Seeking better ways of managing medical waste

It is time for doctors’ rounds in Ward 1 at the Coast General Provincial and Referral Hospital.

The doctors and nurses move from bed to bed giving tablets, fixing drip lines and giving injections.

After giving one of the patients an injection, a nurse in a white hijab drops the used needle in a yellow box labelled “Sharps Only” before moving to another bin where she drops the soiled cotton swab and gloves. 

Every ward in the hospital has the conspicuous red, yellow, and black waste bins.

They might not mean much to an ordinary person, but to the workers here, they are life-changing. Ten years ago, the needles, cotton wool and gloves would have been dumped into the same bin.

The hospital’s deputy nursing officer, Mr Stephen Masha, says the institution produces 60-80kg of infectious and highly infectious waste per day. 

Each patient produces about 0.2kg of waste per day, 20 per cent of which is infectious. Left lying around, this waste provides a breeding ground for infections and diseases and poses a serious threat to those who come across it.

Salome Baya and Jaribu Khamis know this only too well.  In November 2013, just a month after she began working at the hospital, Ms Baya, 32, was  cleaning the labour ward when she came upon a stack of  papers on the floor. When she picked it up, she felt something prick her finger.

“I knew it was a needle. It got stuck on my finger. I flushed my finger under running water before going to see a doctor, who examined my hand and gave me a PEP,” she recalls.

SCARY JOB

PEP is short for post-exposure prophylaxis, an antiretroviral treatment administered for 28 days to reduce the likelihood of HIV infection after potential exposure.

The World Health Organisation (WHO) says that when PEP is started immediately after exposure and the full dose completed, it can reduce the risk of HIV infection by more 80 per cent. 

Two weeks into Ms Baya’s medication, however, she got pricked again.

“I was scared. I could not sleep as I thought that I had been infected. But I continued with the medication and four weeks later, tests showed I was fine,” she recalls with a broad smile.

Mr Khamis, 42, faces similar risks, only that he is responsible for destroying the waste. He has been manning the hospital’s incinerator for 14 years, during which he has been pricked three times, although he tries to be careful. 

“Working  with health waste is  really scary,” he says.

His day begins at 6am, when he incinerates the previous evening’s waste. He wears full protective gear, complete with a gas mask with filters, heat resistant gloves and hardy shoes. He incinerates the waste at least three times a day. The ash from the incinerator is shovelled into a specially designed pit, whose walls are reinforced with concrete to prevent it from seeping into the environment and nearby water bodies.

“This is my office. I am prepared for any eventuality. I make sure the waste is completely burnt so that the ash is free of pathogens,” Mr Khamis says.

However, sometimes he cannot work because the incinerator breaks down. But this is bound to change after the hospital received a modern machine — called an autoclave — on February 27.

The equipment sterilises waste using steam, thereby killing any pathogens present without polluting the environment like an incinerator does through smoke. The sterilised waste is then shredded and can be disposed of like ordinary waste.

Mr David Cavanaugh, a representative of Bondtech Corporation, which installed the autoclave, said the waste produced is safe and tests to confirm its  sterility will be done throughout the process.

“It kills bacteria before being released to the atmosphere, so there are no health hazards,”  he said.

Mr Khamis and Ms Baya are two of about two million of the 35 million healthcare workers globally who are at risk of being infected via the prick of a needle every year.

SAFE DISPOSAL

A 2014 WHO study says that in 2010, some 1.7 million people were infected with the hepatitis B virus, another 315,000 with the hepatitis C virus and as many as 33,800 with HIV through needle pricks.

Medical and nursing students are at a higher risk of getting blood-borne infections from unsafe practices while using needles and sharp objects as few of them know how to manage such injuries. 

The Acting Chief Administrator at the Coast General hospital, Dr Victor Njom, says “people do not know what happens to the needle that gave them the antibiotic”, yet “all that is medical waste that has to be managed, or else more and more people will get sick”.

Indeed, a study published in the journal Clinical Case Reports  in November last year  by doctors at the Moi Teaching and Referral Hospital cites the case a 27-year-old medical intern who contracted a rare form of tuberculosis after being pricked on his little finger while attending to an HIV-infected patient.

He underwent incorrect treatment for almost a year in vain after tests confirmed that he was HIV-negative after the PEP dose. He was finally cured after another test diagnosed TB and he was put on the appropriate medication.

Fortunately, the Ministry of Health, in collaboration with come organisations, has now set out to protect human resources in the sector.

Chief among the raft of measures is the regulation of the disposal of hazardous waste. Through the National Guidelines for Safe Management of Health Care Waste, it lays down the procedures for handling the entire cycle, including waste collection, storage, transportation and disposal.

Chapter 7 of the guidelines provides details on waste management and the importance of separating and categorising waste.

This was evident at the CGPH, where DN2 saw clearly labelled waste bins in the laboratory, emergency rooms, morgue and along the corridors.

“All this was made possible by PATH, a non-governmental organisation that deals in health technologies. It brought us these bins, trained health workers on using them and also got us three waste transportation trolleys which have greatly improved how we manage our waste,” Mr Masha said.

The director of PATH’s Health Care Waste Management (HCWM) Project, Mr Fred Okuku, says: “We are aware of the cost of medical waste. We train health workers across the country on how to handle it to minimise infections and provide protective equipment for their work. We are involved in the whole waste cycle to ensure safety.”

The HCWM project supports healthcare waste management systems in 59 hospitals countrywide.

Thanks to the project, more than 6,000 health workers from the hospitals around the country have so far been trained on health waste management.

The autoclave and shredder, worth Sh25 million, were provided by the US President’s Emergency Plan for AIDS Relief (Pepfar)  through the Centres for Disease Control (CDC, with PATH implementing the project.

The autoclave will be used on a pilot basis to determine the possibility of including non-burn technologies in the country before being rolled out in other counties.

FEWER INJECTIONS

Speaking at the commissioning of the autoclave, Mr Lolem Lokol’ile from the Ministry of Health’s Division of Environmental Health said the findings of the pilot would inform how the ministry manages health waste across the 47 counties.

Treatment logs of all waste will record the processes in each waste management cycle. They will then be shared with the hospital public health officer monthly for analysis before being presented to the Ministry of Health.

“The results of the test will be used for policy information,” said Mr Okuku. “This  is a situation analysis, a descriptive study to pilot key findings on the use of non-burn technologies in Kenya. It will be availed to the Ministry for the possibility of the inclusion of non-burn technologies in Heath Care Waste Management Policy in Kenya.”

The Nairobi National Public Health Laboratory, Karatina Sub-County Hospital, Bungoma County Referral Hospital, Malindi District Hospital and Kemri CDC Kisumu have each received a shredder.

In addition to safe disposal of waste to  prevent infections, WHO has called for more use of oral medication and fewer injections.

According to the organisation, 16 billion injections are administered every year.

Five per cent of these are for immunising children and adults, another five per cent  are for procedures like blood transfusions and injectable contraceptives, and  90 per cent for administering medicines.

The organisation’s call for fewer injections could pose problems, since some people strongly believe that only injections can cure them.

WHAT IS AN AUTOCLAVE

An autoclave is basically a large vessel through which steam is circulated to sterilise things, perform scientific experiments, or carry out industrial processes. Its non-burn technology kills disease-causing organisms with pressurised steam instead of fire.

This is unlike incinerators, which produce highly toxic pollutants such as acid gases, heavy metals and other waste, which are detrimental to human health and the environment.

The autoclave is cylindrical because cylinders can withstand extreme pressures better than boxes, whose edges become points of weakness that can break.

It has a hinged mounted door to provide full movement of the trash and has a lock that prevents the door from opening while under pressure. Steam is pumped through the chamber at pressures higher than atmospheric pressure so it reaches temperatures of about 121°–140°C.

It kills pathogens through the dry, saturated steam created from a steam generator boiler for about 50 minutes.  

The vapour released is filtered of any micro organisms. 

Origin of the autoclave

 Ancient Greeks use boiling water to sterilise medical tools.

 1679: French engineer Denis Papin (1647–1712) invents the steam pressure cooker – an important step in the development of steam engines.

 1860s: French biologist Louis Pasteur (1822–1895) helps to confirm the germ theory of disease. He realises that heating things to kill germs can prevent diseases and extend the life of foodstuffs (which leads him to the invention of pasteurisation).

 1880s: Pasteur’s collaborator, Charles Chamberland (1851–1908), invents the modern autoclave.

Internet sources.

Types of waste

•  Infectious waste: Waste contaminated with blood and its by-products, cultures and stocks of infectious agents, waste from patients in isolation wards, discarded diagnostic samples containing blood and body fluids, infected animals from laboratories, and contaminated materials (swabs, bandages) and equipment (such as disposable medical devices);

•  Pathological waste: Body parts and contaminated animal carcasses.

•  Sharps: Syringes, needles, disposable scalpels and blades, etc.

•  Chemicals: For example mercury, solvents and disinfectants.

•  Pharmaceuticals: Expired, unused, and contaminated drugs and vaccines.

•  Genotoxic waste: Drugs used in cancer treatment, teratogens (capable of producing foetal malformation).

•  Radioactive waste: Such as glassware contaminated with radioactive diagnostic material or radiotherapeutic materials.

 Heavy metals waste: Such as broken mercury thermometers.

The major sources of healthcare waste are:

 Hospitals and other healthcare establishments

 Laboratories and research centres

 Mortuaries and autopsy centres

 Animal research and testing laboratories

 Blood banks and collection services

Risks associated with waste disposal

Although treatment and disposal of healthcare waste reduces risks, indirect health risks may occur through the release of toxic pollutants into the environment through treatment or disposal.

 If not properly constructed, and fills such as an ash pit can contaminate drinking water.

 Incineration of waste has been widely practised, but inadequate incineration or the incineration of unsuitable materials results in the release of pollutants into the air and of ash residue.

Incinerated materials containing chlorine and other heavy metals can generate cancer-causing fumes.

What the world is doing to reduce pollution from health waste:

1. Using alternatives to incineration such as autoclaving, microwaving, steam treatment integrated with internal mixing, and chemical treatment.

2. Scientists are working to develop syringes that cannot be used more than once. One such effort is by British inventor Marc Koska, who  created  the K-1 syringe, the first syringe to automatically become disabled once it’s used. A small ring inside of the barrel of the syringe allows the plunger to move only in one direction, such that after it has been used, the plunger locks in place and will break if forced.

3. WHO is urging countries to transition, by 2020, to the exclusive use of the “smart” syringes, except in specific cases in which a syringe that blocks after a single use would interfere with the procedure, for instance, when a person is on an intravenous pump that uses a syringe.