinerator has been operational for approximately one year now. On average, it is operated twice per week and its reliability is said to be very

15 good. Prior to the commissioning of this incinerator, all biomedical waste was taken by a private waste hauler to the Corito Landfill Site where it was buried along with other waste, i.e., not buried in a separate cell (see Picture 8).

5.

Training of Health Care Personnel in Biomedical Waste Management Concepts Health care personnel and housekeeping staff have not received systematic, specific training in BMW management and concepts. Such training, if given at all, is usually incorporated into on-the-job training activities, typically given by the facility’s Infectious Control Nurse. For example, at the Princess Alexandra Hospital, some aspects of BMW management were recently covered by the Infectious Control Nurse as part of a “Principles of Infection Control and Safety” PowerPoint lecture.

Two of the four Environmental Health Officers attached to the Department of Environment recently (2007) took part in a CEHI workshop on BMW management procedures; however, waste hauling contractors have not received any BMW training. Their contract documents state that “the contractor staff should be well trained and adequately supervised.”

However, BMW training is not specifically

mentioned. The contract documents further state that “all biomedical waste should be disposed of in an incinerator” and “in the absence of such a facility, it may have to be disposed of on site by a suitable method.”

6.

Transportation and Disposal of Biomedical Waste The island is divided into fours zones serviced by three private waste hauling contractors.

The contractors collect and carry only general waste to the Corito

Landfill. For biomedical waste, a contracted waste hauler collects and brings all biomedical waste from government health care centers to the PAH incinerator for disposal.

Similar arrangements are in place at private health care facilities. They, too, contract with private waste haulers to collect and transport their biomedical waste which is then taken to the Corito Landfill for burial along with other waste. This means that a special cell does not exist for biomedical waste.

16 7.

Biomedical Waste Recording, Tracking, and Audit Systems Although there is no weighing scale at the Corito Landfill, a record and approximation of the amount and type of waste entering the landfill is made by noting the type of vehicle (van, pick-up, RCV, Skip tipper), how full it is (full, half full), and the type of waste (household, green, commercial industrial).

Biomedical waste is being

categorized under the ‘Industrial Waste’ category. Data on the amount of biomedical waste entering the Corito landfill are reportedly available through the government’s Statistical Office. It was not possible, however, to obtain such data in time for the writing of this report. Furthermore, data on the amount of biomedical waste being generated by sub-type (e.g., sharps, red bag waste, pharmaceuticals, etc.) are not available.

Comprehensive and accurate BMW tracking systems, either in the public or private health care systems, do not currently exist to document the progression and ultimate fate of biomedical waste, from the generators (cradle) of such waste to the final end point (grave).

The government does not have an audit system in place to monitor BMW management policies and practices at either public or private health care facilities.

17 Table 2

Summary of Biomedical Waste Management Practices Audit in Anguilla, 2007

Audit Area Regulatory Environment Government BMW Policy/Plan BMW-specific Legislation/Regulations Proposed BMW-specific Legislation

Current Practices (Public HC Facilities) BMW facility-specific policy/manual Waste minimization (RRR) observed Waste segregation practices observed Waste segregation practices effectiveness Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate

Status No No No

No No Yes Poor No Yes No N/A No No No

Current Practices (Private HC Facilities)* BMW facility-specific policy/manual Waste minimization (RRR) observed/reported Waste segregation observed/reported Internal Waste Audits being performed Use of Color-coded bags observed/reported Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate

No No No No No No No No No -

BMW Training Given as a stand-alone topic Frequency

No N/A

BMW Treatment Technology Type (incinerator, oven, gasifier, etc.) Reliability of operations (Poor, Fair, Good) Handling and Transportation of BMW Specialized vehicle used Driver and handlers trained Landfill disposal procedure documented BMW Record and Tracking Systems Amounts and type of BMW recorded

Comments

BMW issues possibly will be covered in either proposed Environmental Protection Act or proposed Solid Waste Management Act

Draft policy being formulated for all facilities

No ongoing oncology program

Incinerator Good

No Yes No

Limited

Current BMW procedures being audited

* Based on information garnered from interviews.

No

Hospital planning to purchase one Cannot be independently verified

No data on amount of biomedical waste by type

18 3.2

Antigua & Barbuda

Dates visited: August 2–7, November 15, 2007

3.2.1

General Background

Located between the Caribbean Sea and the North Atlantic Ocean, the island nation of Antigua & Barbuda is 442.6 sq km, roughly 2.5 times the size of Washington, DC. The country is home to just under 70,000 Antiguans/Barbudans, who are primarily of African descent. The nation is divided into six parishes (Saint George, Saint John, Saint Mary, Saint Paul, Saint Peter, and Saint Phillip) and two dependencies (Barbuda, Redonda).

A member of the Commonwealth of Nations, Antigua & Barbuda received its independence from the United Kingdom in 1981. The official language is English and the legal system is based on English Common Law.

The total fertility rate for the nation is 2.24 children

born/woman (2006). The 2006 estimated population growth rate was 0.55 percent and the net migration rate was -6.08 migrants/1,000 population. Some selected demographic and mortality data, sourced from the Pan American Health Organization (PAHO), are provided in Table 3.

Table 3

Selected demographic and mortality data for Antigua & Barbuda demographic indicators—2006*




69

16.9

0.4


69.8

74.7






- 2005 n/a 16 2005 652.1 884.6 710.0 1,078.1 594.7 728.7 * Adapted from Health situation in the Americas Basic Indicators 2006, Pan American Health Organization.

19 3.2.2


All public health care facilities are managed and run by the Ministry of Health. On the island of Antigua, there is one (1) main public hospital, Holberton Hospital, one (1) mental home, and 22 clinics and health centers. There is only one (1) health care facility in Barbuda, the Hannah Thomas Hospital.

There is one (1) major private hospital, Adelin Hospital. Additionally, there are five (5) laboratories, several private clinics, medical schools, and private medical and dental facilities. In total, there are approximately 32 biomedical waste generators located on the island, not counting those in private practice.

On the island, there are approximately 178 doctors registered to practice medicine.

3.2.3


Facility/Institution Visited Ministry of Health

Persons Interviewed  Ms. Clara Emmanuel, PS  Dr. Kenneth Greenaway, Acting CMO  Mr. Lionel Michael, Chief Health Inspector, Central Board of Health

Holberton Hospital

  

National Solid Waste Management Authority (NSWMA)

     

Mr. Gary Thomas, Holberton Hospital Administrator Matron Nathalie Southwell Nurse Ann-Marie King, Infectious Control Nurse Mrs. Denise L. Roberts, General Manager NSWMA Mr. David Spencer, NSWMA Program Manager Dr. Zechariah, Acting Medical Officer Mr. David Spencer (Program Manager, Solid Waste) Mr. Shaka Francis, Acting Operations Manager Mr. Emmanuel Dubois, Cook’s Sanitary Landfill Manager

Bio Med Laboratory



Mr. Richard Hadeed, CEO, Certified Medical Technologist

Adelin Medical Centre



Sister France, Head Nurse

Antigua Medical Association



Dr. Samuel, President

20 3.2.4

Review of Biomedical Waste Management Practices: Antigua

1.

Biomedical Waste Policies, Legislation, and Regulations While there are laws that govern the management of waste in general, there do not currently exist any policy, legislation and attendant regulations that specifically address biomedical waste.

As far back as 1999, under an OECS funded project, a draft Biomedical Waste Management Plan (BMWMP) was developed for Antigua & Barbuda.

This plan,

however, has never been implemented. In spite of the absence of a biomedical waste management policy, the National Solid Waste Management Authority (NSWMA) has developed and adopted several standard operating practices that provide a basic framework for the separation, collection, and disposal of biomedical waste.

In August 2007, the National Solid Waste Management Authority performed a preliminary assessment of biomedical waste management practices in Antigua. Coming out of this assessment was a report the purpose of which was to inform the development of a National Biomedical Waste Management Plan.

The management of biomedical waste is currently divided between two institutions— the NSWMA and the Central Board of Health (CBH). The collection, transportation, and disposal of biomedical waste are handled by the NSWMA, whereas the CBH handles the implementation and enforcement of BMW management polices at health care facilities.

The CBH also provides a biomedical waste drop-off service for

outlying clinics.

2.

Current Biomedical Waste Management Practices at Public Facilities At all of the public facilities visited, there were no written guidelines with respect to segregation, collection, storage, and disposal of biomedical waste.

There is one major public hospital on the island, Holberton Hospital. Although the hospital management was not able to produce a BMW management policy document(s) developed specifically for this facility (i.e., written BMW management

21 manuals specifying standard operating procedures), on walk-through of the facility, some attempts at waste segregation were observed. For example, in all the wards and laboratories toured, sharp containers were observed and appear to be actively used for collecting and storing sharps separate from the other types of biomedical waste.

Other practices reported to be standard operating procedure at Holberton Hospital were:  Color-coded

bags

were

observed

but

used

inconsistently

and

inappropriately (see Picture 9). Therefore, both general and biomedical waste streams are effectively co-mingled and would be considered to be hazardous. It appears that bags are just simply placed where there is a need without any regard being paid to their color.  In the pathology laboratory, it was reported that contaminated blood products were autoclaved before being placed in the disposal bins. However, in the case of reusable items, it was observed that these were being washed by hand before autoclaving, posing a tremendous infectious and safety risk to the worker (see Picture 10).  Empty 5-gallon detergent buckets are being used to collect sharps (see Picture 11).  Workers with the job title of ‘Grounds’ men are the designated personnel assigned to collect and remove waste bags—black and red—to the main collection skips.  Signage on BMW management policy and/or best practices was not observed in any part of the facility that was toured.  Body parts are treated with white lime and buried on site.  Used chemicals for developing and fixing X-ray films are routinely disposed of down the drain.

It should be noted that a new hospital, the Mount St. John Hospital, is nearing completion (see Picture 12). The estimated opening date for this new facility is November 2007. The consensus of MOH persons interviewed was that clear BMW

22 management policies will be formulated for this new facility, and so it is envisioned that a dramatic improvement in BMW management procedures will be noted then.

3.

Current Biomedical Waste Management Practices at Private Facilities A phone interview was conducted with the head nurse, Sister France of Adelin Hospital, the largest private hospital on the island. This is an 18-bed hospital. Sister France reported that Adelin does not have a BMW management policy. As for waste segregation, other than sharps, none takes place.

Even with sharps, which

apparently are collected in appropriate containers, it was reported that these are placed in black bags and aggregated with all other waste to be collected by a private hauler. It is not clear how this private hauler then handles and disposes of this waste.

Other BMW management practices and procedures reported to be standard operating procedure at Adelin were:  Color-coded bags are not used; only black bags  Body parts are buried on site

With respect to waste management practices by private doctors, information was obtained via a phone interview with Dr. Eumel Samuel, President of the Antigua and Barbuda Medical Association. Dr. Samuel reported that the association has sought to educate and sensitize doctors of the need for using good BMW management practices with the emphasis on encouraging doctors to remove sharps from their waste stream. Dr. Samuel felt that most doctors are doing this, but as there is no auditing of waste coming from private practices, it is impossible to verify this.

As for other biomedical waste, such as soiled or bloodied bandages and dressings, Dr. Samuel stated that doctors typically combine these with their general waste and put them out for collection by the regular garbage collection service provided by the National Solid Waste Management Authority.

In addition to the laboratory facilities at Holberton, there are five private laboratories that carry out a range of testing services. One of these private laboratories, Bio Med

23 Laboratories, which has been operating for approximately five years, was toured and its owner, Mr. Richard Hadeed, interviewed. The following was observed and noted:  Bio Med Laboratories has excellent BMW segregation practices. A simple, but effective, three tiered categorization system is used: 1. Black bags for regular waste (e.g., paper, packaging, etc.) 2. Red bags for hazardous wastes (e.g. blood contaminated items) 3. Sharp containers or cardboard-encased plastic bags obtained from used reagent containers labeled with a marker as ‘Biohazardous Waste’ for sharps (see Picture 13).  ‘Red bag’ waste and sharps are collected by the National Solid Waste Management Authority’s special contractor. Regular, ‘black bag’ waste is put out for collection by regular NSWMA personnel.  Typical quantities of biomedical waste generated: o

1 Sharp container per month

o

5 red bags per week

 Verbal training has been given to all laboratory technicians.  Used plates are not autoclaved, but are chemically disinfected instead.  Efforts are currently under way to form a Laboratory Committee which would have as its goal the establishment of criteria for setting up and running a laboratory.

4.

Biomedical Waste Treatment and Disposal Technology Used Other than pathological waste, which is autoclaved, biomedical waste at Holberton Hospital is not treated on-site. All waste is collected into a large skip (see Picture 14) and then taken to the island’s sole sanitary landfill, Cook’s Sanitary Landfill, for burial.

For the new Mount St. John Hospital, soon to be commissioned, there is currently a proposal to install an incinerator, which would have a large enough capacity to deal with not only this hospital’s infectious waste stream but also any such waste generated in the private sector.

24 5.

Training of Health Care Personnel in Biomedical Waste Management Concepts Health care personnel at both public and private health care facilities have not received systematic, specific training in BMW management and concepts.

Such

training, if given at all, is usually incorporated into on-the-job training activities, typically given by the facility’s Infectious Control Nurse.

6.

Transportation and Disposal of Biomedical Waste The collection of all waste, including biomedical waste, comes under the sole jurisdiction and responsibility of the National Solid Waste Management Authority (NSWMA).

It is the current wish of the NSWMA to maintain sole control and

management of biomedical waste, i.e., they would not want health care institutions on the island to take responsibility for the collection and disposal of biomedical waste.

The NSWMA employs two contractors who collect biomedical waste. One contractor is hired to collect only dead animals, whereas the other is contracted to collect biomedical waste generated by health care facilities. As of February 2007, the BMW hauler has been using an appropriately modified vehicle to safely collect and transport biomedical waste to the Cook’s Sanitary Landfill.

Prior to 2007, the

previous biomedical waste hauler used a vehicle that was not appropriately adapted to handle biomedical waste.

No fees are currently charged for this service, but this is likely to change in the future.

To date, this contractor services only 44 per cent of the 32 health care

institutions on the island.

Biomedical waste brought to the Cook’s Sanitary Landfill is reportedly buried in deep holes dug at the site. This is essential in order to ensure the safety of those who operate within the landfill as well as to minimize the likelihood of waste pickers coming into contact with this hazardous class of waste (see Pictures 15 and 16).

The terms and conditions of the hauler’s contract were not seen. However, it was reported that, to date, no specific training on BMW handling had been given to the contractor or his workers.

NSWMA management has reported that they have

25 received at least one report of a worker being stuck with “something” while collecting biomedical waste.

7.

Biomedical Waste Recording, Tracking, and Audit Systems BMW record (logging) systems, either at public or private health care facilities, do not currently exist to document the amount, type, and fate of biomedical waste. Therefore, data on the amount and sub-types of biomedical waste being generated are not available.

With respect to systems for tracking the movement of BMW from the generators (cradle) of such waste to its final end point (grave), none currently exist, either in the public or private health care systems.

The government currently does not have an audit system in place to monitor BMW management policies and practices at either public or private health care facilities.

26 Table 4

Summary of Biomedical Waste Management Practices Audit in Antigua & Barbuda, 2007

Audit Area Regulatory Environment Government BMW Policy/Plan BMW-specific Legislation/Regulations Proposed BMW-specific Legislation Current Practices (Public HC Facilities) BMW facility-specific policy/manual (Public) Waste minimization (RRR) observed Waste segregation practices observed Waste segregation practices effectiveness Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate

Status No No No

No No Yes Poor No Yes No No No No No

Current Practices (Private HC Facilities)* BMW facility-specific policy/manual (Public) Waste minimization (RRR) observed/reported Waste segregation observed/reported Internal Waste Audits being performed Use of Color-coded bags observed/reported Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate


BMW Training Given as a stand-alone topic Frequency BMW management issues taught

No Rare

BMW Treatment Technology Type (incinerator, pit, gasifier, landfill, etc.)

Landfill

Reliability of operations (Poor, Fair, Good)

N/A

Handling and Transportation of BMW Specialized vehicle used Driver and handlers trained Landfill disposal procedure documented

Yes No Yes

BMW Record and Tracking Systems Amounts and type of BMW recorded Current BMW procedures being audited

No No


Comments Currently being developed

Limited mainly to sharps only

Incinerator planned for Mt. St. John’s Hospital

BMW must be buried in special cells

27 3.2.5

Review of Biomedical Waste Management Practices: Barbuda

There is only one hospital on Barbuda, the Hannah Thomas Hospital, located in Codrington, which is run and managed by the Ministry of Health. A telephone interview with Matron Dyrett revealed the following:  Currently no waste segregation takes place. Color-coded bags are not used.  Body parts and other medical waste, such as placentas, are buried on the hospital grounds.  Sharps are collected either in empty bleach bottles or sharp containers.  All waste—biomedical and general waste—are combined and taken to an open landfill and buried or burned.

28 3.3

British Virgin Islands

Date visited: November 13 – 14, 2007

3.3.1

General Background

The British Virgin Islands (BVI) is a British overseas territory, located in the Caribbean to the east of Puerto Rico and make up part of the Virgin Islands archipelago, the remaining islands constituting the U.S. Virgin Islands. Specifically, the British Virgin Islands consist of the main islands of Tortola, Virgin Gorda, Anegada, and Jost Van Dyke, along with over fifty other smaller islands and cays. About 15 of the islands are inhabited. The largest island, Tortola, is approximately 20 km (~12 mi) long and 5 km (~3 mi) wide. Road Town, the capital, is situated on Tortola.

The population of the islands was around 23,000 at 2006. The majority of the population (83%) are Afro-Caribbean, descended from the slaves brought to the islands by the British. Other large ethnic groups include those of British and other European origin.

Some

selected demographic and mortality data, sourced from the Pan American Health Organization (PAHO), are provided in Table 5.

Table 5

Selected demographic and mortality data for the British Virgin Islands demographic indicators—2006*




23

14.9

0.1


75.6

77.8






2005 n/a 2 2005 445.0 488.0 531.8 568.5 353.3 400.4 * Adapted from Health situation in the Americas Basic Indicators 2006, Pan American Health Organization.

29 3.3.2


The BVI Health Services Authority Act (2004) came into force March 1, 2005, and gave birth to the BVI Health Services Authority. All public health care facilities are managed and run by this statutory body. There is one (1) main public hospital, the 50-bed Peebles Hospital, located in Road Town, the capital of Tortola. In addition, there are approximately 13 health care centers/clinics distributed throughout the four largest islands (Tortola: 9; Jost Van Dyke: 1; Virgin Gorda: 2; Anegada: 1).

Private health care is available mainly through several (approximately seven (7)) small to medium-sized health clinics.

There is one (1) major private hospital, the 8-bed

Bougainvillea Clinic, which specializes mainly in cosmetic surgery.

Throughout this island chain, there are approximately 40 licensed doctors that are actively practicing medicine.

3.3.3


Facility/Institution Visited BVI Health Services Authority

Persons Interviewed  Mrs. Winifred Charles, CEO  Dr. Ronald Georges, Director of Primary Health care, Chairman of Medical Council

Peebles Hospital

 

Dr. Hannibal, Acting Director of Hospital Services Mr. Allan Penn, Assistant Maintenance Supervisor

Solid Waste Department (SWD)

   

Mr. Anselm Myers, Manager Mr. Greg Massicote, Assistant Manager Mr. Miguel Smith, Pockwood Pond Incinerator Manager Mr. Lloyd Chung, Pockwood Pond Incinerator Assistant Manager

Services Improvement Unit



Dr. Fairfax, Chief Nursing Executive

30 3.3.4


1.

Biomedical Waste Policies, Legislation, and Regulations There does not currently exist any policy, legislation and/or regulations that specifically address the management of biomedical waste.

2.

Current Biomedical Waste Management Practices at Public Facilities The main public hospital, Peebles Hospital (see Picture 17), does not have a written BMW policy with attendant guidelines on how to segregate, collect, store, and dispose of health care waste.

Based on interviews with several hospital

administrative personnel, it appears that this is also the case for all the other health care centers.

Although a written BMW policy does not exist, it is clear that most health care personnel are aware of the need to manage biomedical waste, in particular sharps, differently from regular waste.

In all the wards and laboratories toured, sharp

containers were observed that appeared to be actively used for collecting and separating sharps from the other types of biomedical waste.

Other BMW management practices and procedures either directly observed or reported to be standard operating procedure at Peebles Hospital are listed below:  Red biohazard bags are available but are rarely, inconsistently, and inappropriately used: o

A check with the Stores Supervisor revealed that red bags are available, but housekeeping staff and hospital administration were not aware of this.

o

In all wards, biomedical waste is being put into regular black, white or clear trash bags (see Pictures 18, 19 and 20). These bags do not have the biohazard symbol on them. It is reported that these regular garbage bags are then transferred to red bags, but no evidence of this was observed.

31 o

On the very rare occasion that a red bag was observed (on walkthrough, only two red bags were seen), both biomedical waste and non-biomedical waste were being put into it (see Picture 21).

o

In the Emergency Room, blood-soiled material is collected and treated as regular waste (see Picture 22).

o

Almost all bins, regardless of the type of waste they contain, either do not have covers, or their covers are not securely placed on them. Several sharp containers were observed with their tamper-proof covers removed (see Picture 23).

o

To a large degree, both general and biomedical waste streams are essentially co-mingled and would have to be considered as hazardous.

 The pathology laboratory has no autoclave.

The laboratory technicians

reported that biomedical waste from the laboratories is placed in regular white or black garbage bags and labeled with a marker as ‘Infectious Waste.’  Workers with the job title of ‘Housekeeping’ are the designated personnel assigned to collect and remove waste bags—biomedical and regular waste—to their respective collection areas. This is apparently being done manually (see Picture 22). o

Regular waste is put into a large skip located on one side of the facility.

o

Biomedical waste is put out in an alley behind the old hospital and the new hospital, which is currently under construction (see Picture 24).

 Biomedical waste is presently being transported by hospital maintenance staff to Pockwood Pond Municipal Solid Waste Incinerator (PPMSWI). o

An uncovered pick-up van from the Maintenance Department is used to take biomedical waste to PPMSWI.

o

At PPMSWI, the driver is required to manually off-load waste into the hopper area of the incinerator.

 No signage on BMW management policy or best practices was observed in any part of the facility that was toured.  Used chemicals for developing and fixing X-ray films are routinely disposed of down the drain.

32

Other public health care facilities were not visited. However, it was reported that all biomedical waste (with the exception of sharps) generated at these facilities is disposed of along with other municipal waste. A driver from the Community Health Unit—a division within the Health Services Authority—collects sharps from the health centers and takes them to Peebles Hospital.

These are then taken along with the

other biomedical waste to the Pockwood Pond Municipal Solid Waste Incinerator.

3.

Current Biomedical Waste Management Practices at Private Facilities No private health care facility was visited.

However, based on interviews, the

following practices and procedures were reported:  The one main private hospital and the larger medical clinics take their biomedical waste directly to the Pockwood Pond Municipal Solid Waste Incinerator (PPMSWI) for disposal.  These wastes are transported to the PPMSWI in doctors’ own personal vehicles.  There is no governmental agency or body that audits these private health care facilities to determine if proper waste segregation is being done. Therefore, although compliance is reported to be high, it is not possible to verify such or the degree to which this is taking place.

It is reported that very few doctors work independently.

As to what waste

management practices these doctors employ to handle their biomedical waste, there is no data or evidence, one way or the other.

4.

Biomedical Waste Treatment and Disposal Technology Used For approximately the last three years, all biomedical waste at Peebles Hospital was disposed of in an on-site incinerator. This incinerator has recently been taken down (two months ago) to make way for a new hospital currently being constructed next to the existing hospital. All biomedical waste is now being taken to the Pockwood Pond Municipal Solid Waste Incinerator (PPMSWI) for disposal.

33 The PPMSWI, commissioned in 1993 to handle all municipal waste generated on the island, has a 40-tons/day capacity.

At present, the facility is being prepared to

receive a new 100-tons/day incinerator (see Pictures 25 and 26). Nevertheless, it is not the long-term plan to have biomedical waste from the Peebles Hospital or any of the public health care centers brought to this facility.

As soon as a new site is

confirmed for the Peebles Hospital incinerator, it will be re-commissioned and used to dispose of its own biomedical waste, as well as biomedical waste from other public and private health care facilities.

5.

Training of Health Care Personnel in Biomedical Waste Management Concepts Health care personnel have not received systematic, specific training in BMW management and concepts. Such training, if given at all, is usually incorporated into on-the-job training activities by the hospital’s infectious control nurse/officer. This position is currently vacant at the Peebles Hospital.

The recently launched Services Improvement Unit has done some training in infectious control for housekeeping staff that covered some aspects of BMW management. Further, CEHI (July 2007) conducted a one-day workshop on BMW management that was attended by Environmental Health Officers.

6.

Transportation and Disposal of Biomedical Waste Under regular circumstances, biomedical waste generated at Peebles Hospital is not transported off-site but disposed of in the facility’s own on-site incinerator. As previously mentioned, this incinerator was taken down some two months ago to make way for a new hospital currently under construction next to the existing hospital. All biomedical waste from all health care centers is now being taken to the Pockwood Pond Municipal Solid Waste Incinerator for disposal using an uncovered pick-up van from the Maintenance Department.

34 7.

Biomedical Waste Recording, Tracking, and Audit Systems Data on the amount of biomedical waste generated by either the Peebles Hospital or the other health care clinics is not being captured. It was not possible, therefore, to obtain any reliable estimate on the total amount of biomedical waste being generated or amounts by sub-type (e.g., sharps, red bag waste, pharmaceuticals, etc.).

As already mentioned, over the past two months, biomedical waste from all health care facilities is now being taken to the PPMSWI for disposal. Although there is a weighing scale at the PPMSWI (see Picture 27), records of the amount of biomedical waste entering the incinerator are not being kept.

With respect to systems for tracking the movement of biomedical waste from the generators (cradle) of such waste to its final end point (grave), none exists, either in the public or private health care systems.


35 Table 6

Summary of Biomedical Waste Management Practices Audit in the BVI, 2007

Audit Area Regulatory Environment Government BMW Policy/Plan BMW-specific Legislation/Regulations Proposed BMW-specific Legislation

Status No No No



Current Practices (Private HC Facilities)* BMW facility-specific policy/manual Waste minimization (RRR) observed/reported Waste segregation observed/reported Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate



No Rare

BMW Treatment Technology Type (incinerator, pit, gasifier, landfill, etc.) Reliability of operations (Poor, Fair, Good)

Comments

Incinerator Good

Handling and Transportation of BMW Specialized vehicle used Driver and handlers trained

No Some

Landfill disposal procedure documented

No


No No


Draft policy being formulated Limited mainly to sharps


Currently dismantled awaiting identification of a new site.

Uncovered maintenance truck being used. One person attended BMW workshop held in St. Lucia, 2002 Biomedical waste generally not planned for regular disposal at PPI

36 3.4

Dominica

Date visited: July 3–August 1, 2007

3.4.1

General Background

Dominica, an island nation located between the Caribbean Sea and the North Atlantic Ocean, is approximately one-half of the way from Puerto Rico to Trinidad & Tobago. Almost 70,000 people (69,029) live on the 754 sq km island, which is slightly larger than four times the size of Washington, DC.

Over 70 percent of the population lives in urban settings

concentrated in coastal areas.

Although English is the official language of the island,

French patois is also commonly spoken.

The country’s 10 parishes (Saint Andrew, Saint David, Saint George, Saint John, Saint Joseph, Saint Luke, Saint Mark, Saint Patrick, Saint Paul, and Saint Peter) are organized into seven health districts—Portsmounth, Marigot, Castle Bruce, La Plaine, St. Joseph, Grand Bay, and Roseau. The Roseau district is further sub-divided into three zones—North, South, and the Valley.

Some demographic and mortality data, sourced from the Pan

American Health Organization (PAHO), are provided in Table 7.

Table 7

Selected demographic and mortality data for Dominica demographic indicators—2006*




69

15.3

0.5


72.0

77.9






2004 n/a 17 2004 801.3 810.5 832.7 970.6 769.7 679.4 * Adapted from Health situation in the Americas Basic Indicators 2006, Pan American Health Organization.

37 3.4.2


All public health care facilities are managed and run by the Ministry of Health and Social Security. Primary health care services are decentralized and delivered from 53 health care centers/clinics and two (2) district hospitals. There is one (1) main public hospital, the Princess Margaret Hospital, located in the capital, Roseau.

Private health care is available but mostly limited to ambulatory care, laboratory testing centers, and family planning services. There is one (1) major private hospital, the Justin Fadipe Medical Centre. Additionally, there is one medical school—Ross University—that is located in the North of the island.

3.4.3



Persons Interviewed  Honorable John Fabien, Minister of Health  Mr. Davis Letang, Permanent Secretary  Dr. David Johnson, Chief Medical Officer  Mr. Boniface Xavier, Chief Environmental Officer  Mr. Ivor Stephenson, Senior Environmental Health Officer

Princess Margaret Hospital

  

Ms. Marvlyn Birmingham, Hospital Services Coordinator Mr. Fountaine, Maintenance Supervisor Mrs, Marilyn Zamore, Facilities Manager

Dominica Solid Waste Management Corporation (DSWMC)



Mr. Anthony Scotland

Justin Fadipe Medical Centre, Mero



Matron Mariann John Baptiste

Dominica Medical Association



Dr. Spencer St. Luce, President

38 3.4.4


1.

Biomedical Waste Policies, Legislation, and Regulations There does not currently exist specific BMW legislation in Dominica. However, there are two pieces of legislation—the Solid Waste Management Act (2002) and the Environmental Health Services Act (1997)—which do give the government a legal basis on which to manage biomedical waste.

For example, the latter piece of

legislation grants the Minister of Health the authority to regulate “pollutants.” Thus, biomedical waste can plausibly be controlled this way.

At present, no legislative efforts are being made to create specific policies and legislation to regulate and manage biomedical waste.

2.

Current Biomedical Waste Management Practices at Public Facilities There is one major public hospital on the island, the 228-bed Princess Margaret Hospital. Hospital management reported and produced a copy of a BMW policy document for this facility. This policy document was developed in January 2002 and the copy produced had ‘Draft’ stamped on it. The hospital administration admitted that this policy document was not currently being used or followed.

Other BMW management practices observed and/or reported to be standard operating procedure at the Princess Margaret Hospital were:  Color-coded bags—red and yellow—were observed, but inappropriately used (see Pictures 28, 29 and 30).

Therefore, both general and

biomedical waste streams are effectively co-mingled and would have to be considered hazardous. It appears that bags are just simply placed where there is a need without any regard being paid to their color.  Workers with the job title of ‘Grounds’ men are the designated personnel assigned to collect and remove hospital waste and other waste to either the main collection skips (see Pictures 28) or the gasifer for biomedical waste (see Pictures 31).

39 o

Grounds men are inappropriately using wheeled biomedical waste containers to collect other waste such as yard clippings (see Pictures 32 and 33).

 In addition to standard, puncture-resistant, properly labeled sharp containers (see Pictures 34), empty bleach containers and other types of containers (e.g., empty reagent containers, cardboard boxes, other empty liquid detergent containers) are being used to collect sharps (see Picture 35).  Non-biomedical waste was frequently observed in red bags (see Picture 36).  Minimal signage on BMW management policy or best practices was observed in all parts of the facility that was toured.  There are isolation rooms within each ward; however, biomedical waste from any patient treated in these rooms is collected and combined with the other waste coming from the rest of the ward.  When the hospital’s gasifier is not working, Solid Waste Management Authority workers take biomedical waste to a sanitary landfill located in Fond Cole where it is placed in special cells.  Records are kept by means of logs of the amounts of biomedical waste generated.  Used chemicals for developing and fixing X-ray films are routinely disposed of down the drain.

3.

Current Biomedical Waste Management Practices at Private Facilities The Justin Fadipe Medical Centre was visited and a tour of the facilities taken with Matron Mariann John Baptiste.

Practices reported and observed at this facility were as follows:  No BMW-specific policy document/manual has been developed for this facility.  Both black (mainly) and yellow (in a few places) bags are being used to collect biomedical waste (see Picture 37).  Empty bleach bottles are used to collect sharps (see Picture 37).  Body parts are buried on site.

40

With respect to waste management practices by private doctors, information was obtained via a phone interview with Dr. Spencer St. Luce, President of the Dominica Medical Association. Dr. St. Luce reported that the current practice by most private doctors is to put all their medical waste in black bags, which are then collected along with other general waste by the Solid Waste Management Corporation.

4.

Biomedical Waste Treatment and Disposal Technology Used At the Princess Margaret Hospital, a Brookes gasifier has been installed and commissioned since February, 2007 (see Pictures 31 and 38). From the start of its commissioning, there have been teething problems with its operation and functionality. Due to the tropical clime, this type of burner has required modification. Additionally, no fail-safe mechanism exists on the gasifier, which means that a problem in one part of the gasifier causes the whole unit to fail. It appears, however, that most of these problems have been or will be ironed out shortly.

On the day this facility was toured, the gasifier was working and its operation observed. The following points were noted:  The gasifier is operated twice a week. Loads are approximately 1000 lb. Therefore approximately 2000 lb are disposed of per week.  The gasifier is used to dispose of body parts, as well as unused or expired pharmaceuticals.  A typical burn runs for about 6–8 hours (see Picture 38).  For liquid waste, the gasifier consumes approximately 7 gallons/hr or 42 gallons/cycle.  A person with minimal education can operate the gasifier.

However, to

maintain, diagnose, tweak operating parameters and effect repairs, does require someone with advanced knowledge. Therefore, Mr. Fountaine, who has a Bachelor’s degree in Electrical Engineering, operates the gasifier.

41 5.

Training of Health care Personnel in Biomedical Waste Management Concepts In general, health care personnel in both the public and private health care sectors have not received systematic, specific training in BMW management and concepts. Such training, if given at all, is usually incorporated into on-the-job training activities, typically given by the facility’s Infectious Control Nurse, if it is a public hospital, or the facility’s head nurse if it is a private health care facility.

At the Princess Margaret Hospital, nurses and other hospital personnel, such as domestic workers, did receive some BMW management training in June 2007, as part of a presentation on food safety done by Mr. Slyvester St. Ville, the District Environmental Health Officer, and Mr. Morrison Macpherson.

6.

Transportation and Disposal of Biomedical Waste A refrigerated truck specifically designed to handle and transport biomedical waste was procured via a Caribbean Development Bank (CDB) loan in 2005. However, it has never been used. It currently sits parked next to the Gasifier Unit at the Princess Margaret Hospital (see Picture 39). The main reason given as to its non-use was cost issues.

Currently, resources to pay someone a yearly salary to drive this

vehicle are not available.

7.

Biomedical Waste Recording, Tracking, and Audit Systems BMW record (logging) systems, either in the public or private health care systems, do not currently exist to document the amount, type, and fate of biomedical waste. Therefore, data on the amount and sub-types of biomedical waste being generated are not available.

With respect to systems for tracking the movement of biomedical waste from the generators (cradle) of such waste to its final end point (grave), none exists at present, either in the public or private health care systems.

The government does not have an audit system in place to monitor current BMW management policies and practices at either public or private health care facilities.

42 Table 8 Summary of Biomedical Waste Management Practices Audit in the Commonwealth of Dominica, 2007 Audit Area Regulatory Environment Government BMW Policy/Plan BMW-specific Legislation/Regulations Proposed BMW-specific Legislation

Status

Comments

No No No


Yes No Yes Poor No Yes No N/A No Yes No




No Rare

BMW Treatment Technology Type (incinerator, pits, gasifier, landfill, etc.) Reliability of operations (Poor, Fair, Good)

Gasifier Fair

Handling and Transportation of BMW Specialized vehicle used

No

Driver and handlers trained Landfill disposal procedure documented

No No

BMW Record and Tracking Systems Amounts and type of BMW recorded

Yes

Current BMW procedures being audited

No


Policy exists only in draft version


Very few (token) signs observed

Initial startup problems; most rectified

Specialized vehicle available but never been used.

Reported that logs kept but these were not seen.

43 3.5

Grenada

Date visited: November 21–22, 2007

3.5.1

General Background

The island of Grenada, which is located north of Trinidad & Tobago between the Atlantic Ocean and the Caribbean Sea, occupies approximately 132.8 sq mi, making it about twice the size of Washington, D.C.

The state of Grenada actually comprises three islands:

Grenada, Carriacou, and Petite Martinique. On the island of Grenada, there are just under 90,000 residents, who are primarily of African descent. Approximately 7,000 persons inhabit the other two islands.

Grenada is divided into six parishes: St. Andrew, St. David, St. George, St. John, St. Mark, St. Patrick, and two dependencies, Carriacou and Petit Martinique.

A member of the

Commonwealth of Nations, the country received its independence from the United Kingdom in 1974.

The total fertility rate for Grenada is 2.34 children born per woman.

Some

demographic and mortality data, sourced from the Pan American Health Organization (PAHO), are provided in Table 9.

Table 9

Some demographic and mortality data for Grenada selected demographic indicators—2006*




90

22.1

0.6


63.1

66.7

selected mortality indicators maternal mortality ratio (100,000) lb





2002 19.6 2002 754.9 477.6 720.3 554.3 790.5 412.7 * Adapted from Health situation in the Americas Basic Indicators 2006, Pan American Health Organization.

44 3.5.2


All public health care facilities are managed and run by the Ministry of Health, Social Security, the Environment and Ecclesiastical Relations (MOH). There is one (1) main public hospital, the 198-bed St. George’s General Hospital, located in the capital St. George’s. Additionally, there are two (2) other smaller district hospitals—the Princess Alice Hospital, located in the parish of St. Andrew and the Princess Royal Hospital, located in Carriacou. Additional health care services are also provided from 33 health care centers/clinics distributed throughout the three islands.

Private health care is available but mostly limited to ambulatory care, laboratory testing centers, and family planning services. There are two (2) major private hospitals, the St. Augustine Medical Associates Hospital and the St. Joseph’s Hospital. Additionally, there is one medical school—St. George’s University—that is located in the parish of St. George.

There are approximately 50 licensed doctors who are actively practicing medicine on the island.

3.5.3



Persons Interviewed  Dr. Christine La Grenade

St. George’s General Hospital

   

Dr. Bert Brathwaite, Director Medical Services Mr. Terron Gilchrist, Director Hospital Services Nurse Jennifer Bain Thomas, Acting Infectious Control Nurse Ms. Arlene Archibald, Laboratory Quality Control Officer

Grenada Solid Waste Management Authority (GSWMA)



Mr. Selby Dabrao, General Manager

Grenada Medical Association



Dr. Robert Yearwood, President

St. Augustine Medical Services Inc



Dr. L.N. Amechi, MD, Managing Director

45 3.5.4


1.

Biomedical Waste Policies, Legislation, and Regulations While there is a Waste Management Act (2001), which governs the management of waste—both hazardous and non-hazardous—there do not currently exist legislation and attendant regulations that specifically address BMW management.

In December 2005, the World Bank through an HIV/AIDS Prevention and Control Project funded the development of a Biomedical Waste Management Manual for health care personnel in Grenada. This manual is not presently being used pending training of health care personnel on how to use and apply it in their individual facilities.

In 2007, a Biomedical Waste Management Committee was formed, again funded through the World Bank HIV/AIDS Prevention and Control Project. This committee, among other things, is helping to steer and coordinate the effort of a legal consultant who has been hired to develop three BMW-related documents:

1. Biomedical Waste Policy Paper 2. Technical Guidelines for the Management of Biomedical Wastes 3. Biomedical Waste Regulations

Advanced drafts of all three documents are now being reviewed with the anticipation that they will soon be sent to Cabinet for approval within the very short term.

2.

Current Biomedical Waste Management Practices at Public Facilities At the St. George’s General Hospital, there are no written guidelines with respect to segregation, collection, storage, and disposal of biomedical waste. It is reported that the same situation applies to all other health care facilities in Grenada, Carriacou, and Petite Martinique.

The Director of Hospital Services mentioned that an

assessment of the hospital’s BMW management practices was made around 2002/3, which resulted in a draft BMW policy. He was not able, however, to produce a copy for inspection.

46 Although a hospital BMW policy and/or manual does not exist, on walk-through of the facility, it was clear that attempts were being made to segregate biomedical waste from the general waste stream and have it treated differently from other types of waste. For example, in all the wards and laboratories toured, sharp containers were observed that appeared to be actively used for collecting and separating sharps from the other types of biomedical waste.

Other practices reported to be standard operating procedure at the St. George’s General Hospital were:  Color-coded bags were observed and reported to be used as follows: o

Red bags – biomedical waste, including placentas, body parts, etc.

o

Green bags – soiled linens

o

Black bags – general waste

 Sharps are put into appropriate sharp containers. Most of these containers, however, are not covered due to the current practices outlined below: o

Sharps are initially put in kidney dishes and then put into small sharp containers (see Picture 40).

o

These containers are then emptied into larger sharp containers (see Picture 41).

o

These larger sharp containers are then themselves emptied into one or two large sharp containers.

o

The large sharp containers are then taken by workers whose job title is ‘Grounds’ men, to the incinerator and emptied into either large cardboard boxes or 50-gallon blue containers (see Picture 42). Sharps from these large blue containers are then manually shoveled into the incinerator (see Pictures 43, 44 and 45).

o

The Grounds men disinfect the empty sharp containers before placing them back into the wards.

o

The above process is fraught with much danger to the Grounds men in particular, and increases the potential for the spread of infectious diseases.

 Non-biomedical waste was frequently observed in red bags (see Picture 46).

47  Red and black bags are initially stored together (see Picture 47) before being sent to different end points—red bags to the incinerator, black bags to the collection skip located at the front of the hospital. Therefore, both general and biomedical waste streams are effectively co-mingled and would be considered to be hazardous.  In the clinical laboratory, biomedical waste is put into red or clear bags that have a biohazard symbol (see Picture 48) and then autoclaved (see Picture 49) before being removed by the Grounds men to the incinerator. There is no system in place, however, to clearly identify which bags have been autoclaved and which have not.  In the pathology laboratory, contaminated containers are chemically disinfected before re-use.  Grounds men are the designated personnel assigned to collect and remove waste bags—black, green, and red—to their respective collection points.  No signage on BMW management policy or best practices was observed in any part of the facility that was toured.  The hospital does not have a policy on how to dispose of old or spent chemicals.

Currently, these are stored in a small room located in the

clinical laboratory (see Pictures 50 and 51).  Used chemicals for developing and fixing X-ray films are routinely disposed of down the drain.

3.

Current Biomedical Waste Management Practices at Private Facilities The St. Augustine Medical Services Inc. (SAMS), a 12-bed facility, is the largest private hospital on the island. An interview and tour of the facility with the managing director, Dr. L. N. Amechi, revealed the following BMW management practices and/or protocols:  St. Augustine Medical Services Inc. does not have a written BMW management policy.  Health care personnel operating at this facility have not received any specific BMW management training.  Red, biohazard bags are only used in the hospital’s laboratory; black bags are used throughout the rest of the facility.

48 o

An effort is being made to place only very heavily contaminated biomedical waste in red bags; bandages and dressings not heavily contaminated are being placed in regular black garbage bags. This waste is collected by a private contractor who subsequently takes it to the municipal landfill located at Perseverance.

 Signage on appropriate biomedical waste protocol was observed only in the laboratory (see Picture 52).  Body parts are taken in the director’s personal vehicle to a private crematorium for disposal.

With respect to waste management practices by private doctors, information was obtained via phone interview with Dr. Yearwood, President of the Grenada Medical Association. Dr. Yearwood reported that although a mechanism had been devised to collect biomedical waste, and in particular sharps from private practices, no practical mechanism (e.g., on how to collect fees for this service) were implemented and so, for all intent and purposes, doctors dispose of their biomedical waste in the way that they deem best. For doctors who have appointments with government run health care facilities, it is reported that they tend to bring their sharps to these facilities to be disposed of. As for other biomedical waste, such as soiled or bloodied bandages and dressings, it appears that doctors are putting these waste out along with other regular waste.

4.

Biomedical Waste Treatment and Disposal Technology Used At the St. George’s General hospital, all biomedical waste is collected by the Grounds men and taken to the hospital’s incinerator located at the back of the facility (see Picture 53). If the incinerator is not working (e.g., it was down recently for approximately two weeks), biomedical waste is then taken to a nearby privately owned crematorium, La Qua Brother’s Funeral Home, to be disposed of in their incinerator.

At the St. Augustine Medical Services Inc. (SAMS), red-bag waste, along with all sharp containers, is burned in a concrete pit located on the western side of the facility (see Picture 54).

St. Augustine Medical Services Inc. also receives the

biomedical waste from a dialysis clinic and burns it in their pit.

49

5.

Training of Health care Personnel in Biomedical Waste Management Concepts Health care personnel have not received systematic, specific training in BMW management and concepts. Such training, if given at all, is usually incorporated into on-the-job training activities, typically given by the facility’s Infectious Control Nurse.

At St. George’s General Hospital, Grounds men have not received any training in proper procedures to use when handling biomedical waste.

6.

Transportation and Disposal of Biomedical Waste The Grenada Solid Waste Management Authority (SWMA) does not handle the transport and disposal of biomedical waste in Grenada. The Ministry of Health has awarded a contract to a private waste hauler to bring biomedical waste from all public health care centers to either the St. George’s General Hospital or the Princess Alice Hospital for disposal. Large private health care facilities are also responsible for making arrangements (if required) to remove their biomedical waste off-site to the nearest facility that has an incinerator.

The ash from the St. George’s General hospital’s incinerator, however, is taken by the SWMA to the Perseverance Landfill site for disposal (see Picture 55).

7.


With respect to systems for tracking the movement of BMW from the generators (cradle) of such waste to its final end point (grave), none exist at present, either in the public or private health care systems.

50 So far, the government does not have an audit system in place to monitor current BMW management policies and practices at either public or private health care facilities.

51 Table 10 Summary of Biomedical Waste Management Practices Audit in Grenada, 2007 Audit Area Regulatory Environment Government BMW Policy/Plan BMW-specific Legislation/Regulations

Status No No

Proposed BMW-specific Legislation

Yes


No No Yes Fair No Yes No No No No No

Current Practices (Private HC Facilities)* BMW facility-specific policy/manual Waste minimization (RRR) observed Waste segregation observed Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate

No No No No Yes Yes N/A No Yes No


No Rare

BMW Treatment Technology Type (incinerator, oven, gasifier, etc.) Reliability of operations (Poor, Fair, Good) Handling and Transportation of BMW Specialized vehicle used Driver and handlers trained Landfill disposal procedure documented

Comments BMW policy being drafted BMW technical guidelines and regulations being drafted

Only in Laboratory

Incinerator Fair

No No No

BMW Record and Tracking Systems Amounts and type of BMW recorded No Current BMW procedures being audited No * Based on information garnered from interview and tour of St. Augustine Medical Services Inc. Hospital with Managing Director.

52 3.6

Montserrat

Date visited: August 6, 2007

3.6.1

General Background

Montserrat is a British overseas territory, located in the Leeward Islands, and part of the chain of islands called the Lesser Antilles in the Caribbean Sea. It is approximately 16 km (10 miles) long and 11 km (7 miles) wide, and has a 40 km coastline.

Its Georgian-era capital city of Plymouth was destroyed and two-thirds of the island's population forced to flee abroad owing to an eruption of the previously dormant Soufrière Hills volcano that began on July 18, 1995. Up to this day, the eruption continues, albeit on a much reduced scale (see Picture 56), the damage being confined to the areas around Plymouth and its docking facilities and the former W.H. Bramble Airport (see Picture 57). An exclusion zone starting from the south coast of the island and extending north to parts of the Belham Valley has been closed due to an increase in the size of the existing volcanic dome. This zone includes St. George's Hill, which provided visitors with a spectacular view of the volcano and the destruction it has wrought upon the capital. A new airport at Geralds in the northern part of the island opened in 2005. Some selected demographic and mortality data, sourced from the Pan American Health Organization (PAHO), are provided in Table 11.

53 Table 11

Selected demographic and mortality data for Montserrat demographic indicators—2006*




9

17.6

0.1


76.7

81.1






2005 2005 639.8 472.4 656.2 474.1 624.1 473.8 * Adapted from Health situation in the Americas Basic Indicators 2006, Pan American Health Organization.

3.6.2


There is one (1) main public hospital on the island—Glendon (St. John) hospital, a 30-bed facility—and four (4) health care clinics.

Private health care is available but limited to ambulatory care and family planning services. There is only one (1) laboratory located at the Glendon (St. John) hospital. However, no pathology is done in the laboratory and all pathology testing is done offshore, mostly in Antigua.

There are no private hospitals.

3.6.3


Facility/Institution Visited Glendon Hospital (St. John)

Persons Interviewed  Mr. Schon Daway, Hospital Facilities Manager  Mr. Trevor Howe, Chief Environmental Health Officer  Nurse Gibson

54 3.6.4


1.

Biomedical Waste Policies, Legislation, and Regulations While there is Solid Waste Legislation (1996), there are at present no specific BMW regulations nor are any currently being planned.

2.

Current Biomedical Waste Management Practices at Public Facilities No facility-specific BMW management policy and manual has not been developed for the one hospital on the island, the public Glendon (St. John) Hospital.

Other practices observed or reported to be standard operating procedure at Glendon (St. John) Hospital were:  Limited biomedical waste segregation is taking place: o

Sharps are collected in sharp containers.

o

Color-coded bags were once used but not at present with the exception of waste generated in the hospital laboratory for which only red bags are used.

o

It appears, however, that even if biomedical waste is separated from other waste streams, it is still eventually combined with other waste and then taken to the New Windward Landfill.

 Expired and/or used drugs are either burned in the incinerator or taken to the landfill. There is currently no clear policy on how to dispose of such waste.  There is no autoclave in the laboratory, since the hospital does not do any pathology.  No signage on BMW management policy or best practices was observed in any part of the facility that was toured.  ‘Orderlies’ remove waste from wards to the main waste collection area located at the back of the hospital. o

Orderly job descriptions do not specifically mention BMW handling as part of their duties.

 No record system is in place to capture and record the amount of general and biomedical waste generated.

55  Used chemicals for developing and fixing X-ray films are routinely disposed of down the drain.

3.

Current Biomedical Waste Management Practices at Private Facilities There is no major private hospital on the island.

With respect to waste management practices by private doctors, no information was obtained on what is the common practice of local doctors with respect to disposing of their biomedical waste.

Given, however, that the Glendon (St. John) hospital

administration did not report that they routinely receive biomedical waste from private practices, it appears that such waste is being disposed of by private doctors along with other municipal waste.

4.

Biomedical Waste Treatment and Disposal Technology Used The on-site incinerator at Glendon (St. John) Hospital is used to dispose of sharps, body parts, red bag waste generated in the hospital laboratory, and some expired and/or used pharmaceuticals. All other biomedical waste is collected into a large skip and then taken to the island’s sole landfill, New Windward Landfill, for burial.

The hospital’s incinerator is seven years old and in need of urgent maintenance works (see Picture 58). The afterburner of the incinerator is not working; therefore the maximum attainable temperature is now limited to approximately 350–400˚C.

5.

Training of Health care Personnel in Biomedical Waste Management Concepts Health care personnel have not received systematic, specific training in BMW management and concepts. Such training, if given at all, is usually incorporated into on-the-job training activities, typically as part of the yearly held Infectious Control Training Program given by the chief environmental health officer.

The Chief Environmental Health Officer attended a CEHI biomedical waste management workshop, held in St. Lucia, in 2002.

56 6.

Transportation and Disposal of Biomedical Waste Ash generated by the incinerator is placed in red bins and taken via pick-up truck by the hospital’s facility manager to the New Windward Landfill (see Picture 60). Such waste is not routinely buried (see Pictures 61 and 62). All other biomedical waste generated at Glendon (St. John) hospital is first combined and aggregated with other waste streams in an area located in a walled-off section right next to the incinerator (see Picture 63). Afterwards, a private waste hauler collects all of this waste once a week and then transports it to the landfill (see Picture 64).

7.

Biomedical Waste Recording, Tracking, and Audit Systems BMW record (logging) systems, either in the public or private health care systems, do not currently exist to document the amount, type, and fate of biomedical waste. Therefore, data on the amount and sub-types of biomedical wastes being generated are not available.

With respect to systems for tracking the movement of biomedical waste from the generators (cradle) of such waste to its final end point (grave), none currently exists, either in the public or private health care systems.

The government does not have an audit system in place to monitor current BMW management policies and practices at either public or private health care facilities.

57 Table 12 Summary of Biomedical Waste Management Practices Audit in Montserrat, 2007 Audit Area Regulatory Environment Government BMW Policy/Plan BMW-specific Legislation/Regulations Proposed BMW-specific Legislation

Status No No No

Current Practices (Public HC Facilities) BMW facility-specific policy/manual Waste minimization (RRR) observed Waste segregation practices observed

No No Yes

Waste segregation practices effectiveness Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate

Poor No Yes No N/A No No No

Current Practices (Private HC Facilities)* BMW facility-specific policy/manual Waste minimization (RRR) observed Waste segregation observed Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A


No Rare

BMW Treatment Technology Type (incinerator, pits, gasifier, landfills, etc.) Reliability of operations (Poor, Fair, Good)

Incinerator Fair


No No No


No No

* None visited.

Comments

Mainly limited to sharps and laboratory waste

Limited only to laboratory No ongoing oncology program

Current maximum temperature < 400˚C

58 3.7

St. Kitts (Christopher) & Nevis

Date visited: August 8–10, 2007

3.7.1

General Background

Located in the Caribbean Sea, the twin island Federation of Saint Kitts (Christopher) & Nevis occupies a total of 261 sq km (Saint Kitts: 168 sq km, Nevis: 93 sq km). The nation is roughly one and one-half times the size of Washington, DC and is approximately one-third the distance from Puerto Rico to Trinidad & Tobago. The country is home to just under 40,000 (estimated: 38,958 in 2006) Kittitians and Nevisians, who are primarily of African descent.

The country is divided into 14 parishes: Saint George Basseterre, Saint Peter Basseterre, Saint Mary Cayon, Christ Church Nichola Town, Saint John Capesterre, Saint Paul Capesterre, Saint Anne Sandy Point, Saint Thomas Middle Island and Trinity Palmetto Point; Saint Paul Charlestown, Saint Thomas Lowland, Saint James Windward, Saint George Gingerland, and Saint John Fig Tree. A member of the Commonwealth of Nations, Saint Kitts & Nevis received its independence from the United Kingdom in 1983. Some demographic and mortality data, sourced from the Pan American Health Organization (PAHO), are provided in Table 13.

59 Table 13

Selected demographic and mortality data for St. Kitts (Christopher) & Nevis

demographic indicators—2006* total population (thousands)



39

18.0

0.3


69.6

75.4






2005 n/a 9 2005 1,933.9 1,767.1 2,072.1 2,083.8 1,800.4 1,496.4 * Adapted from Health situation in the Americas Basic Indicators 2006, Pan American Health Organization.

3.7.2

General Organization of the Health care System

All public health care facilities are organized and managed by the Ministry of Health. On the island of St. Kitts, there is one (1) main public hospital, the Joseph Nathanael France (JNF) Hospital, and two (2) outpost hospitals—the Mary Charles and Pogson Hospitals. Additionally, there is one (1) geriatric home, Cardin Home, and two (2) laboratories—one located at JNF Hospital and the other is privately run. Services at these facilities are further supplemented and supported by 11 health care centers. On the island of Nevis, there is one (1) main hospital, the Princess Alexandra Hospital, six (6) health centers and one (1) main private laboratory, Avalon Laboratory.

Private health care is available but mostly limited to ambulatory care. There is no major private hospital on the island. There are, several medical schools, with Ross School of Veterinary Medicine being the largest, as well as three (3) monkey farms, which conduct research activities.

60 3.7.3



Persons Interviewed  Mr. Elvis J. Newton, Permanent Secretary  Ms. Sharon Gillard, Finance Office

Joseph Nathanael France Hospital

  

Solid Waste (NSWMA)

Management

Authority

   

Mr. France, Medical Stores Manager Ms. Jasmine Hanley, Hospital Laboratory Manager Mr. George Richards, Cardin (Geriatric) Home Supervisor Mr. Willmon McCall, Solid Waste Manager Ms. Hazel Williams-Roberts, Director of Community Based Health Services Mr. Errol A. Rawlins, Chief Environmental Health Officer Ms. Margureite O’Brien-France, Coordinator of Community Nursing

3.7.4


1.

Biomedical Waste Policies, Legislation, and Regulations There currently exist two pieces of legislation that govern the management of waste in general—the Saint Christopher-Nevis Solid Waste Management Act (1996) and the Litter Abatement Act (1989). Plans are afoot to repeal both pieces of legislation and replace them with the Solid Waste Management Act (2007). No specific BMW legislation is currently being planned.

2.

Current Biomedical Waste Management Practices at Public Facilities No facility-specific BMW management policy documents and/or manuals have been developed for any of the health care facilities visited.

The MOH has, however,

initiated and contracted a consultant to develop a BMW policy that would apply to all public health care facilities on the island.

The consultant has submitted several

reports and a number of his recommendations are already being implemented.

Although there is at present no facility-specific BMW policy and management plan at the main hospital, the Joseph Nathanael France (JNF) Hospital, it is clear that some level of BMW management does take place. Practices observed and/or reported by

61 hospital administrative staff, while taking a walk-through of this facility, are itemized below:  Expired and/or used drugs are either burned in an on-site static-grate, single-chamber incinerator (see Picture 65 and 66), dissolved in water and washed into the sewer system (e.g., vitamin C), or taken to the landfill. There is currently no clear policy on how to dispose of such waste.  Limited waste segregation is taking place: o

No color-coded bags are used.

o

Sharps are mainly put into empty bleach bottles or sharp containers (see Picture 67 and 68). Sometimes, cardboard boxes are used (see Picture 69).

o

Biomedical waste was observed in several areas of the hospital in bins without any bag (see Picture 70).

o

In the laboratory, cardboard “Burn-up” bins (see Picture 71 and 72), which have clear plastic bags inside, are used; these bins are then sent to the hospital’s on-site static-grate, single-chamber incinerator to be burned.

o

Microbiology plates are not autoclaved (the laboratory does not have one) but are placed directly into Bag-up bins (see Picture 72).

 The Solid Waste Management Authority collects all other waste from the hospital, i.e., waste that has not been burned in the hospital’s incinerator, and takes it to Conaree Landfill. o

In the absence of color-coded bags, it is quite likely that ‘soft’ biomedical waste, such as blood-stained bandages and dressing, enters the hospital’s collection skip, which is used to collect its nonhazardous waste streams (see Picture 73).

 Body parts are put in containers and then burned in the hospital’s incinerator.  Workers with the job title of ‘Grounds’ men are the designated personnel assigned to collect and remove all waste bags, either to the main collection skips for removal by Solid Waste Management personnel or to the on-site incinerator for burning.

62  No signage on BMW management policy or best practices was observed in any part of the grounds that were toured.  The JNF hospital does not have any policy/procedures on how to properly dispose of other types of hazardous waste, e.g., chemicals such as xylene, toluene, phenol, formaldehyde, etc. (see Picture 74). o

In the X-ray department, spent chemicals for developing and fixing Xray films are routinely disposed of down the drain.

As for the 11 other health centers scattered throughout the island,

standard

operating practices reported by Ministry of Health (MOH) and Solid Waste Management Authority (SWMA) officials as to how biomedical waste is handled, treated, and disposed of are itemized below:  Cardboard sharp containers are used.  A driver assigned from the MOH collects all sharp containers once/week and brings them to the JNF hospital to be disposed of in the hospital’s incinerator.  Each health care center has a small open pit that is used to dispose of other biomedical waste.  Ash from these pits and the JNF incinerator is bagged and then taken by SWMA personnel to the Conaree landfill.

3.

Current Biomedical Waste Management Practices at Private Facilities There are no private hospitals on the island. There are, however, at least three monkey research farms and two medical schools that are in operation. Solid Waste Management Authority officials report that biomedical waste from the monkey farms is collected separately and brought directly to the landfill where it is then buried in special cells.

With respect to waste management practices by private doctors, it was reported by SWMA officials that doctors who are attached to the JNF hospital tend to take their biomedical waste there for disposal. It is not clear what other doctors on the island are doing.

63 4.

Biomedical Waste Treatment and Disposal Technology Used Open and semi-closed concrete pits are used throughout the island to dispose of biomedical waste.

At the JNF hospital, a concrete, static-grate, single-chamber

incinerator has recently been built, replacing a similarly designed previous incinerator. Based on the recommendation of the consultant hired to review and help establish a proper BMW management system in St. Kitts, plans are to have a more sophisticated double-chamber pyrolytic incinerator installed at the JNF, which would have the capacity to handle all of the biomedical waste generated on the island.

5.

Training of Health Care Personnel in Biomedical Waste Management Concepts In the past, very little training in BMW management practices has been given to health care personnel. However, in recent times, with the hiring of a consultant to review and propose a BMW management system and policy for the island, at least two training sessions (2006/2007) have been given. More are being planned.

6.

Transportation and Disposal of Biomedical Waste The SWMA workers take biomedical waste not disposed of on-site to the Conaree landfill where it is buried in special cells.

7.

Biomedical Waste Recording, Tracking, and Audit Systems BMW record (logging) systems, either in the public or private health care systems, do not currently exist to document the amount, type, and fate of biomedical waste. Therefore, data on the amount and sub-types of biomedical waste currently being generated are not available.

With respect to systems for tracking the movement of biomedical waste from the generators (cradle) of such waste to its final end point (grave), none currently exist, either in the public or private health care systems.

The government does not as yet have an audit system in place to monitor current BMW management policies and practices at either public or private health care facilities.

64 Table 14 Summary of Biomedical Waste Management Practices Audit in St. Kitts (Christopher), 2007

Audit Area Regulatory Environment Government BMW Policy/Plan BMW-specific Legislation Proposed BMW-specific Legislation

Status No No No

Current Practices (Public HC Facilities) BMW facility-specific policy/manual Waste minimization (RRR) observed Waste segregation practices observed Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate

No No Yes No No No No No None No


No No Yes No No No No No None -


Yes Once/yr

BMW Treatment Technology Type (incinerator, oven, gasifier, etc.) Reliability of operations

Incinerator Fair


No No No


No No


Comments Being developed by consultant BMW management likely to be incorporated under new Solid Waste Management Act (2007)

Mainly limited to sharps

Limited to sharps

Static-grate, single-chamber

65 3.7.5

1.

Review of Biomedical Waste Management Practices: Nevis


Persons Interviewed  Ms. Jocelyn Liburd, Permanent Secretary, MOH, Nevis Island Administration  Ms. Carlyn Lawrence, Solid Waste Manager, Nevis  Mr. Gladstone Edwards, Solid Waste Supervisor  Mr. Javier Ottley, EH Services, EHO

Alexandra Hospital

  

Ms. Dawn Richardson, Laboratory Technician Mr. Bernard Liburd, Hospital Maintenance Mr. George Meade, Hospital Maintenance

Biomedical Waste Policies, Legislation, and Regulations Same as that given in Section 3.7.4.

2.

Current Biomedical Waste Management Practices at Public Facilities No facility-specific BMW management policy documents and manuals have been developed for the Princess Alexandra Hospital; however, as mentioned above, the MOH has initiated and contracted a consultant to develop a BMW policy that would cover both St. Kitts and Nevis. The consultant has already submitted several reports and some of his recommendations are already being implemented.

Despite the absence of a facility-specific BMW policy and management plan at the Princess Alexandra Hospital, segregation of sharps is taking place.

Practices

observed and/or reported by hospital administrative staff, while taking a walk-through of this facility, are itemized below:  Biomedical waste segregation is primarily limited to sharps only. o

Sharps are usually put in plastic, puncture-resistant containers. Other containers, such as cardboard boxes, are sometimes used.

o

Body parts are taken to an incinerator owned and operated by the University of the Americas, a private, for-profit institution.

o

All other biomedical waste generated by the Princess Alexandra Hospital is collected by Solid Waste Management personnel and taken to the Lowgrounds Sanitary Landfill (opened in 2002)

66  The hospital laboratory does not have an autoclave since no microbiology or pathology testing is done on the island, but samples are sent to St. Kitts for testing.  No color-coded bags are used. o

In the absence of color-coded bags, biomedical waste, with the exception of sharps and body parts, is combined with all other waste streams and put into the collection skip located at the back of the facility.

 Expired drugs and/or injectables are taken and stored in a shed at the Lowgrounds Sanitary Landfill; some are subsequently buried. o

No clear policy exists on what to do with such pharmaceutical waste.

 Workers with the job title of ‘Orderlies’ are the designated personnel assigned to collect and remove all waste bags, either to the main collection skips for removal by Solid Waste Management personnel or to the on-site oven for burning.  Signage on BMW management policy or best practices was observed in only one ward of the facility that was toured.  Used chemicals for developing and fixing X-ray films are routinely disposed of down the drain.

3.

Current Biomedical Waste Management Practices at Private Facilities There are no private hospitals on the island. There is, however, one medical school, the Medical University of the Americas (MUA), which operates on the island. The MUA disposes of all its biomedical waste in an on-site incinerator.

With respect to waste management practices by private doctors, it was reported by SWMA officials that doctors who are attached to the Princess Alexandra Hospital tend to take their biomedical waste—in particular sharps—there for disposal. It is not clear what other doctors on the island are doing.

It should be noted that a new arrangement, proposed by the MOH, to distribute sharp containers to homes that require such (e.g., diabetics) is soon to be implemented. When filled, MOH personnel would collect these containers.

67 4.

Biomedical Waste Treatment and Disposal Technology Used All sharps collected from each health center are taken to an incinerator owned and operated by the University of the Americas, a private, for-profit institution for incineration. This arrangement has been in place for approximately two years.

5.

Training of Health Care Personnel in Biomedical Waste Management Concepts In the past, very little training in BMW management practices has been given to health care personnel in Nevis. However, with the hiring of a consultant to review and propose a BMW management system and policy for both St. Kitts and Nevis, at least one training session (2006) has been given. More are being planned.

6.

Transportation and Disposal of Biomedical Waste In addition to the Princess Alexandra Hospital, there are six (6) health centers scattered throughout the island. Standard operating practices reported by Ministry of Health (MOH) and Solid Waste Management Authority (SWMA) officials as to how biomedical waste is handled, treated and disposed of, are itemized below:  An Environmental Health Officer designated by the MOH collects all sharps from each health care center and takes them to an incinerator owned and operated by the University of the Americas, a private, for-profit institution. This arrangement has been in place for approximately two years.  All other biomedical waste generated at these health care centers is combined with other municipal waste and taken to the Lowgrounds Sanitary Landfill.

7.


With respect to systems for tracking the movement of biomedical waste from the generators (cradle) of such waste to its final end point (grave), none presently exist, either in the public or private health care systems.

68

The government currently does not have an audit system in place to monitor existing BMW management policies and practices at either public or private health care facilities.

69 Table 15 Summary of Biomedical Waste Management Practices Audit in Nevis, 2007

Audit Area Regulatory Environment Government BMW Policy/Plan BMW-specific Legislation Proposed BMW-specific Legislation

Status No No No


No No Yes Poor No No No No No No No


No No Yes No No No No No None -


Yes Once/yr

BMW Treatment Technology Type (incinerator, pits, gasifier, etc.) Reliability of operations

Incinerator Good


No No No


No No


Comments Being developed by consultant BMW management likely to be incorporated under new Solid Waste Management Act (2007)

Mainly limited to sharps and body parts

Mainly limited to sharps

Privately owned

70 3.8

St. Lucia

Date visited: July 23–25, 2007

3.8.1

General Background

Saint Lucia, one of the Windward Islands of the Caribbean Sea, is approximately 40 km (25 mi) south of Martinique and 32 km (20 mi) north of Saint Vincent. The population was estimated at 160,758 in 2005. The 616 sq km (238 square miles) island is approximately 3.5 times the size of Washington, DC, and is divided into 10 quarters, called districts: Ansela-Raye, Castries, Choiseul, Dennery, Gros Islet, Canaries, Laborie, Micoud, Soufrière, and Vieux-Fort. Although the official language of the country is English, French patois is spoken as well. The majority of the population lives along the coast and the less mountainous regions of the north and south. Only 31 percent of the population lives in urban areas.

The island is estimated to have a total fertility rate of 2.21 children born per woman, and population growth rate of 1.28 percent per year. Some selected demographic and mortality data, sourced from the Pan American Health Organization (PAHO), are provided in Table 16.

71 Table 16

Selected demographic and mortality data for St. Lucia

selected demographic indicators—2006* total population (thousands)



162

18.8

1.1


71.4

74.4

selected mortality indicators maternal mortality ratio (100,000) lb





n/a 4 2004 16.2 2004 575.3 608.3 619.8 682.8 532.3 538.6 * Adapted from Health situation in the Americas Basic Indicators 2006, Pan American Health Organization.

3.8.2


All public health care facilities are managed and run by the Ministry of Health. There are five (5) hospitals: Victoria in the North (Castries), St. Jude Hospital in the south (Vieux-Fort), Soufrière Hospital (South-west) and Dennery Hospital (East coast), and one (1) mental facility, Golden Hope, located in Castries.

The hospitals are backed up by 31 health

centers, one (1) health outpost located in La Guerre Babonneau and one (1) polyclinic, the Gros-Islet Polyclinic, located at Gros-Islet. Medical and pharmaceutical services are made available at health centers and district hospitals.

St. Lucia has one (1) private hospital, Tapion, located in Castries. Additionally, private health care is available, but mostly limited to ambulatory care and family planning services. There are two (2) private laboratories and a private diagnostic center that conducts ultra sounds and other like services.

72 3.8.3

Facilities Visited and Persons Interviewed Facility/Institution Visited Ministry of Health

St. Lucia Solid Waste Management Authority (SLSWMA) Organization of Eastern Caribbean States (OECS)

Persons Interviewed  Mr. Darrel Montrope, Permanent Secretary  Mr. Wenn Gabriel, Chief Environmental Officer  Mr. A Griffith, Cuban Consultant attached to MOH  Mrs. Geraldine Lendor-Gabriel, General Manager 

Ms. Vergille Tadia Xavier, OECS Environment & Sustainable Development Unit (ESDU)

Caribbean Environmental Health Institute



Ms. Camille Roopnarine, Sanitary Engineer

Victoria Hospital

     

Mr. Hubert Emmanuel, Acting Director Ms. Brenda Calixte, Assist Director, Adm. Nurse Ruth Adesanya, Quality Improvement Coordinator Ms. Cornelia Jr Baptiste, Executive Housekeeper Nurse Berthia Mr. King – Head Groundsman

St. Jude Hospital

  

Mr. Paul Meroe, Hospital Director Ms. Annette Biscette, Head of Housekeeping Ms. Philippa Dornelly, Infectious Control Nurse

Tapion Hospital

  

Mrs. Sybil Martial, Hospital Director Dr. Stephen King Dr. Romel Daniel, Chief of Medicine

3.8.4


1.

Biomedical Waste Policies, Legislation, and Regulations While there is a Waste Management Act (2004), which does specify biomedical waste as “any solid waste containing human or animal fluids, flesh, bones or other body parts except hair,” no specific regulations and/or guidelines exist to outline how such waste should be handled, stored, and disposed of.

However, draft BMW

regulations and guidelines prepared with the assistance of the local Bureau of Standards are presently being reviewed by the Attorney General’s Legislative Drafting Department, and it is envisioned that coming out of this will be two new regulations:

1. The Waste Management (Biomedical Waste) Standards Regulations. 2. The Waste Management (Biomedical Waste) Transport, Treatment and Disposal Regulations.

73

These two new regulations will be made in accordance with provisions outlined in Section 51 (1) and (2) of the above-mentioned Waste Management Act (2004).

2.

Current Biomedical Waste Management Practices at Public Facilities At all of the facilities visited, there were clear, written policies and guidelines with respect to segregation, collection, storage, and disposal of biomedical waste. However, the degree to which these documents were being used varied from one health care institution to another.

Biomedical waste management practices observed and/or reported to be standard operating procedure at the Victoria Hospital were:  Red bags were seen and mostly used appropriately and consistently. Therefore, both general and biomedical waste streams are effectively segregated. o

Policy for putting item in red bag: “Once it has blood, put into red bag.”

o

Yellow bags are not used.

 Although a designated TB isolation ward does exist at Victoria Hospital, biomedical waste from infectious patients is not separated but combined with other biomedical waste generated at the facility.  Sharps are collected in sharp containers and then taken to a central storage area, which is located very near to the facility’s entrance. This area is not, however, secure, and can be easily accessed by anyone (see Pictures 75 and 76).  Cytotoxic waste is put into either red or black bags and then sent to the Medical Supplies Department for disposal.

The Medical Supplies

Department does not have any written policy on how such waste or pharmaceutical waste in general should be disposed of.  Workers with the job title of ‘Grounds’ men are the designated personnel assigned to collect and remove waste bags—black and red—to the main collection skips.  Signage on BMW management policy or best practices was observed in several parts of the facility that was toured (see Pictures 77 and 78).

74  Body parts are put into red bags and then stored in a freezer before being taken to the Deglos Sanitary Landfill for burial (see Pictures 79 and 80).  Used chemicals for developing and fixing X-ray films are routinely disposed of down the drain.

Biomedical waste management practices observed and/or reported to be standard operating procedure at the St. Jude Hospital were:  The use of color-coded bags is limited to red and black bags. Red bags were observed and reportedly used for all infectious waste, used drugs, chemotherapy drugs, laboratory specimens, and body parts. o

Policy for putting item in red bag: “Only if it has a ‘significant’ amount of blood, put into red bag. Slightly soiled bandages and dressings can be disposed of in black bags.”

(Compare this to Victoria Hospital

Policy.) o

Yellow bags are not used.

o

Hospital staff take red bags containing body parts to the Vieux Fort Solid Waste Dump for burial.

 Workers with the job title of ‘Grounds’ men collect and remove biomedical waste using an open trolley (see Picture 81) to the central waste storage room, which is located approximately in the center of the facility (see Picture 82). There is no lock on the door to this room.  Sharps are initially placed in wall-mounted wooden boxes (see Pictures 83 and 84) which are emptied by housekeeping staff into bigger sharp containers.  Liquid biomedical waste is put into a 10-gallon yellow container and stored in the central waste storage room (see Picture 82).  Although a designated TB isolation ward does exist at St. Jude Hospital, biomedical waste from infectious patients is not separated but combined with other biomedical waste generated at the facility.  A contractor (hired and managed by the SLSWMA) comes once a week to collect and remove all biomedical waste. o

Records (e.g., logs) are kept of the date and number of 35-gallon bins taken per week.

75  Signage on BMW management policy or best practices was observed in several parts of the facility that was toured (see Pictures 85 and 86).  Used chemicals for developing and fixing X-ray films are routinely disposed of down the drain.

3.

Current Biomedical Waste Management Practices at Private Facilities A phone interview was conducted with the Hospital Director, Ms. Marshall, and Dr. Stephen King, of Tapion, a 22-bed hospital facility and the largest private hospital on the island.

Biomedical waste management protocols and practices reported to be standard operating procedure at Tapion Hospital were:  Tapion does have a written facility-specific BMW management policy.  Red biohazard bags are used to collect all biomedical waste. All other types of waste, including pharmaceutical waste, are collected in black bags.  Sharps are collected using empty bleach bottles.  The hospital’s laboratory does not have an autoclave; all specimens and laboratory cultures are put in red bags and handled the same way as all other red bag waste.  Workers with the job title of ‘Porters’ are the designated personnel assigned to collect and remove biomedical waste from the wards to the biomedical waste storage area, which is located outside the facility’s laboratory.  A private waste-hauling contractor is used to remove biomedical waste from the facility to the Deglos Sanitary Landfill for autoclave treatment and then final disposal within the landfill.  Several health care personnel at Tapion have received some training in BMW management from workshops conducted by the St. Lucia Solid Waste Management Authority.

4.

Biomedical Waste Treatment and Disposal Technology Used Biomedical waste from all health care facilities is brought to the Deglos Sanitary Landfill, which uses an autoclave facility (steam sterilization with shredding) to treat

76 biomedical waste. Body parts are not put into the autoclave but buried directly in the landfill.

5.

Training of Health Care Personnel in Biomedical Waste Management Concepts Based on interviews with hospital administrators and senior nurses at the two major hospitals visited, BMW management training, if given at all, is typically given by the facility’s Infectious Control Nurse as part of on-the-job training activities for nurses.

Additionally, SLSWMA personnel have received extensive training in BMW management and handling. In 2002, a Canadian firm developed and presented a 1week ‘Train the Trainer’ workshop to train locals who could then train others in how to set up a BMW Management System. Also in 2002, with receipt of donor funding, training was given to health care orderlies, nurses, etc.

Recently, SLSWMA personnel have given one-hour presentations in proper BMW management at the two main hospitals. Such training does not appear, however, to be administered in a predicable and reliable manner.

6.

Transportation and Disposal of Biomedical Waste The collection of all waste, including biomedical waste, comes under the sole jurisdiction and responsibility of the St. Lucia Solid Waste Management Authority (SLSWMA). A National BMW Management Strategy document does exist, which is used by the SLSWMA to govern and guide its practices with respect to BMW management.

Based on a face-to-face interview with the General Manager of SLSWMA, the following information was obtained:  SLSWMA has only four (4) Enforcement Officers.  A dedicated, specialized vehicle is used to transport all biomedical waste to the Deglos Sanitary Landfill.  Incinerators are not used in St. Lucia; the main method used to dispose of biomedical waste is by autoclave (steam sterilization).

77 o

Body parts are not disposed of in the autoclave but are buried at the landfill.

 Handling of biomedical waste in the private health care setting: o

The SLSWMA has written to local doctors/dentists offering them ‘packages’ which basically requires the payment of weekly/monthly fees to collect and dispose of biomedical waste.

o

Initially, the response was very positive, but it is uncertain how many will actually sign up for following reasons: 

Presently, private doctors are permitted to bring their biomedical waste (primarily sharps) to either of the two major public hospitals for disposal at no charge. Doctors who work out of Tapion hospital, the largest private hospital on the island, also have the option to do the same with their biomedical waste.



There is no legislative mandate that requires doctors, dentists and any other generator of biomedical waste to bring such waste to any particular agency.

7.


With respect to systems for tracking the movement of biomedical waste from the generators (cradle) of such waste to its final end point (grave), none currently exists, either in the public or private health care systems.

Audits of BMW management practices at all public health care facilities are at present carried out by SLSWMA. On average, each public health care facility is visited at least once a year and an audit report generated.

78 Table 17

Summary of Biomedical Waste Management Practices Audit in St. Lucia,

2007 Audit Area Regulatory Environment Government BMW Policy/Plan BMW-specific Legislation/Regulations Proposed BMW-specific Legislation Current Practices (Public HC Facilities) BMW facility-specific policy/manual Waste minimization (RRR) observed Waste segregation practices observed Waste segregation practices effectiveness Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate

Status Yes Yes Yes

Yes No Yes No Yes Yes No No Yes -


Yes Once/yr

Reliability of operations (Poor, Fair, Good)

Currently being developed Currently being developed

Yes No Yes Good Yes Yes Yes No No Yes Yes


BMW Treatment Technology Type (incinerator, pits, gasifier, landfill, etc.)

Comments

Autoclave (Steam Sterilization) Good


Yes Yes No


Yes Yes

Body parts are buried in landfill

* Based on information garnered from interviews with administrators at Tapion Hospital.

79 3.9

St. Vincent & the Grenadines

Date visited: July 25–27, 2007

3.9.1

General Background

St. Vincent & the Grenadines is located in the Eastern Caribbean region, a string of islands between the Caribbean Sea and North Atlantic Ocean, north of Trinidad and Tobago. The country includes the main island of St. Vincent and the inhabited islands and islets of Bequia, Mustique, Mayreau, Canouan, Union Island and Palm Island. The land area of St. Vincent & the Grenadines is approximately 389 square kilometers (Saint Vincent itself is 344 square kilometers) which is almost twice the size of Washington, DC.

The mainland and islands include six parishes: Charlotte, Grenadines, Saint Andrew, Saint David, Saint George, and Saint Patrick. The population is dispersed between the urban and rural areas; approximately 70,000 people (58%) live in urban areas and close to 50,000 reside in rural locations. The projected population in 2030 will be 100,000 urban residents and 31,000 rural residents. Some demographic and mortality data, sourced from the Pan American Health Organization (PAHO), are provided in Table 18.

80 Table 18

Selected demographic and mortality data for St. Vincent & the Grenadines

demographic indicators—2006* total

crude birth

population

rate

(thousands)

(1,000 pop)

120

20.0


0.8


69.0

74.6

mortality indicators maternal

infant mortality

mortality ratio

rate

(100,000) lb

(1,000 lb)

____________

____________

ratio No. year

ratio No. year

-

2005

17.8

2004


640.7

747.4

698.9

889.1

582.9

622.2

* Adapted from Health situation in the Americas Basic Indicators 2006, Pan American Health organization.

3.9.2


The Ministry of Health and Environment owns and operates all public health care facilities, sets the standards for care, and regulates practice within the health sector. There is one (1) main public hospital, the Milton Cato Memorial Hospital, located in the capital, Kingstown. Additional primary health care services are delivered from 30 health care centers/clinics and five (5) district hospitals of which two (2) are located in the Grenadine islands of Bequia and Union Island.

The MOH’s Chief Medical Officer interfaces with the operations of private health care facilities. The Ministry of Health is also responsible for regulating health care practitioners (including private pharmacists) who must be both registered and accredited to practice in the country. All nurses are required to register with the General Nursing Council. Private health care is available but mostly limited to ambulatory care, laboratory testing centers, and family planning services. There is one (1) small private hospital, Maryfield Hospital.

There are 88 doctors licensed to practice medicine in the islands.

81 3.9.3



Persons Interviewed  Mr. Toney, Chief Environmental Officer

Milton Cato Memorial Hospital

 

Central Water & Sewerage Authority (CWSA)



Ms. Tesheira, Ag. Hospital Administrator Mr. Garfield Henderson, Senior Engineering Assistant Nurse Cheroline Primus, Infection Control Nurse

  

Mr. Garth Saunders, General Manager Ms. Joan Ryan, Acting Solid Waste Manager Ms. Sharika Mandiville, Solid Waste Unit

3.9.4


1.

Biomedical Waste Policies, Legislation, and Regulations While there is a Solid Waste Management Act (2000) and attendant Regulations (2006), which govern the management of waste in general, there do not exist BMWspecific legislation and regulations. Furthermore, no effort is currently under way to develop these.

2.

Current Biomedical Waste Management Practices at Public Facilities At the Milton Cato Memorial Hospital, there were no written guidelines with respect to segregation, collection, storage, and disposal of health care waste. On walk-through of the facility, however, attempts at waste segregation were observed. For example, in all of the wards and laboratories toured, sharp containers were seen and appeared to be actively used for collecting and separating sharps from other types of biomedical waste.

Other BMW management practices reported to be standard operating procedure at the Milton Cato Memorial Hospital are:  Since 2001/2002, red bags have been used for biomedical waste o

Compliance is reported to be high (90-95%).

o

BMW audits are not done regularly; the last one was conducted only as a result of a complaint being made.

82 o

Cytotoxic waste is not put into yellow bags but also red bagged.

o

Red and black bags are being stored in the same bins (see Picture 87).

Therefore, both general and biomedical waste streams are

effectively co-mingled and would be considered to be hazardous.  There is an on-site incinerator that has not been used due to smoke emission problems since the second quarter of 2006 (see Picture 88).  Workers with the job title of ‘Grounds’ men are the designated personnel assigned to collect and remove waste.  Cardboard sharp containers are predominantly used. When filled, these are taken from the wards to a storage area located next to the disused incinerator (see Picture 89).  Body parts are red-bagged and then buried in a plot that lies right next to the hospital compound (see Picture 90). This area is not fenced off and forms part of a cemetery that abuts the hospital’s compound.  No signage on BMW management policy or best practices was observed in any part of the grounds that were toured.  Once a week, CWSA personnel pick up biomedical waste separately from regular waste and take it to the Diamond Sanitary Landfill (see Picture 91).  There is no specific dedicated isolation ward, but one area of the hospital, which has four rooms, can be used as such if needed. o

If a patient were isolated, his/her waste would be red bagged and treated just like all the other red bag waste.

 In the pathology laboratory, contaminated blood products are autoclaved before being placed in the disposal bins.  Used chemicals for developing and fixing X-ray films are routinely disposed of down the drain.

3.

Current Biomedical Waste Management Practices at Private Facilities There is no major private hospital on the island. The small Maryfield facility was not visited.

83 4.

Biomedical Waste Treatment and Disposal Technology Used At the Milton Cato Memorial Hospital, pathological waste generated in the pathology laboratory is autoclaved. Other biomedical waste is not treated on-site. An on-site incinerator is no longer used due to complaints of the smoke from it affecting ceremonies taking place in the adjacent cemetery chapel.

Hospital red-bag waste is aggregated in an area located at the back of the facility and then taken by the Solid Waste Management Unit personnel of CWSA via skip, (which is manually loaded), to the island’s sole sanitary landfill, Diamond Sanitary Landfill, for deep burial.

In the Grenadines—Bequia, Mustique, Canouan, and Union Island—biomedical waste generated in these islands is typically disposed of in on-site open pit ovens or incinerators.

The

Grenadines

Solid

Waste

Management

Project

is

being

implemented and is looking at using incineration to handle all medical waste generated in these islands.

5.

Training of Health Care Personnel in Biomedical Waste Management Concepts Health care personnel have not received systematic, specific training in BMW management and concepts. Such training, if given at all, is usually incorporated into on-the-job training activities, typically given by the facility’s Infectious Control Nurse.

Solid Waste Management Unit personnel of CWSA have also not received specific training on how to handle and transport biomedical waste.

There are 14 Environmental Health Officers; none has received specific training in BMW management.

6.

Transportation and Disposal of Biomedical Waste The collection of all waste, including biomedical waste, comes under the sole jurisdiction and responsibility of the Central Water & Sewerage Authority. Biomedical waste from the Milton Cato Memorial Hospital is taken by CWSA personal to the Diamond Sanitary Landfill. On arrival at the landfill, this waste is reportedly buried in specially designated cells within the landfill.

84

The cell where biomedical waste was being buried was pointed out. However, evidence of biomedical waste (a needle) was seen on the ground (see Picture 92). It must be noted that the source of this needle cannot be clearly ascertained and it could have come from a source other than the hospital or health care centers (e.g., home users such as diabetics). It does highlight, however, that biomedical waste from other sources needs to be monitored and mechanisms put in place to control it.

7.

Biomedical Waste Recording, Tracking, and Audit Systems BMW record (logging) systems, either in the public or private health care systems, do not exist to document the amount, type, and fate of biomedical waste. Therefore, data on the amount and sub-types of biomedical waste being generated are not available.

With respect to systems for tracking the movement of biomedical waste from the generators (cradle) of such waste to its final end point (grave), none exist, either in the public or private health care systems.


85 Table 19 Summary of Biomedical Waste Management Practices Audit in St. Vincent & the Grenadines, 2007 Audit Area Regulatory Environment Government BMW Policy/Plan BMW-specific Legislation/Regulations Proposed BMW-specific Legislation

Status No No No

Current Practices (Public HC Facilities) BMW facility-specific policy/manual (Public) Waste minimization (RRR) observed Waste segregation practices observed Waste segregation practices effectiveness Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate

No No Yes Fair No Yes Yes No No Yes No

Current Practices (Private HC Facilities) BMW facility-specific policy/manual Waste minimization (RRR) observed Waste segregation observed Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate



No Rare

BMW Treatment Technology Type (incinerator, oven, gasifier, etc.) Reliability of operations (Poor, Fair, Good)

Comments

Incinerator N/A


No No No


No Rarely

Not used since August 2006 Incinerator has been de-commissioned

Audits performed only if problem reported.

86

4.0 REGIONAL SUMMARY 4.1

General Overview

The results of this situational audit of BMW management practices within the OECS region are summarized in Tables 20 and 21. Although efforts are being made in some member countries to enact legislation that will deal specifically with issues related to the management of biomedical waste, there are, however, in the majority of OECS member states, no such legislation/regulations being planned at present. As a proxy measure, most OECS countries are using legislation that governs the management of solid waste and/or the environment to deal with biomedical waste. It is noteworthy that, in spite of this absence of specific biomedical waste management legislation and an attendant, well-defined clear regulatory framework, meaningful attempts, albeit on an ad hoc basis, are being made at most public health care facilities to separate biomedical waste from other waste streams. This is particularly evident with respect to sharps, which, by and large, are segregated and disposed of separately from other waste.

In general, observed and/or reported standard BMW management practices in public hospitals and health care centers can be summarized as follows:  Segregation of Biomedical Waste: o

In almost all of the nine-member countries of the OECS, some attempts are being made to segregate biomedical waste through the use of color-coded bags.

o

Sharps are, by and large, being segregated from all other waste streams.

o

The effectiveness of waste segregation efforts varies considerably, both within and among the islands. Overall, however, waste segregation practices can only be given a ‘Poor’ grade. In many cases, it appears that bags are just simply placed where there is a need without any regard being paid to their color. Therefore, both general and biomedical waste streams are effectively co-mingled and would have to be considered hazardous.

87 o

Highly infectious waste (e.g., biomedical waste from highly infectious persons) is typically combined with other infectious waste and not managed under more stringent BMW management protocols.

o

Non-biomedical waste is commonly observed in designated biomedical waste bags, thereby unnecessarily increasing the amount of waste that is considered hazardous, as well as the costs associated with treating such waste.

 Packaging of Biomedical Wastes: o

Red (as opposed to yellow) bags are the most commonly used colored bags for collecting biomedical waste with either black, white, or clear bags being reserved for other waste. Clear bags with the biohazard symbol and yellow bags were also being used for the collection of biomedical waste.

o

Sharps are being collected in a variety of containers ranging from rigid, puncture-resistant sharp containers to cardboard type sharp containers. In many facilities, empty bleach and other detergent bottles, as well as empty reagent containers are being used to collect and store sharps. With respect to this latter group/type of containers, almost all of the time these are not marked or labeled with the words ‘Biohazardous Waste’ to indicate the content.

o

Garbage bins used to collect biomedical waste are rarely properly covered. It is also not uncommon to see sharp containers whose covers have been completely removed.

 On-site Biomedical Waste Handling and Movement: o

The collection of biomedical waste from source points (e.g., wards, laboratories, operating theaters) is typically done by Grounds men or Housekeeping staff using rudimentary trolley devices.

o

The likelihood of close contact with biomedical waste is very high due to the significant amount of manual handling that is required to get the waste from its source to the facilities’ central storage area.

o

Almost all multiple-storied facilities lack elevators, thus requiring the workers to manually lift, hold, and carry hazardous waste down several flights of stairs.

88 o

Personal protective equipment (PPE) and training given to these workers are minimal.

 On-site Storage of Biomedical Waste: o

With very few exceptions, areas designated for storage of biomedical waste are poorly kept, unsecured, and permit unauthorized access.

 Off-site Transportation of Biomedical Waste: o

Throughout the region, the final transportation and disposal of biomedical waste is generally handled by

government controlled Solid Waste

Management entities on the island.

These entities either collect the

biomedical waste themselves or subcontract this job to private waste haulers. o

The vehicles used to transport biomedical waste are not always specifically designed for this task (e.g., not completely enclosed, secure, refrigerated, etc.)

 Treatment and Disposal of Biomedical Waste: o

Burning of biomedical waste in concrete pits and incinerators were the most common on-site methods for treatment and disposal technology observed. Two notable exceptions were St. Lucia, which uses an autoclave (steam sterilization) and Dominica, which uses a gasifier. Most of the incinerators observed were not of the double-chamber type (which would facilitate higher temperatures, and therefore, more complete combustion), aged, and in poor repair. Operational reliability is highly variable.

o

Throughout the OECS member countries, in most of the hospitals and major public health centers visited, autoclaving of highly infectious waste (e.g., clinical laboratory cultures, specimens) is not a standard practice. In many cases, such waste is simply combined with other biomedical waste.

o

Biomedical waste not treated on-site is typically transported to landfill sites. Such waste, on reaching the landfill, is not routinely buried in specially designated areas but combined with other municipal waste.

o

None of the OECS member countries has a policy statement on how to dispose of expired, unused, and contaminated pharmaceutical products. Most pharmaceutical waste is either wrongly sent to the incinerator (most of

89 which do not generate high enough temperatures to effectively break down pharmaceutical products), or sent to landfills for burial. o

Other hazardous but non-infectious waste generated at most hospitals, such as used chemicals for developing and fixing X-ray films, standard laboratory chemicals (e.g., formaldehyde, solvents, organic and inorganic chemicals), are routinely disposed of down the drain.

 Training

of

Health

Care

and

Other

Personnel

in

Biomedical

Waste

Management: o

Health care personnel—nurses, doctors, and laboratory technicians—do not receive regular, specific training in BMW management and best practices. By and large, biomedical waste management issues are only addressed as part of on-the-job training efforts or in other training topics typically given by the nurse in charge of infectious disease control.

o

Signage on BMW best practices was rarely observed in most of the facilities toured.

o

Other hospital staff—house-keeping,

grounds

men, orderlies—receive

virtually no training, either formal or otherwise, on best BMW management and handling practices. o

Waste collectors are not being trained on proper handling and transport procedures for biomedical waste. In most cases where private waste haulers are hired to collect biomedical waste, their contracts do not clearly specify that their workers should receive such training.

 Monitoring of Current Biomedical Waste Management Practices: o

With the exception of St. Lucia, comprehensive and accurate cradle-to-grave BMW tracking systems do not currently exist to document the progression and ultimate fate of biomedical waste from the generators of such waste to its final end point.

o

None of the health care institutions reviewed in this study performs internal waste audits of their waste streams. As a result, data on the amount and type of biomedical waste being generated is not available.

o

External, independent, BMW management practices and auditing systems have not been set up in most OECS member countries.

90 With respect to most of the private hospitals visited, the situation is more or less the same. Notable differences in standard biomedical waste management operating practices observed and/or reported are detailed below:  Segregation of Biomedical Waste: o

Attempts to segregate biomedical waste through the use of color-coded bags are being made to an even lesser degree.

Red bags are rarely used.

Biomedical waste is typically collected in regular (i.e. non-biohazardous labeled) black, white, or clear garbage bags. o

In the absence of formal biomedical waste collection arrangements in most OECS member states, it is generally thought that biomedical waste from doctors in single private practice is routinely being put out along with other municipal waste.

 Packaging of Biomedical Waste: o

Sharps are more commonly collected in empty bleach bottles, other types of empty detergent bottles, empty reagent containers, or cardboard boxes. Most of these containers are not puncture- and leak-proof resistant.

o

At most times, these containers are not marked or labeled with the words ‘Biohazardous Waste’ to indicate the contents.

 On-site Biomedical Waste Handling and Movement: o

In addition to Grounds men or Housekeeping staff, the collection of biomedical waste from source points (e.g., wards, laboratories) for transport to the facilities’ storage area is also commonly done by nurses, doctors, or the owners of the health care facility.

 On-site Storage of Biomedical Waste: o

Biomedical waste is rarely stored in an area that is separate from the one used for storing other non-hazardous waste. Typically, these two types of waste are stored in the same area.

91  Off-site Transportation of Biomedical Waste: o

In most OECS member countries, private health care facilities have to make their own arrangements to have their biomedical waste removed off-site.

o

Biomedical waste from many private health care facilities is being transported by the owners of these health care facilities in their own private vehicles.

 Treatment and Disposal of Biomedical Waste: o

Very few private health care facilities have on-site incinerators.

Most

biomedical waste is either burned in drums or concrete pits or transported offsite to the island’s landfill site. o

Autoclaving of highly infectious waste (e.g., clinical laboratory cultures, specimens) was not observed nor reported to be done in any of the private health care facilities reviewed in this report.

 Training

of

Health

Care

and

Other

Personnel

in

Biomedical

Waste

Management: o

Training of health care personnel in BMW management and best practices is even less likely to occur in private health care settings. In the few regional and government sponsored training events in BMW management practices that have occurred within the region, the private sector has not been explicitly invited and incorporated in these efforts.

 Monitoring of Current Biomedical Waste Management Practices: o

For all of the private facilities reviewed in this report, systems for recording and tracking the quantity of biomedical waste were not in place.

o

The BMW management practices of private health care institutions are not being audited by any entity, governmental or otherwise.

92 Table 20 Summarized Regional Findings of Biomedical Waste Management Practices in the OECS, 2007 Regulatory Environment

Government BMW Policy/Plan BMW-specific Legislation/Regulations Proposed BMW-specific Legislation

‘Yes’ No. out of 10* 1 1 2

Comments

Except for legislation covering the operation of the Solid Waste or Environmental Management entities in the region, there are no specific legislation/regulations that provide a legal basis on which to manage biomedical waste. However, in some countries efforts are being made to create specific policies and enact legislation to regulate and manage biomedical waste.

Current Practices (Public HC Facilities) BMW facility-specific policy/manual Waste minimization (RRR) observed Waste segregation practices observed Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate Current Practices (Private HC Facilities)

2 0 10 1 8 2 0 0 3 1

There is a general lack of written guidelines or relevant signage to inform workers of internationally accepted biological waste management practices. However, waste separation and the use of color coded bags were in evidence in 80% of the countries audited. Waste minimization and appropriate systems for managing cytotoxic and hazardous waste were not present throughout.

BMW facility-specific policy/manual Waste minimization (RRR) observed/reported Waste segregation observed/reported Internal Waste Audits being performed Use of color-coded bags observed/reported Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate BMW Training

1 0 3 0 2 2 0 0 2 0

It appears that with the exception of sharps, most doctors in the private sector dispose of their biomedical waste in black plastic bags, which are then collected along with other general waste by the Solid Waste Management entities in their country.

Given as a stand-alone topic Frequency BMW management issues taught

3 Rare

There is a need for more formal, yearly, training programs, as training events occur on an ad hoc basis and is given by the nurse in charge of infectious disease control.

Mainly Incin Fair to Good

The main treatment technology is incineration. Most of the incinerators are in poor repair and operating well below ideal temperature combustion levels.

Specialized vehicle used Driver and handlers trained Landfill disposal procedure documented BMW Record and Tracking Systems

2 3 1

Movement of biomedical waste off-site is generally not done in vehicles specifically designed to carry such waste.

Amounts and type of BMW recorded Current BMW procedures being audited

Limited No

BMW Treatment Technology Type (incinerator, pits, gasifier, landfilletc.) Reliability of operations (Poor, Fair, Good) Handling and Transportation of BMW

* Nevis is reported on separately to St. Kitts.

93 4.2

Recommendations

With a view to improving the current situation as it pertains to the management of biomedical waste from cradle to grave, the following recommendations are made:

1. Enact biomedical waste management specific legislation:

It is simply not

feasible to effectively, consistently, and predictably effect good biomedical waste management in the absence of specific legislation that mandates such.

Such

legislation should be anchored in a clearly articulated national biomedical waste management policy statement and made operational by clear guidelines and regulations. If possible, given the geographic, cultural, and political closeness of the OECS member states, it would probably be best if a regional BMW policy be formulated that could then be tailored to the specific realities of each island.

2. Promote the reduction of biomedical waste: Minimizing waste not only protects the public’s health and the environment, but it also saves health care institutions substantial amounts of money. As less than 20% of health care waste is typically infectious (hazardous) in nature, ensuring that this segment of the waste stream does not co-mingle with other non-hazardous waste streams will reduce the costs associated with treating and disposing of biomedical waste.

3. Enhance and implement BMW management specific training for all health care personnel: BMW management training should become a stand-alone, predicable, at least once-a-year component of training that all health care personnel—whether in the public or private sector—receives. This can be mandated by legislation (see Recommendation #1) and monitored for compliance by an external auditing body (see Recommendation #5).

4. Implement systems to quantify and track the biomedical waste stream: One cannot meaningfully evaluate the effectiveness of any biomedical management system in the absence of data. Recording (logging) and tracking systems should be developed that would allow one to document the amount, type, and fate of all biomedical waste.

94 5. Implement a BMW management audit mechanism:

Besides encouraging or

mandating that each health care institution perform internal audits of their BMW management practices and systems, an external, independent body should be granted legal status to review all health care facilities—both public and private—to monitor the degree of compliance with any BMW legislation and/or codified best BMW practices, guidelines, and regulations.

6. Promote the adoption of non-incineration technology: As the developed world steadily moves away from using incinerators as an acceptable method to dispose of waste, it is somewhat ironic that the Caribbean region is eagerly embracing this problematic technology. Incinerators in essence solve one problem, but in doing so create at least two others—toxic air emissions and highly toxic residual ash. There are other technologies, such as autoclaving (steam sterilization), which do not have these negative side effects while at the same time achieving comparable high rates of waste volume reduction. Given the likelihood that, in time, most Caribbean islands are likely to adopt more stringent laws that are protective of the environment and human health, it would seem more prudent to by-pass this technology in favor of more environmentally sound waste disposal technologies.

Since the above recommendations will take time to be fully implemented, below are listed several immediate to short-term recommendations that, if implemented, could dramatically improve the current state of managing biomedical waste within and outside health care facilities located within the OECS.

1. Create internal BMW management policy documents: Each facility should create a document that clearly outlines its policy towards the segregation, collection, storage, and disposal of health care waste. This document can later be modified to reflect any national BMW management policy that may be promulgated.

2. Form BMW Management Committees at each health care facility: Each health care facility should have a committee whose mandate is to look specifically at and deal with BMW management issues. This committee should be headed by a senior member of the facility’s management (preferably a senior hospital administrator) or

95 whoever’s job requires contact with the external regulatory and service authorities (e.g., the Solid Waste Management Authority).

3. Procure and use the right equipment: Effective BMW management practices can only be implemented if health care facilities have access to the appropriate resources and equipment. Those responsible for ordering bags, for example, should ensure that appropriate, color-coded bags with the biohazard symbol clearly imprinted on them are available in sufficient quantities to cover the facility’s annual needs.

Puncture, leak-resistant sharp containers, also clearly labeled with the

international biohazard symbol, should be stocked at quantity levels that meet the annual needs of the facility.

4. Train all those involved in BMW management: All personnel directly involved in the handling of biomedical waste should be given training that specifically addresses best biomedical waste management practices.

Besides the generators of such

waste (doctors, nurses, laboratory technicians), those who are entrusted with the responsibility to collect, transport and store such waste should not be left out. This latter group of workers, whose job titles vary from institution to institution, should be specifically trained on how to handle biomedical waste so that they do not either expose themselves or others to harm. This would also imply that they are given proper equipment such as covered trolleys and personal protective equipment so that they can safely carry out their job.

5. Develop and implement waste minimization strategies: Each health care facility should develop a waste minimization policy and strategy.

Waste minimizing

techniques should include all three ‘R’s’: reduce, reuse, and recycle.

6. Improve on the amount of BMW Signage: Signage that clearly spells out the health care facility’s (or national) BMW policy should be posted throughout each facility.

Additionally, signage that reminds health care personnel of best BMW

management practices can further reinforce the practice of good biomedical waste management.

96 7. Perform internal biomedical waste audits: Perform a waste audit of each health care facility’s waste stream and then use it to review the efficacy of any biomedical waste management plan. Use data on the amount and type of biomedical waste being generated as the starting point in helping to determine problem areas and ways to reduce the costs associated with handling and disposing of biomedical waste.

Carefully review everything that is coming into the facility (through the

Purchasing/Materials Department) to everything that exits the facility—in the form of recyclables, red-bag waste, solid waste, food waste, laboratory chemicals, chemotherapeutic and pathological waste—to reveal what portion of the waste that exits the hospital is non-infectious in nature.

97 4.3

Conclusions

The effective management of biomedical waste within the OECS region is a realistically attainable goal. Indeed, this issue should be viewed more of as a regional necessity since the health of the environment and that of the peoples inhabiting and visiting this region will be adversely affected if it is ignored.

Critical to the success of any BMW program envisioned for this region is a clear statement of the region’s policy on this issue, which should then be followed up with legislation that specifically addresses the management of biomedical waste, from cradle to grave. Solutions proposed to manage biomedical waste should be ecologically sound and ensure that this issue is treated in a holistic manner. To ensure that good BMW management practices are maintained, ongoing training efforts need to be given to all health care personnel and audit mechanisms instituted to evaluate the effectiveness of the whole system.

98 Table 21

Summary of Biomedical Waste Management Practices Audit in OECS Member Countries, 2007

AUDIT AREA Regulatory Environment Government BMW Policy/Plan BMW-specific Legislation/Regulations Proposed BMW-specific Legislation Current Practices (Public HC Facilities) BMW facility-specific policy/manual Waste minimization (RRR) observed Waste segregation practices observed Waste segregation practices effectiveness Internal Waste Audits being performed Use of Color-coded bags observed Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate Current Practices (Private HC Facilities)* BMW facility-specific policy/manual Waste minimization (RRR) observed/reported Waste segregation observed/reported Internal Waste Audits being performed Use of Color-coded bags observed/reported Color-coded bags used appropriately Appropriate cytotoxic waste management Appropriate hazardous waste management BMW signage observed/reported BMW signage adequate BMW Training Given as a stand-alone topic

Frequency BMW management issues taught BMW Treatment Technology Type - incinerator, gasifier, pits, landfills, etc. Reliability of operations (Poor, Fair, Good) Handling and Transportation of BMW Specialized vehicle used Driver and handlers trained Landfill disposal procedure documented

STATUS AXA**

ANU

BVI

DOM

GND

MNI

SKB

NEV

SLU

SVG

No No No

No No No

No No No

No No No

No No Yes

No No No

No No No

No No No

Yes Yes Yes

No No No


No No Yes Poor No Yes No No No No No


Yes No Yes Poor No Yes No N/A No Yes No

No No Yes Fair No Yes No No No No No


No No Yes Poor No No No No No No No

No No Yes Poor No No No No No Yes No

Yes No Yes Good Yes Yes Yes No No Yes Yes

No No Yes Fair No Yes Yes No No Yes No

No No No No No No N/A No No -



No No No No No No No No No No

No No No No Yes Yes N/A No Yes No


No No Yes No No No No No No -

No No Yes No No No No No No -

Yes No Yes No Yes Yes No No Yes -


No Rare

No Rare

No Rare

No Rare

No Rare

No Rare

Yes Once/yr

Yes Once/yr

Yes Adequate

No Rare

Incinerator

Landfill

Incinerator

Gasifier

Incinerator

Incinerator

Incinerator

Incinerator

Autoclave

Incinerator

Good

N/A

Good

Fair

Fair

Fair

Fair

Good

Good

N/A

No Yes No

Yes No Yes

No Some No

No No No

No No No

No No No

No No No

No No No

Yes Yes No

No No No

Yes No

No No

No No

Yes Yes

No Rarely

BMW Record and Tracking Systems Amounts and type of BMW recorded Limited No No Yes No Current BMW procedures being audited No No No No No * Based on information garnered from interviews ** Airport Codes used for country names ***Steam Sterilization

5.0 GUIDELINES FOR SETTING UP A BIOMEDICAL WASTE MANAGEMENT TRAINING PROGRAM

5.1

General Overview

All those involved in the generation, handling, transporting, and disposal of biomedical waste must be actively educated in their responsibilities and given the necessary tools in order to implement sound BMW policies and procedures that are environmentally and occupationally safe. It should be stressed that all waste management training programs should emphasize the approach of waste avoidance as a prime, over-arching responsibility to be practiced by everyone.

5.2

Target Audience

The type of persons being trained should largely determine the format and content of any training program. In health care settings, a diversity of professions ranging from doctors and nurses to janitors and grounds keepers, exist. Each group requires a different approach. In general, the background of the trainees, their knowledge levels, and ability to grasp new concepts will all be important ingredients in devising the most effective training biomedical waste training program that would best suit them.

5.2.1

Training Administrators

It is critically important that those at the very top of the health care facility’s management explicitly endorse and actively get involved in, firstly, articulating their facility’s BMW policy, and then ensuring that it gets implemented. Training sessions on biomedical waste management for health care facility managers should therefore be geared towards helping these managers to conceptualize, draft, and then implement management systems to effectively and safely handle all biomedical waste generated at their facility.

100

5.2.2

Training Doctors

Doctors typically require and expect any training given to be anchored on well researched, peer-reviewed data, and to be supplemented by working examples from other institutions. Additionally, information about various global trends and international conventions are important features required to convince doctors about the importance of using good biomedical waste practices.

Training sessions on biomedical waste management for doctors should, therefore, be well structured, delivered in a highly professional manner, and be cognizant of the fact that many doctors may view such training as an imposition on their usually very limited time.

5.2.3

Training Nurses

The training of nurses and other health care staff directly involved in the day-to-day care of sick patients is critical if any biomedical waste management program is to have success.

As a rule, nurses are generally quite interested and willing to learn new procedures that can have a direct impact on their work environment. It is important to keep in mind, however, that they may be less than willing to partake in such training, particularly if it comes after their work shift. The timing of such training should, therefore, be carefully chosen to avoid the potential for such an issue to arise.

Training sessions on biomedical waste management for nurses, like that for doctors, should be well planned and structured. Nurses are more amenable, however, to sessions that are interactive and allow them to actively participate in the learning process. Learning tools such as quizzes and in-session problem solving exercises can be most useful. It should be noted that if trainees are aware that they will be quizzed on the material they are being taught, they are generally more likely to be alert and be active participants during the training sessions. The actual enactment of typical nursing procedures, for example, the redressing of a wound on a patient or the administration of several injections to a patient,

101 and the procedures followed to dispose of any waste generated can prove to be more efficacious than a dry reading of approved waste disposal guidelines.

5.2.4

Training Housekeeping Staff

The overall guiding principles of good biomedical waste management practices should be presented in a clear and succinct manner to all staff whose main duties are the collection, transfer or handling of biomedical waste. In addition, training should also cover the following specific aspects of good biomedical waste management:  Checking that storage containers are sealed effectively before handling  Ensuring that the origin of the waste is marked on the container  Handling bags correctly (for example, not clasped to the body, thrown, dropped or supported by hand from below)  Using handles to move rigid containers  Checking that the seal on any used waste storage container is unbroken when movement is completed  Special problems relating to the disposal of sharps  Procedures in case of accidental spillage and how to report an incident  Safe and appropriate cleaning and disinfection procedures.

Furthermore, since some personnel are usually issued personal protective equipment (PPE), they should all receive training on:  The risks for which the PPE equipment is designed to avoid or limit  The way in which any piece of PPE will be used  The procedures for ensuring maintenance and repair of all PPE.

102 5.3

Training Tools

The center (and hence the most important component) of any training program is the trainer(s). Although there are several qualities a trainer needs to have in order to conduct a successful training session, key among them should be the ability to communicate effectively to diverse and varying target audiences—from doctors with multiple degrees to grounds men who cannot read and write—and the ability to mold his/her presentation styles to best meet the needs of that target audience.

There are many books and manuals—many of them available online on the Internet—that provide all the core components required to mount a biomedical waste management training program.

Any of such available information should be tailored and supplemented with

actual pictures taken at the trainees’ facility. Pictures demonstrating poor and good waste management practices can be most effective.

Finally, inviting representatives from other facilities that have implemented successful biomedical waste management practices to share their experiences can provide the final impetus that will convince management and users alike that sound waste management programs do exist in the ‘real’ world, are working, and proving successful.

5.4

Sample BMW Training Program

The fundamentals of good biomedical waste management can easily be covered in one whole-day program or, alternatively, be presented over several shorter periods of time, e.g., two half-day sessions. A template showing a whole-day training program is presented in the following table (see Table 22).

103 Table 22 Sample Biomedical Waste Management Training Program

Time 8:00 – 8:30

Topic Registration and light breakfast

8:30 – 9:00

Overview of Biomedical Waste Management

9:00 – 10:00

Setting up a Biomedical Waste Management Program at our Facility (for Hospital Administrators) The Biomedical Waste Management Program at our Facility (for doctors, nurses, and housekeeping staff)

10:00 – 10:15

Break

10:15 – 10:30

Definitions

10:30 – 11:00

Implementing a Biomedical Waste Management Program at our Facility (for Hospital Administrators) How to practice good Biomedical Waste management at our Facility (for doctors, nurses, and housekeeping staff)

11:00 – 12:00

Classification of Biomedical Waste and Waste Segregation

12:00 – 1:00

Lunch

1:00 – 2:00

Handling of Biomedical Waste (mainly for housekeeping staff)

2:00 – 3:00

Storage, Containment, and Transportation of Biomedical Waste (mainly for housekeeping staff)

3:00 – 3:15

Break

3:15 – 4:00

Optional Blood borne Pathogens (mainly for housekeeping staff) Dealing with Accidents and Spillages (for all)

4:00 – 5:00

Biomedical Waste Minimization Strategies (for all)

5:00 – 5:30

Training Wrap-up and Review

104

APPENDICES

A1 A2 A3

Letter to Permanent Secretary in the Ministry of Health Proposed Biomedical Waste Management Standards for the OECS region Pictures of BMW practices in each OECS country

105 107 108

105

Appendix A1

St. George’s University SCHOOL OF MEDICINE DR. MARTIN FORDE. ST. GEORGE'S UNIVERSITY DEPARTMENT OF PUBLIC HEALTH & PREVENTIVE MEDICINE PO BOX 7 ST. GEORGE'S GRENADA, W.I.

July 11, 2007 Permanent Secretary Ministry of Health Dear Sir or Madam RE: Review of Biomedical Waste Management Practices in OECS Countries

The Windward Islands Research and Education Foundation (WINDREF) in association with the Department of Public Health and Preventive Medicine at St. George's University, Grenada, has been awarded a Pan American Health and Education Foundation grant to carry out a project entitled A Review of Current Biomedical Waste Management Practices in the OECS. Please find a description of the scope of activities covered by this project in the attached document. You will note that the one of the chief objectives of this review project is to assess existing biomedical waste management practices in all major health care facilities in each member country of the OECS with a view towards documenting existing biomedical waste management practices within these facilities. It is anticipated that these results could provide, among other things, a basis for a unified biomedical waste segregation and color-coding scheme that can be adopted by all OECS countries. Additional benefits coming out of this project will be the design of a standard biomedical waste management training program that could be mounted in any OECS country. Such training can help health care administrators to design, set up and then maintain an effective biomedical waste management system for their health care facility and personnel. Implementation of this project will call for my visiting your island sometime during the period 23 July to 15 August 2007 to interview the person(s) most knowledgeable about biomedical waste management procedures and to conduct observations of biomedical waste management and handling practices at each major hospital and health care provider facility in your country. In light of the above, I would greatly appreciate if you could designate a contact person with whom I can liaise with to coordinate the exact date and time of my arrival as well as help me arrange meetings/appointments with the following persons and/or institutions:

106 • • • • •

Hospital administrators (public and private) Chief Medical Officer Solid waste management personnel Chief Environmental Health Officer Presidents of the Medical/Dental Associations

I feel very confident that you will see the importance of this research project and will grant me your approval and support. Please do not hesitate to contact me if you would like to receive additional information about this project. I look forward to visiting your country soon and anticipate that our collective collaborate efforts will lead to a report that will prove of use to you and your government.

Sincerely,

Dr. Martin Forde Associate Professor & Track Director, Environmental and Occupational Health Department of Public Health & Preventive Medicine School of Medicine St. George’s University P.O. Box 7 St. George’s Grenada, West Indies Phone: 473-444-4175 ext.2349 Email: [email protected]

APPENDIX A2

Waste Type

Examples Color Code Marking Packaging

In-House Transport Storage Treatment

Off-Site Transport (Untreated waste) Off-Site Transport (Treated waste) Disposal

PROPOSED BIOMEDICAL WASTE MANAGEMENT STANDARDS FOR OECS REGION

Sharps

Cultures & Stocks

Blood & Body Fluids

Needles, Syringes, Blood Tubes Red Biohazard Symbol, “Sharps” PunctureResistant Sharps Container Covered Cart

Culture Dishes

Free-flowing Blood

Tissues, Body Parts

Red Biohazard Symbol, “Biohazard” Plastic Bag in a Rigid Container

Red Biohazard Symbol, “Biohazard” Leak-proof Container

Covered Cart

(Acceptable BMW treatment technology) Special Vehicle

Protected Enclosure, 4˚C or 39˚F* (Acceptable BMW treatment technology) Special Vehicle

Sanitation Truck Sanitary Landfill

Protected Enclosure

Pathological Waste

Isolation Waste

Contaminated Linen

Regular Garbage

Placentas, Fetuses

Swabs, Soiled Dressing

Bedding

Garbage




Clear Biohazard Symbol, “Biohazard”

Black

Plastic Or Linen Bag

Plastic Bag or Container

Covered Cart

Covered Cart

Covered Cart

Covered Cart

Covered Cart

N/A

Protected Enclosure, 4˚C or 39˚F* (Acceptable BMW treatment technology)

Protected Enclosure, 4˚C or 39˚F* (Acceptable BMW treatment technology)

N/A

Trolley or cart not used for Biomedical waste Regular Storage Area

None

N/A

Special Vehicle

Protected Enclosure, 4˚C or 39˚F* Burial or (Acceptable BMW treatment technology) Special Vehicle

Sanitation Truck

N/A

Sanitation Truck

Sanitation Truck

Sanitation Truck

N/A

Sanitation Truck

Sanitary Landfill

Sanitary Sewer

Sanitary Landfill

Interment in Burial Site or Sanitary Landfill

Sanitary Landfill

N/A

Recycling or Sanitary Landfill

Discharge into Sanitary Sewer

Wash in Hot Water (88˚C or 160˚F) for 20 minutes

N/A

Special Vehicle

N/A

N/A

* If storage time is long enough to result in putrid smells from decaying organic waste Source: Modified from the World Bank Report, Audit of Biomedical Waste Management Practices: Grenada, 2002.

108

APPENDIX A3

PICTURES OF BMW PRACTICES IN EACH OECS COUNTRY

Country

Page

Anguilla

109

Antigua & Barbuda

111

British Virgin Island

113

Dominica

116

Grenada

118

Montserrat

121

Saint Kitts & Nevis

123

Saint Lucia

125

Saint Vincent & the Grenadines

127

109 Pictures from Anguilla

Picture 1: Anguilla - Princess Alexandra Hospital.

Picture 2: Anguilla - non-hazardous waste in red bag.

Picture 3: Anguilla - un-used brand new autoclave due to lack of training given to laboratory technician on how to operate.

Picture 4: Anguilla - Red-bag waste are transported via 50-gallon containers like this to the hospital’s incinerator.


Picture 5: Anguilla – The Princess Alexandra Hospital uses a double-burner incinerator to dispose of all its biomedical waste as well as all other biomedical waste generated by government controlled health care facilities on the island.

Picture 6: Anguilla –The Valley Health Center. Both hazardous and non-hazardous waste placed in red bag.

Picture 7: Anguilla – Biomedical and general waste storage area at The Valley Health Center. Both wastes are collected together and taken to Princess Alexandra Hospital’s incinerator for disposal.

Picture 8: Anguilla – Corito Sanitry Landfill.

111 Pictures from Antigua

Picture 9: Antigua – Red biohazard bags at Holberton Hospital being used inappropriately to collect general waste. Therefore, both general and biomedical waste streams are effectively co-mingled and would be considered to be hazardous.

Picture 10: Antigua – Worker in Holberton Laboratory washing out glass vials before being autoclaved for reuse.

Picture 11: Antigua – Holberton Hospital; empty 5-gallon bucket used to collect sharps.

Picture 12: Antigua - New hospital, Mt. St. John Hospital, nearing completion (est. opening date: November 2007)


Picture 13: Antigua – Bio Med Laboratories sometimes use empty reagent containers to dispose of sharps.

Picture 14: Antigua – Skip used at Holberton Hospital to store biomedical waste.

Picture 15: Antigua - Cook’s Sanitary Landfill.

Picture 16: Antigua – Waste pickers at Cook’s Sanitary Landfill.

113 Pictures from the British Virgin Islands (BVI)

Picture 17: BVI – Peebles Hospital.

Picture 18: BVI – Peebles Hospital; black bag containing sharp.

Picture 19: BVI – Peebles Hospital; biomedical waste is being put into regular white trash bag which is next to a water cooler dispenser.

Picture 20: BVI - Peebles Hospital; biomedical waste is being put into regular white trash bag which is next to a water cooler dispenser.

114 Pictures from British Virgin Islands (BVI)

Picture 21: BVI – Peebles Hospital; red bag containing non-biohazard (regular) waste.

Picture 22: BVI – Peebles Hospital; biomedical waste from the hospital’s emergency room being combined with other regular waste.

Picture 23: BVI – Peebles Hospital; sharp container with the cover removed.

Picture 24: BVI - Biomedical waste is put out in an alley behind the hospital in large grey wheeled trolleys


Picture 25: BVI - Pockwood Pond Municipal Solid Waste Incinerator.

Picture 27: BVI - Weighing scale at the Pockwood Pond Municipal Solid Waste Incinerator.


116 Pictures from Dominica

Picture 28: Dominica – Princess Margaret Hospital, general waste collection skips. Note that both red and yellow bags are being used to collect non-biomedical waste.

Picture 29: Dominica – Princess Margaret Hospital, general waste collection skips. Yellow bags are being used to collect non-biomedical waste such as food wastes from the kitchen.

Picture 30: Dominica – Princess Margaret Hospital; red bags being used for general (non-hazardous) waste.

Picture 31: Dominica – Princess Margaret Hospital’s Gasifier.

Picture 32: Dominica – Princess Margaret Hospital; Clinical waste container being used for yard clippings.



Picture 34: Dominica – Princess Margaret Hospital; yellow sharp containers used to collect sharps.

Picture 35: Dominica – Princess Margaret Hospital; empty bleach containers, as well as other types of containers being used to collect sharps.

Picture 36: Dominica – Princess Margaret Hospital; nonbiohazardous waste in red bag.

Picture 37: Dominica – Dr. Justin Fadipe Centre; black bags mainly used to collect biomedical waste. Empty bleach bottles are used to collect sharps.

Picture 38: Dominica – Princess Margaret Hospital’s gasifier controls.

Picture 39: Dominica – Princess Margaret Hospital refrigerator truck for transporting biomedical waste.

118 Pictures from Grenada

Picture 40: Grenada – St. George’s General Hospital; sharps initially put into kidney dish.

Picture 41: Grenada – St. George’s General Hospital; sharps transferred to larger sharp container.

Picture 42: Grenada – St. George’s General Hospital; sharps from all other sharp containers are emptied into blue 50-gallon containers located next to the incinerator.

Picture 43: Grenada – St. George’s General Hospital; grounds man moves 50-gallon container closer to incinerator.

Picture 44: Grenada – St. George’s General Hospital; grounds man uses a shovel to shovel sharps from 50gallon container into incinerator.



Picture 46: Grenada – St. George’s General Hospital; both biohazardous and non-biohazardous material being put into red bags.

Picture 47: Grenada – St. George’s General Hospital; both biomedical waste (red bags) and regular waste stored in the same located before being taken outside of the hospital.

Picture 48: Grenada – St. George’s General Hospital; Clear biohazard bags used in clinical laboratory.

Picture 49: Grenada – St. George’s General Hospital; clinical laboratory autoclave.

Picture 50: Grenada – St. George’s General Hospital; old chemicals stored in clinical laboratory.



Picture 52: Grenada – St. Augustine Medical Services Inc.

Picture 53: Grenada – St. George’s General Hospital’s incinerator.

Picture 54: Grenada – St. Augustine Medical Services Inc. Concrete pit used to burn biomedical waste.

Picture 55: Grenada – St. George’s General Hospital; ash from the incinerator.

121 Pictures from Montserrat

Picture 56: Montserrat – Soufriere Hills Volcano

Picture 57: Montserrat – Former W. H. Bramble Airport which was destroyed by the Soufriere Hills Volcano.

Picture 58: Montserrat – Glendon (St. John) Hospital Incinerator.




Picture 61: Montserrat – New Windward Landfill.



Picture 64: Montserrat – Private waste hauler.

123 Pictures from St. Kitts

Picture 65: St. Kitts – JNF Hospital’s concrete, staticgrate, single chamber incinerator.


Picture 67: St. Kitts – JNF Hospital; sharp containers and cardboard boxes are used to collect sharps.

Picture 68: St. Kitts – JNF Hospital; empty bleach bottles are being used to collect sharps.

Picture 69: St. Kitts – JNF Hospital; cardboard boxes are used to collect sharps.

Picture 70: St. Kitts – JNF Hospital; not all biomedical waste is being put into bins that have a bag. This particular bin was located outside a doctor’s office in the main corridor.


Picture 71: St. Kitts – JNF Hospital; ‘Burn-up Bin’ used in hospital laboratory.


Picture 73: St. Kitts – JNF Hospital; Skip on the right used to put (supposedly) all non-hazardous waste.

Picture 74: St. Kitts – JNF Hospital; Chemicals commonly used in laboratory.

125 Pictures from St. Lucia

Picture 75: St. Lucia – Victoria Hospital; storage area for biomedical waste

Picture 76: St. Lucia – Victoria Hospital; storage area for all sharps.

Picture 77: St. Lucia – Victoria Hospital’s BMW management policy.


Picture 79: St. Lucia – Victoria Hospital; body parts stored in freezer.



Picture 81: St. Lucia - St. Jude Hospital; Grounds man collecting biomedical waste

Picture 82: St. Lucia - St. Jude Hospital; Storage area for biomedical waste

Picture 83: St. Lucia - St. Jude Hospital; Wooden boxes used to collect sharps


Picture 85: St. Lucia - St. Jude Hospital; Biomedical waste signage


127 Pictures from St. Vincent

Picture 87: St. Vincent – Milton Cato Memorial Hospital; both biomedical and non-biomedical waste are being stored in the same container.

Picture 88: St. Vincent – Milton Cato Memorial Hospital disused incinerator.

Picture 89: St. Vincent – Milton Cato Memorial Hospital;

Picture 90: St. Vincent – Milton Cato Memorial Hospital; body parts buried in plot adjacent to hospital.

Picture 91: St. Vincent – Diamond Sanitary Landfill.

Picture 92: St. Vincent – Diamond Sanitary Landfill; hypodermic needle found lying on the ground near the front of the landfill.


Picture 1: Anguilla - Princess Alexandra Hospital.

Picture 2: Anguilla - non-hazardous waste in red bag.

Picture 3: Anguilla - un-used brand new autoclave due to lack of training given to laboratory technician on how to operate.

Picture 4: Anguilla - Red-bag waste are transported via 50-gallon containers like this to the hospital’s incinerator.


Picture 5: Anguilla – The Princess Alexandra Hospital uses a double-burner incinerator to dispose of all its biomedical waste as well as all other biomedical waste generated by government controlled health care facilities on the island.

Picture 6: Anguilla –The Valley Health Center. Both hazardous and non-hazardous waste placed in red bag.

Picture 7: Anguilla – Biomedical and general waste storage area at The Valley Health Center. Both wastes are collected together and taken to Princess Alexandra Hospital’s incinerator for disposal.

Picture 8: Anguilla – Corito Sanitry Landfill.


Picture 9: Antigua – Red biohazard bags at Holberton Hospital being used inappropriately to collect general waste. Therefore, both general and biomedical waste streams are effectively co-mingled and would be considered to be hazardous.

Picture 10: Antigua – Worker in Holberton Laboratory washing out glass vials before being autoclaved for reuse.

Picture 11: Antigua – Holberton Hospital; empty 5-gallon bucket used to collect sharps.

Picture 12: Antigua - New hospital, Mt. St. John Hospital, nearing completion (est. opening date: November 2007)


Picture 13: Antigua – Bio Med Laboratories sometimes use empty reagent containers to dispose of sharps.

Picture 14: Antigua – Skip used at Holberton Hospital to store biomedical waste.

Picture 15: Antigua - Cook’s Sanitary Landfill.

Picture 16: Antigua – Waste pickers at Cook’s Sanitary Landfill.


Picture 17: BVI – Peebles Hospital.

Picture 18: BVI – Peebles Hospital; black bag containing sharp.

Picture 19: BVI – Peebles Hospital; biomedical waste is being put into regular white trash bag which is next to a water cooler dispenser.

Picture 20: BVI - Peebles Hospital; biomedical waste is being put into regular white trash bag which is next to a water cooler dispenser.

114 Pictures from British Virgin Islands (BVI)

Picture 21: BVI – Peebles Hospital; red bag containing non-biohazard (regular) waste.

Picture 22: BVI – Peebles Hospital; biomedical waste from the hospital’s emergency room being combined with other regular waste.

Picture 23: BVI – Peebles Hospital; sharp container with the cover removed.

Picture 24: BVI - Biomedical waste is put out in an alley behind the hospital in large grey wheeled trolleys




Picture 27: BVI - Weighing scale at the Pockwood Pond Municipal Solid Waste Incinerator.

Pictures from Dominica

116

Picture 28: Dominica – Princess Margaret Hospital, general waste collection skips. Note that both red and yellow bags are being used to collect non-biomedical waste.

Picture 29: Dominica – Princess Margaret Hospital, general waste collection skips. Yellow bags are being used to collect non-biomedical waste such as food wastes from the kitchen.

Picture 30: Dominica – Princess Margaret Hospital; red bags being used for general (non-hazardous) waste.

Picture 31: Dominica – Princess Margaret Hospital’s Gasifier.




Picture 34: Dominica – Princess Margaret Hospital; yellow sharp containers used to collect sharps.

Picture 35: Dominica – Princess Margaret Hospital; empty bleach containers, as well as other types of containers being used to collect sharps.

Picture 36: Dominica – Princess Margaret Hospital; nonbiohazardous waste in red bag.

Picture 37: Dominica – Dr. Justin Fadipe Centre; black bags mainly used to collect biomedical waste. Empty bleach bottles are used to collect sharps.

Picture 38: Dominica – Princess Margaret Hospital’s gasifier controls.

Picture 39: Dominica – Princess Margaret Hospital refrigerator truck for transporting biomedical waste.


Picture 40: Grenada – St. George’s General Hospital; sharps initially put into kidney dish.

Picture 41: Grenada – St. George’s General Hospital; sharps transferred to larger sharp container.

Picture 42: Grenada – St. George’s General Hospital; sharps from all other sharp containers are emptied into blue 50-gallon containers located next to the incinerator.

Picture 43: Grenada – St. George’s General Hospital; grounds man moves 50-gallon container closer to incinerator.




Picture 46: Grenada – St. George’s General Hospital; both biohazardous and non-biohazardous material being put into red bags.

Picture 47: Grenada – St. George’s General Hospital; both biomedical waste (red bags) and regular waste stored in the same located before being taken outside of the hospital.

Picture 48: Grenada – St. George’s General Hospital; Clear biohazard bags used in clinical laboratory.

Picture 49: Grenada – St. George’s General Hospital; clinical laboratory autoclave.




Picture 52: Grenada – St. Augustine Medical Services Inc.

Picture 53: Grenada – St. George’s General Hospital’s incinerator.

Picture 54: Grenada – St. Augustine Medical Services Inc. Concrete pit used to burn biomedical waste.

Picture 55: Grenada – St. George’s General Hospital; ash from the incinerator.


Picture 56: Montserrat – Soufriere Hills Volcano

Picture 57: Montserrat – Former W. H. Bramble Airport which was destroyed by the Soufriere Hills Volcano.








Picture 64: Montserrat – Private waste hauler.




Picture 67: St. Kitts – JNF Hospital; sharp containers and cardboard boxes are used to collect sharps.

Picture 68: St. Kitts – JNF Hospital; empty bleach bottles are being used to collect sharps.

Picture 69: St. Kitts – JNF Hospital; cardboard boxes are used to collect sharps.

Picture 70: St. Kitts – JNF Hospital; not all biomedical waste is being put into bins that have a bag. This particular bin was located outside a doctor’s office in the main corridor.




Picture 73: St. Kitts – JNF Hospital; Skip on the right used to put (supposedly) all non-hazardous waste.

Picture 74: St. Kitts – JNF Hospital; Chemicals commonly used in laboratory.


Picture 75: St. Lucia – Victoria Hospital; storage area for biomedical waste

Picture 76: St. Lucia – Victoria Hospital; storage area for all sharps.






Picture 81: St. Lucia - St. Jude Hospital; Grounds man collecting biomedical waste

Picture 82: St. Lucia - St. Jude Hospital; Storage area for biomedical waste





127 Pictures from St. Vincent

Picture 87: St. Vincent – Milton Cato Memorial Hospital; both biomedical and non-biomedical waste are being stored in the same container.

Picture 88: St. Vincent – Milton Cato Memorial Hospital disused incinerator.

Picture 89: St. Vincent – Milton Cato Memorial Hospital;

Picture 90: St. Vincent – Milton Cato Memorial Hospital; body parts buried in plot adjacent to hospital.

Picture 91: St. Vincent – Diamond Sanitary Landfill.

Picture 92: St. Vincent – Diamond Sanitary Landfill; hypodermic needle found lying on the ground near the front of the landfill.