DOH Health Care Waste Management Manual - 4th Edition - FINAL PDF

COVER PAGE
HEALTH CARE WASTE

MANAGEMENT MANUAL
FOURTH EDITION
2020
DEPARTMENT OF HEALTH
HEALTH FACILITY DEVELOPMENT BUREAU
Health Care Waste Management Manual
Fourth Edition
2020
The preparation and publication of this document was made possible through
the Technical Assistance of the World Health Organization (WHO), “Updating the
Manual on Health Care Waste Management” funded through the Australian
Department of Foreign Affairs and Trade (DFAT).
This document is published by the Department of Health (DOH) – Health Facility
Development Bureau (HFDB) with office at Building 4, San Lazaro Compound,
Tayuman St. cor. Rizal Ave., Sta. Cruz, Manila, Philippines 1003, for general distribution.
All rights reserved. Subject to the acknowledgement of DOH-HFDB, the Manual
may be freely abstracted, reproduced or translated in part or in whole for non-
commercial purposes only. If the entire work or substantial portions will be translated
or reproduced, permission should be requested from the DOH-HFDB.
Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY
MESSAGE
“Health is everybody’s business. Health systems only work when everyone works
together to ensure that no one is left behind.”
Universal Health Care (UHC) is both a vision and a commitment to the health
of all Filipinos by providing the full range of high-quality health care services—from
preventive to promotive, curative, rehabilitative, and palliative—at affordable cost.
The signing of the UHC Act is a remarkable achievement as it marks the

beginning of a new chapter in the reform of the Philippine health system. These
include operationalizing primary health care and mainstreaming health promotion to
protect people from disease, empowering individuals and communities to maintain
good health, and supporting effective management of illness and disability. It will shift
the health system’s current treatment-oriented approach towards a more balanced
approach emphasizing prevention and health promotion.
Among the significant reforms that will be implemented over time include:
automatic enrollment of all Filipinos to PhilHealth; designating PhilHealth as the
national purchaser for health goods and services for individuals, such as medicines;
improvement of health facilities especially in underserved areas; responding to the
gap in health workers throughout the country; strategic engagement of the private
sector; and creating and expanding new functions in DOH to improve the delivery of
health services.
It is with these reforms in mind that the Health Care Waste Management
Manual is revisited, updated, and fortified with information that will be accessible and
useful to different types of health care facilities in the country, from hospitals and
clinics that offer a wide range of specialized health services, to the rural health units
and barangay health stations that deliver primary care at the community level.
FRANCISCO T. DUQUE III

Secretary of Health
ACKNOWLEDGEMENT
This Fourth Edition of the Health Care Waste Management Manual was made
possible through the collaborative effort of the various stakeholders and resource
persons whose names appear in the succeeding pages and whom we thank for
actively participating in the consultative meetings and for sharing their experience
and knowledge:
Department of Health
Ms. Madeliene Gabrielle Doromal Health Facility Development Bureau
Ar. Jean Paolo Policarpo Health Facility Development Bureau
Ms. Teresita Cruz Health Facility Development Bureau
Engr. Rodelio Pineda Health Facilities and Services Regulatory Bureau
Engr. Severino Reyes III Health Facilities Enhancement Program
Engr. Maria Sonabel Anarna Disease Prevention and Control Bureau
Engr. Gerardo Mogol Disease Prevention and Control Bureau
Engr. Luis Cruz Disease Prevention and Control Bureau
Dr. Valeriano Timbang, Jr. Disease Prevention and Control Bureau
Ms. Maria Victoria Madura Health Promotion and Communication Service
Mr. Brian Aviguetero Health Promotion and Communication Service
Mr. Julius Solano Center for Health Development – CAR
Ms. Jamborette Pangsiw Center for Health Development – CAR
Ms. Arrami Mayon Center for Health Development – CARAGA
Mr. Adrian Doctolero Center for Health Development – Ilocos
Mr. Ashlrey Antonio Center for Health Development – Region I
Mr. Nikky Bryan Taguibao Center for Health Development – Region II
Department of Environment and Natural Resources

Engr. Leonie Ruiz EMB Hazardous Waste Management Section
Engr. Santini Quiocson EMB Hazardous Waste Management Section
Mr. Julito Tangalin EMB Hazardous Waste Management Section
Mr. Irvin Cadavona EMB Hazardous Waste Management Section
Department of Science and Technology

Ms. Cynthia Borromeo Industrial Technology Development Institute
Ms. Clarissa Reyes Philippine Council for Health Research and
Development
Ms. Ervinna Cruz Philippine Council for Health Research and
Development
Local Government Units

Mr. Wilfredo Leyva Antipolo City Health Office
Mr. Michael Mang-usan Baguio City Health Services Office
Dr. Eduardo Posadas La Union Provincial Health Office
Mr. Reymark Tasico Malvar Rural Health Unit
Mr. Alfhie Manto Malvar Rural Health Unit
Mr. Romeo Halcon Manila Health Department
Engr. Mitzie Salvador Manila Health Department
Ms. Riah Fojas San Pedro Rural Health Unit
Mr. Reynante Arboleda San Pedro Rural Health Unit
Ms. Camille Canubar Santo Tomas, Batangas Rural Health Unit
Mr. Pedrito Mayuga Santo Tomas, Batangas Rural Health Unit
Hospitals
Dr. Roberto A. Espos, Jr. De La Salle Medical Center Cavite
Ms. Riza Bautista-Lumagui De La Salle Medical Center Cavite
Engr. Lowell Lee De La Salle Medical Center Cavite
Ms. Amelani A. Banca De La Salle Medical Center Cavite
Ms. Carmi Anahaw De La Salle Medical Center Cavite
Ms. Michelle Saulog De La Salle Medical Center Cavite
Ms. Paola Katrina Ching Dr. Jose N. Rodriguez Memorial Hospital
Mr. Mark Louie A. Ona Manila Doctors Hospital
Mr. Aries M. Esma Manila Doctors Hospital
Dr. Ma. Lourdes Otayza Mariano Marcos Memorial Hospital and Medical
Center
Dr. Ma. Paz Otayza Mariano Marcos Memorial Hospital and Medical
Center
Engr. Jose Barsaga Philippine Heart Center
Engr. Jennifer Quintero Rizal Medical Center
Ms. Gilda Cirila A. Ramos San Juan de Dios Hospital
Ms. Ma. Melody S. Licuanan San Lazaro Hospital
Engr. Aida Calma San Lazaro Hospital
Ms. Jonalyn T. Lacsamana San Pedro Jose L. Amante Emergency Hospital
Mr. Jose B. Barsaga Philippine Heart Center
Mr. Primitivo Jose C. Reyes III The Medical City
Mr. Jonathan M. Ambrocio The Medical City
Ms. Cristy Donato The Medical City
Medical Association, Regulators, NGO, Academe

Ms. Gina Noble Philippine Association of Medical Technologists, Inc.
Dr. Elma Leones Javier Philippine Dental Association
Mr. Emerson Lesly D. Cruz Philippine Health Insurance Corporation
Mr. Climaco E. Caliwara Philippine Hospital Association
Mr. Rogelio V. Dazo, Jr. Philippine Medical Association
Ms. Moresa T. Reyes Health Care Without Harm – Asia
Mr. Alex Mendoza National University
World Health Organization

Engr. Bonifacio Magtibay World Health Organization – Philippines
Mr. Eduardo Genciagan, Jr. World Health Organization – Philippines
Ms. Christine Gaylan World Health Organization – Philippines
Engr. Jose Marie U. Lim APW Contractor/LCI Envi Corporation
Ms. Rebecca L. Husayan APW Contractor/LCI Envi Corporation
Engr. Patricia Ann C. Go APW Contractor/LCI Envi Corporation
Ms. Krisha L. Santos APW Contractor/LCI Envi Corporation
TABLE OF CONTENTS
MESSAGE ..................................................................................................................................................... i
ACKNOWLEDGEMENT .............................................................................................................................. i
TABLE OF CONTENTS............................................................................................................................. iii
LIST OF TABLES...................................................................................................................................... vii
LIST OF FIGURES ................................................................................................................................... vii
LIST OF BOXES ...................................................................................................................................... viii
LIST OF ABBREVIATIONS.................................................................................................................... iix
PART I—GENERAL CONSIDERATIONS AND OVERVIEW ...............................................................1
1 Introduction ....................................................................................................................................................... 2
1.1 Background ....................................................................................................................................................... 2
1.2 Purpose and Intent ........................................................................................................................................ 2
1.3 Scope and Limitations .................................................................................................................................. 2
1.4 Contents of the Manual .............................................................................................................................. 3
1.5 Approach ............................................................................................................................................................ 3
1.6 Key Concepts .................................................................................................................................................... 4
1.7 Expected Outcomes....................................................................................................................................... 6
2 Health Care Waste Source, Categorization, and Characterization ........................................... 7

2.1 General Definition of HCW ........................................................................................................................ 7
2.2 Categorization of HCW ................................................................................................................................ 7
2.3 Generation of HCW .....................................................................................................................................15
2.4 Waste Assessment Approaches .............................................................................................................20
3 Risks Associated with Health Care Waste ....................................................................................... 23

3.1 Persons at Risk ...............................................................................................................................................23
3.2 Types of Hazard and Mode of Transmission ..................................................................................23
3.3 Additional Considerations and Emerging Threats of HCW to Public Health and the
Environment ................................................................................................................................................................29
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3.4 Risk Assessment Approach to HCWM ................................................................................................33
4 Legislative, Regulatory, and Policy Aspects of Health Care Waste ....................................... 37

4.1 Guiding Principles ........................................................................................................................................37
4.2 International Agreements/Conventions ..............................................................................................38
4.3 National Policies and Related Issuances ...........................................................................................39
4.4 Other Relevant Issuances and Guidelines .........................................................................................44
PART II—HEALTH CARE WASTE MANAGEMENT SYSTEM ........................................................ 47

5 Health Care Waste Management Planning ...................................................................................... 48
5.1 Organization and Functions ....................................................................................................................49
5.2 Health Care Waste Management Committee .................................................................................50
5.3 Health Care Waste Management Plan ...............................................................................................51
6 Health Care Waste Minimization ........................................................................................................... 57

6.1 Principles...........................................................................................................................................................59
6.2 Benefits of Waste Minimization .............................................................................................................60
6.3 Waste Minimization Techniques ...........................................................................................................61
6.4 Administrative Control Measures ..........................................................................................................68
7 Health Care Waste Segregation, Collection, Storage, and Transport .................................. 70

7.1 Principles...........................................................................................................................................................70
7.2 HCW Segregation .........................................................................................................................................71
7.3 Collection and Transport within the HCF .........................................................................................79
7.4 On-site Storage of HCW ...........................................................................................................................82
7.5 Off-site Collection ........................................................................................................................................88
7.6 Off-site Transport .........................................................................................................................................89
8 Health Care Waste Treatment and Disposal ................................................................................... 90

8.1 Selection of Treatment Methods ..........................................................................................................90
8.2 Basic Treatment Processes .......................................................................................................................91
8.3 Treatment Technologies ............................................................................................................................94
8.4 On-site HCW Treatment Facilities ...................................................................................................... 103
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8.5 HCW Disposal ............................................................................................................................................. 104
9 Managing Wastewater Generated by Health Care Facilities ................................................. 114

9.1 Composition of HCF Wastewater ......................................................................................................... 114
9.2 Sources and Characteristics of HCF Wastewater ........................................................................ 115
9.3 Collection of HCF Wastewater ............................................................................................................ 115
9.4 Treatment of HCF Wastewater ............................................................................................................ 116
PART III—ADMINISTRATIVE CONTROLS AND REQUIREMENT ............................................ 124

10 Administrative Requirements .............................................................................................................. 125
10.1 Oversight and Management at the National and Local Levels ........................................ 125
10.2 Administrative Requirements at the Facility Level .................................................................. 126
10.3 Budgetary Requirements to Implement the HCWM Program .......................................... 128
10.4 Options for Financing ........................................................................................................................... 132
11 Health and Safety Practices .................................................................................................................. 134

11.1 Principles ..................................................................................................................................................... 134
11.2 Occupational Health Risks .................................................................................................................. 135
11.3 Exposure Prevention and Control ................................................................................................... 137
11.4 Hospital Hygiene and Infection Control ...................................................................................... 141
11.5 Occupational Health and Safety Program .................................................................................. 146
11.6 Education, Communication, Training and Awareness ........................................................... 149
12 Health Care Waste Management in Emergencies ...................................................................... 153

12.1 Emergency Management Plan .......................................................................................................... 153
12.2 Contingency Planning and Emergency Preparedness ........................................................... 161
12.3 Emerging Issues....................................................................................................................................... 162
PART IV—GLOSSARY, ANNEXES, AND REFERENCES ................................................................ 167

Definition of Terms .................................................................................................................................................... 168
ANNEX A: Process Flow Diagrams .......................................................................................................................... 177
ANNEX B: Requirements and Guides .................................................................................................................. 194
ANNEX C: Procedures .................................................................................................................................................209
ANNEX D: Sample Checklists and Forms........................................................................................................... 218
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ANNEX E: Drawings and Illustrations.................................................................................................................. 229
ANNEX F: Links................................................................................................................................................................ 242
References .................................................................................................................................................................... 246
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LIST OF TABLES
Table 1: Type of HCW typically generated by HCFs......................................................... 16
Table 2: Potential infections caused by exposure to HCW ............................................. 25
Table 3: Example of hazards identified in HCFs (under WASH) ....................................... 33
Table 4: HCW bins and plastic liners specifications, color-coding, marking/labelling 77
Table 5: Applications of treatment and disposal methods for specific HCW categories
................................................................................................................................................ 108
Table 6: Sources and characteristics of HCF wastewater ............................................. 115
Table 7: Significant effluent parameters for HCFs ........................................................... 118
Table 8: Responsibilities of implementing and cooperating agencies for HCWM ..... 125
Table 9: Hazards to health care workers .......................................................................... 136
Table 10: Ways to improve infection control ................................................................... 145
Table 11: Key issues in rapid initial assessment ................................................................ 154
Table 12: Segregation of HCW in emergencies .............................................................. 156
Table 13: Summary of pharmaceutical disposal methods in and after emergencies157
Table 14: HCWM practice in emergencies ...................................................................... 158
Table 15: Key points relating to climate change ............................................................ 163
Table 16: Key points relating to environmental issues .................................................... 164
Table 17: Key points relating to waste technology ........................................................ 165
Table 18: Key points relating to social, cultural, and regulatory changes .................. 166
LIST OF FIGURES
Figure 1: Categories of health care waste .......................................................................... 7
Figure 2: Comparison of estimated daily waste generation in two types of HCFs ...... 19
Figure 3: Seven important points in waste management ............................................... 48
Figure 4: Basic elements for safe HCWM in primary care facilities ................................. 56
Figure 5: HCW handling ........................................................................................................ 57
Figure 6: Waste management hierarchy ........................................................................... 58
Figure 7: Waste minimization techniques ........................................................................... 61
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LIST OF BOXES
Box 1: HCW covered in the classification of hazardous wastes under DAO 2013-22 .... 8
Box 2: Highly infectious diseases ............................................................................................ 9
Box 3: Categories of harmful cytotoxic drugs ................................................................... 10
Box 4: Examples of heavy metals found in HCW .............................................................. 13
Box 5: Non-hazardous chemical waste .............................................................................. 13
Box 6: Volume of generated M501 and M503 as per EMB data .................................... 17
Box 7: Chain of infection ...................................................................................................... 24
Box 8: Endocrine disruptors................................................................................................... 30
Box 9: Antimicrobial resistance ............................................................................................ 32
Box 10: Microplastics ............................................................................................................. 32
Box 11: Overview of WASH FIT .............................................................................................. 34
Box 12: Objectives of HCWM Planning ............................................................................... 48
Box 13: Planning according to facility size ......................................................................... 49
Box 14: HCWM Committee for hospitals ............................................................................. 51
Box 15: Details to include in the HCWM Plan..................................................................... 54
Box 16: Examples of practices to encourage waste minimization ................................. 59
Box 17: Factors to consider in Green Procurement .......................................................... 62
Box 18: Life Cycle Analysis (LCA) Tool ................................................................................. 63
Box 19: Examples of sterilization methods for re-usable items ......................................... 65
Box 20: Recycling of plastics ................................................................................................ 66
Box 21: Composting techniques.......................................................................................... 67
Box 22: Environmental Management System .................................................................... 68
Box 23: Minimum requirement for HCW segregation: three-bin system ........................ 71
Box 24: Sharp containers ...................................................................................................... 74
Box 25: Minimum requirements for HCW storage.............................................................. 88
Box 26: Minimum measures for HCW transport.................................................................. 89
Box 27: Selecting HCW treatment and disposal methods for primary care facilities .. 90
Box 28: Microbial inactivation .............................................................................................. 91
Box 29: General considerations in the use of autoclave ................................................. 95
Box 30: Treatment of wastes from medical laboratories.................................................. 95
Box 31: Small-scale incineration ........................................................................................ 101
Box 32: Construction of sharps pit/concrete vault ......................................................... 105
Box 33: Overview of treatment and disposal of HCW in primary care facilities ......... 110
Box 34: Management of wastes from home care services ........................................... 111
Box 35: Management of wastes from immunization campaign activities .................. 112
Box 36: Minimum approach for management of liquid HCW ...................................... 113
Box 37: Wastewater generation rate in HCFs .................................................................. 114
Box 38: Pre-treatment of HCF wastewater ....................................................................... 117
Box 39: Septic tank systems operation and maintenance criteria ............................... 121
Box 40: Guide to basic wastewater system ..................................................................... 123
Box 41: Required PPEs for health care workers................................................................ 140
Box 42: Summary of PEP recommendations .................................................................... 147
Box 43: “My Five Moments of Hand Hygiene” in HCF .................................................... 149
Box 44: Methods of communication and training .......................................................... 152
Box 45: Emergency contingency plan for HCW transporter ......................................... 161
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LIST OF ABBREVIATIONS
ABR Anaerobic Baffled Reactor
ADB Asian Development Bank
AMR Antimicrobial Resistance
AO Administrative Order
ASC Ambulatory Surgical Clinic
APP Annual Procurement Plan
BHDT Bureau of Health Devices and Technology
BHFS Bureau of Health Facilities and Services
BHS Barangay Health Station
BSF Blood Service Facility
CAT Costing Analysis Tool
CD Cleaning and Disinfection
CDC Center for Disease Control and Prevention
CHD Center for Health Development
COD Chemical Oxygen Demand
CPR Certificate of Product Registration
CSA Central Storage Area
DBP Development Bank of the Philippines
DENR Department of Environment and Natural Resources
DILG Department of Interior and Local Government
DOH Department of Health
ECAT Expanded Costing Analysis Tool
ECC Environmental Compliance Certificate
EHS Environmental Health Service
EIA Environmental Impact Assessment
EIS Environmental Impact Statement
EISCP Environmental Infrastructure Support Credit Program
EMB Environmental Management Bureau
EMS Environmental Management System
EO Executive Order
EOHO Environmental and Occupational Health Office
FEFO First to Expire, First Out
FIFO First In, First Out
GPP Green Procurement Policy
HCF/s Health Care Facility/ies
HCW Health Care Waste
HCWM Health Care Waste Management
HEMS Health Emergency Management Service
HFDB Health Facility Development Bureau
HFSRB Health Facilities and Services Regulatory Bureau
ICN Infection Control Nurse
ICO Infection Control Officer
ICU Intensive Care Unit
IEC Information, Education, and Communication
IEE Initial Environmental Examination
IRR Implementing Rules and Regulations
ISO International Organization for Standardization
ix
JAO Joint Administrative Order
LCA Life Cycle Analysis
LGU Local Government Unit
LLDA Laguna Lake Development Authority
LTO License to Operate
MC Memorandum Circular
MSDS Material Safety Data Sheet
NCDPC National Center for Disease Prevention and Control
NCHFD National Center for Health Facility Development
NEC National Epidemiology Center
NIH National Institutes of Health
NPCC National Pollution Control Commission
NRL National Reference Laboratory
NSWMC National Solid Waste Management Commission
NSRC Newborn Screening Reference Center
OIC Officer in Charge
OIR Occupational Incident Report
OPD Outpatient Department
OR Operating Room
OSHA Occupational Safety and Health Administration
PCO Pollution Control Officer
PD Presidential Decree
PDCA Plan-Do-Check-Act
PHIC/PhilHealth Philippine Health Insurance Corporation
PNRI Philippine Nuclear Research Institute
POPs Persistent Organic Pollutants
PPE Personal Protective Equipment
RA Republic Act
RBC Rotating Biological Contractors
RHU Rural Health Unit
SBR Sequential Batch Reactor
SDG/s Sustainable Development Goal/s
SLF Sanitary Landfill Facility
STP Sewage Treatment Plant
TSD Treatment, Storage, and Disposal
UHC Universal Health Care
UHU Urban Health Unit
WASH Water, Sanitation, and Hygiene
WASH FIT Water and Sanitation for Health Facility Improvement Tool
WHA World Health Assembly
WHO World Health Organization
WMO Waste Management Officer
WPRO Western Pacific Regional Office
WWTP Wastewater Treatment Plant
x
Health Care Waste Management Manual PART I—GENERAL CONSIDERATIONS AND OVERVIEW
Fourth Edition Chapter 1: Introduction
PART I—GENERAL CONSIDERATIONS AND

OVERVIEW
1
1 Introduction
1.1 Background
The First Edition of the “Hospital Waste Management Manual” was formulated
and issued by the Department of Health (DOH) through the Environmental Health
Service (EHS) in 1997.
In 2004, the DOH Environmental and Occupational Health Office (EOHO) issued
the Second Edition, renamed “Health Care Waste Management Manual” and
designed to provide guidance and practical information regarding safe, efficient,
and environment-friendly waste management options not just for hospitals but for
other health facilities in the country.
The DOH adopted a more participatory approach by collaborating with various
stakeholders in reviewing, enhancing, and updating its policies and guidelines on
health care waste management (HCWM). Published in 2011, the Third Edition is more
user-friendly and substantiated with the new trends and universally accepted
technologies.
Review and updating of the Manual is essential after five years or so to align with
current initiatives and strategies and provide responsive information to all the
stakeholders. Any proposal for revision should have been forwarded to the National
Center for Health Facility Development for consideration and subject to the formal
approval of the Secretary of Health.
1.2 Purpose and Intent

This document shall serve as the most comprehensive set of guidelines on the safe
management of waste generated from heath care activities in the country.
It incorporates the requirements of all Philippine laws and regulations governing
HCWM and is designed for the use of individuals, public and private establishments,
and other entities involved in segregation, collection, handling, storage, treatment,
and disposal of waste generated from heath care activities.
1.3 Scope and Limitations

This Manual covers all health care waste (HCW) as defined in Chapter 2.1. Waste
generated by establishments that are not considered as health care facilities (HCFs)
as defined in Chapter 2.3 are not covered by this Manual and shall be governed by
the existing environmental laws and policies of the different governing agencies
other than the DOH.
2
1.4 Contents of the Manual

This Manual has four (4) major parts, each of which is subdivided into chapters:
PART I—GENERAL CONSIDERATIONS AND OVERVIEW includes this introduction to the Manual
(Chapter 1); the general definition, typical sources, known categories, and current
generation of HCW in the Philippine context (Chapter 2); expanded discussion on
HCW risks and impacts to human health and the environment (Chapter 3); updated
list and overview of the guiding principles, relevant international agreements,
national policies, issuances, and guidelines (Chapter 4).
PART II—HEALTH CARE WASTE MANAGEMENT SYSTEM discusses the main components of the
HCWM system, including HCWM planning (Chapter 5); concept of HCW minimization
(Chapter 6); principles of proper HCW segregation, collection, storage, and transport
(Chapter 7); some options for HCW treatment and disposal (Chapter 8); and
guidelines on management of wastewater generated by HCFs (Chapter 9).
PART III—ADMINISTRATIVE CONTROLS AND REQUIREMENTS presents the administrative
requirements to implement HCWM (Chapter 10); health and safety practices
(Chapter 11); HCWM during emergencies, as well as emerging issues and trends in
HCWM (Chapter 12).
PART IV—GLOSSARY, ANNEXES, AND REFERENCES provides an updated listing and definition
of terms used in the Manual, the annexed supplementary materials (i.e., process flow
diagrams, requirements and guides, procedures, sample checklists and forms,
drawings and illustration, links to online resources), and the list of references.
1.5 Approach
The DOH recognizes its responsibility in setting up necessary policies, guidelines,
and standards for safe management of HCW and its role in ensuring the compliance
of all concerned on the effective and efficient handling of wastes, and in imposing
discipline. To address the issues at hand, the following approaches will be
undertaken:
 Clear definition of HCW, its various categories and the hazards/risks
involved and acceptable methods of handling, collection, transport,
treatment, storage, and final disposal, including waste minimization
practices that generate the best results;
 Application of concepts that can minimize risks to human health and the
environment, such as the chain of infection, the International Organization
for Standardization (ISO) hierarchy of controls, and the waste
management hierarchy;
 Implementation of appropriate review, monitoring, and evaluation system
to ensure strict enforcement of the laws, policies, and guidelines on
3
HCWM;
 Streamlining national and local regulations on HCWM with international
agreements and guidelines to achieve standardized HCWM approach for
all types of HCFs;
 Inclusion of approved HCWM practices appropriate to the type, service
capability, and subsequent waste generation of HCFs.
 Continuous review of the applicability of the laws, policies, and guidelines
on HCWM vis-à-vis latest standards, trends, technologies; and
 Adopting measures that shall address issues on climate change, emerging
pathogens, antimicrobial resistance, and social or cultural changes, which
all have an impact on HCWM.
1.6 Key Concepts

The Fourth Edition Manual is a comprehensive compilation of the latest and most
relevant instruments and processes designed for effective implementation of HCWM
in all types of HCF whether in the urban or rural setting.
In order to realize its purpose, some health concepts, policies, and principles were
adopted to serve as the groundwork for the Manual.
1.6.1 Sustainable Development Goals
The Sustainable Development Goals or SDGs are a collection of 17 global goals

set by the United Nations General Assembly in 2015 for the year 2030. It is the blueprint
to achieve better and sustainable future for all. It addresses several global challenges
including access to safe and sustainable water, sanitation, hygiene, and
environmental degradation. HCWM specifically addresses SDG No.3 on good health
and well-being, SDG No. 6 on clean water and sanitation, and SDG No. 12 on
responsible consumption and production.
1.6.2 Risk Management Concept
The concept of risk management in the HCF setting is best defined as the overall
approach to identify, assess, and reduce the exposure to hazards of the patients,
visitors and health care workers, the hazards being specific to HCW in this aspect.
Risks are the likelihood of the identified hazards to cause harm in exposed population
and the severity of the exposure. In order to prevent the hazard from affecting the
population, a risk assessment is done using available information and data to predict
how often it is likely to occur and the magnitude of the consequence. This risk
management concept is an important tool of an HCF as it strives to integrate policies
on HCWM Program within its day to day operations. This concept is elaborated in
Chapter 3 (Risks Associated with Health Care Waste).
4
Water and Sanitation for Health Facility Improvement Tool (WASH FIT)
WASH FIT is a multistep, iterative process to facilitate improvements in WASH
services, quality, and experience of care in all types of HCFs. Among its purpose is to
identify areas for quality improvement in facilities, including strengthening WASH and
infection prevention and control policies and standards that will lead to lower
infection rates, better health outcomes for patients and improved staff safety and
morale. WASH FIT covers four broad areas: water, sanitation (including HCWM),
hygiene (hand hygiene and environmental cleaning), and management. WASH
services strengthen the resilience of health care systems to prevent disease
outbreaks, allow effective responses to emergencies (including natural disasters and
outbreaks) and bring emergencies under control when they occur. This concept is
elaborated in Chapter 4 (Legislative, Regulatory, and Policy Aspects of Health Care Waste).
1.6.3 Chain of Infection
The Chain of Infection is a model used to understand the infection process. It is

illustrated by a circle of links, each representing a component in the cycle. Each link
must be present and in sequential order for an infection to occur. The links are
infectious agent, reservoir, portal of exit from the reservoir, mode of transmission, and
portal of entry into a susceptible host. Understanding the characteristics of each link
and the means by which the chain of infection can be interrupted provides the HCF
workers with methods for supporting vulnerable patients, preventing the spread of
infection and self-protection. Breaking any link in the chain will prevent infection,
although control measures are most often directed at the “mode of transmission.”
This concept is further discussed in Chapter 3 (Risks Associated with Health Care Waste).
1.6.4 Hierarchy of Controls
Controlling exposures to occupational hazards is the fundamental method of

protecting workers. Hierarchy of controls has been used as a means of determining
feasible and effective controls in the workplace. The methods of control are defined
in five groups as elimination, substitution, engineering and administrative controls
and personal protective equipment. This concept is detailed in Chapter 11 (Health and
Safety Practices).
1.6.5 The Waste Management Hierarchy
A concept in waste management in which it is most preferable to prevent the

generation of waste at source and reduce the quantity generated by adopting
different methods of safe re-use, recycling, and recovery. Proper treatment and
residuals disposal are the end-of-pipe approach. In addressing HCWM, waste
minimization utilizes the first two elements that could help reduce the bulk of HCW for
disposal; hence, the most “desirable” management practice aims to address the
problem at source rather than “end-of-pipe.” ‘Desirability’ is defined in terms of the
overall benefit of each method from their specific impacts on the environment,
5
protection of public health, financial affordability, and social acceptability. This is

elaborated in Chapter 6 (Health Care Waste Minimization).
1.7 Expected Outcomes

Under the “duty of care” principle (elaborated in Chapter 4.1), every HCF has the
ethical responsibility of ensuring that there are no adverse health effects and
environmental consequences resulting from the handling, collection, storage,
treatment, and disposal of HCW it generates. Users of this Manual will be guided in
implementing safe and environmentally sound management of HCW in any HCF.
Proper and strict compliance with the set standards will result to benefits such as:
 Protection of human health and safety by controlling and/or reducing
exposure of persons at risk to hazardous HCW and minimizing indirect
impacts from environmental exposures to HCW;
 Contribution to the global effort to improve provision of safe water,
sanitation, and hygiene (WASH) in HCFs; and curb the proliferation of
diseases and environmental problems caused by pollution and
contaminants resulting from improper handling of HCW;
 Committed compliance of HCF to the regulatory laws, policies, and
guidelines required by national and local authorities in observing proper
HCWM;
 Prevention of any long-term liability resulting to any contravention or
violation incurred in the implementation of HCWM laws;
 Advancing of community ecological awareness and relationship by
demonstrating commitment and dedication in implementation of HCWM
programs and activities;
 Increase of socio-economic benefits resulting from the effective and
efficient application of HCWM laws, policies, and procedures;
 Sustainability of the HCWM Program of HCFs including evidences of
continuous improvement, less events of accidental exposure and
incidents of injury among HCW handlers; and
 Resiliency of HCFs in the face of emergencies, disasters, threats of
emerging pathogens and diseases, and ever-changing socio-cultural and
regulatory changes that impact the efficiency and effectiveness of HCWM
implementation.
6
Fourth Edition Chapter 2: Health Care Waste Source, Categorization, and Characterization
2 Health Care Waste Source, Categorization,

and Characterization
2.1 General Definition of HCW1
“Health care waste” (HCW) includes all the solid and liquid waste generated as
a result of any of the following:
 Diagnosis, treatment, or immunization of human beings;
 Research pertaining to the above activities;
 Research using laboratory animals for the improvement of human health;
 Production or testing of biological products; and
 Other activities performed by an HCF defined as an institution that has
health care as its core service, function, or business.
In addition, HCW includes the same types of waste originating from minor and
scattered sources, such as waste produced in the course of health care undertaken
in the home (e.g., home dialysis, self-administration of insulin, recuperative care).
2.2 Categorization of HCW

HCW can be broadly categorized into “hazardous” and “non-hazardous” waste
types.2 Each category is described in detail in the succeeding sub-sections.
Figure 1: Categories of health care waste
HAZARDOUS NON-HAZARDOUS (GENERAL)
Sharps
Infectious Recyclable
Pathological
Anatomical
Pharmaceutical Biodegradable
Genotoxic
Chemical
Radioactive Residual
Pressurized Containers
1 As provided in the Health Care Waste Management Manual, 3rd Edition (DOH, 2011)
2 Adopted from Safe Management of Wastes from Health-Care Activities, 2nd Edition (WHO, 2014)
7
2.2.1 Hazardous HCW
Hazardous HCW refers to waste that may pose a variety of environmental and
health risks. It can be further classified into sharps waste, infectious waste,
pathological and anatomical waste, pharmaceutical waste, genotoxic waste,
chemical waste, radioactive waste, and pressurized containers.
Box 1: HCW covered in the classification of hazardous wastes under DAO 2013-22
Classification of Hazardous Wastes as per DENR Administrative Order No. 2013-22:

Class Waste Number
Wastes with Cyanide A101
Acid Wastes B201 to B299
Alkali Wastes C301 to C399
Wastes with Inorganic Chemicals D401 to D499
Reactive Chemical Wastes E501 to E599
Inks/Dyes/Pigments/Paint/Resins/Latex/Adhesives/Organic Sludge F601 to F699
Waste Organic Solvents G703 to G704
Organic Wastes H802
Oil I101 to I104
Containers J201
Stabilized Waste K301 to K303
Organic Chemicals L401 to L404
Miscellaneous Wastes M501 to M507
HCW may fall under the following sub-classifications of Miscellaneous Wastes (Class M):
 Pathological or Infectious Wastes (Waste No. M501)

Includes health care wastes from hospitals, medical centers, and clinics containing
pathological, pathogenic, and infectious wastes, sharps, and others
 Pharmaceuticals and Drugs (Waste No. M503)

Expired pharmaceuticals and drugs stocked at producers and retailers’ facilities which
contain hazardous constituents harmful to the environment such as antibiotics, veterinary
and phytopharmaceuticals, and others
2.2.1.1 Sharps Waste
Sharps are considered as the most hazardous HCW and must be managed with
utmost care. This is because of the double danger it poses—it can cause accidental
pricks, cuts, or punctures; it can also potentially spread infection through these
injuries. Examples of sharps include needles, syringes, scalpels, saws, blades, broken
glass, infusion sets, knives, nails, and other items that can cause a cut or puncture
wound. Whether or not they are infected, such items are usually considered highly
hazardous and should be treated as if potentially infected.
2.2.1.2 Infectious Waste
This type of waste is most likely to contain pathogens (bacteria, viruses, parasites,
or fungi) in sufficient concentration or quantity to cause diseases in susceptible hosts.
Examples of infectious waste include:
a) Cultures and stocks of infectious agents from laboratory work;
8
b) Wastes from surgeries and autopsies on patients with infectious diseases

(e.g., tissues, materials or equipment that have been in contact with blood
or other body fluids);
c) Wastes from infected patients in isolation wards (e.g., excreta, dressings
from infected or surgical wounds, clothes heavily soiled with human blood
or other body fluids);
d) Wastes that have been in contact with infected patients undergoing
hemodialysis (e.g., dialysis implements such as tubing and filters,
disposable towels, gowns, aprons, gloves, and laboratory coats);
e) Infected animals from research laboratories; and
f) Other instruments or materials that have been in contact with infected
persons or animals.
Among these are highly infectious wastes (see PART IV for definition of terms) that
require disinfection at source, such as microbial cultures and stocks of highly
infectious agents from medical analysis laboratories and body fluids from patients
with highly infectious diseases. Special requirements regarding management of
infectious waste must be imposed whenever waste is known or – based on medical
experience – expected to be contaminated with causative agents of diseases and
when this contamination gives cause for concern that the disease might spread.
Box 2: Highly infectious diseases
Based on WHO Laboratory Biosafety Manual, 3rd edition (2004):

Highly infectious disease refers to those causative organisms under Biosafety Levels III and IV,
such as Severe Acute Respiratory Syndrome (SARS), Human Immunodeficiency Virus (HIV),
Acquired Immunodeficiency Syndrome (AIDS), pulmonary tuberculosis (PTB), anthrax, and
Ebola.
As per DOH Administrative Order 2010-33:

Considered as dangerous communicable diseases are Hepatitis B and C, rabies, Invasive Group
A streptococcal infections, transmissible spongiform encephalitis (e.g., Creutzfeldt-Jakob
disease and mad cow disease), HIV/AIDS, meningococcemia, viral hemorrhagic fevers (e.g.,
African Ebola, Lassa or Marburg), yellow fever, plague, SARS, among others.
2.2.1.3 Pathological and Anatomical Waste
Pathological waste could be considered a subcategory of infectious waste but

is often classified separately – especially when special methods of handling,
treatment, and disposal are used. It consists of tissues, organs, body parts, blood,
body fluids, and other waste from surgery and autopsies, including human fetuses
and animal carcasses. Within this category, recognizable human or animal body
parts are also called anatomical waste.
2.2.1.4 Pharmaceutical Waste
9
Pharmaceutical waste includes expired, spilt, and contaminated

pharmaceutical products, drugs, vaccines, and sera that are no longer required and
need to be disposed of appropriately. This category also includes discarded items
used in handling of pharmaceuticals, such as bottles, vials, or boxes with residues,
gloves, masks, and connective tubing.
2.2.1.5 Genotoxic including Cytotoxic Waste
Genotoxic waste is highly hazardous may have mutagenic (capable of inducing

a genetic mutation), teratogenic (capable of causing defects in an embryo or
fetus), or carcinogenic (cancer-causing) properties. Disposal of genotoxic waste
raises serious safety problems, both inside hospitals and after disposal, and should be
given special attention.
Genotoxic waste may include certain cytostatic drugs vomit, urine, or feces from
patients treated with cytostatic drugs, chemicals, and radioactive material.
Technically, genotoxic means toxic to the deoxyribonucleic acid (DNA);
cytotoxic means toxic to the cell; cytostatic means suppressing the growth and
multiplication of the cell; antineoplastic means inhibiting the development of
abnormal tissue growth; and chemotherapeutic means the use of chemicals for
treatment, including cancer therapy. Genotoxic waste causes damage to the cell’s
DNA. This includes certain antineoplastic (anti-tumor) and cytotoxic (cell-killer) drugs.
This type of waste is highly hazardous and may have mutagenic, teratogenic, or
carcinogenic effects.
Box 3: Categories of harmful cytotoxic drugs
Harmful cytotoxic drugs can be categorized as follows:
 Alkylating Agents: also called DNA-damaging agents; cause alkylation of DNA

nucleotides, which leads to cross-linking and miscoding of the genetic stock (e.g.,
vesicant drugs – aclarubicin, mechlorethamine, cisplatin, mitomycin; irritant drugs –
carmustine, cyclophosphamide, dacarbazine, ifosfamide, melphalan, streptozocin,
thiotepa)
 Anti-metabolites: imitate the role of purine and pyrimidine as the building blocks of DNA
thus inhibiting the biosynthesis of nucleic acids in the cell (e.g., irritant: methotrexate,
fludarabine, cytarabine)
 Mitotic Inhibitors: prevent cell division
 Intercalating Agents: wedge between the DNA bases, affecting the structure of the DNA
and preventing polymerase and other DNA binding proteins from functioning properly
(e.g., vesicant drugs – amsacrine, dactinomycin, daunorubicin, doxorubicin, epirubicin,
pirarubicin, zorubicin; irritant drugs – mitoxantrone)
 Plant Alkaloids and Terpenoids: inhibit microtubule function thereby halting cell division.
Examples: vinca alkaloids derived from the Catharanthus roseus plant or Tsitsirika (e.g.,
vesicant drugs – vinblastine, vincristine, vindesine, vinorelbine)
 Podophyllotoxins: prevent cell division by inhibiting the cell from entering the G1 Phase;
10
also affect DNA synthesis; derived from Podophyllum peltatum or Mayapple (e.g., irritant
drugs – teniposide)
Cytotoxic waste is generated from several sources and includes the following:
 Contaminated materials from drug preparation and administration, such as
syringes, needles, gauges, vials, and packaging;
 Outdated drugs, excess (leftover) solutions, and drugs returned from the
wards; and
 Urine, feces, and vomit from patients, which may contain potentially
hazardous amounts of the administered cytostatic drugs and/or of their
metabolites, and which shall be considered genotoxic for at least 48 hours
and sometimes up to 1 week after drug administration.
It is necessary for patients who are taking cytotoxic medication to have a
separate water closet, which is exclusive for the use of these patients. This will ensure
that other patients will not be exposed to cytotoxic drugs. Moreover, it will also ensure
that the urine, vomit, excreta, and other body fluids coming from these patients will
be adequately treated before these wastes are mixed with other wastes in the
Sewage Treatment Plant (STP).
2.2.1.6 Chemical Waste
Chemical waste consists of discarded solid, liquid, and gaseous chemicals used
in diagnostic and experimental work and in cleaning, housekeeping, and
disinfecting procedures.
Chemical waste is considered hazardous if it has at least one of the following
properties:
 Toxic: chemicals that have the capacity to harm biological tissue;
 Reactive: chemicals that can react by themselves when exposed to heat,
pressure, shock, friction, catalyst presence or by contact with air or water;
 Flammable: chemicals that ignite/burn easily in normal working
temperatures (e.g., chemicals with flashpoint below 37.8°C or 100°F);
 Corrosive: chemicals that can cause severe burns to skin and other
biological tissues including eyes and lungs (e.g., acids of pH<2 and bases
of pH>12); and
 Oxidizing: liquid or solid chemicals that readily give off oxygen or other
oxidizing substances (such as bromine, chlorine, or fluorine); also include
materials that react chemically to oxidize combustible (burnable)
materials; this means that oxygen combines chemically with the other
material in a way that increases the chance of a fire or explosion.
11
The most common types of hazardous chemicals used in health care, and the
most likely to be found in HCW, are as follows:
 Formaldehyde is a significant source of chemical waste in hospitals. It is
used to clean and disinfect equipment (e.g., hemodialysis or surgical
equipment); to preserve specimens; to disinfect liquid infectious waste;
and in pathology, autopsy, dialysis, embalming, and nursing units.
 Photographic fixing and developing solutions are used in X-ray
departments where photographic film continues to be used. The fixer
usually contains 5–10% hydroquinone, 15% potassium hydroxide, and less
than 1% silver. The developer contains approximately 45% glutaraldehyde.
Acetic acid is used in both “stop” baths and fixer solutions.
 Waste organic chemicals generated in HCFs include disinfecting and
cleaning solutions, vacuum-pump and engine oils, insecticides, and
rodenticides. Waste inorganic chemicals consist mainly of acids, alkalis,
oxidants, and reducing agents. Wastes containing solvents are generated
in various departments of a hospital, including pathology and histology
laboratories and engineering. Solvents include halogenated and non-
halogenated compounds. Although nearly any chemical could
potentially be found in a health care or research laboratory, some are
more commonly found:
o Disinfecting equipment and materials are important to the
accuracy of laboratory functions, so a range of disinfecting
solutions is often found in laboratories.
o Many laboratories have automated chemical analyzer systems.
These systems contain many reagent reservoirs and reagents with
preservatives.
o Common solvents used in the laboratory include xylene, ethanol,
toluene, and methanol.
o Sodium azide is often used as a preservative in a variety of
laboratory reagents usually at concentrations of less than 0.1%.
 Wastes from materials with high heavy metal contents represent a
subcategory of hazardous chemical waste and are usually highly toxic.
Heavy metals refer to metallic chemical elements that have a high density
and are relatively toxic at low levels. Heavy metals have a specific gravity
lesser than five times the specific gravity of pure water, which is 1 at 4°C.
These cannot be degraded nor destroyed by the body. Thus, heavy metals
are bio-persistent and tend to bio-accumulate.
12
Box 4: Examples of heavy metals found in HCW
 Mercury is a naturally occurring silvery-white liquid metal that readily vaporizes. When
released to the air, mercury is transported and deposited globally. Mercury ultimately
accumulates in the lake bottom in the form of sediments, where it is transformed into its
more toxic organic form, methyl mercury, which accumulates in fish tissue. There are 3
types of mercury: elemental, inorganic, and organic. Mercury waste is typically
generated by spillage from broken clinical equipment (mercury thermometer,
sphygmomanometer, etc.). Residues from dental laboratories have high mercury
content. Whenever possible, spilled drops of mercury shall be recovered.
 Cadmium is a soft, bluish white metal that has a rapid electrical and thermal conductivity.
It is highly resistant to stress and corrosion. Cadmium waste comes mainly from discarded
batteries, dental alloys, pigments, and electronic devices.
 Lead is a bluish white lustrous metal that is highly malleable and ductile. Lead waste usually
comes from batteries, petroleum, rolled and extruded products, ammunition and pipes.
Also, certain “reinforced wood panels” containing lead is still being used in radiation
proofing in X-ray and diagnostic departments.
Box 5: Non-hazardous chemical waste
Non-hazardous chemical waste consists of chemicals with none of the aforementioned

properties. Examples are sugars, amino acids, and certain organic and inorganic salts.
2.2.1.7 Radioactive Waste
Radioactive wastes are materials contaminated with radionuclides. They are

produced as a result of procedures such as in vitro analysis of body tissue and fluid,
in vivo organ imaging and tumor localization, and various investigative and
therapeutic practices.
Radionuclides used in health care are in either unsealed (or open) sources or
sealed sources. Unsealed sources are usually liquids that are applied directly, while
sealed sources are radioactive substances contained in parts of equipment or
encapsulated in unbreakable or impervious objects, such as pins, “seeds” or needles.
Radioactive HCW often contains radionuclides with short half-lives (i.e., half of the
radionuclide content decays in hours or a few days); consequently, the waste loses
its radioactivity relatively quickly. However, certain specialized therapeutic
procedures use radionuclides with longer half-lives; these are usually in the form of
small objects placed on or in the body and may be reused on other patients after
sterilization. Waste in the form of sealed sources may have a relatively high
radioactivity but is only generated in low volumes from larger medical and research
laboratories. Sealed sources are generally returned to the supplier and should not
enter the waste stream.
The waste produced by health care and research activities involving
radionuclides and related equipment maintenance and storage can be classified
as follows:
13
 sealed sources;
 spent radionuclide generators;
 low-level solid waste (e.g., absorbent paper, swabs, glassware, syringes,
vials);
 residues from shipments of radioactive material and unwanted solutions of
radionuclides intended for diagnostic or therapeutic use;
 liquid immiscible with water, such as liquid scintillation counting;
 residues used in radioimmunoassay, and contaminated pump oil;
 waste from spills and from decontamination of radioactive spills;
 excreta from patients treated or tested with unsealed radionuclides;
 low-level liquid waste (e.g., from washing apparatus); and
 gases and exhausts from stores and fume cupboards.
2.2.1.8 Pressurized Containers
Many types of gas are used in health care and are often stored in portable
pressurized cylinders, cartridges, and aerosol cans. Many of these are reusable, once
empty or of no further use (although they may still contain residues). However, certain
types – notably aerosol cans – are single-use containers that require disposal.
Whether inert or potentially harmful, gases in pressurized containers should always be
handled with care; containers may explode if incinerated or accidentally punctured.
2.2.2 Non-hazardous HCW or General Waste
More commonly known as “general waste,” non-hazardous HCW refers to waste

that has not been in contact with infectious agents, hazardous chemicals, or
radioactive substances and does not pose any special handling problem or hazard
to human health or to the environment. General waste is usually similar in
characteristics to municipal solid waste and comes mostly from the administrative
and housekeeping functions of HCFs. Non-hazardous HCW can be further classified
into recyclable waste, biodegradable waste, and (c) residual waste that is neither
recyclable nor biodegradable.
2.2.2.1 Recyclable General Waste
The following are recyclable materials commonly found in HCFs:

 Paper products: corrugated cardboard boxes, office paper, computer
printout paper, colored ledger paper, newspaper, magazines
 Aluminum: beverage cans, food cans, other aluminum containers
 Plastics: polyethylene terephthalate (PET) bottles, high density
polyethylene (HDPE) containers for food and mild solutions, polypropylene
14
(PP) plastic bottles for saline solutions or sterile irrigation fluids, polystyrene
packaging
 Glass: clear, colored, or mixed glass
 Wood: scrap wood, shipping pallets
In addition, durable goods such as used furniture, bed frames, carpets, curtains,
and dishware, as well as computer equipment, printer cartridges and photocopying
toners, are also potentially reusable.
2.2.2.2 Biodegradable General Waste
This includes kitchen waste, leftover food of patients with non-communicable

disease, flowers, and garden waste such as cut grasses or tree trimmings that can be
composted.
2.2.2.3 Residual General Waste
This includes general wastes that do not belong to the previous two categories
(recyclable and biodegradable).
2.3 Generation of HCW

The volume and characteristic of HCW generated depends on the type of HCF
and the number of clients served. An HCF is defined as an institution that has health
care as its core service, function, or business. Health care pertains to the
maintenance or improvement of the health of individuals or populations through the
prevention, diagnosis, treatment, rehabilitation, and chronic management of
disease, illness, injury, and other physical and mental ailments or impairments of
human beings.3 Different types of HCFs can be viewed as major or minor sources of
HCW, according to the quantities produced.
2.3.1 Sources of HCW
Table 1 presents the type of HCW typically generated by HCFs. The source often
characterizes the composition of HCW being generated. Knowing the types and
quantities of HCW generated in an HCF is important in understanding the hazard and
risk that people, community, and the environment maybe facing.
3 DOH-HFDB Health Facilities Dictionary
15
Table 1: Type of HCW typically generated by HCFs

Classification/Facility Type of HCW Generated
Pharmaceutica
Pathological
Radioactive
Anatomical
Chemical
Infectious
General
Sharps
Highly
l
PRIMARY CARE FACILITY
Urban/Rural Health Unit       
Barangay Health Station       
Medical Outpatient Clinic      
Medical Facilities for Overseas Workers and      
Seafarers
Dental Clinic      
Birthing Home       
HOSPITAL
General Hospital (Level 1, 2, 3)        
Specialty Hospital       
SPECIALIZED HEALTH FACILITY
Specialized Outpatient Clinic      
Dialysis Clinic      
Ambulatory Surgical Clinic       
Physical Therapy and Rehabilitation Facility 
Drug Abuse Treatment and Rehabilitation Facility   
Blood Services Facilities     
Pharmaceutical Outlet    
Human Stem Cell Clinic    
Quarantine Clinic      
DIAGNOSTIC FACILITY
Radiologic Facility   
Clinical Laboratory Facility     
National/Subnational Reference Laboratory     
Drug Testing Facility     
HIV Testing Facility     
Newborn Screening Reference Center      
Newborn Hearing Reference Center      
Nuclear Medicine Facility       
TRANSITIONAL CARE FACILITY
Custodial Care Facility (Nursing Home, Hospice)      
Mental Health Facility/Custodial Psychiatric      
Facility
Infirmary      
Sanitarium      
Halfway House    
OTHERS
Animal Bite Center/Animal Bite Treatment Center   
Home Treatment    
Traditional and Complementary Medicine Clinic  
Note: The definition and functions of each type of HCF are provided in PART IV of this Manual.
16
Box 6: Volume of generated M501 and M503 as per EMB data
The Hazardous Waste Management Section of the DENR-EMB Environmental Quality Division
provided the following data on the quantity (in tons per year) of Pathological or Infectious
Waste (M501) and Pharmaceuticals and Drugs (M503) generated from year 2015 to 2017:
Pathological or Infectious Waste (M501)

Region Volume of M501 Generated (tons/year)
2015 2016 2017
I 1,108.17039 461.22000 1,259.57000
II 0.00000 6.14230 5.94730
III 13,404.00000 376.00000 916.04000
IV-A 4,740.50000 3,702.46000 4,716.91400
IV-B 0.00000 8.45900 1.98100
V 328.92383 600.23803 348.19200
VI 937.25900 66.70000 534.34327
VII 301.57900 162.67400 570.62900
VIII 9.20400 4.34015 23.72140
IX 35.65087 92.42337 2,466.74900
X 157.86450 0.00000 154.87512
XI 36,521.64100 145.71610 3,852.53320
XII 0.00000 163.73000 151.51470
NCR 80,451.54571 2,899.37900 20,212.73400
CAR 51.38132 28.82418 129.25190
CARAGA 4,125.30385 10.14937 17.54880
TOTAL 142,173.02000 8,728.46000 35,362.54000
Source: EMB Regional Offices
Pharmaceuticals and Drugs (M503)

Region Volume of M503 Generated (tons/year)
2015 2016 2017
I 16.78208 11.36000 627.90000
II 0.00000 0.32640 2.74140
III 9,529.00000 769.00000 156.27000
IV-A 7,148.74000 657.62000 190.47900
IV-B 0.00000 0.00000 0.08000
V 6.53864 15.35700 11.25300
VI 6.89900 1.22300 30.77714
VII 18.65328 71.11800 68.59000
VIII 0.11000 0.97750 1.28770
IX 1.47849 22,306.02211 4.26492
X 2.41996 0.00000 4.42715
XI 1,008.15210 1.47300 3.88270
XII 0.00000 0.00000 0.11050
NCR 20,700.96880 331.21500 1,685.43800
CAR 0.35194 1.40609 1.69990
CARAGA 0.00000 0.00046 0.00001
TOTAL 38,440.09000 24,167.10000 2,789.20000
Source: EMB Regional Offices
17
2.3.2 General Composition of HCW
The general composition of HCW is often characteristic of the type of HCF and its
health care activities. Knowing the types and quantities of waste produced in an
HCF is an important first step in safe management. Many factors affect the rate of
waste generation:
 Type or level of facility (e.g., clinic, provincial hospital);
 Level of activity (often measured in terms of the number of occupied beds,
number of patients per day, and/or number of staff);
 Type of department (e.g., general ward, surgical theatre, office);
 Location (rural or urban);
 Regulations or policies on waste classification;
 Segregation practices;
 Temporal variations (e.g., weekday versus weekend, seasonal);
 Level of infrastructure development of the country.
Variations in waste generation according to the type or level of HCF, or between
rural and urban HCFs, may reflect differences in services provided, scale,
organizational complexity, availability of resources and the number of medical and
other staff.
Average waste generation rates are calculated in kilograms (kg) per day or per
year. Kilograms per occupied bed per day, and kg per patient per day, are used
especially when comparing different HCFs with different levels of activities. If
inpatient occupancy rates and the daily number of outpatients are not available,
the total number of beds is often used to estimate kg per bed per day.
18
Figure 2: Comparison of estimated daily waste generation in two types of HCFs
GENERAL COMPOSITION OF WASTE GENERATED IN AN

URBAN HEALTH CENTER (26KG/DAY)
General Infectious Pathological & Anatomical

Pharmaceutical Genotoxic Chemical
Radioactive Sharps Pressurized Containers
24%
39%
13%
24%
GENERAL COMPOSITION OF WASTE GENERATED IN A

300-BED CAPACITY TERTIARY CARE HOSPITAL (810KG/DAY)
General Infectious Pathological & Anatomical

Pharmaceutical Genotoxic Chemical
Radioactive Sharps Pressurized Containers
1%
1%
31% 36%
31%
Source: Survey on health care waste generation and management (LCI, 2019)
19
2.4 Waste Assessment Approaches4

HCW generation data are best obtained from quantitative waste assessments.
An assessment entails defining goals, planning, enlisting the cooperation of staff,
procurement of equipment (e.g., weighing scales, personal protective equipment),
data collection, analysis, and recommendations. The process of waste assessment
provides an opportunity to improve current practices, sensitize health workers about
waste, and determine the potential for waste minimization. Implementing rigorous
segregation can avoid over-sizing of equipment and result in cost savings.
Described in the following sub-sections are three common approaches to
conducting a waste assessment: 1) records examinations; 2) facility walk-throughs;
and 3) waste sorts. An assessment might require just one of these activities or a
combination of approaches. The team should determine the best approach for the
organization based on factors such as facility type and size, complexity of the waste
stream, availability of resources (money, time, labor, equipment) to implement the
waste reduction program, and scope of waste reduction program.
2.4.1 Records Examination
Examining records can provide insight into the organization's waste generation
and removal patterns. The types of records that might be useful include:
 Purchasing, inventory, maintenance, and operating logs;
 Supply, equipment, and raw material invoices;
 Waste hauling and disposal records and contracts; and
 Contracts with recycling facilities and earned revenues from recycling.
2.4.2 Walk-through
A walk-through involves touring the facility, observing different function areas or

departments' activities, and talking with employees and managers about waste-
producing activities and equipment. A walk-through is a relatively quick way to
examine the facility’s waste-generating practices. Specifically, a walk-through will
enable the team to:
 Observe the types and relative amounts of waste produced;
 Identify waste-producing activities and equipment;
 Detect inefficiencies in operations or in the way waste moves through the
organization;
 Observe the layout and operations of various departments;
4 From US EPA Archive: https://archive.epa.gov/epawaste/conserve/smm/wastewise/web/html/approach.html
20
 Assess existing space and equipment that can be used for storage,
processing recyclables, and other activities;
 Assess current waste reduction efforts; and
 Collect additional information through interviews with supervisors and
employees.
2.4.3 Waste Sort
A waste sort involves the physical collection, sorting, and weighing of a

representative sample of the facility’s waste. The goal of a waste sort is to identify
each waste component and calculate its percentage share in the total waste
generation. Waste sorts can focus on the facility’s entire waste stream or target
specific functional areas.
Some organizations choose to assemble and measure one day's worth of waste.
Others choose to assemble a portion of the waste from each department for
measuring. Any which way, the team should consider whether waste generation
varies significantly enough from one day to the next to distort results. Multi-day
sampling provides a more accurate representation of the facility’s waste generation.
The team will also need to determine which waste categories to quantify.
Typically, the major components of an organization's waste stream include paper,
plastic, glass, metal, and organic material such as yard trimmings and food scraps. If
possible, the team should strive to separate and measure the waste sample as
completely as possible. These measurements will be useful when determining which
materials can be exchanged, reused, sold, or recycled.
2.4.4 Characterization of Physicochemical Composition
One aspect of a waste assessment is the characterization of the physicochemical

composition of HCW. This information is essential in developing waste minimization
plans. Setting up an efficient recycling program requires an understanding of the
composition of general (non-hazardous) waste.
Physicochemical parameters of the infectious portion of the waste stream are
useful in establishing equipment specifications or operating parameters for treatment
technologies. For example, some steam and microwave treatment systems rely on a
minimum amount of moisture to be present in waste; some chemical systems are
affected by the organic load and water content; and incineration is influenced by
the percentage of incombustibles (ash), heating (calorific) value and moisture
content of waste.
Physical properties, such as bulk density (uncompacted mass per unit volume),
are used to estimate storage, transport, and treatment chamber capacities, as well
as specifications for compactors, shredders, and other size-reduction equipment.
Common to any waste classification, the physicochemical characteristics of HCW
21
will vary between HCFs within a country.

The approximate chemical composition of hospital waste is 37% carbon, 18%
oxygen, and 4.6% hydrogen, as well as numerous other elements (Liberti et al., 1994).
The toxic metals that are found in HCW and that are readily emitted during
combustion include lead, mercury, cadmium, arsenic, chromium, and zinc. In the
past, elemental compositions were used to estimate the products of combustion, but
this can be misleading since HCW varies widely.
Moreover, persistent organic pollutants (POPs), such as polychlorinated dioxins
and furans, cannot be predicted reliably from basic elemental compositions. These
dioxins and furans are toxic at extremely low concentrations. However, decreasing
the percentage of halogenated plastics (such as polyvinyl chloride) reduces the
amounts of hydrogen chloride and other halogenated pollutants. As much as 40%
of plastic waste in modern hospitals is chlorinated plastics.
22
Fourth Edition Chapter 3: Risks Associated with Health Care Waste
3 Risks Associated with Health Care Waste

As presented in the previous chapter, the large component of non-hazardous
HCW is similar to municipal waste and should not pose any higher risk than waste
produced in households. It is the smaller hazardous HCW component that needs to
be properly managed so that the health risks from exposure to known hazards can
be minimized. Protection of the health of staff, patients, and the general public is the
fundamental reason for implementing a system of HCWM. This chapter is concerned
with identifying the types of hazards associated with HCW and who may be at risk
from them by describing the public and environmental health impacts that need to
be controlled.
3.1 Persons at Risk

All individuals coming into proximity with hazardous HCW are potentially at risk,
including those who generate hazardous HCW, as well as those who either handle
such waste or are exposed to it as a consequence of improper management.
The main groups of people at risk to potential health hazards associated with
HCW are the following:
 HCF staff, e.g., doctors, nurses, auxiliaries, and maintenance personnel;
 Patients in the HCF or receiving home care;
 Visitors to the HCF;
 Workers providing support and allied services to the HCF, such as laundry;
 Workers transporting hazardous HCW to treatment, storage, and disposal
facilities; and
 Workers and operators of waste management facility (e.g., sanitary landfill
and TSD facilities) including informal recyclers or scavengers.
The general public could also be at risk whenever hazardous HCW is abandoned
or disposed of improperly.
3.2 Types of Hazard and Mode of Transmission

Exposure to hazardous HCW can result to disease or injury. The hazardous nature
of HCW may be due to one or more of the following characteristics: presence of
infectious agents; genotoxic or cytotoxic chemical composition; presence of toxic
or hazardous chemicals or biologically aggressive pharmaceuticals; presence of
radioactivity; and presence of sharps.
23
Box 7: Chain of infection
The Chain of Infection is a model used to understand the infection process. The concept is
depicted as a circle of links, each representing a component in the cycle. Each link must be
present and in sequential order for an infection to occur. The links are infectious agent,
reservoir, portal of exit from the reservoir, mode of transmission, and portal of entry into a
susceptible host. Understanding the characteristics of each link and the means by which the
chain of infection can be interrupted provides the HCF workers with methods for supporting
vulnerable patients, preventing the spread of infection and self-protection. Breaking any link
in the chain will prevent infection, although control measures are most often directed at the
“mode of transmission.”
The elements of infection in the context of HCW are:

 Some components of HCW are potential reservoir of disease-causing microorganisms
such as culture dishes, liquid blood, pathological waste, etc.
 The infective dose depends on the virulence of the microorganisms, the portal of entry,
and the susceptibility of the host.
 Modes of transmission may involve contact (e.g., contaminated needles or blood
splatter), vehicle-borne (e.g., contaminated wastewater), air-borne (e.g., aerosolized
pathogens from broken culture dishes or the rapture of yellow bags), and vector-borne
(e.g., rodents in an HCW storage area) transmission.
 Portals of entry include breaks in the skin and mucous membranes (e.g., needle-stick
injuries or blood splashes into the mucous membranes), the respiratory tract (inhalation of
pathogenic aerosols), etc.
 Potential susceptible host include HCF workers, waste handlers, patients, and visitors in the
HCF, landfill operators, scavengers, and the general public.
24
3.2.1 Hazards from Infectious, Sharps, Pathological and Anatomical Wastes
Infectious, sharps, pathological and anatomical wastes should always be

assumed to potentially contain a variety of pathogenic microorganisms. This is
because the presence or absence of pathogens cannot be determined at the time
a waste item is produced and discarded into a container. Pathogens in infectious
waste that is not well-managed may enter the human body through several routes:
 through a puncture, abrasion, or cut in the skin;
 through the mucous membrane;
 by inhalation; or
 by ingestion.
Examples of infections that might be caused by exposure to HCW are listed in
Table 2.
Table 2: Potential infections caused by exposure to HCW

Type of Infection Examples of Causative Agent Mode of Transmission
Gastroenteric infection Enterobacteria, e.g. Salmonella, Shigella Feces and/or vomit
spp.; Vibrio cholera; Giardia lambdia;
Clostridium difficile; helminths
Respiratory infection Mycobacterium tuberculosis; measles Inhaled secretions; saliva
virus; Streptococcus pneumonia, Severe
Acute Respiratory Syndrome
Ocular infection Herpes virus Eye secretions
Genital infection Neisseria gonorrhoeae; herpes virus Genital secretions
Skin infection Streptococcus spp Pus
Anthrax Bacillus anthracis Skin secretions
Meningitis Neisseria meningitides Cerebrospinal fluid
Acquired Human immunodeficiency virus Blood, sexual secretions,
Immunodeficiency body fluids
Syndrome (AIDS)
Hemorrhagic fever Junin, Lassa, Ebola, and Marburg viruses Feces and all body
secretions
Septicemia Staphylococcus spp. Blood
Bacteremia Coagulase-negative Staphylococcus Nasal secretion, skin
spp.; (including Methicillin-resistant S. contact
aureus); Enterobacter, Enterococcus,
Klebsiella, and Streptococcus spp
Candidemia Candida albicans Blood
Viral Hepatitis A Hepatitis A virus Feces
Viral Hepatitis B and C Hepatitis B and C viruses Blood and body fluids
Avian influenza H5N1 virus Blood, feces
Source: Health Care Waste Management Manual, 3rd Edition (DOH, 2011)
3.2.2 Hazards from Chemical and Pharmaceutical Waste
Although chemical and pharmaceutical wastes may be found in small quantities

in HCFs, these substances are hazardous. They may cause intoxication, either by
acute or by chronic exposure and injuries, including burns. Intoxication can result
from absorption of a chemical or pharmaceutical substance through the skin or the
25
mucous membranes, or from inhalation or ingestion. Injuries to the skin, the eyes or
the mucous membranes of the airways can be caused by contact with flammable,
corrosive or reactive chemicals (e.g., formaldehyde and other volatile substances).
The most common injuries are burns.
Disinfectants are one of the commonly used chemical product in HCFs. It is used
in large quantities and is often corrosive. It shall be noted that reactive chemicals
may form highly toxic secondary compounds. Like silver, they may also be priming
bacteria to become antibiotic resistant (McCay et al., 2010). Where chlorine is used
in an unventilated place, chlorine gas is generated as a by-product of its reaction
with organic compounds. Consequently, good working practices should be used to
avoid creating situations where the concentration in air may exceed safety limits.
Chemical residues discharged into the sewerage system may have adverse
effects on the operation of STP or on the natural ecosystems of receiving waters.
Similar problems may be caused by pharmaceutical residues, which may include
antibiotics and other drugs, heavy metals such as mercury, phenol and derivatives,
disinfectants, and antiseptic.
Mercury is highly toxic, especially when metabolized into methyl mercury. It may
be fatal if inhaled and harmful if absorbed through the skin. Around 80% of the
inhaled mercury vapor is absorbed in the blood through lungs. It may cause harmful
effects to the nervous, digestive, respiratory and immune systems. While the use of
mercury in HCFs is decreasing, another toxic heavy metal, silver, is being used in even
more applications, including nanotechnology. It is a bactericide and large doses
can turn a person’s skin permanently grey (Silver, 2003).
Obsolete pesticides, stored in leaking drums or torn bags, can directly or indirectly
affect the health of anyone who comes into contact with them. During heavy rains,
leaking pesticides can seep into the ground and contaminate groundwaters.
Poisoning can occur through direct contact with a pesticide formulation, inhalation
of vapors, drinking contaminated water or eating contaminated food. Other hazards
may include the possibility of spontaneous combustion if improperly stored, and
contamination as a result of inadequate disposal, such as open burning or
indiscriminate burying (WHO 2014).
3.2.3 Hazards from Genotoxic Waste
The severity of the hazards for health care workers responsible for the handling or
disposal of genotoxic waste is governed by a combination of the substance toxicity
itself and the extent and duration of exposure. Exposure to genotoxic substances in
health care may also occur during the preparation of or treatment with specific
drugs or chemicals.
The pathways of exposure are inhalation of dust or aerosols, absorption through
the skin, ingestion of food accidentally contaminated with cytotoxic drugs, ingestion
26
as a result of bad practice, such as mouth pipetting. Exposure may also occur
through contact with body fluids and secretions of patients undergoing
chemotherapy.
The cytotoxicity of many antineoplastic drugs is cell-cycle-specific, targeted on
specific intracellular processes such as DNA synthesis and mitosis. Other
antineoplastic substances, such as alkylating agents, are not phase specific, but
cytotoxic at any point in the cell cycle. Many cytotoxic drugs are extreme irritants
and have harmful local effects after direct contact with skin or eyes. They may also
cause dizziness, nausea, headache, or dermatitis. Special care in handling genotoxic
waste is therefore essential; any indiscriminate disposal of such waste into the
environment could have disastrous ecological consequences.
There are very little data on the long-term health impacts of genotoxic HCW. This
is partly because of the difficulty of assessing human exposure to this type of
compound. Numerous published studies have investigated the potential health
hazard associated with the handling of antineoplastic drugs, manifested by
increased urinary levels of mutagenic compounds in exposed workers and an
increased risk of abortion. A study by Sessink et al. (1992) demonstrated that exposure
of personnel cleaning hospital urinals exceeded that of nurses and pharmacists.
These individuals were less aware of the potential danger and took fewer
precautions. The concentration of cytotoxic drugs in the air inside hospitals has been
examined in several studies designed to evaluate health risks linked to such exposure.
3.2.4 Hazards from Radioactive Waste
Health effects caused by exposure to radioactive substance or contaminated

materials can range from reddening of the skin and nausea to more serious problems
such as cancer induction and genetic consequences to succeeding generations of
the exposed individual. The handling of high activity sources, e.g., certain sealed and
unsealed radiation sources used in cancer therapy, poses higher health risks such
that adequate protective measures must be established to minimize these risks.
The health hazards from low activity contaminated wastes may arise from
external and internal exposures from undetected contaminated working
environment and improper handling and storage of radioactive wastes and
spent/unused radiation sources. Both the workers and other staff personnel are at risk
to this health hazard.
Several accidents resulting from improper disposal of radioactive HCW have
been reported. The only recorded accidents involve exposure to ionizing radiations
in HCFs as a result of unsafe operation of X-ray apparatuses, improper handling of
radiotherapy solutions, or inadequate control of doses of radiation during
radiotherapy.
27
3.2.5 Hazards from Wastewater
Wastewater from HCF is composed of a myriad of materials that pose a hazard

to public health and to the environment. Wastewater may contain pathogens such
as bacteria, helminths, protozoa, and viruses that are hazardous if the wastewater is
inadequately treated or the untreated wastewater is used for irrigation of crops. The
salt content in wastewater may also increase soil salinity in the area, rendering the
soil useless for agricultural purposes.
Wastewater may also contain trace amounts of metals that can accumulate in
the environment. Toxic organic compounds with carcinogenic, teratogenic, and
mutagenic effects may also be present in wastewater from HCF. Pharmaceutical
residues or their by-products present in the wastewater may also contaminate
surface water or ground water, thereby exposing humans through drinking water.
Suspended solids in wastewater are generally non-biodegradable and may lead to
clogging of drains if not treated.
Pathogens present in the wastewater can cause waterborne diseases and thus
can survive in the liquid medium. The people in the HCF and the general public are
in danger of contracting these waterborne diseases if the wastewater from the HCF
is not given adequate treatment. Several diseases that can be transmitted via
wastewater include capylobacteriosis, cholera, cryptosporidiosis, hepatitis A,
hepatitis E, and typhoid fever.
3.2.6 Hazards from HCW Treatment Methods
There are occupational hazards associated with waste treatment processes.

Some are similar to those common in industries using machinery:
Autoclave and steam disinfection treatment methods can pose potential
hazards that need to be managed. Particularly, good maintenance and operation
should be undertaken to avoid physical injuries from high operating temperatures
and steam generation. Waste treatment autoclaves must also treat the air removed
at the start of the process to prevent pathogenic aerosols from being released. This
is usually done by treating the air with steam or passing it through a specific filter,
e.g., High Efficiency Particulate Air (HEPA) filter or microbiological filter before being
released. Furthermore, it needs to be assured that the resulting condensate is
decontaminated before release to the wastewater system. Post-waste treatment
water contains organic and inorganic contaminants.
HCW treatment mechanical equipment, such as shredding devices and waste
compactors, can cause physical injury when improperly operated or inadequately
maintained.
Flue gases from waste incinerators may have an impact on people living and
working close to a treatment site. The health risk is most serious where an incinerator
is improperly operated or poorly maintained. If poorly controlled, emissions from
28
waste incinerators may cause health concern from particulates (associated with
increased cardiovascular and respiratory mortality and morbidity); volatile metals,
such as mercury and cadmium (associated with damage to the immune system,
neurological system, lungs, and kidneys); and dioxins, furans, and polycyclic
aromatic hydrocarbons (which are known carcinogens but may also cause other
serious health effects).
Ash from the incineration of hazardous HCW may continue to pose a risk and is
considered as hazardous waste. Burnt-out needles and glass may have been
disinfected but can still cause physical injury. Furthermore, incinerator ash may
contain elevated concentrations of heavy metals and other toxic items, and the ash
provides ideal conditions for the synthesis of dioxins and furans, because it is often
exposed for a long time to a temperature range of 200–450°C.
Burial of HCW in landfill sites may pose hazards to workers and public. The risks are
often difficult to quantify, and the most likely injury comes from direct physical
contact with waste items. Chemical contaminants or pathogens in landfill leachate
may be released into surface streams or groundwater. On poorly controlled land-
disposal sites, the presence of fires and subsurface burning waste poses the further
hazard of airborne smoke. The smoke may contain heavy metals and other chemical
contaminants that over time may affect the health of site workers and the general
public.
3.3 Additional Considerations and Emerging Threats of HCW to

Public Health and the Environment
Apart from the risk to the patients and HCF workers, consideration must be given
to the adverse impacts of HCW to the general public and the environment.
Particularly, attention shall be focused on the possible result of unmanaged waste to
air, water, and soil, including the community. Minimizing the risk to public health and
the environment will require actions to deal with HCW within the HCF such as proper
waste segregation and minimization so that it does not enter the waste stream
requiring further treatment before disposal.
While the HCF workers are at greater risk of infection through injuries from
contaminated sharps, other workers, and waste management operators outside of
the HCF are also at risk. Certain infection, however, spread through media or caused
by more resilient agents, may pose a significant risk to the public. For example, the
uncontrolled discharges of wastewater from HCF such as field hospitals treating
cholera patients are potential source of cholera epidemic. However, the use of
strong disinfectant shall be minimized when there are alternatives as these can also
chemically pollute the water.
In evaluating the spread or survival of pathogenic microorganisms in the
environment, the role of vectors (e.g., rodents and insects) shall be considered. This
29
applies to management of HCW both within and outside HCF. Vectors such as rats,
flies, cockroaches, which feed or breed on organic waste, are well known passive
carriers of microbial pathogens; their population may increase dramatically where
there is lack of waste management.
Except for waste containing pathogenic cultures or excreta from infected
patients, the microbial load of HCW is generally not very high. Furthermore, HCWs do
not seem to provide favorable media for the survival of pathogens, perhaps because
they frequently contain antiseptics. Results from several studies have shown that the
concentration of indicator microorganisms in HCW is generally no higher than in
domestic waste and that survival rates are low.
Chemicals used in the HCF are potential sources of water pollution via the sewer
system. Chemical waste survey is a prerequisite to the development of an effective
waste management program. Any hazardous chemical waste generated shall be
dealt with by a proper chemical waste management system. For safety purposes,
always refer to the Material Safety Data Sheet (MSDS). Substituting chemicals with
substance that have lesser environmental and health impacts is a sound practice.
Accidental spillage within the HCF shall also be dealt with accordingly to minimize
impact on human health and environment.
Although there is no scientifically documented evidence of widespread illnesses
among the general public due to chemical or pharmaceutical waste from hospitals,
excreted pharmaceuticals from patients do find their way into waterways, which can
contribute to potentially serious environmental effects, including toxicity to wildlife
and the generation of antibiotic resistance in bacteria (e.g., Guardabassi et al.,
1998).
Better assessment of both risks and effects of exposure would permit
improvements in HCWM and in the planning of adequate protective measures.
Within HCFs, the surveillance of infection and record keeping are important tools to
identify indications of inadequate waste management practices or contamination
of the immediate environment. Surveillance allows an outbreak of infection or other
hazards to be recognized and investigated. It also provides a basis for introducing
control measures, assessing their efficacy, reinforcing routine preventive measures,
and determining the level of avoidable infection.
Box 8: Endocrine disruptors
Endocrine disruptors (EDCs) are also found in synthetic chemicals used as industrial solvents,
lubricants, and their by-products. These include polychlorinated biphenyls (PCBs),
polybrominated biphenyls (PBBs), and dioxins. Other examples of endocrine disruptors include
bisphenol A (BPA) from plastics, dichlorodiphenyltrichloroethane (DDT) from pesticides,
vinclozolin from fungicides, and diethylstilbestrol (DES) from pharmaceutical agents. Certain
metals such as cadmium, mercury, arsenic, lead, manganese, and zinc also disrupt endocrine
systems.
30
Known or Suspected Endocrine Disrupting Chemicals
Pesticides Metals Pharmaceuticals
Ingredients in household
Industrial ingredients Solvents
products and materials
The most prominent and well-documented health concerns from exposure to EDCs are
reproductive and developmental effects. Some of the disorders that have been seen in
animal studies include oligospermia (low sperm count), testicular cancer, and prostate
hyperplasia in adult males; vaginal adenocarcinoma, disorders of ovulation, breast cancer,
and uterine fibroids in adult females. Disruption to thyroid functions, obesity, bone metabolism
and diabetes are also linked to exposure endocrine disruptors.
References:
Canadian Center for Occupational Health and Safety, Endocrine Disruptors Fact Sheets,
https://www.ccohs.ca/oshanswers/chemicals/endocrine.html
Endocrine Disrupting Chemicals (EDCs), World Health Organization
https://www.who.int/ceh/risks/cehemerging2/en/
31
Box 9: Antimicrobial resistance
Antimicrobial resistance (AMR) happens when microorganisms (such as bacteria, fungi, viruses,
and parasites) change when they are exposed to antimicrobial drugs (such as antibiotics,
antifungals, antivirals, antimalarials, and anthelmintics). Microorganisms that develop
antimicrobial resistance are sometimes referred to as “superbugs”. As a result, the medicines
become ineffective and infections persist in the body, increasing the risk of spread to others.
Antimicrobial resistant-microbes are found in people, animals, food, and the environment (in
water, soil and air). They can spread between people and animals, including from food of
animal origin, and from person to person. Poor infection control, inadequate sanitary
conditions and inappropriate food-handling encourage the spread of antimicrobial
resistance.
References:
Antimicrobial Resistance, Center for Disease Control and Prevention
https://www.cdc.gov/drugresistance/about.html
WHO List of Critically Important Antimicrobials for Human Medicine (WHO CIA List)
https://www.who.int/en/news-room/fact-sheets/detail/antimicrobial-resistance
Box 10: Microplastics
A lot of attention has been drawn recently to microplastics in freshwater and marine
environments and the threat they pose to ecosystems and people’s health. The source of
microplastics is generally thought to be well known; most plastic items are not recycled or
incinerated when they are discarded. Plastic waste therefore ends up in landfill or in our rivers
and oceans where it gradually breaks down into smaller and smaller pieces and particles.
Microplastics are defined as pieces of plastic 5mm in diameter or less. A new study however
concludes that treated sewage effluents are also key sources of microplastics – the
implication being that wastewater treatment plants are not effective at filtering them out. An
additional reason for concern is that microplastics can also trap or act as a vehicle for the
dispersal of harmful chemicals. These chemical-laced particles can be ingested by small
organisms which are eaten by bigger animals and so on up the food chain.
Reference: Wastewater Treatment Plants-A Surprising Source of Microplastics Pollution, UN

Environment Program (https://www.unenvironment.org/news-and-stories/story/wastewater-
treatment-plants-surprising-source-microplastic-pollution)
32
3.4 Risk Assessment Approach to HCWM

The primary objective of risk assessment is to identify all potential hazards
associated with HCWM from the point of generation to treatment and disposal. This
would include all hazards and hazardous event that will compromise the safety of
patients, health care personnel, waste handlers and the proximate community at
every step of waste management. The risk is then evaluated to distinguish those
highly significant from least significant in order of priority of action. The potential to
affect public health and safety is the most important consideration in doing risk
assessment.
Risk assessment defines the following:
 Hazard – A hazard is defined as a "condition, event or circumstance that
could lead to or contribute to an unplanned or undesirable event." It may
also be referred to as a problem. Any indicators that do not meet the
target should be considered a potential hazard.
 Risk – A risk is the potential of a set of unwanted circumstances or events
occurring as the result of the hazard. All hazards have associated risks. The
risk exposure is the probability of an unfortunate event occurring,
multiplied by the potential impact or damage incurred by the event.
Table 3: Example of hazards identified in HCFs (under WASH)

Hazards Risks
 Waste is not correctly segregated at waste  Staff, patients, visitors, and community
generation points. members at risk of infection from HCW,
 Appropriate protective equipment for staff in including needle stick injuries and exposure
charge of waste treatment and disposal is to contaminated fluids.
not available.  Staff at risk of infection during treatment and
disposal of HCW.
3.4.1 Risk Categorization
In doing risk assessment for an HCF, the recommended reference is the Water
and Sanitation Health Facility Improvement Tool (WASH FIT), a risk-based approach
for improving and sustaining water, sanitation, and hygiene and HCWM infrastructure
and services in HCFs in low- and middle-income countries.
WASH FIT uses global standard indicators to determine potential hazards and
problems in an HCF. It is an improvement tool to be used on a continuous and regular
basis, to first and foremost help HCF staff and administrators prioritize and improve
services, and, second, to inform broader district, regional, and national efforts to
improve quality health care. The tool provides a table for recording the hazards and
risks associated with each WASH area in the HCF; the level of risk versus the feasibility
of addressing a problem; and the actions to be taken at the facility/community
and/or district/regional.
33
Box 11: Overview of WASH FIT
Water and Sanitation for Health Facility Improvement Tool (WASH FIT) is a multistep, iterative
process to facilitate improvements in WASH services, quality, and experience of care. It is
designed for use by HCF managers and staff to make improvements in settings where
resources are limited. It covers four broad areas: water, sanitation (including HCWM), hygiene
(hand hygiene and environmental cleaning) and
management.
Each area includes indicators and targets for achieving

minimum standards for maintaining a safe and clean
environment. These standards are based on global
standards as set out in the WHO Essential environmental
health standards in health care (WHO, 2008) and the
WHO Guidelines on core components of infection
prevention and control programmes at the national and
acute health care facility level (WHO, 2016a).
The WASH FIT process has five (5) tasks that should be
implemented sequentially. In the tool kit, each task
includes a description of the steps necessary to
complete the task, a list of “dos and don’ts” to consider
and instructions for using the templates.
Reference: Water and Sanitation for Health Facility Improvement Tool (WHO, 2018)
34
The level of risk is categorized using the following ratings:

 High Risk – The hazard/problem very likely results in injuries, acute and/or
chronic illness, infection, or an inability to provide essential services.
Immediate actions need to be taken to minimize the risk.
 Medium Risk – The hazard/problem likely results in moderate health effects,
discomfort, or unsatisfactory services, for example unpleasant odors,
unsatisfactory working conditions, minor injuries. Once the high risks issues
are addressed, actions should be taken to minimize medium-level risks.
 Low Risk – No major health affects anticipated. These risks should be
addressed as resources become available and should be revisited in the
future as part of the review process.
 Unknown Risk – Further information is needed to categorize the risk. Some
action should be taken to reduce the risk while more information is
gathered.
Some hazards may be easier to address than others depending on the resources
currently available and/or the time it will take to fix a problem.
3.4.2 Improvement Plan
To prioritize which hazards/problems will be addressed and develop a detailed

action plan outlining what improvements will be made within a given timeframe. The
improvement plan is the “action plan” to mitigate or introduce control measures to
prevent the hazard from causing harm.
The improvements could be achieved through a number of different
mechanisms, including building new infrastructure or repairing existing infrastructure,
coordinated dialogue with district and national authorities for new/revised
infrastructure, writing standards and protocols to improve behaviors, training staff in
a new technique or initiative and/or improving management methods. It is important
to consider the level of difficulty or ease with which the improvements can be made.
Considerations for implementing an improvement plan:
 Do make the actions as specific as possible. Specify who is responsible for
ensuring the action is completed, when it will be completed and what
resources are needed. The resources could be financial, technical (such
as external support specialists) or someone’s time. Make sure each activity
is realistically achievable with the resources and time available.
 Do think of improvements and preventive measures that can be made
with limited resources. Consider, for example, ensuring that a latrine or
toilet and area around it are clean, providing soap and water or alcohol-
based hand rubs at all hand hygiene stations or putting up a poster with
pictures and diagrams describing basic hand hygiene principles.
35
 Do remember that no change is too small. Whatever positive actions are

taken will make a difference. For those action items that are more difficult
to address (e.g., installing an on-site wastewater treatment), think of small
actions that can be taken to begin the process of change (e.g.,
presenting a case for a new water STP to the local authorities).
 Do use the improvement plan as a basis for seeking financial or other
support for larger upgrades and improvements. A detailed plan could be
used to approach the government, donors, or NGOs for additional
support.
Review the improvement plan to determine whether all actions are being
implemented, how far along the actions are toward completion and what further
steps need to be taken to ensure that the action item will be completed by the
expected completion date.
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Fourth Edition Chapter 4: Legislative, Regulatory, and Policy Aspects of Health Care Waste
4 Legislative, Regulatory, and Policy Aspects of

Health Care Waste
HCFs are responsible for ensuring the proper handling, collection, transport,
treatment, storage, and disposal of the HCW they generate. This chapter presents
the salient points of the guiding principles and the existing international agreements,
national policies, and related issuances and guidelines that can provide direction to
HCFs in developing and implementing their respective HCWM programs. Links to the
full text of these are provided in ANNEX F 1 of this Manual.
4.1 Guiding Principles5

These principles are recognized as fundamental to effective waste
management:
“POLLUTER PAYS” PRINCIPLE implies that all producers of waste are legally and
financially responsible for the safe and environmentally sound disposal of the waste
they produce. This principle also attempts to assign liability to the party that causes
damage.
“PRECAUTIONARY” PRINCIPLE is a persuasive principle governing health and safety
protection. It was defined and adopted under the Rio Declaration on Environment
and Development (1992) as Principle 15: “Where there are threats of serious or
irreversible damage, lack of full scientific certainty shall not be used as a reason for
postponing cost-effective measures to prevent environmental degradation.”
“DUTY OF CARE” PRINCIPLE stipulates that any person handling or managing hazardous
substances or wastes or related equipment is ethically responsible for using the
utmost care in that task. This is best achieved when all parties involved in the
production, storage, transport, treatment, and final disposal of hazardous wastes
(including HCW) are appropriately registered or licensed to produce, receive, and
handle named categories of waste.
“PROXIMITY” PRINCIPLE recommends that treatment and disposal of hazardous waste
take place at the closest possible location to its source to minimize the risks involved
in its transport. Similarly, every community should be encouraged to recycle or
dispose of the waste it produces, inside its own territorial limits, unless it is unsafe to do
so.
“PRIOR INFORMED CONSENT” PRINCIPLE, as embodied in various international treaties, is
designed to protect public health and the environment from hazardous waste. It
5 Adopted from “Safe management of wastes from health-care activities” (WHO, 2014)
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requires that affected communities and other stakeholders be apprised of the

hazards and risks, and that their consent be obtained. In the context of HCW, the
principle could apply to the transport of waste and the siting and operation of waste-
treatment and disposal facilities.
4.2 International Agreements/Conventions

These international agreements/conventions are particularly relevant to HCWM.
4.2.1 The Basel Convention on the Control of Trans-boundary Movements of Hazardous Wastes
and Their Disposal (1989)
The Basel Convention is a comprehensive global environmental treaty that aims

to protect human health and the environment against the adverse effects resulting
from the generation, management, transboundary movement, and disposal of
hazardous and other wastes. Parties to the Basel Convention are obliged to ensure
that hazardous and other wastes are managed and disposed of in an
environmentally sound manner.
The Convention specifically refers to the following waste streams as “hazardous
wastes” among other categories of wastes to be controlled: clinical wastes from
medical care in hospitals, medical centers, and clinics (Y1); and waste
pharmaceuticals, drugs, and medicines (Y3). Also included in the list of hazardous
characteristics specified under the Convention are infectious substances defined as
“substances or wastes containing viable microorganisms or their toxins which are
known or suspected to cause disease in animals or humans” (H6.2).
4.2.2 The Stockholm Convention on Persistent Organic Pollutants (2001)
The Stockholm Convention is a global treaty to protect human health and the
environment from persistent organic pollutants (POPs), which are chemicals that
remain intact in the environment for long periods, become widely distributed
geographically, accumulate in the fatty tissue of living organisms, and are toxic to
both humans and wildlife.
Parties to the Stockholm Convention are enjoined to reduce or eliminate releases
of POPs into the environment, including those unintentionally formed and released
from waste incinerators and co-incinerators of municipal, hazardous, or medical
waste or of sewage sludge, among other source categories. Governments must
require the use of best available techniques (BAT) and promote best environmental
practices (BEP) for new sources within four years after the Convention come into
force for the country.
4.2.3 The Minamata Convention on Mercury (2013)
The Minamata Convention on Mercury has been signed in 2013 and is a global
treaty to protect human health and the environment from the adverse effects of
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mercury. The Convention draws attention to a global and ubiquitous metal that,
while naturally occurring, has broad uses in everyday objects and is released to the
atmosphere, soil, and water from a variety of sources. Controlling the anthropogenic
releases of mercury throughout its lifecycle has been a key factor in shaping the
obligations under the Convention. Article 4 calls for the phase-out of the import,
export, and manufacture of mercury thermometers and sphygmomanometers used
in health care by 2020 and the phasing down of dental amalgam.
4.2.4 World Health Assembly Resolution on Water, Sanitation and Hygiene (WASH) in Health Care
Facilities (2019)
At the 2019 World Health Assembly (WHA), Member States unanimously approved
a resolution to work towards universal access to WASH, including safe management
of HCW in HCFs. The resolution calls upon Member States and specifically Ministries
of Health to conduct national assessments and analyses, develop roadmaps, set
targets, and implement standards.
4.3 National Policies and Related Issuances

These national policies and issuances are particularly relevant to HCWM.
4.3.1 Republic Act No. 4226: “Hospital Licensure Act” (1965)
The Act requires the registration and licensure of all hospitals in the country and
mandates the DOH – Bureau of Medical Services (presently the Health Facilities and
Services Regulatory Bureau or HFSRB), as the acting licensing agency, to set
standards in hospital construction and operation. Relevant to this Act are the
following administrative orders (AO):
 DOH Administrative Order No. 2005-0029 dated December 12, 2005 “Amendment to
Administrative Order No. 147 s. 2004: Amending Administrative Order No. 70-A series 2002
re: Revised Rules and Regulations Governing the Registration, Licensure and Operation
of Hospitals and Other Health Facilities in the Philippines”
The AO amends specific provisions of the preceding issuances, which require all
hospitals and other health facilities, government or private, to conform with the
prescribed guidelines on planning, design, construction, and management of the
service capability, personnel, equipment, physical plant as part of licensing
requirements. The amendment includes the requirement for hospitals and other
health facilities applying for initial License to Operate to accomplish/submit a Waste
Management Plan, among other documents.
 DOH Administrative Order No. 2007-0027 dated August 22, 2007 “Revised Rules and
Regulations Governing the Licensure and Regulation of Clinical Laboratories in the
Philippines”
39
The AO requires all clinical laboratories, government or private, to have written

policies and procedures for the provision of laboratory services and for the operation
and maintenance of the laboratory, including proper disposal of waste and
hazardous substances, as well as biosafety and biosecurity.
 DOH Administrative Order No. 2012-0012 dated July 18, 2012 “Rules and Regulations
Governing the New Classification of Hospitals and Other Facilities in the Philippines”
The AO promulgates rules and regulations to protect and promote the health of
the public by ensuring a minimum quality of service rendered by all government and
private hospitals and other regulated health facilities and to assure the safety of
patients and personnel.
4.3.2 Presidential Decree No. 856: “The Code on Sanitation of the Philippines” (1975)
The Code mandates the DOH to promote and preserve public health and
upgrade the standards of medical practice, among other functions and provides
the other legal basis for the DOH to issue and require compliance with the HCWM
Manual. Relevant to HCWM are the following implementing rules and regulations
(IRR):
 Implementing Rules and Regulations of PD 856 Chapter XVII on “Sewage Collection and
Disposal, Excreta Disposal and Drainage” (1995)
The IRR provides specific requirements in the design, construction/installation,
operation, and abandonment of drainage, sewerage, sewage, and excreta
disposal systems. Hospitals, clinics, and laboratories are identified among special
establishments required to obtain approval from the DENR before construction and
issuance of sanitary permit by the local health office. Special precaution is also
advised for radioactive excreta and urine of hospitalized patients.
 Implementing Rules and Regulations of PD 856 Chapter XXI on “Disposal of Dead
Persons” (1997)
The IRR provides specific requirements in the establishment, operation, and
closure of crematories, funeral and embalming establishments, medical and
research institutions, public and private burial grounds, and other similar institutions.
 Implementing Rules and Regulations of PD 856 Chapter XVIII on “Refuse Disposal” (1998)
The IRR provides sanitary requirements for the segregation, storage, collection,
transportation, treatment/processing, and disposal of solid waste. It also specifies
that management of biomedical waste produced by health care institutions and
other similar establishments shall be in accordance with the DOH standards and
guidelines.
 Rules and Regulation Governing the Collection, Handling, Transport, Treatment and
Disposal of Domestic Sludge and Septage, (2004), a “Supplement to the IRR of Chapter
XVII on Sewage Collection and Disposal and Excreta Disposal and Drainage of 1998”
40
The Rules and Regulations require individuals, firms, public and private operators,
owners, and administrators engaged in desludging, collection, handling and
transport, treatment, and disposal of domestic sewage treatment plants/facilities
and septage from house septic tanks to secure environmental sanitation clearances
from DOH.
 DOH Administrative Order No. 2019-0047 dated October 29, 2019 “National Standard on
the Design, Construction, Operation and Maintenance of Septic Tank Systems”
The AO sets a national standard on the design, construction/installation,
operation, and maintenance of septic tank as the major component of basic
sanitation facilities and other alternative sanitation technology design. It applies to
all public and private sewage collection system projects planned by any
government agency or instrumentality including government-owned and controlled
corporations, private organizations, firms, individuals, or other entities.
4.3.3 Presidential Decree No. 984: “Providing for the Revision of Republic Act No. 3931, Commonly
Known as the Pollution Control Law, and for Other Purposes” (1976)
The Pollution Control Law is the primary legislation that governs discharges of
potentially polluting substances to air and water. It provides the basis for the DENR
regulations on water pollution through its IRR, DENR Administrative Order Nos. 34 and
35. The IRR for air emissions was initially set by DENR Administrative Order No. 14 but
was later replaced by the Philippine Clean Air Act of 1999 (RA 8749).
 DENR Administrative Order No. 2014-02 dated February 3, 2014 “Revised Guidelines for
Pollution Control Officer Accreditation”
The AO covers the accreditation of PCOs of establishments that discharge solid,
liquid, or gaseous wastes to the environment or whose activities, products, or services
are actual and/or potential sources of land, water, or air pollution. It also applies to
LGUs, development authorities, government-owned and controlled corporations,
and other public establishments.
 DENR Administrative Order No. 2018-07 dated June 14, 2018 “Amendment of Section 7 of
the DENR Administrative Order No. 2014-02 or the Revised Guidelines for Pollution Control
Officer Accreditation”
The AO requires government institutions and LGUs that operate establishments
such as, but not limited to, slaughterhouses, public markets, and hospitals whose
activities necessitate the appointment/designation of a PCO under the said Order
to appoint/designate a PCO.
4.3.4 Presidential Decree No. 1586: “Environmental Impact Statement (EIS) System” (1978)
The law and its IRR (DENR Administrative Order No. 2003-30) require development
projects, including HCFs, to undergo Environmental Impact Assessment (EIA) and
secure an Environmental Compliance Certificate (ECC) from the DENR EMB prior to
41
construction and operation. An ECC is likewise required for the installation or

construction and operation of HCW treatment systems (e.g., pyrolysis, autoclave,
microwave) and disposal facilities (i.e., sanitary landfill).
4.3.5 Republic Act No. 6969: “Toxic Substances and Hazardous and Nuclear Wastes Control Act of
1990”
The law and its IRR (DENR Administrative Order No. 1992-29) require the
registration of waste generators, waste transporters and operators of toxic and
hazardous waste treatment facilities with the EMB. The waste generators are required
to ensure that its hazardous wastes are properly collected, transported, treated, and
disposed of to a sanitary landfill. In support of this Act are the following issuances:
 DENR Administrative Order No. 36, Series of 2004, dated August 31, 2004 “Revising DENR
Administrative Order No. 29, Series of 1992, to Further Strengthen the Implementation of
Republic Act 6969 (Toxic Substances and Hazardous and Nuclear Wastes Control Act of
1990) and Prescribing the Use of the Procedural Manual”
The Procedural Manual requires a comprehensive documentation on the legal
and technical requirements of hazardous waste management. The Manual does not
include provisions regarding the management of nuclear wastes. It is composed of
ten sections that discuss the classification of hazardous wastes, waste generators and
transporters, storage and labelling, Treatment, Storage and Disposal (TSD) facilities,
manifest system, monitoring, prohibited acts and schedule of fees.
 Joint DENR-DOH Administrative Order No. 02, Series of 2005, dated August 24, 2005
“Policies and Guidelines on effective and proper handling, collection, transport,
treatment, storage and disposal of health care wastes”
The Joint Administrative Order aims to: a) provide guidelines to generators,
transporters and operators/owners of TSD Facilities on proper handling, collection,
transport, storage, treatment and disposal of HCW; b) clarify the jurisdiction, authority
and responsibility of the DENR and DOH with regard to HCWM; and c) harmonize the
efforts of the DENR and the DOH on HCWM.
 DOH Administrative Order No. 2008-0021 dated July 30, 2008 “Gradual Phase-out of
Mercury in all Philippine Health Care Facilities and Institutions”
The AO requires all HCFs to gradually phase out the use of mercury containing
devices and equipment. The initial targets of the phase-out are mercury
thermometers and sphygmomanometers in the HCF.
 DENR Administrative Order No. 2013-22 dated December 4, 2013 “Revised Procedures and
Standards for the Management of Hazardous Wastes (Revising DAO 2004-36)”
The AO seeks to ensure the important aspects of the Title III of DAO 1992-29,
particularly the requirements for hazardous waste generators, transporters, and
treaters are developed and presented in a useful information/reference document
42
for various stakeholders; and to further streamline procedures for generation and
compliance to the legal and technical requirements for hazardous waste
management in the light of recent development.
4.3.6 Republic Act No. 8749: “The Philippine Clean Air Act of 1999”
The law promotes the use of state-of-the-art, environmentally sound, and safe
thermal and non-burn technologies for the handling, treatment, thermal destruction,
utilization, and disposal of sorted biomedical and hazardous wastes. It prohibits
incineration, defined as the burning of municipal, biomedical, and hazardous
wastes, which process emits toxic and poisonous fumes.
 DENR Administrative Order No. 2000-81 dated November 7, 2000 “Implementing Rules and
Regulations of the Philippine Clean Air Act of 1999”
The IRR provides guidelines on the operationalization of RA 8749, including
national ambient air quality guideline values, national emission standards for source
specific air pollutants, and emission standards for treatment facilities using non-burn
technologies.
4.3.7 Republic Act No. 9003: “Ecological Solid Waste Management Act of 2000”
The law seeks to ensure the protection of public health and the environment
through the utilization of environmentally sound methods for treating, handling, and
disposing of solid wastes, and encourages waste minimization and segregation at
the point of generation, including households and institutions such as hospitals.
 DENR Administrative Order No. 2001-34 dated December 20, 2001 “Implementing Rules
and Regulations of the Philippine Ecological Solid Waste Management Act of 2000”
The IRR prescribes procedures and guidelines to facilitate the implementation of
and compliance to RA 9003, including the minimum requirements and standards for
volume reduction, segregation, storage, collection, transport, and handling of solid
wastes; provisions on materials recovery, composting, and implementing recycling
programs; as well as minimum considerations for siting, designing and operating
sanitary landfills.
4.3.8 Republic Act No. 9275: “The Philippine Clean Water Act of 2004”
The law pursues a policy of economic growth in a manner consistent with the
protection, preservation, and revival of the quality of the country’s fresh, brackish,
and marine waters.
 DENR Administrative Order No. 2005-10 dated May 16, 2005 “Implementing Rules and
Regulations of the Philippine Clean Water Act of 2004”
The IRR contains provisions for the development and establishment of industry-
specific, technology-based standards that limit the amount of industrial wastewater
pollutants being discharged into waters either directly to surface waters or indirectly
43
through existing sewerage and treatment systems. It also requires owners or operators
of facilities that discharge regulated effluents to secure a wastewater discharge
permit.
 DENR Administrative Order No. 2016-08 dated May 24, 2016 “Water Quality Guidelines and
General Effluent Standards of 2016”
The AO provides, among others, guidelines for the classification of water bodies
in the country and the General Effluent Standards (GES) for all point sources of
pollution, regardless of volume and industry category.
4.3.9 Republic Act No. 11223: “Universal Health Care Act”
The law and its IRR aims to progressively realize universal health care in the country
through a systemic approach and clear delineation of roles of key agencies and
stakeholders towards better performance in the health system and to ensure that all
Filipinos are guaranteed equitable access to quality and affordable health care
goods and services and protected against financial risk. Among the provisions in this
Act is the strengthening of the capacity of PhilHealth and DOH to monitor and
regulate health facilities. An incentive scheme shall be provided by PhilHealth to
reward health facilities that provide better service quality, efficiency, and equity,
among these shall be proper management of HCW.
4.4 Other Relevant Issuances and Guidelines

 BFAD Bureau Circular No. 16, Series of 1999, dated January 6, 1999 “Amending BFAD MC
#22 dated September 8, 1994 regarding Inventory, Proper Disposal and/or Destruction
of Used Vials or Bottles”
This issuance amends BFAD Memorandum Circular No. 22, Series of 1994, which
provides guidelines on the proper inventory and destruction of bottles and vials to
prevent the proliferation of adulterated, misbranded, and counterfeit drugs brought
about by the recycling of used pharmaceutical bottles and vials.
 Executive Order No. 301, Series of 2004, dated March 29, 2004 “Establishing a Green
Procurement Program for All Departments, Bureau, Offices and Agencies of the Executive
Branch of Government”
The Green Procurement Program (GPP) was implemented in all government
offices in order to a) promote the culture of making environmentally-informed
decisions in government, especially in the purchases and use of different products;
b) include environmental criteria in public tenders, whenever possible and
practicable; c) establish the specifications and requirements for products or services
to be considered environmentally advantageous; and d) develop incentive
programs for suppliers of environmentally advantageous products or services.
44
 PhilHealth Benchbook for Quality Assurance in Health Care (2006)

The PhilHealth Benchbook included HCWM as one of its parameters in the quality
assurance of health care.
 DOH Administrative Order No. 2008-0023 dated July 30, 2008 “National Policy on Patient
Safety”
The AO requires the establishment and maintenance of a culture of patient safety
in every HCF as the responsibility of its leadership. As such, each HCF shall ensure that
an enabling mechanism/strategy is in place to ensure patient safety. The key priority
areas in patient safety include but are not limited to proper patient identification,
assurance of blood safety, safe clinical and surgical procedures, provision and
maintenance of safe quality drugs and technology, strengthening infection control
standards, maintenance of the environment of care standards and energy and
waste management standards.
 DOH “Operation Manual on the Rules and Regulations Governing Domestic Sludge and
Septage” (2008)
The Manual provides detailed procedures and forms needed to comply with the
IRR Governing Collection, Handling, Transport, Treatment and Disposal of Domestic
Sludge and Septage. It is designed to guide private and public service providers as
well as government regulators to effective sludge and septage management
program in the country.
 WHO “Safe management of wastes from health-care activities” (2014)
This document is the second edition of the WHO handbook on the safe,
sustainable, and affordable management of HCW—commonly known as “the Blue
Book”. It is a comprehensive publication used widely in health care centers and
government agencies to assist in the adoption of national guidance. It is intended to
provide support to committed medical directors and managers to make
improvements and presented practical information on waste management
techniques for medical staff, waste workers, regulators, policymakers, development
organizations, voluntary groups, environmental bodies, environmental health
practitioners, advisers, researchers, students, and other individuals and organizations
with an active interest in the safe management of HCW.
 WHO “Water Sanitation for Health Facility Improvement Tool (WASH FIT)” (2018)
As described in Chapter 3.4, WASH FIT is a risk-based approach for improving and
sustaining water, sanitation, and hygiene and HCWM infrastructure and services in
HCFs in low- and middle-income countries. It is an improvement tool to be used on a
continuous and regular basis, to first and foremost help HCF staff and administrators
prioritize and improve services, and, second, to inform broader district, regional and
national efforts to improve quality health care. WASH in HCFs is a fundamental
prerequisite for achieving national and global health goals. Safe water, functioning
45
hand washing facilities, latrines, and hygiene and cleaning practices are especially
important for improving health outcomes linked to maternal, newborn and child
health, as well as carrying out basic infection prevention and control procedures
necessary to prevent antimicrobial resistance (AMR).
 WHO “Overview of technologies for the treatment of infectious and sharp waste from
health care facilities” (2019)
The document aims to: 1) provide criteria for selecting technologies to facilitate
decision making for improved management of waste in HCFs; and 2) provide an
overview of specific HCW technologies for the treatment of solid infectious and sharp
waste for HCF administrators and planners, WASH and infection prevention control
staff, national planners, donors and partners. For each technology, details on its
operation, effects on the environment and health, requirements for installation,
capacities for treating waste, examples of consumables and advantages and
disadvantages are described.
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Health Care Waste Management Manual PART II—HEALTH CARE WASTE MANAGEMENT SYSTEM
Fourth Edition Chapter 5: Health Care Waste Management Planning
PART II—HEALTH CARE WASTE MANAGEMENT

SYSTEM
47
5 Health Care Waste Management Planning

Wastes generated at the HCFs may pose harm and risks to the health care
workers and communities if not properly managed. Health care waste management
(HCWM) is a process that helps in ensuring the proper management of HCW from
the point of generation to until disposal.
Figure 3: Seven important points in waste management
GENERATION SEGREGATION COLLECTION TRANSPORTATION STORAGE TREATMENT DISPOSAL
HCWM operation must be organized and planned and will vary depending on
the type of wastes being handled. Planning defines the strategy for the
implementation of improved waste management and the allocation of roles,
responsibilities, and resources. A well-thought-out plan describes the actions to be
implemented by authorities, health care personnel and waste workers.
Box 12: Objectives of HCWM Planning
HCWM planning should cover the six objectives listed below:
 Develop the legal and regulatory framework for HCWM.

 Rationalize the waste management practices within HCFs.
 Develop specific financial investment and operational resources dedicated to waste
management.
 Launch capacity building and training measures.
 Set up a monitoring plan.
 Reduce the pollution associated with waste management.
Source: WHO; Basel Convention, UNEP (2005)
The HCWM Plan should include all the aspects of managing wastes, from waste
avoidance and minimization, proper segregation and containment, safe handling,
storage and transport until treatment and disposal. It should also provide a clear
definition of the roles and responsibilities of the staff that are involved in HCWM.
Requirements for training and awareness should also be listed in the plan.
Legal requirements should be referenced to ensure the compliance of the facility
48
to the national standards. The allocation of resources needed should be set out in
terms of finances, time, equipment, and personnel. As HCWM is an evolving field, the
planning process should allow for periodic updates to policies as improvements in
processes and technology become known.
Box 13: Planning according to facility size
Hospitals should aim to establish a formal waste

management plan. This is a document that contains
the combined knowledge and decisions for all
involved in the production, handling and treatment of
wastes. A senior person at the HCF should be chosen
and made responsible for preparing the plan,
collecting ideas from others and, once agreed,
promoting the way HCW should be managed to
medical and ancillary staff.
At a primary care facility, the local plan would be a

shorter description of the waste management
arrangements that should be put in place in each
medical area, as well as identifying who is responsible
for good practices in each area, where the waste will
go, and how it should be disposed of after it has been
removed by a cleaner or porter.
5.1 Organization and Functions

The success of the implementation of the HCWM Plan is completely dependent
on the commitment of the entire staff of the HCF. The entire organization of the HCF
must be responsible for the proper segregation, collection, storage, treatment, and
disposal of waste generated by the facility. However, there are certain units and
individuals in the HCF that usually have more responsibilities relative to HCWM.
The Office of the Administrator and/or Head of the HCF shall oversee the
implementation of the HCWM Plan. The duties and responsibilities of the Head of the
HCF in relation to the HCWM Plan are as follows:
 Organize a HCWM Committee that is fully represented by all medical,
nursing, and administrative services in the HCF to develop and implement
a written HCWM Plan;
 Appoint/designate a Waste Management Officer (WMO) or its equivalent
Pollution Control Officer (PCO) to supervise and coordinate the HCWM
planning and its subsequent implementation;
 Conduct periodic review and update the HCWM Plan and incorporate
monitoring procedures;
 Allocate sufficient financial and personnel resources to ensure effective
and efficient implementation of the HCWM Plan;
49
 Appoint/designate alternative members in the event of personnel leaving

key positions in the HCWM Committee or temporarily assign responsibility
to another staff member until another one can be formally
appointed/designated;
 Provide adequate training for key members and designate the staff
responsible for coordinating and implementing training courses;
 Provide speedy resolution of complaints and other related legal matters;
and
 Maintain good working relationship with other related agencies by proper
referral, consultation, and cooperation concerning HCWM
5.2 Health Care Waste Management Committee

Appointment or designation of specific committee to handle HCWM in the HCF
is critical on the part of the Administrator or Head of the facility. The qualification and
political will of the person to be designated would determine the success of the
program. The HCWM Committee shall be responsible for the following functions:
 Formulate a policy formalizing the HCF commitment to properly manage
its waste with the goal of protecting health and the environment;
 Establish baseline data and develop the HCWM Plan, which shall include
a minimization plan, training, and written guidelines on waste
management;
 Implement the HCWM Plan; review and update the policy, plans, and
guidelines on an annual basis;
 Ensure adequate financial and human resources for HCWM Plan
implementation;
 Conduct regular committee meeting and submit minutes of meeting;
 Regularly monitor and evaluate the HCWM Plan efficiency and
effectiveness; and
 Ensure strict compliance with existing laws, policies, and guidelines.
The composition and structure of the HCWM Committee depends on the needs
and capacities of the HCF. The specific duties and functions of the HCWM
Committee members are described in ANNEX B 1.
 In hospitals where large quantities of waste are generated, a separate
HCWM Committee is required to be formed. (see Box 14)
 In primary care facilities with limited staff, the suggested approach is to set
up a Waste Management Team or have a smaller Infection Control
Committee with one person responsible for HCWM or at least an
50
appointed WMO. At the minimum, the team should include the head of
the facility, physicians, nurses, and the general services.
 In an institution that is not directly involved in patient care, such as a
medical research institution, the head of the establishment should use their
discretion to appoint members of the Waste Management Team from
among the relevant staff.
Box 14: HCWM Committee for hospitals
Core Team
In hospitals, the HCWM Committee shall be composed of at least a minimum of five (5)
members as the Core Team, to be composed of: (1) Head/Administrator of the HCF as
chairperson; (2) Waste Management Officer; (3) Infection Control Officer; (4) Pollution Control
Officer, and (5) Finance/Budget Officer/Supply Officer.
The Core Team shall be responsible for the following duties and responsibilities:
 Organize and establish the HCWM sub-committees or group who will directly implement
within specific units of the HCF the HCWM policies and guidelines;
 Prepare the budgetary plan for the logistic requirements to implement HCWM within the
HCF;
 Formulate policies and guidelines in the implementation of HCWM including granting of
incentives for best practices;
 Approve request for unit activities and programs which will include training;
 Provide assistance to all units relative to proper orientation of all staff; and
 Document and prepare report on regular basis.
Members
Key staff of the HCF should also be part of the HCWM Committee, such as the department
heads, division heads, senior nursing officer, chief pharmacist, radiation officer, head of the
general services, maintenance and ground services, motor pool services, and the HCF
engineer.
5.3 Health Care Waste Management Plan

A comprehensive HCWM Plan is the key ingredient to a successful waste
management within an HCF. It is important that the plan be understood or followed
51
to be of great value to the organization.
5.3.1 Development of the HCWM Plan
The following shall be addressed in developing a comprehensive HCWM Plan:

A. Assessment of waste generation and waste disposal
In developing a HCWM Plan, the HCWM Committee needs to assess all waste
generated in the HCF. The Waste Management Team should take special care to
test the robustness of the Plan during periods of “peak” waste production. The Plan
should also consider potential slack periods or other unusual circumstances that may
significantly reduce waste quantities.
Surveys can be used to help plan for these periods of higher or lower waste
generation; for example, survey results can sometimes be used to predict future
changes in hospital capacity or the establishment of new departments. The WMO
shall be responsible for coordinating such a survey and for the analysis of the results.
The assessment shall include the following: average daily volume of waste generated
per category within a given period (refer); site and location of the HCF vis-à-vis the
existence of accredited TSD within the locality; and assessment of any future
changes in the facility, departmental growth, or the establishment of new
departments.
Refer to ANNEX D 1 for a sample HCWM assessment checklist for primary care
facilities and to ANNEX D 2 for a sample sheet for waste generation assessment. Data
from the waste generation survey shall be a basis of the HCWM Plan.
B. Review of existing HCWM policies and procedures being implemented
During HCWM Plan development, every member of the HCWM Committee
should review existing HCWM arrangements in their area of responsibility. Existing
practices should then be evaluated in the light of national guidelines and
recommendations made to the WMO on how the guidelines can be implemented
in each area. The following activities must be done in developing the HCWM Plan:
 Understanding of existing policies, laws, and regulations related to HCWM;
 Review and evaluation of present HCWM system to include where and
what types of waste are being generated, how and where waste is stored,
treated, and disposed, and the cost effectiveness of the current handling
processes, including purchase and product utilization practices;
 Possibilities for waste minimization, reuse, and recycling; segregation; on-
site handling, transport, and storage practices;
 Identification and evaluation of recordkeeping/documentation, training,
and monitoring options;
 Estimation of costs relating to HCWM, including capital, operational, and
52
maintenance costs;
 Strategy for implementing the Plan, and;
 Revision/redesigning of the Plan to ensure all issues have been addressed.
C. Formulation and drafting of HCWM Plan
The following may be used as guide in drafting and formulating the HCWM Plan:
1) Short description of the HCF – This will include the background of the HCF
including its mandates, type of clients being served, demographic profile
and geographic location of the HCF. This will also discuss briefly the
different national, local, and international laws, policies, and issuances
relevant to the implementation of HCWM within the HCF.
2) Objective and rationale of the HCWM Plan – This will briefly discuss the
purpose of the plan, targets, its coverage, scope, and limitations.
3) Composition of HCWM Committee – its structure, duties, and
responsibilities; roles and responsibilities of the other staff of the HCF.
4) HCWM Plan – From point of waste generation up to final disposal including
flow chart, route plans, and schedules. This will also identify the different
activities and persons responsible for handling specific activities and whom
to be responsible for. This will also include the milestones or strategies to
move the current HCWM system into the system envisioned in the HCWM
Plan, the minimization plan, the procurement plan, and others.
5) Information, Education, and Communication (IEC) and training activities –
A comprehensive training and orientation of HCF worker shall be
conducted. Each HCF staff must know their specific roles in the effective
implementation of the HCWM Plan. Every HCF worker must be aware of
the policy, significant health and environmental impacts of their work
activities, their roles and responsibilities, procedures that apply to their
work, and importance of conforming with requirements as well as
consequences of not non-compliance. The HCWM Plan will identify the
timetable and responsible persons for the development of training
materials and conduct training for different HCF categories, development
of advocacy materials (if needed), and conduct of orientation for patients
and watchers.
6) HCF worker protection and safety – This will include the plans for HCF
worker’s occupational health and safety program including emergency
management for possible related risks or accidents during the process. This
will also indicate the infection control policies and procedures to be
observed in handling HCW, specifically infectious and mercury waste.
7) Monitoring and evaluation – Action plan for the conduct of regular
53
monitoring of implementation and submission of required reports,

including self-monitoring tools, assessment of findings, submission of
recommendations, and status follow-up.
8) Financial requirements for the HCWM Plan implementation – Without
specific financial resources, it is impossible to get sustainable
improvements in HCWM, which is an integral part of health care and thus
needs to be budgeted for.
9) Provision for feedback mechanism, updating, and revision of the HCWM
Plan – The HCWM Committee should review the HCWM Plan annually and
initiate changes necessary to upgrade the system.
Box 15: Details to include in the HCWM Plan
Location and organization of collection and storage facilities

 Drawings of the establishment showing designated bag/disposal container for every ward
and department; disposal container shall be appropriately designated for HCW or other
waste.
 Drawings showing the central storage site for HCW and the separate site for other waste.
Details of the type of containers, security equipment, and arrangements for washing and
disinfecting waste collection trolleys/carts (or other transport devices) should be
specified. The document should also address eventual needs for refrigerated storage
facilities.
 Drawings showing the individual waste collection routes within the HCF.
 Collection timetable for each trolley route, type of waste to be collected, and number of
wards and departments to be visited on one round. The central storage point in the facility
for that particular waste should be identified.
Design specifications
 Drawings showing the type of bag holder to be used in the wards and departments.
 Drawings showing the type of trolley or wheeled container to be used for bag collection.
 Drawings of sharps containers, with their specification.
Required material and human resources

 An estimate of the number and cost of bag holders and collection trolleys.
 An estimate of the number of sharps containers and HCW drum containers required
annually, categorized into different sizes, if appropriate.
 An estimate of the number and cost of color-coded bags or bins to be used annually.
 An estimate of the number of personnel required for waste collection.
Responsibilities
 Definitions of responsibilities, duties, and codes of practice for each of the different
categories of personnel of the hospital who, through their daily work, will generate waste
and be involved in the segregation, storage, and handling of the waste.
 Definition of the responsibilities of hospital attendants and ancillary staff in collecting and
handling wastes, for each ward and department; where special practices are required
(e.g., for radioactive waste or hazardous chemical waste), the stage at which attendants
or ancillary staff become involved in waste handling shall be clearly defined.
Procedures and practices

 Simple diagram (flowchart) showing procedure for waste segregation.
 Procedures for segregation, storage, handling of wastes requiring special arrangements,
such as autoclaving.
 Outline of monitoring procedures for waste categories and their destination.
 Contingency plans, containing instructions on storage or evacuation of HCW in case of
54
breakdown of the treatment unit or during closure for planned maintenance.

 Emergency procedures.
Training
 Description of the training courses and programs to be set up and the personnel who
should participate in each.
5.3.2 Implementation of the HCWM Plan
The head of the HCF is responsible for the HCWM Plan implementation, which
involves the following steps:
1) Development of interim measures, as precursor to complete
implementation of the new HCWM system, in collaboration with the HCWM
Committee, and be appended to the plan;
2) Inclusion of provision on future expansion of HCF/waste storage facilities;
3) Appointment of personnel responsible for HCWM. Notice of this
appointment should be widely circulated and updates be issued when
changes occur; and
4) Organization and supervision of training programs for all staff, by ICO in
collaboration with the WMO and other members of the HCWM
Committee.
As soon steps 1 to 4 have been completed and the necessary equipment for
waste management is available, the operations described in the HCWM Plan can
be put into practice. The approach and recommendations in a HCWM Plan should
be implemented incrementally, through gradual improvements. It is important for
public authorities and managers of HCFs to be fully aware of the infection control
reasons for having proper waste management procedures. The HCWM Committee
should review the HCWM Plan annually and initiate changes necessary to upgrade
the system. Interim revisions may also be made as and when necessary. These
revisions should be documented at the time and added as an appendix to the
HCWM Plan; they should be incorporated into the full plan when it is reviewed. The
HCWM Committee should also update policies and practices as new national
guidance becomes available.
55
Figure 4: Basic elements for safe HCWM in primary care facilities
SELECTION OF OPTIONS AWARENESS AND TRAINING IMPLEMENTATION
•Choice of off-site options – •Risks related to sharps and •Assessment of current HCW
Identify available EMB- other infectious wastes system in place
registered TSD facilities in the •Segregation practices •Joint development of a sound
area •Safe handling, storage and HCW system
•Choice of sustainable operation and maintenance •Assignment of responsibilities
management and disposal of treatment technologies for waste management
options based on: •Allocation of sufficient
•Context and needs resources
•Availability •Waste minimization policies
•Affordability and procedures
•Environment-friendliness •Segregation of HCW
•Efficiency •Implementation of safe
•Worker’s safety handling, storage,
•Social acceptability transportation, treatment,
disposal practices and options
•Involve key stakeholders
•Tracking of waste production
and destination
•Evaluation of HCW system
Source: Management of Solid Health Care Waste at Primary Health Care Centres (WHO, 2005)
56
Fourth Edition Chapter 6: Health Care Waste Minimization
6 Health Care Waste Minimization

The HCW generated within the HCF follows an appropriate and well identified
stream from point of generation until their final disposal, that is composed of several
steps that includes waste generation, segregation, collection, transportation (on-site
and off-site), storage, treatment, and disposal. To illustrate, Figure 5 summarizes the
HCW handling – the flow of waste from point of generation up to its final disposition.
Figure 5: HCW handling
Reference: Health Care Waste Management Manual, 3rd Edition (DOH, 2011)
57
Protecting public health through the management of wastes can be achieved

by variety of methods. As mentioned in Chapter 1.6, these can be summarized in order
of preference called the “waste management hierarchy” (Figure 6), with the most
desirable method at the top to the least desirable at the base. “Desirability” is
defined in terms of the overall benefit of each method from its particular impacts on
the environment, protection of public health, financial affordability and social
acceptability.
Figure 6: Waste management hierarchy
As illustrated, the most preferable approach is to avoid producing waste as far as

possible and thus minimize the quantity entering the waste stream. Where
practicable, recovering waste items for secondary use is the next most preferable
method.
Waste that cannot be recovered must then be dealt with by the least preferable
options, such as treatment or land disposal, to reduce its health and environmental
impacts.
In addressing HCWM, waste minimization basically utilizes the first two elements
that could help reduce the bulk of HCW for disposal; so, the best waste management
practice aims to address the problem at source rather than the end-of-pipe solution.
58
6.1 Principles
The underlying principle of Waste Minimization is rooted in the Hierarchy of
Controls, that prevention is very important, thus before producing waste; the HCF
shall investigate whether the amount of waste to be generated from the daily
operation of the HCF could be minimized in order to reduce the efforts in subsequent
handling, treatment, and disposal operations. The critical point in minimizing waste
starts from the planning stage of the preparation of the Annual Procurement Plan
(APP), which includes the list of items required for HCF activities. The management of
HCF must adopt the following strategies to implement waste minimization:
 Establish an updated database for the waste generation rates, current
hazardous waste management strategies and current waste
management costs;
 Institutionalize waste minimization and sustain the program in the long run;
 Have a written policy with established vision and mission to implement
Waste Minimization Program (WMP);
 Be aware of their specific role in HCWM and be properly trained in waste
minimization; and
 Adopt the Green Procurement Policy (GPP) pursuant to Executive Order
No. 301, Series of 2009.
Box 16: Examples of practices to encourage waste minimization
Source reduction
 Purchasing reductions: selecting supplies that are less wasteful where smaller quantities
can be used, or that produce a less hazardous waste product;
 Use of physical rather than chemical cleaning methods (e.g., steam disinfection instead
of chemical disinfection);
 Prevention of wastage of products (e.g., in nursing and cleaning activities);
Management and control measures at HCF level

 Centralized purchasing of hazardous chemicals;
 Monitoring of chemical use within the health center from delivery to disposal as hazardous
wastes.
Stock management of pharmaceutical products

 More frequent ordering of relatively small quantities rather than large amounts at one
time, to reduce the quantities used (particularly applicable to unstable products).
 Use of the oldest batch of a product first.
 Use of all the contents of each container.
 Checking of the expiry date of all products at the time of delivery, and refusal to accept
short-dated items from a supplier.
Management of chemical products

 Use of less toxic and environmentally friendly chemicals;
 Use minimum concentrations where possible;
 Ensuring good inventory control (i.e., “just-in time” purchasing);
 Integrating pest management
59
If waste minimization is to be undertaken by the HCF, it is important to develop a

good baseline data of the amount of waste generated prior to implementation of
the waste minimization program. HCW generation data from the various units of the
HCF shall be properly recorded on a chart with the amount of waste displayed in
descending order. This method can be used to determine the highest waste
generating areas where the minimization strategies shall first be initiated. This
information shall be displayed and communicated throughout the HCF. The waste
minimization strategy shall be formally approved in writing by top management
within the HCF as a demonstration of their support and commitment to the program.
Waste minimization is beneficial not just to the waste-receiving environment but
to the waste generators also. The cost for both the purchase of goods and waste
treatment and disposal are reduced and the liabilities associated with the disposal
of HCW is lessened. All employees have a role to play in this process and should be
trained in waste minimization. This is particularly important for the staff of departments
that generate large quantities of hazardous HCW. Encouraging staff to extend waste
minimization requires the adoption of more rigorous methods and disciplines. Waste
minimization targets can be established for each area of medical or support
activities, and people can be made more personally responsible for waste
minimization – possibly by providing incentives for those people and departments
who are successful in achieving their targets. Educating staff to use medical materials
carefully to avoid generating unnecessary waste is a further simple measure that can
be undertaken.
6.2 Benefits of Waste Minimization

Institutionalization of Waste Minimization Program will enhance the HCF as to:
 Financial—Cost savings through effective waste management and more
efficient use of natural resources (electricity, water, gas, and fuels);
Additional income generated from sale of recyclable waste; Fines and
penalties are avoided in meeting environmental legislation by identifying
environmental risks and addressing weaknesses; Reduction of insurance
and health costs by demonstrating better risk management.
 Operational and Internal—Improved overall performance and efficiency;
Compliance with the PHIC Bench book Performance Indicator.
 External—Better public perception of the HCF; Reduction of the adverse
environmental impact (i.e., land, air, and water pollution); Promoting
environmental sustainability.
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6.3 Waste Minimization Techniques

Waste minimization can be done in two points of the HCW handling. Best practice
waste management will aim to avoid or recover as much of the waste as possible in
or around an HCF, rather than disposing of it by burning or burial. This is sometimes
described as tackling waste “at source” rather than adopting “end-of-pipe”
solutions.
Waste can be minimized during procurement of materials needed by the HCF
(Step 0). By purchasing environmentally friendly products, one can already minimize
the amount of waste to be generated. To achieve lasting waste reduction (or
minimization), focus should be on working with medical staff to change clinical
practices to ones that use less materials. Although waste minimization is most
commonly applied at the point of its generation, health care managers can also
take measures to reduce the production of waste through adapting their purchasing
and stock control strategies. Suppliers of chemicals and pharmaceuticals can also
become responsible partners in waste minimization program. The HCF can
encourage this by ordering only from suppliers who provide rapid delivery of small
orders, who accept the return of unopened stock, and who offer off-site waste
management facilities for hazardous wastes.
Waste can also be minimized through segregation. In this process, the 3R’s
principle is applied, effectively reducing the amount of waste to be treated or
collected.
Figure 7: Waste minimization techniques
61
6.3.1 Green Procurement: Waste Prevention and Reduction at Source
Waste can be minimized in an HCF through proper procurement planning. Th HCF

can adopt the Green Procurement Program (GPP) wherein the process of
procurement considers the environmental impact of items/goods/services.
Addressing the issue of HCW at the source is more economically and environmentally
beneficial than looking into the perennial issue of waste management disposal.
Box 17: Factors to consider in Green Procurement
Some factors to consider in green procurement are as follows:
 Less toxic
 Minimally polluting
 Energy efficient
 Safer and healthier for patients, workers, and the environment
 Higher recyclability and recycled content
Source: Philippine Health Center, Initiative on Green Procurement
6.3.1.1 Waste prevention through the adoption of GPP pursuant to Executive Order No. 2004-31
GPP urges HCFs to buy less-polluting products from a less polluting supplier. The
objectives of such program are to create awareness of environmental impact,
develop guidelines for green procurement, rethink material requirements and
consumption, reduce the use of hazardous materials, improving energy efficiency of
purchased materials, and use recycled materials and recycling of waste.
An HCF can consider some of the following approaches as part of its GPP
strategy:
 Supplier Focus—through the supplier registration form with emphasis on
environmental performance of supplier;
 Product and Service Focus—including environmental specifications; and
 Life Cycle Analysis—internal analyses/using LCA completed by external
groups. (see Box 18)
In the GPP, the production of goods is required to have less environmental impact
to avoid environmental contamination and harm to human health. Thus, every HCF
will only procure goods from companies that fulfilled the following requirements:
 Producing goods that do not contain any substance included in the EMB-
DENR list of banned substances;
 Establishing a complete elimination program for banned substances; and
 Making a commitment to sustain the program.
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Box 18: Life Cycle Analysis (LCA) Tool
Using the Life Cycle Analysis (LCA) tool, the administrators of the HCF will be able to decide
which product or service will be most suitable or applicable for its operations. LCA is a
compilation and evaluation of the input, output and potential environmental impacts of a
product or system throughout its life cycle.
The goal of LCA is to compare the full range of environmental damages assignable to
products and services. Following this assessment, businesses can identify the most effective
improvement that they can make in terms of environmental impacts and use of resources.
LCA can also be used for comparing the environmental credentials of similar products and
services to be able to choose the least burdensome ones. For each stage, the impact is
measured in terms of resource use and environmental impacts.
Reference: Safe Management of Wastes from Health-Care Activities, 2nd Edition (WHO, 2014)
In order to ensure the effective implementation of this program, the HCF may
review and assess its existing procurement policies and practices in order to evaluate
where the major environmental impacts lie. Methods can then be sought to
integrate environmental considerations into its purchasing practices.
The HCF can introduce measures to increase the utilization of recycled materials
and the purchase of more environment-friendly equipment and those with green
designs. These can be designed to fit with existing procurement methods, and to act
as a support tool for the purchasing staff. The policy, procedures and practices shall
not be designed to prohibit the purchase of any goods but merely to favor goods
that are environmentally friendly. Other factors such as the quality, price, delivery
time, etc. remain paramount in purchasing decisions.
6.3.1.2 Waste reduction at source through proper segregation of waste
Segregation is an important step in HCWM for the following reasons:

 Segregation minimizes the amount of waste that needs to be managed
as hazardous waste (since mixing non-hazardous waste with hazardous
waste renders the combined waste as hazardous).
 Segregation facilitates waste minimization by generating a solid waste
63
stream which can be easily, safely, and cost-effectively managed through

recycling or composting.
 Segregation reduces the amount of hazardous substances released to the
environment through disposal of general waste (i.e., by removing mercury
from general waste).
 Segregation makes it easier to conduct assessment of the quantity and
composition of different waste streams thereby allowing an HCF to obtain
baseline data, identify options, determine waste management costs, and
evaluate the effectiveness of waste minimization strategies.
6.3.2 Resource Development (3R’s)
Another principle applied in waste minimization is Resource Development referring

to the “3R’s” or Safe Re-use, Recycle, and Recovery programs.
6.3.2.1 Safe re-use
Another option for the waste minimization is the safe re-use. Re-use is not only
finding another use for a product but, more importantly, reusing the product
repeatedly for a given function as intended. Promoting re-use entails the selection
of reusable rather than disposable products whenever possible. Re-use will also entail
setting reliable standards for disinfection and sterilization of equipment and materials
for use (see Box 19). Reuse requires a realistic assessment of which reuse practices are
considered safe and which to avoid because the risk of infection transmission to
patients and staff is unacceptable.
When considering reuse, it is important to make a distinction between different
types of products:
 Non-medical supplies, disposable items (which should be avoided);
 Medical devices that pose no cross-infection risk (e.g., blood pressure
meters); and
 Medical devices specifically designed for reuse (e.g., surgical instruments).
Before the reuse of the product, it must undergo the following steps: (1) cleaning;
(2) decontamination; (3) reconditioning; (4) disinfection; and (5) sterilization.
The following are the products that can be reused:
 Certain devices that are intended for limited reuse by the individual and
only require washing with mild detergents (e.g., patient self-administered
intermittent urinary catheters, face masks for oxygen administration);
 Long-term radionuclides conditioned as pins, needles, or seeds and used
for radiotherapy may be reused after sterilization;
 Special measures must be applied in case of potential or proven
64
contamination with the causative agents of transmissible spongiform

encephalopathies;
 Certain types of containers, provided they are carefully washed and
disinfected;
 Pressurized gas containers should be sent to specialized centers to be
refilled; and
 Containers that once held detergent/other liquids may be reused as
containers for sharps waste (if purpose-made containers are not
affordable), provided they are puncture-proof and clearly marked on all
sides for used sharps.
Items that cannot be reused are the following:
 Single-use devices or items, such as syringes and hypodermic needles,
must not be reused because of the risk of cross-infection. Where syringes
are in short supply, nurses may replace the needle, but the chance of
infection remains.
 Plastic syringes and catheters should not be reused. However, they may
be recycled after sterilization.
 Disposable items such as gloves, masks and gowns should not be reused.
Box 19: Examples of sterilization methods for re-usable items
Thermal sterilization
 Dry sterilization: Exposure to 160°C for 120 minutes or 170°C for 60 minutes in a “Poupinel”
oven.
 Wet sterilization: Exposure to saturated steam at 121°C for 30 minutes in an autoclave.
Chemical sterilization
 Hydrogen peroxide: A 7.5% solution can produce high-level disinfection in 30 minutes at
20°C. Alternatively, equipment exists that can generate a hydrogen peroxide plasma
from a 58% hydrogen peroxide solution. The equipment has a 45-minute process time.
Hydrogen peroxide can also be used in combination with peracetic acid.
 Peracetic acid: Can produce sterilization in 12 minutes at 50–55°C, with instruments ready
to use in 30 minutes. Peracetic acid can also be used in combination with hydrogen
peroxide.
 OPA (ortho-phthaldehyde): High-level disinfection in 12 minutes at 20°C.
 Hypochlorous acid/hypochlorite: 400–450 ppm active free chlorine, contact conditions
established by simulated use testing with endoscopes.
NOTE: Ethylene oxide and glutaraldehyde are widely used but are being replaced in an increasing number of HCFs
because of their health effects. Ethylene oxide is a human carcinogen, and glutaraldehyde can cause asthma and skin
irritation.
The effectiveness of the thermal sterilization must be checked – Bacillus stearothermiphilus test
(thermal sterilization) and Bacillus subtilis test (chemical sterilization).
65
6.3.2.2 Recycling
Recycling involves processing of used materials (waste) into new products to

prevent loss of potentially useful materials, reduce the consumption of fresh raw
materials, reduce energy usage, reduce air pollution and water pollution (from land
filling) by reducing the need for “conventional” waste disposal and lower
greenhouse gas emissions as compared to virgin production. However, from an
environmental perspective, recycling is less desirable than reusing a waste item,
because it frequently requires substantial energy input and transport to off-site
recycling centers.
Recyclable materials include many kinds of glass, paper, metal, plastics (see Box
19), textiles, and electronics. Materials to be recycled are brought to a collection
center or picked up from the curb side, then sorted, cleaned, and reprocessed into
new materials bound for manufacturing.
Recycling is increasingly popular in some HCFs, especially for the large, non-
hazardous portion of waste. It can reduce costs considerably, either through
reduced disposal costs or through payments made by a recycling company for the
recovered materials.
Some of the hazardous infectious portion of the waste will contain recyclable
materials (e.g., paper, cardboard, packaging, tubing). These materials can also be
recycled, provided they are disinfected to eliminate possible pathogens, and safe
handling guidelines are followed.
Box 20: Recycling of plastics
To facilitate recycling, common plastics are now frequently labelled with internationally
recognized symbols and numbers:
Unfortunately, many PVC products in health care, such as blood bags, gloves, enteral feeding
sets and film wraps, are not labelled.
66
6.3.2.3 Recovery
The recovery of waste is defined in two ways. Most simply, recovery refers to
energy recovery, whereby waste is converted to fuel for generating electricity or for
direct heating of premises. Alternatively, waste recovery is a term used to encompass
three sub-sets of waste recovery: recycling, composting, and energy recovery.
6.3.3 End-of-Pipe: Composting
Although similar in effect, composting or other re-use of biodegradable waste is

not typically considered recycling. Composting uses natural decomposition to turn
food scraps and yard waste into nutrient-rich soil additives, thereby reducing the
amount of solid waste for disposal in landfills. The resulting compost can be sold or
donated to local farmers and gardeners or can be used for plants around the HCF.
Box 21: Composting techniques
Red worms in bins feed on food scraps, yard trimmings,

and other organic matter to create high quality
compost called castings. One pound of mature worms
(approximately 800-1,000 worms) can eat up to half a
pound of organic material per day. Worm bins are easy
to construct and are also available for purchase. The
bins can be sized to match the volume of food scraps
that will be turned into castings. It typically takes 3 to 4
months to produce usable castings, which can be used
Vermicomposting
as potting soil. The other by-product of vermicomposting
known as “worm tea” is used as a high-quality liquid
fertilizer for houseplants or gardens.
This involves forming organic waste into rows of long piles

called “windrows” and aerating them periodically by
manually or mechanically turning the piles. The ideal pile
height is 4 to 8 feet with a width of 14 to 16 feet, large
enough to generate heat and maintain temperatures
but small enough to allow oxygen flow to the windrow's
core. Large volumes of diverse wastes such as yard
Aerated (Turned) trimmings, grease, liquids, and animal by-products can
Windrow Composting be composted through this method.
Aerated static pile composting produces compost

relatively quickly (within 3 to 6 months). It is suitable for a
relatively homogenous mix and larger quantity of
organic waste. However, it does not work well for
composting animal by-products. Organic waste is mixed
in a large pile, which is aerated by adding layers of
loosely piled bulking agents (e.g., wood chips, shredded
newspaper). The piles also can be placed over a
Aerated Static Pile network of pipes that deliver air into or draw air out of
Composting the pile. Air blowers might be activated by a timer or a
temperature sensor.
67
In-vessel composting can process large amounts of

waste without taking up as much space as the windrow
method. It can accommodate virtually any type of
organic waste. It involves feeding organic materials into
a drum, silo, concrete-lined trench, or similar equipment
that allows good control of environmental conditions
(i.e., temperature, moisture, airflow). The material is
mechanically turned or mixed to aerate. This method
produces compost in just a few weeks. It takes a few
In-vessel Composting more weeks or months until it is ready to use because the
microbial activity needs to balance, and the pile needs
to cool.
6.4 Administrative Control Measures

Green Procurement, the 3R’s, and end-of-pipe solutions can be achieved
through, among others, administrative control measures such as:
 Adopting Environmental Management System (EMS) as described in Box
22;
 Systemized use of product “first in, first out” (FIFO) or “first to expire, first out”
(FEFO) for chemical and pharmaceutical products;
 Monitoring of chemical flows within the healthy facility from receipt as raw
materials to disposal as hazardous waste;
 Elimination of medical supplies/equipment containing hazardous
chemicals;
 Using less hazardous method in cleaning such as steam disinfection instead
of chemical disinfection; and
 Checking the expiry date of all products at the time of delivery and based
on its optimum consumption rate.
Box 22: Environmental Management System
An Environmental Management System (EMS) framework encompasses the environmental

aspects of waste management, including reduction, reuse, and recycling. An EMS should be
an integral part of an organization’s approach to good management. It is used to develop
and implement its environmental policy and to manage its continuing environmental impacts.
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PLAN: Environmental
policies, objectives, and
targets, legal register,
significant aspects and
impacts
DO: Procedures,
ACT: Management
document control,
review, corrective actions
training, and
and improvements
communication
CHECK: Internal
monitoring and auditing,
report
Key elements of an EMS should include the following:

 Process or mechanism for screening project plans and proposals for potential
environmental risks; for example, using screening tools, checklists, and expert review;
 Development and use of environmental management plans that clearly define
environmental mitigation measures to be taken, by whom, and at which point in the
project’s implementation;
 Monitoring and reporting activities to verify that relevant environmental management
actions are being taken and that they are generating the intended results;
 Evaluation of the overall environmental performance of projects and activities to inform
organizational learning and future environmental mitigation actions.
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Fourth Edition Chapter 7: Health Care Waste Segregation, Collection, Storage, and Transport
7 Health Care Waste Segregation, Collection,

Storage, and Transport
This chapter describes the proper segregation of HCW at the point of generation,
collection, storage, and transport for treatment prior to its final disposal. Segregation
is the key to effective waste management and only implementation of proper waste
management can ensure all HCW will be treated according to the hazards.
7.1 Principles
HCF managers have a “duty of care” to ensure that waste is kept under control
at all times within the HCF and disposed of safely either on-site or off-site. The
following general principles relate to the control of waste flow from generation to
disposal:
 HCW is generated in a medical area and should be segregated into
different fractions, based on their potential hazard and disposal route, by
the person who produces each waste item.
 HCW must be segregated, collected, stored, and transported in a safe
manner considering the risk and occupational safety and in accordance
with existing laws, policies, and guidelines.
 Hazardous and general waste must not be mixed during collection,
transport, and storage.
 Separate containers should be available in each medical area for each
segregated waste fraction.
 Appropriate labelling, signage, route, and segregation system must be
established. Waste containers when filled should be labelled to help
managers control waste production.
 Plastic liners preferably containing three-quarters full of waste must be
sealed when transported from waste generating source to the storage
area.
 The storage area must be designed based on the volume of waste
generated by the HCF and must be provided with compartments for
general, hazardous, and recyclable wastes. Closed local storage inside or
near to a medical area may be needed if wastes are not collected
frequently.
 A separate storage area for phase-out mercury containing devices and
products must be provided (as per DOH AO 2008-21 and DM 2011-0145).
70
 Staff must be well-trained on the risk and safety procedures on handling

waste.
 The HCF must register as waste generator with the DENR and secure a
DENR waste generator identification number.
7.2 HCW Segregation

Segregation is the process of separating different types of waste at the point of
generation until its final disposal. The correct segregation of HCW is the responsibility
of the person who produces each waste item, whatever their position in the
organization.
Segregation at the point of generation reduces the health risk from the smaller
potentially infectious factions (typically waste items contaminated with body fluids
and used sharps). With proper segregation, appropriate resource recovery and
recycling technique can be applied to each separate waste stream. Proper
segregation may also minimize the amount of hazardous wastes that needs to be
treated thus, prolonging the operational life of the disposal facility and may gain
benefit in terms of conservation of resources. To improve segregation efficiency and
minimize incorrect use of bins, proper placement, labelling of waste bins and use of
color-coded plastic liner must be strictly implemented.
Box 23: Minimum requirement for HCW segregation: three-bin system
The simplest waste segregation system is to separate all hazardous waste from the larger
quantity of non-hazardous general waste. However, to provide a minimum level of safety to
staff and patients, the hazardous waste portion is commonly separated into two parts: used
sharps and potentially infectious items. Consequently, the segregation of general, non-
hazardous waste, potentially infectious waste and used sharps into separate containers is
often referred to as the “three-bin system.” This is most applicable to the primary care facilities.
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If classification of a waste item is uncertain, as a precaution it should be placed into a

container used for hazardous HCW. Waste that has been poorly segregated should never be
re-sorted, but instead should be treated as the most hazardous type of waste in the container.
Source: WHO & UNICEF, https://slideplayer.com/slide/14374406/
7.2.1 General Considerations after Basic Segregation
Within each major category (e.g., non-hazardous, potentially infectious, used

sharps), further segregation of the HCW according to the categorization discussed
in Chapter 2.2 is needed when other hazardous waste is generated (e.g.,
pharmaceutical, pathological, chemical). In doing so, the following practices must
be observed during segregation at the point of generation.
A. General / Non-hazardous waste
 As discussed in Chapter 2.2, general non-hazardous wastes may further be
segregated into recyclables, biodegradables, and non-
biodegradable/non-recyclable wastes. If these are mixed at the point of
generation, it may prevent recyclables from being recovered.
 Food wastes can be collected from medical areas and returned directly
to the kitchens. Non-hazardous biodegradable wastes (e.g., flowers) may
be disposed of with kitchen waste. Aerosol containers can be collected
with the general wastes.
B. Hazardous waste
 Sharps waste (needle and syringe combination) should be placed directly

into the designated puncture-proof container.
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 Highly infectious waste, such as diagnostic laboratory samples and waste

from infectious patients in isolation, should be collected separately and
disinfected at the point of generation. Once disinfected, the waste would
leave a medical area in the infectious HCW container.
 Pathological waste must be refrigerated if not collected/treated within 24
hours.
 Anatomical waste, particularly recognizable body parts or fetal material,
should be handled according to prevailing religious and cultural
preferences (most commonly, authorized burial or cremation). In low-
resource areas, placentas and other non-recognizable anatomical waste
can be disposed of in a pit where it can biodegrade naturally.
 Various chemical and pharmaceutical wastes should be segregated and
collected separately: subcategories include mercury, batteries, cadmium-
containing wastes, photochemicals, stains and laboratory reagents,
cytotoxic drugs, and other pharmaceuticals.
o Liquid chemical wastes should never be mixed or disposed of down
the drain but should be stored in strong leak-proof containers or
amber disposal bottles. Expired and discolored pharmaceuticals
shall be returned to the pharmacy for return to the
manufacturers/supplier.
o Pharmaceuticals should be kept in their original packaging to aid
identification and prevent reaction between incompatible
chemicals. Spilt and contaminated chemicals and
pharmaceuticals should not be returned to the pharmacy but
should go directly from the point of production to a waste store.
Typically, they are stored and transported within the HCF in brown
cardboard boxes and must be kept dry.
o Wastes containing mercury shall be collected separately and be
managed according to DOH Department Memorandum 2011-
0145.
 Radioactive wastes may be stored in secure, radiation-proof repositories
(leak-proof, lead-lined, and clearly labelled with the name of the
radionuclide and date of deposition) where it should be left to decay
naturally. If it has reached the background radiation level and is not mixed
with infectious or chemical wastes, it can be considered as general waste.
Radioactive wastes can also be collected and handled by registered
service providers.
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Box 24: Sharp containers
Sharps shall be placed in puncture-proof containers. Since sharps can cause injuries that leave
people vulnerable to infection, both contaminated and uncontaminated sharps should be
collected in a puncture-proof and impermeable container that is difficult to break open after
closure.
Sharps containers may be disposable or designed for disinfection and reuse. Disposables are
boxes made of plasticized cardboard or plastic; reusable designs are plastic or metal. Low-
cost options include the reuse of plastic bottles or metal cans. If this is to be done, the original
labels should be removed or obscured, and the containers should be clearly relabeled as
“Sharps containers.”
7.2.2 Waste Bins and Plastic Liners
7.2.2.1 Siting
Segregation should be carried out by the producer of the waste as close as

possible to its place of generation, which means segregation should take place in a
medical area, at a bedside, in an operating theatre or laboratory by nurses,
physicians and technicians. The following must be considered in selecting the
location of waste bins in the HCF:
 Hazardous waste containers should be located away from patients;
typical sites are the sluice (utility) room, treatment room and nurses’
station.
 Where containers for segregating hazardous and non-hazardous HCWs
are in use, they should be located close together, wherever possible.
 Containers for hazardous waste like infectious waste should not be placed
in public areas because patients and visitors may use the containers and
come into contact with potentially infectious waste items.
 Only waste bins for general non-hazardous waste bins must be in public
areas.
 Waste bins with yellow liners for infectious wastes shall be placed in, but
not limited to, the following areas away from the public: Emergency Room,
Outpatient Department, Laboratory, Radiology, Dental and Isolation
Rooms, Infectious Wards, Dialysis and Nurses Stations. The alternative is
establishing a limited number of locations in a medical area where general
waste (black bags) and infectious HCW (yellow bags and sharps
containers) are placed.
 Static bins should be located as close as possible to sinks and washing
facilities, because this is where most staff will deposit gloves and aprons
after treating patients. If the general waste container is closest to the sink
or under a towel dispenser, it will encourage staff to place towels into the
non-infectious receptacle.
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 Unless patients are known or suspected to have readily transmitted

infections, the assumption should be that general waste generated in a
medical area is of low risk. However, if there is a known communicable
infection (e.g., methicillin-resistant Staphylococcus aureus, tuberculosis, or
leprosy), all waste used in and around the patient should be classed as an
infection risk and placed in the yellow, potentially infectious waste
container. This “blanket” approach to all waste being assumed to be
infectious can be avoided where there is a high level of training and
communication between the clinical and support staff. Waste from each
patient should be treated according to their known infection status.
 If intervention at the bedside is required, a waste container should be
taken to the bed – preferably placed on or at a trolley or cart. Sharps bins
are also sometimes taken to a patient for drug administration or blood
sampling. A mobile trolley with infectious waste and sharps containers may
therefore be more versatile and should be given serious consideration.
7.2.2.2 Specifications
Waste bins are of different types. Some bins are designed for automated system
others are re-used plastic and metal containers. The general specifications of the
waste bins and plastic liners that must be followed are as follows:
 The most important is the quality of material – it shall be sturdy and leak-
proof;
 Bins shall have well-fitting lids, either removable by hand or operated by a
foot pedal;
 Both bins and plastic liners shall be preferably of the same color for the
type of waste intended to be placed. This is to avoid confusion and poor
segregation;
 The recommended thickness of the plastic liners is 0.07mm (ISO 7765 2004).
Plastics used for either containers or bags should be chlorine-free. Not all
plastic bags can withstand temperatures of 121°C, and some can melt
during an autoclave process;
 Containers should be large enough for the quantity of waste generated
at that location during the period between collections; and
 Containers should be of similar size to overcome the observed tendency
for staff to put waste in the largest receptacle.
The appropriate waste receptacle (bags, bins, sharps boxes) should be available
to staff in each medical and other waste-producing area in the HCF. This permits staff
to segregate and dispose of waste at the point of generation and reduces the need
for staff to carry waste through a medical area. The specifications of waste
bin/container and plastic liner per type of HCW are provided in Table 4.
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7.2.2.3 Color-Coding
The purpose of color-coding is to make it easier for HCF workers to put the waste
into correct bins and maintain segregation during collection, storage, transport,
treatment, and disposal. The color-coding scheme of waste bin/container and
plastic liner per type of HCW is likewise indicated in Table 4. HCFs may adopt the color-
coded waste bin or innovate using recycled materials. However, strict compliance
shall be observed in the use of corresponding plastic liners and proper labelling.
7.2.2.4 Labelling and Marking
Proper tagging of plastic liners before placing on the waste bin is to be strictly
implemented. The tag of the plastic liner shall indicate the following:
 Name of the HCF;
 Area of the HCF where the waste was generated (or the source);
 Type of waste and the weight and date of collection on-site, or date and
time of closure of the container; and
 Name of the person filling out the label.
The waste bins must also be labelled according to the type of waste so as to
avoid confusion in the disposal of the wastes. The label must contain the DENR-EMB
symbols representing the hazard classifications of the wastes or any necessary
hazard labels. Refer to ANNEX E 1. These symbols must have the following specification
when used in the tags:
 The minimum size of the symbol is 25cm x 25cm for vessels, containers, and
tanks and 30cm x 30cm for conveyances carrying vessels, containers, and
tanks;
 Basic shape of the symbols is a square rotated 45 degrees to form a
diamond;
 At each of the four sides, a parallel line shall be drawn to form an inner
diamond of the outer diamond; and
 The color should follow the colors specified.
The labelling and marking requirements for the waste bin/container and plastic
liner per type of HCW are also described in Table 4.
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Table 4: HCW bins and plastic liners specifications, color-coding, marking/labelling

Type of HCW Specifications Color- Markings/Labeling
coding
SHARPS: Bin/  Puncture proof Yellow  Properly labelled
Bin/container container container with wide “Sharps”
mouth and cover.  With label indicating
source and weight of
waste generated and
date of collection.
 With Biohazard symbol.
INFECTIOUS Bin/  Strong, leak-proof Yellow  Properly labelled
WASTE: container bin with cover “Infectious Waste”
Bin/container with  Size varies  With Biohazard symbol
plastic liner depending on
waste volume
Plastic liner  Strong, leak-proof Yellow  Properly labelled
plastic bag “Infectious Waste”
 Can withstand  Tag indicating source
autoclave and weight of waste
 Thickness: 0.07mm generated, date of
(70µm) collection
 Sample sizes: XL size  Biohazard symbol
(39cm x 39cm x optional
95cm) – Size varies
depending on
waste volume
PATHOLOGICAL Bin/  Strong, leak-proof Yellow  Properly labelled
WASTE: container bin with cover “Pathological Waste”
waste volume
Plastic liner  Thickness: 0.07mm Yellow  Properly labelled
 Sample sizes: XL size “Pathological Waste”
(39cm x 39cm x  Tag indicating source
95cm) – Size varies and weight of waste
depending on generated, date of
waste volume collection
 Biohazard symbol
optional
ANATOMICAL Bin/  Strong, leak-proof Yellow  Properly labelled
WASTE: container bin with cover “Anatomical Waste”
waste volume
Plastic liner  Thickness: 0.07mm Yellow  Properly labelled
 Sample sizes: XL size “Anatomical Waste”
(39cm x 39cm x 95  Tag indicating source
m) – Size varies and weight of waste
 Biohazard symbol
optional
PHARMACEUTICAL Bin/  Strong, leak-proof Brown  Properly labelled
WASTE: container bin with cover “Pharmaceutical
Bin/container with  Size varies Waste” – expired drugs
additional plastic depending on and containers
liner for cytotoxic waste volume  “Cytotoxic Waste”
or liquid waste  “Genotoxic Waste”–
cytotoxic, genotoxic,
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Type of HCW Specifications Color- Markings/Labeling

coding
and antineoplastic
waste
Plastic liner  Thickness: 0.07mm Brown  Properly labelled
 Sample sizes: XL size “Pharmaceutical
(39cm x 39cm x Waste” – expired drugs
95cm) – Size varies and for containers
depending on  “Cytotoxic Waste”
waste volume  “Genotoxic Waste”–
cytotoxic, genotoxic,
and antineoplastic
waste
 Tag indicating source
and weight of waste
generated, date of
collection
CHEMICAL WASTE: Bin/  Strong, leak-proof Brown  Properly labelled
Bin/Container container bin with cover “Chemical Waste”
 Material must be
resistant to the
wasted chemical
 Size varies
depending on the
volume of waste
RADIOACTIVE Bin/  Radiation proof  Properly labelled
WASTE: container repositories, leak “Radioactive Waste”
Bin/container with proof and lead-lined  Labelled with the
plastic liner container name of radionuclide
 Size varies and date of deposition
depending on with radioactive
waste volume symbol
Plastic liner  Thickness: 0.07mm Orange  Properly labelled
“Radioactive Waste”
 Labelled with the
name of radionuclide
and date of deposition
NON- Bin/  Size varies Black  Properly labelled “Non-
BIODEGRADABLE container depending on the biodegradable Waste”
WASTE (NON- volume of  Recyclable symbol
HAZARDOUS radioactive waste optional
GENERAL WASTE): Plastic liner  Thickness: 0.07mm Black or  Properly labelled “Non-
Bin/container with  Sample sizes: XL size Colorless biodegradable Waste”
plastic liner (39cm x 39cm x  Tag indicating source
BIODEGRADABLE Bin/  Size varies Green  Properly labelled
WASTE (NON- container depending on the “Biodegradable
HAZARDOUS volume of Waste”
GENERAL WASTE): radioactive waste
Bin/container with Plastic liner  Thickness: 0.07mm Green  Properly labelled
plastic liner (70µm) “Biodegradable
 Sample sizes: XL size Waste”
(39cm x 39cm x  Tag indicating source
Note: the use of colorless plastic liner shall be allowed for security purposes and for easier monitoring
of proper waste segregation.
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7.2.3 Maintaining Standards in Segregation
To successfully implement segregation in all areas of the HCF, consider the

following:
 Segregation methods should be clearly set out in the HCWM policy;
 It is important that the HCWM policy is supported and enforced by senior
staff and managers;
 Medical staff and waste handlers should understand the reasons for, and
operation of, segregation practices, waste auditing, spill management,
and accident and injury reporting;
 Training should be repeated periodically to ensure that all staff are
reminded of their responsibilities;
 The HCWM Committee is responsible for seeing that segregation rules are
enforced; and
 Segregation posters for medical and waste workers help to raise
knowledge about segregation practices and improve quality of
separated waste components.
7.3 Collection and Transport within the HCF

Proper collection and transport of HCW is an important component in HCWM. Its
implementation requires commitment and cooperation of the HCF’s maintenance,
housekeeping, and motor pool services personnel and all the HCF workers. HCW
collection and transport practices shall be designed to achieve an efficient
movement of waste from point of generation to storage or treatment while
minimizing the risk to the personnel.
7.3.1 On-site Collection of HCW
This refers to the collection of wastes from the waste bins going to the on-site
storage area of the HCF by the general service personnel. Collection times should
be fixed and appropriate to the quantity of waste produced in each area of the
HCF. The following are the general guidelines for the on-site collection of the HCW.
 Follow the established plan for the collection and transport of HCW.
 Infectious and general waste should be collected daily (or as frequently
as required) with collection time matching the pattern of waste
generation during the day. For example, in a medical area where the
morning routine begins with the changing of dressings, infectious waste
could be collected mid-morning to prevent soiled bandages remaining in
the medical area for longer than necessary. Visitors arriving later in the day
will bring with them an increase in general waste, such as newspapers and
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food wrappings; therefore, the optimum time for general and recyclable
waste collection would be after visitors have departed.
 Waste bags should be filled to no more than three-quarters full. Once this
level is reached, they should be sealed ready for collection. Plastic bags
should never be stapled but may be tied or sealed with a plastic tag or tie.
 Sharp containers should be collected when three-quarters full.
 Pharmaceutical and chemical waste can be collected on demand.
 Radioactive waste should be collected after finalization of the procedure.
 Upon waste collection, the personnel must ensure that the waste bags and
containers are properly labelled as discussed in Chapter 7.2.2.
 Replacement bags or containers should be available at each waste
collection location so that full ones can immediately be replaced.
 A monitoring sheet for the collection of the wastes must be filled out by the
personnel upon collection. A sample monitoring sheet is shown in ANNEX D 5.
7.3.2 On-site Transport of HCW
This refers to the transport of the wastes from the point of generation to the on-
site waste storage area. In doing the on-site transport, the following must be
observed:
 Transport of the collected HCW must be done using wheeled trolleys/carts
or wheeled bins;
 On-site transport should take place during less busy times whenever
possible. Set routes should be used to prevent exposure to staff and
patients and to minimize the passage of loaded carts through patient care
and other clean areas;
 Depending on the design of the HCF, the internal transport of waste should
use separate floors, stairways, or elevators as far as possible. On-site
transport of HCW in HCFs with more than two-story building/s shall use
service elevators, mechanical pulley, hoist, or ramp. In the case of
elevators or ramps, the schedule of on-site transport of HCW shall be prior
to the end of shift of workers, preferably not coinciding with scheduled
visiting hours;
 Regular transport routes and collection times should be fixed and reliable;
 Transport staff should wear adequate personal protective equipment,
gloves, strong and closed shoes, overalls, and masks;
 Hazardous and non-hazardous waste should always be transported
separately. The use of waste chutes in HCFs is not recommended, because
they can increase the risk of transmitting airborne infections;
80
 Hazardous waste should never be transported by hand due to the risk of

accident or injury from infectious material or incorrectly disposed sharps
that may protrude from a container;
 General wastes should not be collected and transported at the same time
as the infectious or other hazardous wastes;
 Infectious waste can be transported together with used sharps wastes.
Infectious waste should not be transported together with other hazardous
waste, to prevent the possible spread of infectious agents;
 Other hazardous waste, such as chemical and pharmaceutical wastes,
should be transported separately in boxes.
 The trolleys shall be disinfected after every use. The on-site transport trolley
shall be cleaned and disinfected daily using 4-5% concentration of sodium
hypochlorite (NaClO).
 Spare trolleys should be available in case of breakdowns and
maintenance.
7.3.2.1 Transport trolley or cart
There should be a dedicated transport trolley or cart for each waste category.
There should be at least a cart dedicated for infectious waste, non-biodegradable
and for biodegradable/recyclable. The transport trolleys or carts should be colored
based on the appropriate colored code and properly labelled.
 Waste transportation carts for general waste should be painted black, only
be used for non-hazardous waste types, and labelled clearly “General
waste” or “Non-hazardous waste”.
 For infectious wastes, the transportation carts should be painted yellow
and clearly labelled with “Infectious waste” sign.
The transport wheeled trolley or cart can be single or can accommodate up to
three collection bins. To avoid injuries and infection transmission, trolleys and carts
should meet the following requirements:
a) Easy loading and unloading, be easy to push and pull with heavy duty
wheel caster;
b) Be easy to clean and, if enclosed, fitted with a drainage hole and plug;
c) Have no sharp edges that could damage waste bags or containers during
loading and unloading;
d) Be labelled and dedicated to a particular waste type;
e) Not be too high (to avoid restricting the view of staff transporting waste);
f) Be secured with a lock (for hazardous waste); and
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g) Be appropriately sized according to the volumes of waste generated at

the HCF.
7.3.2.2 HCW transport routing
In general, a waste route should follow the principle “from clean to dirty”.
Collection should start from the most hygienically sensitive medical areas (e.g.,
intensive care, dialysis, theatres) and follow a fixed route around other medical areas
and interim storage locations. Upon departure from the source, no further handling
shall be done. An efficient and effective collection system route shall consider the
following:
a) Assignment of worker responsible for the zone or area;
b) Logical planning of the route (shall avoid passing congested areas);
c) Schedule of collection;
d) All logical progression of HCW, and waste type;
e) Waste volume and number of waste bags or containers;
f) Capacity of the waste storage within medical areas and at interim storage
area;
g) Capacity of the transportation trolleys;
h) Transport distances and journey times between the collection points; and
i) Established routing plan can be revised if circumstances warrant it.
A sample HCW transport route plan is provided in ANNEX E 2. The route plan shall be
posted from point of generation to the storage area.
7.4 On-site Storage of HCW

7.4.1 Interim Storage in Medical Departments
For hospitals, hazardous waste generated in medical areas should be stored in

utility rooms, which are designated for cleaning equipment, dirty linen, and waste.
From here, the waste can be kept away from patients before removal, then
collected conveniently and transported to a central storage facility. This is known as
interim or short-term storage.
For other HCFs that do not have available utility rooms, waste can be stored at
another designated location near to a medical area but away from patients and
public access. Another possibility for interim storage is a closed container stationed
indoors, within or close to a medical area. A storage container used for infectious
waste should be clearly labelled and preferably lockable.
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7.4.2 Central Storage
Central storage areas are places within the HCF where different types of waste
should be brought for safe retention until it is treated or collected for transport off-
site. A storage location for HCW should be designated within the HCF. Space for
storing wastes should be incorporated into a building design when new construction
is undertaken. The HCF shall have separate storage areas for the following:
a) General wastes;
b) Recyclable materials;
c) Hazardous waste (other than phased-out mercury devices); and
d) Phased-out mercury devices;
If there is area available for composting of biodegradable wastes, storage area
is not necessary. It must be disposed of directly in composting site. The HCF must use
appropriate containers in storing the wastes in the central storage and must also be
properly labelled in compliance with DAO 2013-22 Revised Procedures and
Standards for the Management of Hazardous Wastes.
7.4.2.1 General requirements for the central storage area (except for phased-out mercury devices)
The general requirements for the central storage areas are listed below:
 Located within the HCF or research facility. However, these areas must be
located away from the dietary section, patient rooms, laboratories,
hospital function/operation rooms or any public access areas. It shall be
protected from rain, strong winds, floods, etc.;
 Easily accessible to the staff in charge of handling the waste and for waste
collection vehicle without entering HCF premises;
 Locked at all times to prevent access of unauthorized persons and entry
of animals, insects, and birds;
 Floor level higher than the anticipated flood level of the area during heavy
rainfall with concrete flooring that is waterproofed and adequately sloped
for easy cleaning and finished with ceramic tiles;
 With impermeable, hard-standing floor with good drainage and
connected to a wastewater treatment plant;
 With continuous water supply for cleaning purposes and have a washing
basin with running tap water and soap that is readily available for the staff;
 With adequate ventilation, lighting, and electrical supply;
 With supply of cleaning implements such as a water hose with spray nozzle,
scrubber with long handle, disinfectant, protective clothing, waste bags or
bins and fire-fighting equipment/devices located conveniently close to
83
the storage area; or have spillage containment equipment;

 Appropriate to the volumes of waste generated from each HCF; and
 With the warning sign posted in a conspicuous place: “CAUTION: HEALTH
CARE WASTE STORAGE AREA – UNAUTHORIZED PERSONS KEEP OUT”;
7.4.2.2 Hazardous waste storage requirements
In addition to the general requirements, the following specification must be

considered for the hazardous waste storage. Hazardous waste should always be
stored in enclosed rooms.
A. Infectious Waste Storage
 The storage place must be identified as an infectious waste area by using
the biohazard sign.
 Floors and walls should be sealed or tiled to allow easy disinfection. If
present, the storage room should be connected to a special sewage
system for infectious hospital wastewater.
 The compacting of untreated infectious waste or waste with a high
content of blood or other body fluids destined for off-site disposal (for
which there is a risk of spilling) is not permitted.
 Infectious waste should be kept cool or refrigerated at a temperature
preferably no higher than 3°C to 8°C if stored for more than a week, also
sharps can be stored without problems.
 Unless a refrigerated storage room is available, storage times for infectious
waste (e.g., the time gap between generation and treatment) should not
exceed 48 hours during the cool season and 24 hours during the hot
season.
B. Pathological Waste Storage
 Pathological waste and the growth of pathogens it may contain are

considered as biologically active waste, and gas formation during storage
should be expected. To minimize these possibilities, the storage places
should have the same conditions as those for infectious and sharps wastes.
 Body parts passed to the family for ritual procedures or buried in
designated places should be placed in sealed bags to reduce infection
risks before release to the public.
C. Pharmaceutical Waste Storage
 In general, pharmaceutical wastes can be hazardous or non-hazardous,

and liquid or solid in nature, and each should be handled differently.
 Pharmaceutical waste with non-hazardous characteristics that can be
stored in a non-hazardous storage area:
84
o ampoules with non-hazardous content (e.g., vitamins); - fluids with

non-hazardous contents, such as vitamins, salts (sodium chloride),
amino salts;
o solids or semi-solids, such as tablets, capsules, granules, powders for
injection, mixtures, creams, lotions, gels, and suppositories; and
o aerosol cans, including propellant-driven sprays and inhalers.
 Hazardous waste that should be stored in accordance with their chemical
characteristics (e.g., genotoxic drugs) or specific requirements for disposal
(e.g., controlled drugs or antibiotics):
o controlled drugs (should be stored under government supervision);
o disinfectants and antiseptics;
o anti-infective drugs (e.g., antibiotics);
o genotoxic drugs (genotoxic waste) - highly toxic and should be
identified and stored carefully away from other HCW in a
designated secure location; and
o ampoules with, for example, antibiotics.
D. Chemical Waste Storage
 For hazardous chemical waste, the characteristics of the different

chemicals to be stored and disposed of must be considered (inflammable,
corrosive, explosive).
 The storage place should be an enclosed area and separated from other
waste storage areas. The storage area itself should have adequate lighting
and good ventilation to prevent the accumulation of toxic fumes. Sample
layout is shown in ANNEX E 3.
 When storing liquid chemicals, the storage should be equipped with a
liquid- and chemical-proof sump. If no sump is present, catch-containers
to collect leaked liquids should be placed under the storage containers.
 Spillage kits, protective equipment and first aid equipment (e.g., eye
showers) should be available in the central storage area.
 To ensure the safe storage of chemical wastes, the following separate
storage zones should be available to prevent dangerous chemical
reactions:
o explosive waste;
o corrosive acid waste;
o corrosive alkali waste (bases);
o toxic waste;
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o flammable waste;
o oxidative waste;
o halogenated solvents (containing chlorine, bromine, iodine, or
fluorine); and
o non-halogenated solvents.
 The storage zones should be labelled according to their hazard class. If
more than one hazard class is defined for a specific waste, use the most
hazardous classification.
 Liquid and solid waste should be stored separately. If possible, the original
packaging should be taken for storage too. The packaging used to store
and transport chemical wastes off-site should also be labelled. This label
should have the following information: hazard symbol(s), waste
classification, date, and point of generation (if applicable).
 The storage area for explosive or highly flammable materials must be
suitably ventilated above and below, with a bonded floor and
constructed of materials suitable to withstand explosion or leakage.
E. Radioactive Waste Storage
 Radioactive waste should be stored in containers that prevent dispersion

of radiation and stored behind lead shielding.
 Waste that is to be stored during radioactive decay should be labelled
with the type of radionuclide, date, period of time before full decay, and
details of required storage conditions. Radioactive waste shall be
separated according to the length of time needed for storage.
 The decay storage time for radioactive waste differs from other waste
storage, because the main target will be to store the waste until the
radioactivity is substantially reduced and the waste can be safely
disposed of as normal waste.
 A minimum storage time of 10 half-life times for radioisotopes in wastes with
a half-life of less than 90 days is a common practice.
 Infectious radioactive waste should be decontaminated before disposal.
Sharp objects such as needles, Pasteur pipettes and broken glass should
be placed into the designated container for sharps.
 Liquids associated with solid materials, such as assay tube contents, should
be decanted or removed by decay time.
 All radioactive labelling should be removed on any items to be disposed
of.
 Empty containers of radionuclides solution are stored in dedicated empty
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room for certain number of days until it decays to background level.

 Storage places must be equipped with sufficient shielding material, either
in the walls or as movable shielding screens. The storage must be clearly
marked with “RADIOACTIVE WASTE”, and the international hazard label
should be placed on the door.
 The storage place should be constructed in a manner that renders it flame-
proof and should have such surfaces on floors, benches and walls that
allow proper decontamination. An air-extraction system and radioactive
monitoring system should be put in place.
F. Mercury-containing Waste Storage
 Mercury wastes shall be collected and stored in the designated storage

area. It shall be clear that the mercury wastes require a more thorough
storage system.
 Mercury containing products must be stored in non-breakable containers
with tight-fitting lids. The containers must be clearly labelled as to their
contents.
 Rooms where mercury containing items are stored shall be tested
periodically using a mercury vapor sniffer or analyzer.
 Even after the use of mercury has long been discontinued in the HCF,
mercury containing products may still be in storage from past uses. All HCF
shall check storage areas for old, damaged, or outdated equipment. If
mercury-containing products are found, contact the HCWM Officer.
 After the removal of the mercury containing products, the areas shall be
checked with the mercury vapor sniffer or analyzer.
 HCF shall keep a permanent record of all materials brought in and out of
the mercury storage area.
 Safe handling, transport and temporary storage of mercury wastes and
the management of mercury spills must be in accordance to the DOH
Department Memorandum No. 2011-0145.
7.4.3 Layout of Waste Storage Areas
If new HCWM systems are developed and if new infrastructure is planned, a

“waste yard” should be built. A waste yard is where all the relevant waste
management activities are brought together. To concentrate certain tasks, it is best
to set up multifunctional buildings (waste-storage area), including a fenced storage
area for general waste, a room for infectious waste, a treatment room, a fenced
area with an ash or sharps pit, a container cleaning room and a clean office with
lockers and toilets. Refer to ANNEX E 4 for a sample layout of waste storage area.
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7.4.4 Documentation of Operation in Waste Storage Places
For easier monitoring of the wastes that are being stored, the personnel in-
charged must maintain a record of the waste stored and the dates of its storage,
treatment, and disposal. In addition, the following are also needed to ensure the safe
storage of HCW:
 a written spill contingency plan;
 a weekly store inspection protocol;
 protocols for using, repairing, and replacing emergency equipment;
 training system and documentation (names of trained staff, job
descriptions, form of training, date of training, date for refresher or
revalidation training);
 hazardous waste storage documentation; and
 collection of relevant material safety data sheets (MSDS).
Box 25: Minimum requirements for HCW storage
The following are the minimum requirements for storage of HCW:
 Infectious, general, and used sharps waste are stored in separate color-coded containers
and locations within medical areas, and subsequently at a central storage site at the HCF.
 Central storage area(s) are fenced, lockable and isolated from patients and the public.
 Maximum storage times before treatment or disposal of infectious waste are not longer
than- 48 hours during the cooler season and 24 hours during the hot season.
 Staff receive instruction on three-bin waste segregation and safe handling and storage
of HCW.
 Staff are aware of how to protect themselves from injuries and infection from waste.
 Waste containers and storage areas are cleaned regularly.
7.5 Off-site Collection

This refers to the collection of waste from the HCF on-site central storage area by
an accredited DENR transporter, Municipal Collector or Supplier into their respective
vehicles. The waste collector at this point will depend on the type of waste collected.
The HCW generator is responsible for the safe packaging and adequate labelling
of waste to be transported off-site for treatment and disposal. Packaging and
labelling shall comply with the requirements of the national regulation governing the
transport of hazardous wastes (RA 6969) and must not present danger to the public
during transport. The off-site collector of HCW shall provide collection bins that meet
the following requirements:
 Puncture-proof for sharps;
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 Resistant to aggressive chemicals;

 Made of high-density polyethylene materials (HDPE);
 Must be leak-proof and be fitted with a self-sealing lid that is tight enough
to withstand turbulence during transport in the vehicle; and
 Must follow the requirements of EMB-DENR in DAO 2013-22.
Infectious and pathological waste must be placed in appropriate color-coded
or other special bins when transported. In case of radioactive wastes, it must be
packaged for off-site collection and transported in accordance with the accepted
criteria for low level radioactive wastes established by PNRI (AO No. 01 series of 1990).
7.6 Off-site Transport

This refers to the transport of waste from the central storage of the HCF to a TSD
or to the final disposal site. The transporter shall comply with DENR requirements and
be registered with the DENR as waste transporter.
The requirements for off-site transport vehicles are listed in ANNEX B 3. A sample
placard for off-site transport vehicle is shown in ANNEX E 5.
The waste generators are ultimately responsible for ensuring that their HCW are
properly treated and disposed of in an approved disposal facility. Tracking of HCW
could be done with the implementation of the consignment system and through the
Hazardous Waste Manifest System of the EMB. The authorized transporter/carrier shall
maintain a completed consignment note of all HCW for treatment or disposal and
an updated transport permit. The transporter and generator shall separately
maintain a copy of the consignment note.
Refer to ANNEX B 2 for the consignment note requirements and ANNEX D 3 for the
template.
Box 26: Minimum measures for HCW transport
The following are minimum measures for transporting HCW:
 General waste and infectious HCW is collected separately and at least once a day.
 Collection is at regular times and is reliable.
 Waste containers and on-site transport trolleys are closed with lids to isolate wastes from
patients and the public.
 Where wastes are transported off-site for disposal, the vehicle can carry wastes in a closed
or covered container, and the driver knows what to do if there is an accident or incident
during transportation on public roads.
 Transport staff are vaccinated at least against hepatitis A and B, polio, and tetanus.
 Waste containers, trolleys, and vehicles are maintained and cleaned regularly.
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Fourth Edition Chapter 8: Health Care Waste Treatment and Disposal
8 Health Care Waste Treatment and Disposal

The purpose of treatment is to reduce the potential hazard posed by HCW, while
endeavoring to protect the environment. Treatment should be viewed in the context
of the waste management hierarchy described in Chapter 6. This chapter illustrates
different technologies and methods in waste treatment and disposal. After
treatment, the wastes should be stored in plastic liners/containers with the same color
as stated in Chapter 7.
8.1 Selection of Treatment Methods

In determining the method to be used in HCW treatment and disposal by any
HCF, the HCF administrator must look into several requirements and conditions
relevant to HCWM. The choice of treatment system involves consideration of waste
characteristics, technology capabilities and requirements, environmental and safety
factors, and costs – many of which depend on local condition. The treatment
technology must comply with the national standards and international conventions.
Factors to consider include: types and quantity of waste for treatment and
disposal/capacity of the system; treatment efficiency; volume and mass reduction;
occupational health and safety and environmental considerations; infrastructure
and space requirements; locally available treatment options for final disposal;
training requirements for operation of the method; cost of operation and
maintenance; location/surroundings of the treatment site and disposal facility;
regulatory requirements; social and political acceptability; cost of transport and
disposal of treated waste; and cost of decommissioning.
Box 27: Selecting HCW treatment and disposal methods for primary care facilities
In choosing the option for treatment and disposal of HCW from primary care facilities, the
following conditions must be considered:
 The quantities of waste produced daily at the PHC level

 Availability of appropriate sites for waste treatment and disposal
 Possibility of treatment in central facility or treatment facility within reasonable distance.
 Rainfall and level of groundwater (e.g., to take precautions against flooding of burial pits)
 Availability of reliable transportation
 Compliance to the national policies and standards
 The availability of equipment and manufacturers in the country or region
 Social acceptance of treatment and disposal methods and sites
 Space available at the HCF
 Availability of resources (human, financial, material)
 Estimate of capital and operating cost
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The selection of HCW technology goes far beyond cost implications since this
may have significant impact on the environment, the workers in the treatment and
disposal facilities and the surrounding community. Several questions need to be
asked and answered regarding this matter, refer to some guide questions provided
in ANNEX B 4 of this Manual.
8.2 Basic Treatment Processes

The treatment of hazardous wastes, particularly sharps, infectious, and
pathological wastes, consists of five basic processes: thermal, chemical, irradiation,
biological, which may be connected with mechanical processes. The minimum
treatment required for the HCW is disinfection.
Box 28: Microbial inactivation
The largest proportion of hazardous HCW generated is potentially infectious. The most
established waste management technologies focus on disinfection. Disinfection can be
defined as the reduction or removal of disease-causing microorganisms (pathogens) to
minimize the potential for disease transmission. Sterilization is defined as the destruction of all
microbial life. Since the complete destruction of all microorganisms is difficult to establish,
sterilization of medical and surgical instruments is generally expressed as a 6 log10 reduction
(i.e., a 99.9999% reduction) or greater of a specified microorganism that is highly resistant to
the treatment process. A 6 log10 reduction, sometimes also written as “log 6 kill”, corresponds
to a one millionth (0.000001) survival probability of the microbial population. On the other
hand, disinfection is defined as low, intermediate, or high (using the Spaulding system)
depending on the survival probability of specific microbial groups.
The State and Territorial Association on Alternate Treatment Technologies (STAATT)

classification system, in lieu of the terms disinfection or sterilization, denotes levels of “microbial
inactivation” specifically for HCW treatment. The classification system was established to
define measures of performance of HCW treatment technologies. The levels defined for
microbial inactivation are:
 Level I Inactivation of vegetative bacteria, fungi, lipophilic viruses at 6log10 reduction or

greater
 Level II Inactivation of vegetative, fungi, lipophilic/hydrophilic viruses, parasites, and
mycobacteria at 6log10 reduction or greater
 Level III Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses, parasites,
and mycobacteria at a 6log10 reduction or greater; and inactivation of B.
stearothermophilus spores and B. subtilis spores at 4log10 reduction or greater
 Level IV Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses, parasites
and mycobacteria and B. stearothermophilus spores at a 6log10 reduction or greater.
A common microbial inactivation standard for HCW treatment based on the STAATT criteria is
Level III. Regular testing of the efficacy of disinfection techniques is important.
8.2.1 Thermal Processes
Thermal treatment processes rely on heat (thermal energy) to destroy pathogens

contained in the waste. This category can be further subdivided into low-heat and
high-heat designs. This sub-classification is useful because of the marked differences
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in the thermochemical reactions and physical changes taking place in the wastes
during their treatment in the different types of equipment. These differences produce
very different atmospheric emissions characteristics.
Low-heat thermal processes are those that use thermal energy at elevated
temperatures high enough to destroy microorganisms but not sufficient to cause
combustion or pyrolysis of the waste. In general, low-heat thermal technologies
operate between 100°C and 180°C. The low-heat processes take place in either
moist or dry-heat environments.
 Pyrolysis is the thermal degradation of a substance through the application
of heat in the absence of oxygen. Pyrolysis is a special case of thermolysis
and is most commonly used for organic materials. It occurs at high
temperatures but does not involve reactions with oxygen. In practice, it is
difficult to have a completely oxygen-free atmosphere, so some oxidation
takes place.
 Microwave treatment is essentially a moist thermal process, because
disinfection occurs through the action of moist heat (hot water and steam)
generated by the microwave energy.
 Dry-heat processes use hot air without the addition of water or steam. In
dry-heat systems, the waste is heated by conduction, convection and/or
thermal radiation using infrared or resistance heaters.
 Moist (or wet) thermal treatment involves the use of steam to disinfect
waste and is commonly performed in an autoclave or steam-based
treatment system.
8.2.2 Chemical Processes
Infectious wastes can also be decontaminated by using chemicals. Chemical

treatment processes often involve shredding, grinding, or mixing to increase
exposure of the waste to the chemical agent.
The speed and efficiency of chemical decontamination depends on operational
conditions, including the type of chemical disinfectant used, its concentration, the
contact time between the disinfectant and the waste, the extent of contact, the
organic load of the waste, operating temperature, and factors that may affect the
efficacy of the disinfectant such as humidity and pH. Chemicals used should be
neutralized prior to discharge.
 Chemical treatment methods use disinfectants such as dissolved chlorine
dioxide, bleach (sodium hypochlorite), peracetic acid, lime solution,
ozone gas or dry inorganic chemicals (e.g., calcium oxide powder).
However, the soaking of infectious and sharp waste in chlorine solutions
have become less used due to concerns of environmental and
occupational safety. Manual systems using chemical disinfection are not
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regarded as a reliable method for the treatment of waste.

 Chemical system that uses heated alkali to digest tissues, pathological
waste, anatomical parts, and animal carcasses in heated stainless-steel
tanks.
8.2.3 Biological Processes
Biological treatment processes are found in natural living organisms but refer
specifically to the degradation of organic matter when applied to HCW treatment.
 Some biological treatment systems use enzymes to speed up the
destruction of organic waste containing pathogens.
 Composting and vermiculture (digestion of organic wastes through the
action of worms) are biological processes and have been used
successfully to decompose hospital kitchen waste, as well as other organic
digestible waste (Mathur, Verma & Srivastava, 2006) and placenta waste.
 The natural decomposition of pathological waste through burial.
8.2.4 Mechanical Processes
Mechanical treatment processes include several shredding, grinding, mixing and

compaction technologies that reduce waste volume, although they cannot destroy
pathogens. Mechanical processes are not stand-alone HCW-treatment processes,
but supplement other treatment methods.
 Mechanical destruction can render a waste unrecognizable and can be
used to destroy needles and syringes (depending on the type of
shredding).
 In the case of thermal or chemical treatment processes, mechanical
devices such as shredders and mixers can also improve the rate of heat
transfer or expose more surface area of waste to waste treatment.
 Mechanical devices used to prepare wastes before other forms of waste
destruction add significantly to the level of management and
maintenance required to treat HCW safely and efficiently.
Unless shredders, mixers and other mechanical devices are an integral part of a
closed treatment system, they should not be used before the incoming HCW is
disinfected, otherwise, workers are at an increased risk of being exposed to
pathogens in aerosols released into the environment by mechanical destruction of
untreated waste bags. If mechanical processes are part of a closed system, the
technology should be designed in such a way that the air in and from the
mechanical process is disinfected before being released to the surroundings.
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8.3 Treatment Technologies

The advantage and disadvantages of the following options for treatment of HCW
are presented in ANNEX B 5.
8.3.1 Steam Treatment Technology
A. Autoclave
Autoclaves are capable of treating a range of infectious waste, including

cultures and stocks, sharps, materials contaminated with blood and limited amounts
of fluids, isolation and surgery waste, laboratory waste (excluding chemical waste)
and “soft” waste (including gauze, bandages, drapes, gowns and bedding) from
patient care. Volatile and semi-volatile organic compounds, chemotherapeutic
waste mercury, other hazardous chemical waste and radiological waste should not
be treated in an autoclave.
An autoclave consists of a metal vessel designed to withstand high pressures, with
a sealed door and an arrangement of pipes and valves through which steam is
introduced into, and removed from, the vessel. Air is an effective insulator and a
principal factor in determining the efficiency of steam treatment. Removal of air from
the autoclave is essential to ensure penetration of heat into the waste. Unlike
instrument sterilization autoclaves, waste-treatment autoclaves must treat the air
that is removed at the start of the process to prevent the release of pathogenic
aerosols. This is usually done by treating the air with steam or passing it through a high-
efficiency particulate air (HEPA) filter before it is released.
The operation of autoclaves requires the proper combination of
temperature/pressure and exposure time to achieve disinfection, a minimum
recommended temperature–exposure time criterion of for example 121°C for 30
minutes was suggested. However, the effective penetration of steam and moist heat
depends on many factors, including time, temperature/pressure, process sequence,
load size, stacking configuration and packing density, types and integrity of bags or
containers used, physical properties of the materials in the waste (such as bulk
density, heat capacity and thermal conductivity), the amount of residual air and the
moisture content in the waste (Lemieux et al., 2006). Regular validation tests using
biological indicators should be performed at periodic intervals (typically, every week,
every 40 hours of use, or once a month, depending on usage).
As an added check, color changing chemical indicators, such as strips that
contain thermochromic agents (chemicals that change color when they reach a
given temperature) or integrators (indicators that respond to both time and
temperature) can be used with each waste load to document that the required
temperature has been achieved.
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Box 29: General considerations in the use of autoclave
The following must be considered in using

autoclave:
 Autoclaves are generally not used for large

anatomical remains (body parts), because it is
difficult to determine beforehand the time and
temperature parameters needed to allow full
penetration of heat to the center of the body
part. With sufficient time and temperature, it is
technically possible to treat small quantities of
human tissue, but ethical, legal, cultural,
religious and other considerations may
preclude their treatment.
 Volatile and semi-volatile organic compounds, chemotherapeutic waste, mercury, other
hazardous chemical waste, and radiological waste should not be treated in an
autoclave.
 Large and bulky bedding material, large animal carcasses, sealed heat-resistant
containers and other waste loads that impede the transfer of heat should be avoided.
 If liquids such as blood bags or urine bags are to be sterilized, the sterilization process and
time have to be adapted. The Robert Koch Institute recommends treating prions, which
cause Creutzfeld–Jacob disease, at 134°C for 60 minutes because of their exceptional
resistance.
Reference:
Global Healthcare Waste Project, Module 15: Non-Incineration Treatment and Disposal of
Healthcare Waste:
https://www.who.int/water_sanitation_health/facilities/waste/module15.pdf?ua=1
Box 30: Treatment of wastes from medical laboratories
In laboratories, decontamination of wastes and their ultimate disposal are closely interrelated.
In terms of daily use, few if any contaminated materials will require actual removal from the
laboratory or destruction. Most glassware, instruments and laboratory clothing will be reused
or recycled. The overriding principle is that all infectious materials should be decontaminated,
autoclaved, or incinerated within the laboratory. (WHO, Biosafety).
 Steam autoclaving is the preferred method for all decontamination processes. Materials
for decontamination and disposal should be placed in containers, e.g., autoclavable
plastic bags, that are color-coded according to whether the contents are to be
autoclaved and/or incinerated.
 Non-contaminated (non-infectious) waste that can be reused or recycled or disposed of
as general, “household” waste.
 Contaminated (infectious) “sharps” – hypodermic needles, scalpels, knives, and broken
glass; these should always be collected in puncture-proof containers fitted with covers
and treated as infectious.
 No pre-cleaning should be attempted of any contaminated (potentially infectious)
materials to be autoclaved and reused. Any necessary cleaning or repair must be done
only after autoclaving or disinfection.
 All contaminated (potentially infectious) materials should be autoclaved in leakproof
containers, e.g., autoclavable, color-coded plastic bags, before disposal.
 Discard containers, pans, or jars, preferably unbreakable, should be placed at every
workstation. When disinfectants are used, waste materials should remain in intimate
contact with the disinfectant (i.e., not protected by air bubbles) for the appropriate time,
according to the disinfectant used.
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B. Autoclave with Integrated Shredders
This is sometimes referred as advanced autoclave, hybrid autoclave, or

advanced stream treatment technology. This system functions as an autoclave but
combined with various mechanical processing before, during, or after steam
treatment. The purpose is to improve the transfer of heat into the waste, achieving
more uniform heating of the waste, rendering the waste unrecognizable and/or
making the treatment system continuous process. Volatile and semi-volatile organic
compounds, chemotherapeutic waste mercury, other hazardous chemical waste
and radiological waste should not be treated thru this technology.
8.3.2 Microwave Treatment Technology
Microwave technology is essentially a steam-based process where treatment

occurs through the action of moist heat and steam generated by microwave
energy. Water contained in the waste is rapidly heated by microwave energy at a
frequency of about 2450 MHz and a wavelength of 12.24cm. In general, microwave-
treatment systems consist of a treatment area or chamber into which microwave
energy is directed from a microwave generator (magnetron). Generally, 2 to 6
magnetrons are used with an output of about 1.2 kW each. Some systems are
designed as batch processes and others are semi-continuous (Emmanuel, 2001;
Emmanuel & Stringer, 2007).
The types of waste commonly treated in microwave systems are identical to those
treated in autoclaves: cultures and stocks, sharps, materials contaminated with
blood and body fluids, isolation and surgery waste, laboratory waste (excluding
chemical waste) and soft waste (e.g., gauze, bandages, gowns and bedding) from
patient care. One microwave system has been successfully tested with animal waste
and can potentially be used to treat pathological waste such as tissues (Devine et
al., 2007). Volatile and semi-volatile organic compounds, chemotherapeutic waste
mercury, other hazardous chemical waste and radiological waste should not be
treated in a microwave. A fully enclosed microwave unit can be installed in an open
area and, with a HEPA filter to prevent the release of aerosols during the feed
process, odor is somewhat reduced, except in the immediate vicinity of the
microwave unit.
8.3.3 Dry Heat Treatment Technology
In dry-heat processes, heat is applied without adding steam or water. Instead,

the waste is heated by conduction, natural or forced convection, or thermal
radiation. In forced convection heating, air heated by resistance heaters or natural
gas is circulated around the waste in the chamber. In some technologies, the hot
walls of the chamber heat the waste through conduction and natural convection.
Other technologies use radiant heating by means of infrared or quartz heaters.
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Circulating hot-air ovens have been used to sterilize glassware and other reusable
instruments for many years. This concept of dry-heat treatment has been applied to
treatment of infectious health waste more recently. As a general observation, dry-
heat processes use higher temperatures and longer exposure times than steam-
based processes. They are not commonly used in large-scale facilities and usually
treat only small volumes. Bacillus atrophaeus spores are known to be resistant to dry
heat and are commonly used as a microbiological indicator to measure the
effectiveness of dry-heat technologies. Volatile and semi-volatile organic
compounds, chemotherapeutic waste mercury, other hazardous chemical waste
and radiological waste should not be treated thru this technology.
8.3.4 Chemical Treatment Technology
8.3.4.1 Chemical Disinfection
Used routinely in HCFs to destroy or inactivate microorganisms on medical

equipment and on floors and walls, is now being extended to the treatment of HCW.
This treatment usually results in disinfection rather than sterilization. Chemical
disinfection is most suitable for treating liquid waste such as blood, urine, stools, or
hospital sewage.
Manual systems using chemical disinfection are not regarded as a reliable
method for treating waste. Chemical disinfection is usually carried out on HCF
premises; however, commercial, self-contained, and fully automatic systems have
recently been developed for HCW treatment and are being operated away from
medical centers at industrial zones. Subsequently, the disinfected waste requires
specialized disposal.
Solid, even highly hazardous, HCWs, including microbiological cultures and
sharps, may also be disinfected chemically, with the following limitations:
 Shredding or milling of waste is usually necessary before disinfection. The
shredder is often the weak point in the treatment chain, being susceptible
to mechanical failure or breakdown. Internal shredding of waste before
disinfection plus subsequent compacting can reduce the original waste
volume by 60–90%, depending on the type of equipment used. Shredding
of solid HCW before or during disinfection should be done in a closed
system to avoid release of pathogens into the air.
 Chemical treatment of solid infectious waste is potentially problematic
because of the variability of chemical efficacy based upon load
characteristics, and the generation of toxic liquid waste. Powerful
disinfectants are required, which can be hazardous and should be used
only by well-trained and adequately protected personnel.
 Disinfection efficiency depends on the operational conditions within
treatment equipment. The speed and efficiency of chemical disinfection
97
will depend on operational conditions, including the following:

o kind of chemical used;
o amount of chemical used;
o contact time between disinfectant and waste;
o extent of contact between disinfectant and waste;
o organic load of the waste; and
o operating temperature, humidity, pH.
 Only the surface of intact solid waste items will be disinfected.
In application of chemical disinfection, the following must be considered by the
HCF:
 The types of chemicals used for disinfection of HCW are mostly chlorine
compounds, aldehydes, lime-based powders or solutions, ozone gas,
ammonium salts and phenolic compounds. Formaldehyde and ethylene
oxide are no longer recommended for waste treatment due to significant
hazards related to their use.
 Studies showed that chlorine-based technologies using sodium
hypochlorite and chlorine dioxide as well as its by-products in wastewater
may possibly have long-term environmental effects.
 Non-chlorine-based technologies are quite varied in the way they operate
and the chemical agents they employ. Others use peroxyacetic acid,
ozone gas, lime-based dry powder, acid and metal catalyst or
biodegradable disinfectants. Occupational and safety exposures shall be
monitored when using the chemical process.
 Some disinfectants are effective in killing or inactivating specific types of
microorganisms, and others are effective against all types. It is therefore
important to know the identity of the target microorganisms to be
destroyed.
 Users of chemical disinfectants should consider their stability and shelf life.
Some disinfectants are stable for several years and can remain effective
for months after opening the container. Other disinfectants degrade
quickly.
 Powerful disinfectants are often hazardous and toxic, and many are
harmful to skin and mucous membranes. Users should therefore be aware
of their physiological effects and wear protective clothes, including gloves
and protective eyeglasses or goggles. Disinfectants are also aggressive to
certain building materials and should be handled and stored according
to manufacturers’ instructions.
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 Microbial resistance to disinfectants has been investigated, and it is

possible to list the major groups of microorganisms from most to least
resistant as follows:
o bacterial spores;
o mycobacteria;
o hydrophilic viruses;
o lipophilic viruses;
o vegetative fungi and fungal spores; and
o vegetative bacteria.
 In planning the use of chemical disinfection, requirements for the eventual
disposal of the residues should be carefully considered. Improper disposal
could give rise to serious environmental problems.
8.3.4.2 Alkaline Hydrolysis
Alkaline hydrolysis or digestion is a process that converts animal carcasses, human

body parts and tissues into a decontaminated aqueous solution. The alkali also
destroys fixatives in tissues and various hazardous chemicals, including
formaldehyde, glutaraldehyde, and chemotherapeutic agents.
The technology is designed for tissue wastes including anatomical parts, organs,
placenta, blood, body fluids, specimens, human cadavers, and animal carcasses.
The process has been shown to destroy prion waste. The by-products of the alkaline
digestion process are biodegradable mineral constituents of bones and teeth (which
can be crushed and recovered as sterile bone meal) and an aqueous solution of
peptide chains, amino acids, sugars, soaps, and salts.
The technology uses a steam-jacketed, stainless-steel tank and a basket. After
the waste is loaded in the basket and into the hermetically sealed tank, alkali (sodium
or potassium hydroxide) in amounts proportional to the quantity of tissue in the tank
is added, along with water. The contents are heated to between 110°C and 127°C
or higher and stirred. Depending on the amount of alkali and temperature used,
digestion times range from six to eight hours. Alkaline hydrolysis units have been
designed to treat from 10 to 4500kg per batch. The technology has been approved
for the destruction of prion waste when treated for at least six hours (European
Commission Scientific Steering Committee, 2003; Thacker, 2004).
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8.3.5 High Temperature Processing Technologies
8.3.5.1 Incineration
Incineration is a high-temperature, dry oxidation process that reduces organic

and combustible waste to inorganic, incombustible matter, and results in a
significant reduction of waste volume and weight. High-heat thermal processes take
place at temperatures from about 200°C to more than 1000°C. They involve the
chemical and physical breakdown of organic material through the processes of
combustion, pyrolysis, or gasification.
In accordance with the Stockholm Convention, the best available technology (BAT)
should be used to achieve an emission of lower than 0.1ng TEQ/m³ of dioxins and
furans.6 It is stated that primary measures for incinerators are two burning chambers
(850°C/1100°C), auxiliary burner, two seconds’ residence time of air in the second
chamber, sufficient oxygen content, and high turbulence of exhaust gases. The
primary measures described here should be a minimum standard. By applying primary
measures, a performance around 200ng TEQ/m³ of dioxins and furans can be
achieved. This minimum standard should be followed by an incremental improvement
approach, with which the requirements of the Stockholm Convention can be
reached. In order to achieve emissions lower than 0.1ng TEQ/m³, additional flue gas
treatment systems are needed (secondary measures). These may be comparatively
expensive for small and medium-sized incinerators, and this should be taken into
consideration at the planning stage. Furthermore, air filters and wastewater resulting
from the filtering processes are considered as hazardous waste and need to be
handled accordingly.
There are few small and medium-sized incinerators available on the market which
operate in accordance with the Stockholm Convention. See ANNEX A 7 for the flow
diagram of incineration process with flue gas.
High-tech incinerators require reliable controls of combustion parameters, a flue
gas cleaning system (dust removal, ceramic filters, cyclonic scrubbers, and
electrostatic precipitators) and wastewater treatment.
Burning HCW without flue gas treatment releases a wide variety of pollutants into
the atmosphere, according to the composition of the waste. These pollutants may
include particulate matter such as fly ash, heavy metals (arsenic, cadmium,
chromium, copper, mercury, manganese, nickel, and lead), acid gases (hydrogen
chloride, hydrogen fluoride, Sulphur dioxides, nitrogen oxides), carbon monoxide,
and organic compounds (including dioxins and furans, benzene, carbon
tetrachloride, chlorophenols, trichloroethylene, toluene, xylenes, trichloro-
trifluoroethane, polycyclic aromatic hydrocarbons, vinyl chloride).
If medical waste is incinerated in conditions that do not constitute best available
6TEQ or toxic equivalents report the toxicity-weighted masses of mixtures of polychlorinated-p-dibenzodioxins (PCDDs)
and polychlorinated dibenzofurans (PCDFs) and polychlorinated biphenyls (PCBs).
100
techniques or best environmental practices, there is potential for the release of

dioxins and furans in relatively high concentrations. Dioxins and furans are bio-
accumulative and toxic. Pathogens can also be found in solid residues and in the
exhaust gases and particulates of poorly designed and badly operated incinerators.
In addition, the bottom ash residues can be contaminated with dioxins, leachable
organic compounds, and heavy metals and should be treated as hazardous waste.
Box 31: Small-scale incineration
Small-scale incinerators are designed to meet an immediate need for public health protection
where there is no access to more sophisticated technologies. This involves a compromise
between the environmental impacts from controlled combustion and an overriding need to
protect public health if the only alternative is indiscriminate dumping. As far as possible, a
small-scale facility should avoid burning PVC plastics and other chlorinated waste.
If small-scale incinerators are the only option available, the best practices possible should be
used, to minimize operational impacts on the environment. Best practices in this context are
(Batterman, 2004):
 Effective waste reduction and segregation, ensuring only the smallest quantities of
combustible waste types are incinerated;
 An engineered design with sufficient residence time and temperatures to minimize
products of incomplete combustion;
 Siting incinerators away from health care buildings and residential areas or where food is
grown;
 Construction using detailed engineering plans and materials to minimize flaws that may
lead to incomplete destruction of waste and premature failures of the incinerator;
 A clearly described method of operation to achieve the desired combustion conditions
and emissions;
 Periodic maintenance to replace or repair defective components (including inspection,
spare parts inventory and daily record keeping);
 Improved training and management, possibly promoted by certification and inspection
programs for operators, the availability of an operating and maintenance manual, visible
management oversight, and regular maintenance schedules.
8.3.5.2 Pyrolysis and gasification
Pyrolysis and gasification processes operate with substoichiometric air levels. It is

the thermal decomposition of HCW in the absence of supplied molecular oxygen in
the destruction chamber in which the said HCW is converted into gaseous, liquid, or
solid form. Pyrolysis can handle the full range of HCW. Waste residues may be in form
of greasy aggregates or slugs, recoverable metals, or carbon black. These residues
are disposed of in a landfill.
8.3.6 Emerging Technologies
Developing and emerging technologies should be carefully evaluated before

selection for routine use, because most do not have demonstrable track record in
HCW application.
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8.3.6.1 Ozone
Ozone (O3) can be used for disinfecting waste. Ozone gas is a strong oxidizer and
breaks down easily to a more stable form (O2). Ozone systems require shredders and
mixers to expose the waste to the bactericidal agent. Ozone has been used for water
treatment and air purification. At concentrations greater than 0.1 ppm, ozone can
cause eye, nose, and respiratory tract irritation. As with other chemical treatment
technologies, regular tests should be conducted to ensure that the microbial
inactivation standard is met.
8.3.6.2 Plasma Pyrolysis
Plasma pyrolysis makes use of an ionized gas in the plasma state to convert
electrical energy to temperatures of several thousand degrees using plasma arc
torches or electrodes. The high temperatures are used to pyrolyze waste in an
atmosphere with little or no air.
8.3.6.3 Promession
Promession is a new technology that combines a mechanical process and the

removal of heat to destroy anatomical waste. It involves cryogenic freeze-drying
using liquid nitrogen and mechanical vibration to disintegrate human remains into
powder before burial. The process speeds up decomposition, reduces both mass
and volume, and allows the recovery of metal parts.
8.3.6.4 Pyroclave
The process involved in a pyroclave is a combination of pyrolysis and autoclave.

The pyroclave can disinfect and reduce the mass and volume of the medical wastes
by 95%. Like pyrolysis, wastes are thermally decomposed without direct contact to
fire and without the presence of oxygen. HCW is placed inside a sealed rotating
chamber. The pyroclave operates in intense heat (up to 1,200˚C) to carbonize the
HCW. A synthesized gas called “syngas”, produced by the intense heat and
decomposition process, is recycled and fed into the burners, thereby serving as
added fuel to continue the process and help boost combustion. Through this process,
disinfection, carbonization, and decomposition can be accomplished.
8.3.6.5 Superheated steam
Superheated steam at 500°C can be used to break down infectious, hazardous

chemical or pharmaceutical wastes. The vapors are then heated further in a steam
reforming chamber to 1500°C. This technology is expensive, and – like incineration –
requires pollution control devices to remove pollutants from the exhaust gas.
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8.4 On-site HCW Treatment Facilities

If the HCF opt to operate its own HCW treatment facility, the following factors
must be considered for the location of the treatment facilities:
 Safe transfer routes must be provided from the storage area to the
treatment facility;
 The HCW treatment facilities must be located within the HCF. However, the
area must be located away from the dietary section, patient rooms,
laboratories, hospital function/operation rooms or any public access
areas;
 The facilities should be located in a way that it does not produce nuisance
such as odor, noise, the visual impact of HCW operations on patients and
visitors;
 Public access and security are provided;
 Consider the proximity of the treatment facility to the temporary or central
storage;
 Be strategically placed so as not to cause traffic problems in the entry and
exit of vehicles;
 Consider the volume of waste generated by the HCF when it comes to the
size of the treatment facility;
 Be protected from rain, strong winds, floods, etc.;
 Have elevated, concrete finish flooring and with waterproofing,
adequately sloped for easy cleaning;
 Have a good drainage system and connected to a WWTP.
 Have continuous water supply for cleaning purposes.
 Have locking device to prevent access by unauthorized persons.
 Be inaccessible to animals, insects, and birds.
 Have adequate ventilation and lighting
 Have supplies of cleaning implements (e.g., hose with spray nozzle,
scrubber with long handle, disinfectant, protective clothing, waste bags or
bins) and fire-fighting equipment/devices located conveniently close to
the storage area.
 Have space allowances needed by workers to maneuver safely around
the treatment facility.
 Have floors, walls, and ceilings that are clean at all times.
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 Have a warning sign posted in a strategic place: “CAUTION: TREATMENT

AREA: UNAUTHORIZED PERSONS KEEP OUT.”
8.5 HCW Disposal

8.5.1 Encapsulation
Encapsulation involves filling containers with waste, adding an immobilizing

material, and sealing the containers. A sample schematic diagram is shown in ANNEX
E 6. The process uses either cubic boxes made of high-density polyethylene or
metallic drums, which are three-quarters filled with sharps or chemical or
pharmaceutical residues. The containers or boxes are then filled up with a medium
such as plastic foam, bituminous sand, and cement mortar. After the medium has
dried, the containers are sealed and disposed of in landfill.
This process, where the encapsulation materials are available, is appropriate for
establishments for the disposal of sharps and chemical or pharmaceutical residues.
Encapsulation alone is not recommended for non-sharps waste but may be used in
combination with treatment of such waste. The main advantage of the process is its
effectiveness in reducing the risk of scavengers gaining access to the hazardous
HCW.
8.5.2 Inertization – Stabilization/Solidification
Inertization involves mixing waste with cement and other substances before
disposal to minimize the risk of toxic substances contained in the waste migrating into
surface water or groundwater. Inertization can be by the process of stabilization or
solidification. Stabilization refers to the chemical changes of the hazardous
substances in the waste while solidification means physical immobilization of the
hazardous substances to reduce the vaporization or leaching to the environment.
This process is especially suitable for pharmaceuticals and for incineration ashes
with a high metal content (in this case, the process is also called “stabilization”). For
the inertization of pharmaceutical waste, the packaging should be removed, the
pharmaceuticals ground, and a mixture of water, lime and cement added. A
homogeneous mass is formed, and cubes or pellets are produced on-site.
Subsequently, these can be transported to a suitable storage site. Alternatively, the
homogeneous mixture can be transported in liquid state to a landfill and poured
onto the surface of previously landfilled municipal waste, then covered with fresh
municipal waste.
The process is reasonably inexpensive and can be performed using relatively
unsophisticated mixing equipment. Other than personnel, the main requirements are
a grinder or road roller to crush the pharmaceuticals, a concrete mixer and supplies
of cement, lime, and water.
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8.5.3 Sharps Pit/Concrete Vault
This method is especially suitable for the disposal of used sharps and syringes. The
collected safety boxes filled with used sharps and needles will be deposited inside
the concrete vault. Refer to ANNEX E 7 for a sample concrete vault design.
Box 32: Construction of sharps pit/concrete vault
The following shall be observed when constructing the concrete vault:
 The site is isolated and at least 150 meters

away from the water supply sources and
dwelling units.
 Dig a pit (minimum size of 1m x 1m x 1.8m
depth) enough to accommodate
sharps/syringes for an estimated period of time
without reaching the groundwater level.
 Construct concrete walls and slabs of pit.
 Provide slab with opening/manhole for easy
deposition of collected sharps and syringes.
Manhole shall be extended a few centimeters
above soil surface to overcome infiltration of
surface water.
 Install security fence around the site with
signage.
8.5.4 Placenta Pit
In many communities, burying placentas is an important ritual and one option for
disposal. If it is done safely, burial can protect the community from pathogens while
respecting cultural norms and religious traditions. The disposal of the placenta can
use concrete pits. The process of biodegradation in the pit can destroy pathogenic
microorganisms as the waste is subjected to changes in temperature, pH, and a
complex series of chemical and biological reactions. The degradation processes in
a pit are anaerobic, with some aerobic decomposition in the upper layers where
oxygen is available for aerobic bacteria. The waste should not be treated with
chemical disinfectants such as chlorine before being disposed of, because these
chemicals destroy the microorganisms that are important for biological
decomposition.
In selecting the location of the placenta pit, the following should be considered:
 Should be as far away as possible from publicly accessible areas and from
hygienically critically areas (e.g., water wells, kitchens);
 Placenta pits should not be built too close to buildings due to possible
odors;
 A safety distance of at least 1.5 meters from the bottom of the pit to the
groundwater level is recommended; and
105
 Placenta pits are not recommended in sites where the water table is near
the surface or in areas prone to flooding.
The dimensions of the pit will be context specific and will depend on the average
number of births and infiltration rate of the soil. In principle, allow 0.5 liters of soil
infiltration per placenta, and a maximum of 5 liters of total space per placenta if all
the bloody liquids are collected and no infiltration is occurring.
It is recommended that two placenta pits are built so that the second one is
available as soon as the first is filled. Once a pit is filled up, it should be closed. Any
sealed pits should be marked, and their locations recorded. However, it may be
possible to reopen pits after enough time has passed and the material has been
degraded. When pits are reopened, it may be necessary to remove some of the
degraded material.
Refer to ANNEX E 8 for a sample placenta pit design.
8.5.5 Safe On-site Burial at HCF Located in Remote Areas
Safe burial of HCW within the HCF as a disposal method is applicable only to
treated infectious waste, sharps waste, pathological and anatomical waste, small
quantities of encapsulated/inertisized solid chemical and pharmaceutical wastes.
Safe burial may be implemented but should be considered transitional, interim
solution.
Safe burial of HCW shall only be allowed in the following situations:
 HCF is located in a remote and far-flung area;
 HCF does not have access to TSD facilities;
 HCF is located in a local government unit (LGU) with an income
classification of 5th or 6th Class;
 HCF located in 1st to 4th Class LGU has available area within the HCF
premises (only pathological, anatomical, expired drugs and sharps wastes
can be buried);
 Safe burial of HCW within the HCF premises is the only viable option at a
specific period of time, e.g., temporary refugee encampments and areas
experiencing exceptional hardship.
The following shall be the characteristics for the safe burial site:
 Not located in flood prone areas;
 Downhill or down-gradient from any nearby wells and about 50 meters
away from any water body such as rivers or lakes to prevent
contaminating water source; new water wells should not be dug near the
disposal pit;
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 Bottom of the pit located at least 1.5 meters above groundwater level;
 Secured (e.g., fenced with warning signs); accessible only to authorized
personnel;
 Lined with a material of low permeability, such as clay or HPDE, to prevent
pollution of shallow groundwater that may subsequently reach nearby
wells;
 Allow only hazardous HCW to be buried. If general HCW are also buried
on the premises, available space would be quickly filled-up;
 Managed as a landfill, with each layer of waste covered with a layer of
earth to prevent odor, as well as to prevent proliferation of rodents and
insects; and
 Larger quantities (<1kg) of chemical wastes should not be buried at one
time; however, burying small quantities occasionally is less likely to create
adverse pollution.
Refer to ANNEX E 9 for a sample on-site waste burial pit design. The HCF shall keep
a permanent record of the size and location of all their on-site burial pits to prevent
construction workers, builders, and others from digging in those areas in the future.
The safe burial of waste depends critically on rational operational practices. It shall
be noted that safe on-site burial is practicable only for relatively limited period, about
1 to 2 years, and for relatively small quantities of waste, about 5 to 10 tons in total.
When these conditions have been exceeded, a long-term solution will be needed.
8.5.6 Sanitary Landfill Facility
HCW that is properly treated with the applicable technology as stated in this
Manual can be disposed in a sanitary landfill but must not be mixed with the
municipal wastes. Dedicated cells for the treated HCW must be provided in the
sanitary landfill. To allow the disposal of the HCW to the sanitary landfill, the following
must be met:
 The waste treatment facility/system for the treatment of infectious and
sharps wastes passed the standards for microbial inactivation test; and the
properly treated HCW passed the spore strip test;
 The waste treatment facility/system has a valid CPR from the DOH-Bureau
of Health Devices and Technology (BHDT), and;
 The waste treatment facility is an EMB-registered TSD facility.
A sanitary landfill is an engineered method designed to keep the waste isolated
from the environment. Appropriate engineering preparations and corresponding
permits from DENR shall be completed before the site is allowed to accept waste.
There shall be a trained staff present on-site to control and manage the operations.
The landfill shall:
107
 Be accessible to site and working areas for easy passage of delivery

access;
 Have landfill personnel capable of effective control of daily operations;
 Divide the site into manageable phases, which are appropriately
prepared, before disposal of wastes;
 Have adequate sealing of the base and sides to minimize the movement
of wastewater (leachate);
 Have adequate mechanisms for leachate collection and treatment
systems;
 Have an organized deposit of waste in a small area, allowing waste to be
spread, compacted, and covered daily;
 Have surface water collection trenches around site boundaries;
 Have a construction of a final cover to minimize rainwater infiltration when
each phase of the landfill is completed.
Certain types of HCW, such as anatomical waste, will still have an offensive visual
impact after treatment and preferably should not be landfilled. Disposing of such
waste in landfill may also be culturally or religiously unacceptable in many countries.
Such wastes should be placed in approved burial grounds or cremated. If this is not
possible, these wastes could be placed in containers or rendered unrecognizable
before disposal.
Table 5: Applications of treatment and disposal methods for specific HCW categories
Category of HCW Treatment/Disposal Method Options
Sharps  Disinfection: Autoclave, Microwave technology, Chemical
disinfection
 Mechanical shredding: On-site mechanical needle cutters or
electric needle destroyers
 Encapsulation in cement blocks
 Sharps pits/Concrete vaults
Anatomical waste, pathological  Burning in crematoria or specially designed incinerators
waste, placenta waste and  Alkaline digestion, especially for contaminated tissues and
contaminated animal carcasses animal carcasses
 Promession
 Interment (burial) in cemeteries or special burial sites
 Placenta waste is composted or buried in placenta pits
designed to facilitate natural biological decomposition.
Pharmaceutical waste  Return to the original supplier (preferred option)
 Encapsulation
 Chemical decomposition in accordance with the
manufacturer’s recommendations if chemical expertise and
materials are available;
 Dilution in large amounts of water and discharge into a sewer
for moderate quantities of relatively mild liquid or semi-liquid
pharmaceuticals, such as solutions containing vitamins,
cough syrups, intravenous solutions and eye drops and
harmless liquids such as intravenous fluids.
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 Incineration in kilns equipped with pollution-control devices
designed for industrial waste and that operate at high
temperatures;
 Dilution and sewer discharge for relatively harmless liquids
such as intravenous fluids (salts, amino acids, glucose).
 Sanitary landfill for non-hazardous pharmaceutical waste
Cytotoxic Waste  Incineration at high temperatures with gas-cleaning
equipment
 Chemical degradation in accordance with manufacturers’
instructions.
 Alkaline hydrolysis
 Encapsulation or Inertization may be considered as a last
resort
 Return to the original supplier (preferred option)
Chemical Waste  Large amounts of chemical waste should not be buried,
because they may leak from their containers, overwhelm the
natural attenuation process provided by the surrounding
waste and soils, and contaminate water sources.
 Encapsulation. (Large amounts of chemical disinfectants
should not be encapsulated, because they are corrosive to
concrete and sometimes produce flammable gases)
 Where allowed by local regulations, non-recyclable, general
chemical waste, such as sugars, amino acids and certain
salts, may be disposed of with municipal waste or discharged
into sewers.
 An option for disposing of hazardous chemicals is to return
them to the original supplier, who should be equipped to
deal with them safely
 Sanitary landfill (for small quantities only)
Waste containing heavy metals  Wastes containing mercury or cadmium should not be
burned or incinerated. Cadmium and mercury volatilize at
relatively low temperatures and can cause atmospheric
pollution.
 If none of the above options are feasible, the wastes would
have to go to a disposal or storage site designed for
hazardous industrial waste.
 Send back the waste to the suppliers of the original
equipment, with a view to reprocessing or final disposal
Radioactive Waste  The treatment and disposal of radioactive waste is generally
under the jurisdiction of PNRI.
 Return to supplier
 “Decay in storage”, which is the safe storage of waste until its
radiation levels are indistinguishable from background
radiation; a general rule is to store the waste for at least
10 times the half-life of the longest-lived radionuclide in the
waste.
 Long-term storage at an authorized radioactive waste
disposal site.
 It is not appropriate to disinfect radioactive solid waste by
wet thermal or microwave procedures
 Disposable syringes containing radioactive residues should be
emptied in a location designated for the disposal of
radioactive liquid waste. Syringes should then be stored in a
sharps container to allow decay of any residual activity,
before normal procedures for disposal of syringes and
needles are followed.
 Higher-level radioactive waste of relatively short half-life (e.g.,
from iodine-131 therapy) and liquids that are immiscible with
109

water, such as scintillation-counting residues and
contaminated oil, should be stored for decay in marked
containers, under lead shielding, until activities have reached
authorized clearance levels.
 Radioactive waste resulting from cleaning-up operations
after a spillage or other accident should be retained in
suitable containers, unless the activity is clearly low enough to
permit immediate discharge.
 Solid radioactive waste, such as bottles, glassware, and
containers, should be destroyed before disposal to avoid
reuse by the public
Box 33: Overview of treatment and disposal of HCW in primary care facilities
Treatment of wastes mainly aims at reducing direct exposure less dangerous to humans, at
recovering recyclable materials, and at protecting the environment. For wastes from the
primary care facilities, the main aim is to disinfect infectious waste, to destroy disposable
medical devices, in particular used syringe needles, which should not be reused, or at least to
render them inaccessible or sterile prior to plastic reprocessing. The table below shows the
different possible treatment of different HCW.
Treatment/Disposal Non-plastic Anatomical Sharps Pharmaceutical Chemical Waste

Options Infectious Waste Waste Waste Waste
Waste Burial Yes1 Yes1 Yes1 Small quantities Small quantities
Sharp pit No No Yes1 Small quantities No
Placenta pit No Yes1 No No No
Encapsulation No No Yes Yes Small quantities
Inertization No No No Yes No
Low temp burning Yes (interim Yes (interim No No No
(< 800°C) solution) solution)
Med temp burning Yes Yes Yes No No
(800 – 1000°C)
High temp burning Yes Yes Yes Small quantities Small quantities
(> 1000C°)
Steam autoclave Yes No Yes No No
Microwave Yes No Yes No No
Chemical Yes No Yes No No
Discharge to Sewer No No No Only non- Small quantities
hazardous
Others Return expired Return unused
drugs to supplier chemicals to supplier
Note: 1 Waste should be disinfected first
Source: Management of Solid Health-care Waste at Primary Health-Care Centers (WHO, 2005)
110
Box 34: Management of wastes from home care services
Home care wastes are typically the type of wastes normally encountered when administering
home health care include needles, syringes, lancets, other sharp objects, soiled bandages,
gauze, disposable sheets, tubings, and used medical gloves. The improper disposal of
contaminated sharps is a serious safety concern for garbage collectors and landfill workers. If
improperly thrown in trash bags along with regular trash, these sharps can puncture the bags
and cause injury.
The disposal of clinical waste in a patient’s home, where the patient is treated by a community
nurse or a health care professional, is the responsibility of the nurse/health care professional
giving the treatment. The health care professional / nurse needs to ask permission from the
homeowner prior to disposing of waste into their rubbish bin.
It is important that hospitals and other HCFs shall provide instructions to the family and relatives
of the patient prior to approval for homecare, the basic information on homecare waste
management and disposal. Further, homecare waste management and disposal shall be
monitored by the local health authorities in the area. The following must be observed for the
proper management and disposal of HCW from home care:
 Dispose lancets, syringes and other sharp objects separately by placing in hard plastic or
metal containers with screw-on or tightly secured lid. Many containers found in the
household will do.
 Before disposal the tightly sealed lead must be reinforced with heavy-duty tape and
labelled “NOT FOR RECYCLING”.
 Do not place sharps in glass containers and those intended for re-use or recycling.
Containers should have a small opening so that no one else is able to stick their hand into
it.
 Do not recap, purposely bend, break, or otherwise manipulate needles before inserting
them into the disposal container.
 Sharps should be disposed once container is three-quarters full. Be sure to keep all
containers with discarded sharps of reach of children and pets. Drop all parts into the
container. Before disposal the tightly sealed lead must be reinforced with heavy-duty
tape and labelled “NOT FOR RECYCLING”.
 Other hazardous infectious materials such as soiled bandages, gloves, disposable sheets
must be placed in securely fastened yellow plastic bags prior to disposal.
 If the waste is classified as non-hazardous, (non-infectious) and as long as it is double
bagged in a small translucent/white bag and sealed, it is acceptable for the waste to be
disposed of with household waste. This is usually the case with plasters, small dressings,
sanitary towels and incontinence products.
 If the waste is classified as hazardous in the patient’s home, the health care professional
can remove that waste and transport it in approved containers (i.e. rigid, leak proof,
sealed, secured etc.) and take it to the nearest HCF with HCW disposal units. The
caregivers who are family members can also do the same procedure to dispose of
hazardous and infectious waste ensuring always to follow the required type of containers.
Source: Adapted from “Disposal Tips for Home Healthcare” (USEPA, 1998)
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Box 35: Management of wastes from immunization campaign activities
Immunization activities generate sharps and infectious non-sharp wastes that should be
properly managed on-site to avoid or reduce its negative health impacts on the community
and the personnel working.
Waste Segregation and Packaging

 Always segregate sharps from non-sharps at the source
 Immediately after use, discard entire syringe with needle into a safety box without
recapping needles
 Put safety boxes into plastic bags closed hermetically when full to avoid any leakage
during transportation. Mark the bag clearly.
 Put empty vials into waste containers with plastic lining to avoid leakage. Seal/mark
clearly when full.
Waste Treatment and Final Disposal

For Sharps (needles with syringe)
 Prepare sufficient number of sharps safety boxes for the day;
 Discard entire syringe and needle immediately after vaccination in safety box without
recapping;
 When the sharps safety box is three-quarters full, put it aside and make sure that waste
handlers close, seal it with adhesive tape and mark it before putting it in a plastic bag.
 Place plastic bags carefully in storage area or take to disposal system if ready to process
immediately.
For Infectious non-sharps (empty or expired vials)
 Prepare sufficient numbers of waste containers with plastic lining for the day;
 Put empty vaccine flasks and cotton swabs in the waste container;
 Once nearly full, put it aside and make sure that waste handlers close, seal it with adhesive
tape and mark it before taking it away to the storage or disposal area
Source: Management of wastes from immunization campaign activities (WHO, 2004)
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Box 36: Minimum approach for management of liquid HCW
The following actions should be only carried out if no other way of hazardous waste disposal
is available or during an emergency and should be considered transitional, interim solution.
The use of appropriate PPE is of utmost importance in all situations:
 Body fluids and the contents of suction systems from non-infectious patients from an
operating theatre should be discharged via the drain by staff wearing PPE and with all
possible further precautions to avoid fluid splashing.
 Stool, vomit, and mucus from highly infectious patients (e.g., cholera patients) should be
collected separately and thermally treated before disposal (e.g., by an autoclave
reserved for waste treatment). Lime milk (calcium oxide) can be used during emergencies
and if no appropriate autoclave or other disinfectant is available.
 Blood can be emptied into a septic or sewerage system if safety measures are followed
(e.g., PPE and precautions against spatter). If no other disposal option is available, expired
blood bags may be isolated from patients and staff by placing unopened into a
protected pit excavated within the grounds of the HCF or at another secure location.
 Solid HCW, especially solid hazardous waste (pharmaceuticals, chemicals), should not be
mixed into wastewater.
 Liquid laboratory hazardous waste (colorants, formalin) should be collected separately.
Adsorbent (e.g., sawdust) should be used for easier handling. The solid mass should be
rendered immobile or encapsulated.
 Chlorine-based disinfectant should be diluted to reach a concentration of <0.5% active
chlorine and should be disposed of directly in a soak-away pit. Chlorine-based
disinfectant should not be disposed of in a septic tank, because it will harm the
biodegradation process.
 Liquid pharmaceuticals in vials (but not cytotoxic materials) can be crushed in a closed
bucket, mixed with sawdust, and the solid mass incinerated or encapsulated.
 Glutaraldehyde should be stored after use and can be neutralized using glycine.
Subsequently, it can be slowly disposed of via a soak-away pit.
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Fourth Edition Chapter 9: Managing Wastewater Generated by Health Care Facilities
9 Managing Wastewater Generated by Health

Care Facilities
As stipulated in the Philippine Clean Water Act of 2004, all HCFs must have its own
wastewater treatment plant or must be connected to a municipal or common
wastewater treatment facility or an equivalent system for small HCFs (with bed
capacity of 25 or less). In some cases, the HCF must provide a pretreatment to the
wastewater prior to discharge to the municipal sewer. It is also important that
sufficient sanitation facilities are provided in the HCF. The recommended minimum is
one toilet per 20 users for inpatient medical areas, and at least four toilets per
outpatient location.
9.1 Composition of HCF Wastewater

Health care wastewater is any water that has been adversely affected in quality
during the provision of health care services. It is mainly liquid waste, containing some
solids produced by humans (staff and patients) or during health care-related
processes, including cooking, cleaning, and laundry. Health care wastewater can
be divided into the following three categories:
 Blackwater (sewage) is heavily polluted wastewater that contains high
concentrations of fecal matter and urine.
 Greywater (sullage) contains more dilute residues from washing, bathing,
laboratory processes, laundry, and technical processes such as cooling
water or the rinsing of X-ray films.
 Stormwater is technically not a wastewater itself, but represents the rainfall
collected on hospital roofs, grounds, yards, and paved surfaces. This may
be lost to drains and watercourses and as groundwater recharge, or used
for irrigating hospital grounds, toilet flushing and other general washing
purposes.
Box 37: Wastewater generation rate in HCFs
Wastewater generation in secondary- and tertiary-level hospitals is mainly measured on an

inpatient ratio (liter of generated wastewater per patient treatment day). Typical generation
rates are:
 Small—medium-sized hospitals: 300–500 L per inpatient per day

 Large health care settings: 400–700 L per inpatient per day
 University hospitals: 500–>900 L per inpatient per day
In primary health care clinics, the rate of waste generation is often measured as the sum of
the number of inpatients and outpatients. Minimum water requirement in the health care
setting are (WHO, 2008):
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 40–60 L per inpatient

 5 L per outpatient
 100 L per surgical procedure
9.2 Sources and Characteristics of HCF Wastewater

Wastewater from HCFs contains organic particles (feces, hairs, food, vomit, paper
fibers, etc.), soluble organic material (urea, proteins, pharmaceuticals, etc.),
inorganic particles (sand, grit and metal particles), soluble inorganic material
(ammonia, cyanide, hydrogen sulphide, thiosulphates) and other substances. The
quality depends on the source of origin.
Table 6: Sources and characteristics of HCF wastewater

HCF Department Waste Source and Characteristics
Administration and Urine of patients from some wards (surgery wards, oncology, infectious disease
Wards ward, etc.) might contain higher amounts of antibiotics, cytotoxic and X-ray
contrast media. These antibiotics and their metabolites are excreted with urine
and feces and end up in the wastewater stream, a problem recently
recognized worldwide. Hospital wastewaters are a source of bacteria with
acquired resistance against antibiotics with a level of at least a factor of 2 to
10 times higher than in domestic wastewater.
Kitchen Food leftovers, waste from food processing, disinfectants and detergents,
starch, grease and oil.
Laundry It is where greywater is mostly produced. The wastewater often is hot, has a
high pH (alkaline) and might contain high amounts of phosphate, surfactants
and AOX (adsorbable organically bound halogens) if chlorine-based
disinfectants are used.
Operating Room Higher contents of disinfectants, detergents and pharmaceuticals. Organic
and ICU content can be high due to the disposal of body fluids and rinsing liquids
(suction containers).
Laboratories Halogenated and organic solvents, colorants from the histology and
hematology (gram staining), cyanides (hematology) and formaldehyde and
xylem (pathology) and other reagents, wastewater from autoclaves.
Laboratories may also contribute to the presence of blood in wastewater from
the emptying of samples into the sinks.
Radiology Photochemical (developing and fixing solutions) containing wastewater and
potentially contaminated rinsing water, fixers and developers. Developing
solution can contain formaldehyde, which is a known human carcinogen.
Renal Department/ Body fluids from machine, disinfectants, dialyzer solutions, wastewater from
Hemodialysis reverse osmosis process.
Dental Department Mercury (amalgam) if no amalgam separators are installed; disinfectant, body
fluids, wastewater from autoclaves. Mercury is a neurotoxin. It is
environmentally persistent and bioaccumulates in the food chain
Central Sterilization Disinfection solution, including aldehyde-based disinfectants. Hot water from
Room the sterilizers and detergents from the CD Machine (Cleaning and
Disinfection), wastewater from autoclaves and sterilizing equipment.
9.3 Collection of HCF Wastewater

Segregation, minimization, and safe storage of hazardous materials are just as
important for liquid wastes as they are for solid wastes. A wastewater management
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must also be implemented by the HCF. The basic principle of effective wastewater
management is a strict limit on the discharge of hazardous liquids to sewers.
Wastewater generated in the HCF are collected by sewer pipes, going to the
wastewater treatment facility of the HCF or to the municipal sewer to be transported
in a treatment facility together with the wastewater from the community. The
preferred set-up is to construct separate sewerage systems for wastewater and
stormwater (referred to as sanitary sewers and storm sewers). Combined sewerage
systems that transport liquid waste discharges and stormwater together to a
common treatment facility are no longer recommended. Stormwater or rainwater
can be collected separately and used for gardens or other purposes that do not
need highly processed water, such as toilet flushing, washing vehicles, or cleaning
outdoor paved areas. Furthermore, the separate collection of greywater and
blackwater is normally not recommended, because it can cause hydraulic problems
(blockages) due to low flow volumes in the collection of the blackwater.
Chemical waste—especially photochemicals, aldehydes (formaldehyde and
glutaraldehyde), colorants, and pharmaceuticals—should not be discharged into
wastewater but should be collected separately and treated as a chemical HCW.
Radioactive wastewater from radiotherapy (e.g., urine of patients undergoing
thyroid treatment) should be collected separately and stored in a secured place
until the levels of radioactivity have decreased to background concentrations. After
the required storage time, the wastewater can be disposed of into a sewer. A
separate toilet facility must be provided to the patients that are given with high doses
of radioactive isotopes for therapy.
Larger quantities of blood may be discharged in the sewers if a risk assessment
shows that the likely organic loading in the wastewater does not require pre-
treatment. Otherwise, blood should be first disinfected, preferably by a thermal
method, or disposed of as pathological waste. Blood can also be disposed of directly
to a septic tank system if safety measures are followed.
9.4 Treatment of HCF Wastewater

The HCF may provide its own wastewater treatment facility or may connect to a
municipal or centralized wastewater treatment facility for the treatment of
wastewater.
9.4.1 Connection to a Municipal/Centralized Wastewater Treatment Plant
If the HCF is to be connected in the municipal or in a centralized sewer system,

the following are the minimum requirements for discharging to the municipal or
centralized sewer system:
 The sewers should be connected to an efficient wastewater treatment
plant with primary, secondary, and tertiary treatment;
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 A central treatment plant ensures at least a 95% removal of bacteria;

 The sludge resulting from sewage treatment should be subjected to further
treatment, such as anaerobic digestion, leaving no more than one
helminth egg per liter in the digested sludge; and
 The waste management system of the HCF maintains high standards,
ensuring only low quantities of toxic chemicals, pharmaceuticals,
radionuclides, cytotoxic drugs, and antibiotics in the discharged sewage.
If the HCF is connected to a municipal sewer system, the HCF may need to
provide a pre-treatment to the wastewater prior to discharging to the municipal
sewer. The pre-treatment system depends on the quality of the wastewater to be
pre-treated and the required quality of the wastewater that can be discharged to
the municipal sewer.
Box 38: Pre-treatment of HCF wastewater
Pre-treatment is recommended for wastewater streams from departments such as medical

laboratories. This pre-treatment could include acid–base neutralization, filtering to remove
sediments, or autoclaving samples from highly infectious patient.
 Non-hazardous chemicals such as syrups, vitamins or eye drops can be discharged to the
sewer without pre-treatment.
 A grease trap can be installed to remove grease, oil, and other floating materials from
kitchen wastewater. The trap and collected grease should be removed every 2–4 weeks.
 Collected body fluids, small quantities of blood and rinsing liquids from theatres and
intensive care can be discharged in the sewer without pre-treatment. Precautions against
blood spatter should always be taken (e.g., wearing personal protective equipment [PPE]
and following standardized handling procedures), and care should be taken to avoid
blood coagulation that could block pipes. Expired blood bags shall not be emptied into
a sink because of the risk of infection from blood splatters.
 The 5% sodium hypochlorite (NaOCl – bleach) is not effective for disinfecting liquids with
a high organic content such as blood and stools. Sodium hypochlorite should never be
mixed with detergents or used for disinfecting ammonia-containing liquids, because it
might form toxic gases.
 Chlorine-based disinfectants (such as sodium hypochlorite) shall not be disposed of in a
septic tank as it will harm the bacteria used for the biological treatment process.
 Lime milk (calcium oxide) can be used to destroy microorganisms in liquid wastes with
high organic content requiring disinfection (e.g., stool or vomit during a cholera
outbreak). In these cases, feces, and vomit should be mixed with the lime milk in a ratio
of 1:2, with a minimum contact time of six hours. Urine can be mixed 1:1, with a minimum
contact time of two hours (Robert Koch Institute, 2003).
 Wastewater from the dental department should be pre-treated by installing an amalgam
separator in sinks, particularly those next to patient treatment chairs. Mercury waste must
be safely stored.
9.4.2 On-site Wastewater Treatment Plant (WWTP)
Larger HCFs, particularly those that are not connected to any municipal
treatment plant, should operate their own wastewater-treatment plant. This could
include physical, chemical, and biological processes to remove contaminants from
the raw sewage. The advantages and disadvantages of different types of WWTP
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technology and the factors to consider for establishment of on-site WWTP are listed
in ANNEX B 7 and ANNEX B 8, respectively.
Typically, wastewater treatment involves three stages (refer to ANNEX A 8 for the
process flow diagram). The first stage is the removal of solids that are separated by
sedimentation (primary treatment). Second, dissolved biological matter is
progressively converted into a solid mass using indigenous waterborne bacteria.
Some inorganic components will be eliminated by sorption to sludge particles, which
are then separated from the liquid phase of the wastewater by sedimentation
(secondary treatment). During the third stage (at the end of the treatment process),
after the solid and liquid materials are separated, the treated water may be further
treated to remove suspended solids, phosphates, or other chemical contaminants,
or may be disinfected (tertiary treatment).
9.4.2.1 Disposal of treated effluent
The treated effluent of the on-site wastewater treatment plant must comply to
the general effluent standards of DENR-EMB (DAO 2016-08) prior to discharge. The
quality of the treated effluent required depends on the classification of the
discharging water body. The significant effluent quality parameters for the HCFs
according to DAO 2016-08 are shown in Table 7.
Table 7: Significant effluent parameters for HCFs

PSIC Code Industry Category Significant Parameters
86, 87 Hospitals, clinics, nursing homes and  Color
other health and residential care  Temperature
activities  pH
 Biochemical Oxygen Demand
(BOD)
 Total Suspended Solids (TSS)
 Fecal Coliform
 Ammonia
 Nitrate
 Phosphate
 Oil and Grease
 Surfactants
86900 Other human health activities- All significant parameters depending
medical laboratories inside and on the nature of their activity.
outside of medical facilities
Source: DAO 2016-08
9.4.2.2 Disposal of sludge
The treatment process of the wastewater will generate sludge or biosolids that
contains high concentrations of helminths and other pathogens and should be
treated before disposal. The most common treatment options include anaerobic
digestion, aerobic digestion, and composting. Composting or sludge de-watering
and mineralization beds are most commonly used for on-site treatment in hospitals.
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For composting, sludge is mixed with a carbon source such as sawdust, straw, or
wood chips. In the presence of oxygen, bacteria digest the sludge and the carbon
source, and create heat that will pasteurize the sludge. In dewatering and
mineralization beds, sludge is applied on a horizontal system – flow reed bed (refer
to ANNEX E 10). One part of the water is absorbed by the reeds, which then transpire
moisture into the air; the other part is returned to the wastewater treatment plant
through a drainage layer in the bottom of the reed bed. The de-watered sludge is
incorporated into the microbiologically active top layers of the root zone of the
reeds, where it is mineralized and turned into soil.
9.4.2.3 Re-use of wastewater effluent and sludge
The reuse of wastewater and sludge from hospitals with standard wastewater-
treatment plants is generally not recommended and should only be done if
knowledgeable staff and appropriate testing facilities are available. Wastewater
treatment plants of HCF often face operational problems, due to concerns about
chemicals and pharmaceuticals in wastewater and the potential hygiene risks. The
use of treated health care wastewater should only be carried out if resources to meet
environmental and safety standards can be assured and the relevant national or
WHO guidelines on wastewaters and sludge can be followed. If the treated effluent
will be reused for irrigation, the standards in DA Administrative Order 2007-26 must be
complied.
If sludge is reused for agricultural purposes, it should be tested to confirm that it
does not contain more than one helminth egg per gram of total solids and contains
no more than 1000 fecal coliforms per gram of total solids (WHO, 2006). The sludge
should be applied to fields in trenches and then immediately covered with soil.
9.4.3 Emerging Technologies
Membrane Biological Reactor (MBR) is a combination of activated sludge

treatment with a membrane liquid–solid separation process. The membrane
component uses low-pressure microfiltration or ultrafiltration membranes and
eliminates the need for clarification and tertiary filtration. The membranes are
typically immersed in the aeration tank (however, some applications use a separate
membrane tank).
Anaerobic pre-treatment with reed beds is a process in which microorganisms
convert organic matter into biogas in the absence of oxygen. An anaerobic system
can be used for pre-treatment prior to discharging to a municipal wastewater
treatment plant or before polishing in an aerobic process. Reed bed system for
wastewater treatment has been proven to be effective and sustainable alternative
for conventional wastewater treatment technologies. Use of macrophytes to treat
wastewater is also categorized in this method.
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9.4.4 Operation Monitoring and Maintenance of WWTP
The following elements must be in place for the efficient and effective operation
and maintenance of the WWTP system:
 Awareness among the management and senior staff on wastewater
problems;
 Physical Assent Management (PAM) and Preventive Maintenance
Program (PMP);
 Basic tools to carry out regular maintenance;
 PPE and other safety equipment measures;
 Trained operators and workers; and
 Budget for operational costs and regular maintenance.
The management shall designate wastewater treatment operator who will be
responsible for the operation and maintenance of the WWTP. A maintenance plan
which includes corrective as well as preventive maintenance shall be set up for the
collection, pre-treatment, and treatment of wastewater.
For monitoring, regular testing of the influent as well as the effluent shall be
monitored to test the efficiency of the treatment plant. Parameters required by DAO
2016-08 Water Quality Guidelines and General Effluent Standards of 2016 will be
tested based on the prescribed frequency.
9.4.5 Basic Wastewater Treatment System for Rural HCF
For HCFs, especially primary care facilities and HCFs located in the rural areas,
that do not have an on-site wastewater treatment plant or a sewerage system in
their area may opt to provide basic wastewater treatment system. This system
consists of a primary and secondary treatment stage, which is considered as the
minimum treatment for primary- and secondary- level rural hospitals.
Note that sludge and sewage from HCF generated by a basic wastewater
management system should never be used for agricultural or aquaculture purposes.
Effluents from the basic treatment should not be discharged into water bodies that
are used nearby to irrigate fruit or vegetable crops or to produce drinking-water or
for recreational purposes.
Basic systems can reduce the risk of waterborne diseases drastically if
appropriately planned and implemented; more advanced systems reduce the risk
further. Pharmaceuticals and other hazardous liquid wastes in wastewater may form
a serious future problem and must be carefully observed and minimized. This includes
reducing to an absolute minimum the presence of antibiotics and pharmaceutical
residues in wastewater.
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There are three basic wastewater management systems that can be used by the
HCFs: (1) septic tank system; (2) centralized basic system; and (3) lagoon system.
The effluent from septic tank and centralized basic systems can be further treated
but if not possible, a controlled discharge to soakaway pits or leachfields should be
carried out. However, soakaway pits and leachfields present a threat of
contamination to nearby wells. Both should be kept as far as practicable from
shallow water wells and, where possible, they should be installed downstream of
water abstraction sources. The distance between the bottom of the infiltration system
and the groundwater table should be at least 1.5 meters (more in coarse sands,
gravels, and fissured geological formations), and the system should be at least 30
meters from any groundwater source (Harvey, 2002).
9.4.5.1 Septic tank system
The minimum treatment method for wastewater is the septic tank, a watertight
receptacle for the separation of solid and liquid components of wastewater and for
the digestion of organic matter in an anaerobic environment. A septic tank also
takes on the functions of storing solids and allowing clarified liquid to outflow for
further treatment or discharge.
A septic tank normally consists of two or more chambers and can be divided into
the following zones: (1) horizontal: inflow, settlement and clarifying zone; and (2)
vertical: scum, detention, and sludge zone. The capacity of the septic tank should
be equivalent to a total of two days’ wastewater flow. If a two-chamber system is
used, the first chamber should be two-thirds of the total capacity. The effective
settling and floating of solids are directly dependent upon the retention time within
the tank, which should be not less than 24 hours. Anaerobic bacteria partly break
down this solid matter.
Note that excessive build-up of sludge and scum reduces the capacity of the
detention zone, resulting in discharge of suspended solids to the effluent disposal
system. Specific guidelines on the design, construction/installation, operation, and
maintenance of septic tank systems are provided in the DOH AO No. 2019-0047 (see
ANNEX F 1 for link to the document). The operation and maintenance criteria are
presented in Box 38.
Box 39: Septic tank systems operation and maintenance criteria
The national standard for septic tank systems operation and maintenance consists of the ff.
criteria:
 Septic tank must be desludged every four (4) years to maintain its designed treatment
efficiency.
 Keep a record of pumping, inspections, maintenance, and repairs.
 Inspect the tank for cracks, and check that baffles or tees are in place. Check for ponding
of water near the treatment and disposal system.
 Refrain from using septic starters, additives, or feeders (i.e., enzymes).
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 Practice water conservation to prevent overloading the septic tank system. Check for
defective toilet tank valves, repair leaky fixtures, and install appliances and fixtures that
use less water and avoid wasteful practices.
 Divert excess rainwater runoff away from the septic tank and leaching field system.
 Keep trees and deep-rooted plants and shrubs away from the immediate area that may
intrude or clog the system.
 Do not park or drive heavy vehicles or equipment over the septic system or any of its
components.
Reference: DOH AO No. 2019-0047 “National Standard on the Design, Construction,

Operation and Maintenance of Septic Tank Systems”
9.4.5.2 Centralized basic system
Basic centralized systems consist of primary treatment (sand catchment and

screen to remove large particles) and an anaerobic secondary treatment system.
This is recommended for HCF to minimize maintenance, allow more advanced
treatment, and improve the monitoring of the wastewater system. Typical secondary
treatment systems include: (1) baffled flow reactors; (2) anaerobic filters; (3) Imhoff
tank; and (4) upflow anaerobic sludge blanket reactor. Most of the systems allow for
the harvesting of methane biogas if facilities are available. The effluents can be
further treated. If this is not possible, a controlled discharge to soakaway pits or
leachfields should be carried out.
A. Soakaway Pits
A soakaway pit should have one or more tanks, with the total volume equal to
the wastewater-treatment plant. Effluents from the treatment plant are collected
and allowed to infiltrate into the ground. The pit may be filled with stones, broken
bricks or similar material or may be lined with open-jointed masonry. The top 0.5
meter of the pit should be lined solidly, to provide firm support for a reinforced
concrete cover. Planting trees adjacent to or over a soakaway can improve liquid
removal through transpiration and increased soil permeability.
B. Leachfields
When larger amounts of wastewater need to be infiltrated (e.g., district hospitals),

a leachfield is often a better solution. Leachfields consist of gravel-filled underground
trenches, called leachlines, which allow the liquid effluent from the wastewater
treatment to permeate into the ground. A leachfield may be characterized by:
open-jointed (stoneware) or perforated (polyvinyl chloride) pipes carry the liquid
effluent into the leachfield; trenches that are usually 0.3–0.5 meter wide and 0.6–1.0
meter deep (from the top of the pipes) and laid with a 0.2–0.3% gradient of gravel
(20–50mm diameter), covered by a 0.3–0.5 meter layer of soil.
9.4.5.3 Lagoon system
In an individual HCF that cannot afford sophisticated sewage-treatment plants,

and where infiltration of the wastewater is not possible, a lagoon system is a basic
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solution for treating wastewater, if enough land is available. There are two lagoon
systems that can be considered; aerated lagoon and facultative lagoon.
A. Aerated Lagoons
Oxygen is supplied by mechanical surface aeration thus requires comparatively
high operational costs due to electricity.
B. Facultative Lagoons
Oxygen is supplied primarily by algae. Facultative means the presence of an

anaerobic bottom region below an aerobic top layer. Facultative lagoons consist of
a shallow basin in which settleable solids carried by the wastewater fall to the bottom
and form a sludge layer that decomposes anaerobically. Facultative lagoons can
have the disadvantages of potentially generating pungent odors, variable effluent
quality, and a need for a large land surface area.
Box 40: Guide to basic wastewater system
Basic systems can reduce the risk of waterborne diseases drastically if appropriately planned
and implemented; more advanced systems reduce the risk further. Pharmaceuticals and
other hazardous liquid wastes in wastewater may form a serious future problem and must be
carefully observed and minimized. This includes reducing to an absolute minimum the
presence of antibiotics and pharmaceutical residues in wastewater. A good, well-maintained
sewerage system is as important as an efficient wastewater-treatment plant.
 Enforce liquid hazardous waste management; segregate and pre-treat hazardous waste.
 Set up a maintenance system for the sewers and the septic tanks, provide maintenance
equipment and clean septic tanks regularly.
 Set up a budget line to cover wastewater-treatment costs.
 Ensure that chemical disinfection is only used when the suspended organic matter in
wastewater is >10 mg/l.
 Replace any broken or non-watertight septic tanks and install sewer pipes with watertight
joints.
 Install grease traps for the kitchen wastewater and clean regularly.
 Regularly inspect the sewerage system and repair whenever necessary.
 Introduce tertiary treatment systems such as sand filtration or a subsurface horizontal
gravel filter overplanted with vegetation to increase transpiration.
 Disinfect the wastewater by UV or change to chlorine dioxide or ozone (a combination
of UV and ozone is most effective).
 Neutralize wastewater from laboratories before discharge into the sewerage system.
 Set up an “antibiotic committee” to minimize the usage of antibiotics within the HCF.
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Health Care Waste Management Manual PART III—ADMINISTRATIVE CONTROLS AND REQUIREMENTS
Fourth Edition Chapter 10: Administrative Requirements
PART III—ADMINISTRATIVE CONTROLS AND

REQUIREMENT
124
10 Administrative Requirements
Appropriate HCWM practices depend largely on the administration and
organization and require adequate legislative and financial support, as well as the
active participation by trained and informed staff.
10.1 Oversight and Management at the National and Local Levels

In the Joint DENR-DOH Administrative Order No. 02, Series of 2005, specific duties
and responsibilities have been indicated for the Department of Environment and
Natural Resources (DENR) through the Environmental Management Bureau (EMB)
and its regional offices, the National Solid Waste Management Commission
(NSWMC) and the department of Health (DOH) through its Center for Health
Development (CHD), Bureau of Health Devices and Technology (BHDT),
Environmental and Occupational Health Office (EOHO) of the National Center for
Disease Prevention and Control (NCDPC), the National Center for Health Facility
Development (NCHFD), and the National Reference Laboratory (NRL) – East Avenue
Medical Center, Quezon City.
Table 8: Responsibilities of implementing and cooperating agencies for HCWM

Agency Responsibilities
DENR through the  Formulate an implement pertinent rules and regulations on the
EMB and its regional management of HCW in the Philippines, particularly concerning the
offices issuance of necessary permits and clearances for the Transport,
Treatment, Storage and Disposal of such wastes, as governed by PD 1586,
RA 6969, RA 8749, RA 9275, and RA 9003;
 Formulate policies, standards, and guidelines on the transport, treatment,
storage, and disposal of HCW;
 Oversee compliance by generators, transporters, TSD facility operators,
and/or final disposal facility operators with the proper transport,
treatment, storage, and disposal of HCW;
 Conduct regular sampling and monitoring of wastewater in HCFs and TSD
facilities to determine compliance with the provisions of RA 9275;
 Require TSD facility operators and on-site treaters to present to the DENR
copies of the results of microbiological tests on the HCW treated using
autoclave, microwave, hydroclave, and other disinfection facilities prior
to the renewal of their Permits under RA 6969;
 Provide technical assistance and support to the advocacy programs on
HCWM; and
 Notify the DOH on cases of non-compliance or notice of violation issued
to HCF, institutions and establishments licensed by the DOH.
DOH  Include HCWM criteria in the licensing and accreditation requirements for
HCFs;
 Formulate policies, plans, standards, guidelines, systems, and procedures
on the management of HCW;
 Develop training programs and corresponding modules on HCWM;
 Provide technical and resource mobilization to ensure an effective and
efficient implementation of HCWM program;
 Require all HCW TSD facility operators and HCW generators with on-site
waste treatment facilities to use DOH-BHDT registered equipment or
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Agency Responsibilities
devices used for the treatment of HCW;
 Conduct regular performance evaluation of equipment/devices used for
the treatment of HCW by the DOH-BHDT;
 Monitor the microbiological test of treated wastes to ensure compliance
with DOH standards;
 Evaluate the HCF’s compliance with proper HCWM program and provide
incentive program for compliant hospital and for best practices;
 Issue Department Circulars to ensure that all environmental requirements
are complied with; and
 Notify the DENR on actions taken on cases of non-compliance or notice
of violation issued to HCF, institutions and business establishments.
DOH Centers for  Advocate HCWM practices to the Local Chief Executives, key leaders,
Health and other stakeholders;
Development  Monitor HCWM implementation and compliance of DOH-licensed HCF
and submit reports to DOH; and
 Provide technical assistance on HCWM through:
o Training
o Issuance of advisory on the preparation of HCWM Plan as a
requirement for licensing or renewal thereof
o Dissemination of policies, guidelines, and information
o Monitoring and validation of the implementation of HCWM
o Development, reproduction, and dissemination of HCWM IEC
materials
o Participation in any public hearing related to HCWM
Philippine Health  Incorporate the following in the core indicator requirements for HCFs to
Insurance qualify as Center of Safety, Center of Quality and/or Center for
Corporation (PHIC) Excellence:
and other o HCWM Plan being implemented and monitored within the HCF
accrediting bodies/ o Functional organized and established HCWM Committee
agencies o Proper waste management segregation and compliance to
color-coding
o On-site or off-site treatment disposal
o Updated discharge permit
o Waste generator ID
o Adequate signage in place for HCW deposition and other
established criteria for HCFs to meet the standards for safety,
quality, and excellence
Department of  Monitor the compliance of HCFs under its jurisdiction on the proper waste
Interior and Local management, segregation, and disposal;
Government (DILG)  Provide assistance in the provision of an appropriate landfill, collection of
through the waste, and installation of the WWTP within the municipality; and
different Local  Ensure HCF’s compliance with mandatory requirements for the transport,
Government Units treatment storage and disposal of HCW as governed by PD 1586, RA 6969,
(LGUs) RA 8749, RA 9275, and RA 9003.
10.2 Administrative Requirements at the Facility Level

The HCF has to comply with certain administrative requirements for a functional
HCWM. The requirements include the overall aspect of HCWM in the facility including
the organized committee and plan of operations.
The following are the administrative requirements for the HCF:
1) Organization of a HCWM Committee
a) Identification of functions, roles, and responsibilities
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b) Designation, identification, and appointment of core members

2) Formulation of a comprehensive HCWM Plan
a) Assessment of waste generation and waste disposal
b) Review of existing HCWM policies and procedures being
implemented
c) Formulation and drafting of HCWM Plan
3) Adoption of different approaches to waste management as tools in the
development of HCWM Plan:
a) Life Cycle Analysis (LCA) is a “cradle to grave” approach to
estimate the cumulative environmental impacts associated with
the life cycle (manufacture, use and maintenance to its final
disposal) of a product, process, or service.
b) Environmental Management System (ISO 14001) is a continuous
process of improvement which involves environmental planning,
implementation, checking and management review on the
programs being implemented within the HCF in compliance with
existing environmental and HCWM laws and policies.
4) Monitoring and Evaluation of the HCWM Plan – This is to validate the
effectiveness and the efficiency of the HCWM Plan. This includes using the
designated tools such as Self-Monitoring Sheet (for links, please refer to
ANNEX D 4 of this Manual). The six major parameters that will be used to
determine the extent of the plan implementation are the following:
a) Waste Minimization Practices
b) Waste Segregation
c) Waste On-Site Collection, Transport and Disposal
d) Waste Treatment On-Site (if applicable)
e) Wastewater Management
f) Administrative Control
5) Communication and Training – All HCFs, the DOH and the EMB-DENR have
the responsibility and a “duty of care” for the environment and public
health, particularly in the institutionalization of awareness among HCW
and the general public. (please refer to Chapter 11.6 for detailed discussion)
a) Methods of communication and training used
b) Training of health care workers
c) Training package for each target group
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10.3 Budgetary Requirements to Implement the HCWM Program

The benefits of HCWM are in terms of infection control, protection of HCF workers,
and the protection of the environment and the accreditation of the HCF with the
national social health insurance scheme or PhilHealth. To realize these benefits and
be compliant with the existing laws and policies, the HCF needs to identify the most
cost-effective option that fits its needs and financial capacities. Consequently, each
HCF should be financially responsible for the safe management of any waste it
generates. This is in accordance with the widely accepted “polluter pays” principle
and the obligation of the duty of care.
10.3.1 Investment and Operations Cost
The costs of separate collection, packaging and on-site handling are internal to
the establishment; while costs of off-site transport, treatment and final disposal are
external and paid to the contractors who provide the service. The costs that will be
incurred by the HCF in managing HCW will include:
10.3.1.1 Waste segregation and on-site handling
Proper segregation and on-site handling of wastes includes the cost for the
following materials, goods, and services:
 Waste bins, color-coded plastic liners that shall be placed in appropriate
locations in the hospital, transport trolleys and collection bins;
 Proper labels for the waste bins, tags for the plastic liners and
signage/posters;
 Training of personnel to place wastes in the appropriate containers and to
handle them in a safe manner;
 IEC materials;
 Storage spaces for HCW within the HCF, spill kits and measure to secure
and protect the wastes when needed;
 PPE needed to safely and properly handle wastes;
 Occupational health and safety measures such as immunization;
 Sealer for plastic liners and packing the wastes for transport if the
treatment facility is located at a distance from the HCF;
 Transportation borne by the HCF; and
 Operating and maintenance costs including salaries and wages.
Segregation of wastes effectively reduces the amount of wastes needed for
transport (if located off-site), treatment and disposal at the treatment facility.
Investments in training and equipment may not be offset by lower costs. However,
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total costs to the environment will diminish because the inclusion of materials that
may release harmful substances to the environment during treatment processes is
lessened.
10.3.1.2 Waste treatment
Establishing and operating an on-site waste treatment include the investment

and operating costs listed below:
 Non-burn waste treatment technology and its accessories and related
processes;
 Microbiological testing equipment and supplies;
 Installation and facility costs: installation labor, facility modifications –
cement pad/s, curb cuts, sewers, electricity, space, security, etc.;
 Costs of pollution control equipment if required to control emissions and
effluents from the facility (e.g., wastewater treatment plant);
 Construction of temporary storage and hauling areas for treated wastes;
 Direct labor costs: number of HCF workers needed to operate the
treatment and disposal equipment;
 “Down time” costs: including repair (parts and labor) and alternative
treatment;
 Operating costs if the facility uses special chemicals and catalysts;
 Utility costs;
 Permitting and compliance fees: water and air monitoring fees,
Environmental Compliance Certificate (ECC), Discharge Permit (DP),
Permit to Operate (PTO) Pollution Source Equipment (e.g., generator sets),
and registration with the DENR as waste generator, treater and/or
transporter;
 Fines: depending on permit requirements, national and local regulations;
violations of permits or emissions which may result to the payment of fines;
 All transportation, processing, and tipping fees;
 Supply costs – personal protective equipment, spill supplies, special bags
(e.g., some autoclaving systems require specific bags), collection
containers (boxes or reusable containers);
 Community approval cost if a public hearing is required; and
 Sterilization equipment.
In cases where the HCF enters into a contract with a DENR-accredited TSD, the
costs that will be incurred by the HCF will be charges of the waste treater and the
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associated transportation costs. Investment in on-site treatment facilities may be

costly but allows the HCF to control how the waste is treated as well as the costs
associated with treatment. Off-site treatment facilities, when available, may be more
costly in the long run but it allows the HCF to concentrate on its basic occupational
function and not on operations it is not built to do, which is the treatment of waste.
10.3.1.3 Disposal
Disposal to a sanitary landfill is considerably more costly than disposal in open

dumpsites; sanitary landfills may charge a higher fee for waste coming from HCFs. In
evaluating treatment options, costs with relation to final disposal shall be considered
since treatment systems can almost eliminate wastes altogether (pyrolysis) but some
even increase the weight of wastes (steam systems without dryers). Care shall also
be taken to render the wastes unrecognizable.
The following are some costs that should be considered when using an on-site
facility for the disposal of treated waste:
 Construction of temporary storage and hauling areas for treated waste;
 Costs related to wastes not handled by the hauler;
 Cost of encapsulation, inertization, septic vault;
 Labor costs for hauling, labelling, waste documentation, security, and
maintenance of temporary storage areas;
 Hauling costs;
 Transport containers; and
 Landfill tipping fees.
10.3.2 Costing Tools
The WHO prepared two (2) costing tools to help calculate the true cost of setting
up an HCWM system: the Costing Analysis Tool (CAT), which estimates the costs of
HCWM at the national and HCF levels; and the Expanded Costing Analysis Tool
(ECAT), which is a modified version of the CAT and estimates costs at the HCF, central
treatment facility, or cluster and national levels.
Both costing tools require some basic data, such as the amounts of waste
generated and the number of facilities, and then apply assumptions to compute
average annualized capital and operating costs for HCFs of different bed sizes, as
well as costs on the national level. Users can input specific values (such as the unit
price of a wheeled cart or the wage rate) or use the default values in the tool. CAT
deals only with on-site treatment. ECAT expands on CAT by differentiating between
low-, middle-, and high-income countries; providing more size categories for HCFs
(based on number of beds); presenting more treatment options (autoclaves and
autoclave shredders, incinerators, microwave treatment, and hybrid steam
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treatment systems); and allowing the user to define a mix of centralized and
decentralized treatment.
Links to these tools are provided in ANNEX F 1 of this Manual.
10.3.3 Measures to Reduce Costs
In the long run, cost reductions can be achieved by implementing the following
measures at the different stages in the management of wastes:
A. Comprehensive Planning
 Development and implementation of a comprehensive HCWM Plan which

includes the recommendations below on on-site management;
 Designing all elements of the system to be of adequate capacity in order
to obviate the need for subsequent costly modifications;
 Anticipating future trends in waste production and the likelihood of
legislation becoming more stringent;
 Planning collection and transport in such a way that all operations are safe
and cost-efficient;
 Possible cooperative use of regional waste treatment facilities, including
private sector facilities when appropriate; and
 Establishment of wastewater disposal plan
B. On-site Management (Source Reduction, Recycling, and Re-Use)
 Comprehensive management of chemicals and pharmaceuticals stores,

which includes centralized purchase and use of chemicals and
pharmaceuticals; and the centralized monitoring of chemical flows within
the HCF;
 Improved waste identification to simplify segregation, treatment, and
recycling;
 Reduction of the amount of material used to accomplish tasks (e.g., use
of email instead of paper and the use of smaller amounts of disinfectant
to clean rooms);
 Reduction of toxicity of the materials used in order to reduce the disposal
costs and the hazards to the HCF workers. Purchase of materials that may
be reused and recycled such as in the case of disposable medical care
items and reusable salad plates for the hospital cafeteria;
 Practice just in time delivery in order to minimize on wastes incurred due to
the expiry of items like drugs and chemicals; and
 Adequate segregation of waste to avoid costly or inadequate treatment
of waste that does not require it.
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C. Adequate Treatment and Disposal Method
 Selection of a treatment and disposal option that is appropriate for waste

type and local circumstances;
 Use of treatment equipment appropriate type and capacity; and
 Possible cooperation between local HCFs.
D. Measures at Worker Level
 Establishment of training programs for HCF workers to improve the quality

and quantity of work; and
 Protection of HCF workers against occupational risks.
E. Documentation
 Documentation of waste management and assessment of the true costs

makes it easier to identify priorities for cost reduction and to monitor
progress in the achievement of objectives.
10.4 Options for Financing

HCWM may be financed through in-house funds of the HCF, revenues from
recyclable waste, loans from credit facilities and through sub-contracting,
partnerships or joint venture with other institutions providing TSD services (sharing
WWTP, waste treatment, mercury storage).
Government-owned or private HCF may use internal revenues to pay for the cost
of the HCWM system. The costs of managing HCW shall be covered by a separate
budget line item in the HCF budget. In case in-house funds are not available, HCF
and TSD facilities can avail of credit financing for the investment and operation costs
of HCW treatment, wastewater treatment, and air pollution control devices from loan
facilities, such as the Environmental Infrastructure Support Credit Program (EISCP) of
the Development Bank of the Philippines (DBP).
Privatization is a method of financing various types of public works, including
HCWM. Under such an arrangement a private entity finances, designs, builds, owns,
and operates the treatment facilities and sells its collection and disposal services to
government and private HCF. Privatization is an option that may be considered
under the following conditions:
 Inability of hospitals to raise the needed capital;
 Expected greater efficiency in the private sector because of fewer
constraints than in the public sector (e.g., greater flexibility in purchasing
and personnel policies, allowing for more rapid adaptation to changing
needs); and
 Transfer of responsibility for proper operation and maintenance to an
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organization with more resources for minimizing risk.

However, a perceived disadvantage of privatization is the potential loss of overall
control of waste management operations by the HCF. The risk of a service failure is
minimized where a facility has a well-functioning contract management team in
place and has negotiated a contract with penalties for poor service.
In contracting with the private sector, the agreement between the private
operator and the HCF shall include agreements on the following issues:
 Minimum risk level of service, especially with regards to reliability, safety,
public health risk and future expansions;
 Future increases in cost resulting from factors that cannot be fully assessed
at the outset;
 Environmental concerns;
 Future transfer of ownership of the facilities; and
 Regular inspection and regulatory control.
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Fourth Edition Chapter 11: Health and Safety Practices
11 Health and Safety Practices

HCWM policies, plans, and programs shall include provision for the health and
safety of HCF workers. Educating the HCF workers on the risks associated with HCW
shall be part of this policy. Established policies and procedures ensuring the health
and safety of HCF workers from generation, segregation, storage, to collection,
transport, treatment, and disposal of HCW shall be consistently implemented and
complied by all concerned. The purpose of this chapter is to explain the hazards and
infection risks they may encounter, and the prevention and control of exposure to
them. HCWM policies or plans should include arrangement for the continuous
monitoring of workers’ health and safety.
11.1 Principles
Sensible occupational health and safety measures include the following:
 Develop a standardized set of management rules and operating
procedures for HCW, when respected by personnel and monitored by the
hospital management, can dramatically reduce the risk of accidents.
Hospital staff should be taught and kept informed about the HCWM system
and procedures in place.
 Inform and train waste workers so that they perform their duties properly
and safely. Training in health and safety is intended to ensure that workers
know of and understand the potential risks associated with HCW, and the
rules and procedures they are required to respect for its safe
management.
 Involve waste workers in hazards identification and recommendations for
prevention and control. Workers at risk from infection and injury include
health care providers, cleaners/maintenance staff, treatment equipment
operators, and all personnel involved in waste handling and disposal within
and outside HCFs.
 Provide equipment and clothing for personal protection. They should be
informed on the importance of consistent use of personal protective
equipment (PPE) and should be aware of where to obtain post-exposure
follow-up in case of a needle-stick injury or other blood exposure.
 Establish an occupational health program that includes information,
training, and medical measures when necessary, such as immunization,
post-exposure prophylactic treatment and regular medical surveillance.
Health care personnel should be trained for emergency response if injured
by a waste item, and the necessary equipment should always be readily
available. Written procedures for the different types of emergencies
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should be drawn up.

To limit the risks, the hospital management must set up management rules and
operating procedures for HCW and establish standardized emergency procedures.
It is the responsibility of everybody involved in handling waste to know the
emergency procedures and to act accordingly.
11.2 Occupational Health Risks

11.2.1 Cytotoxic Safety
In hospitals that use cytotoxic products, specific guidelines on their safe handling
should be established for the protection of personnel. These guidelines should include
rules on the following waste handling procedures:
 Separate collection of waste in leak-proof bags or containers and labelling
for identification;
 Return of outdated drugs to suppliers;
 Safe separate storage of genotoxic waste away from other HCW;
 Arrangements for the disposal of contaminated material, the
decontamination of reusable equipment and the clean-up of spillages;
and
 Arrangements for the treatment of infectious waste contaminated with
cytotoxic products, including excreta from patients, disposable linen, and
absorbent material for incontinent patients.
The following measures are important to minimize exposure:
 Written procedures that specify safe working methods for each process;
 Data sheets, based on the suppliers’ specifications, to provide information
on potential hazards and their minimization;
 Established procedure for emergency response in case of spillage or other
occupational accident (such as needle prick injury—refer to ANNEX C 7); and
 Appropriate education and training for all personnel involved in handling
of cytotoxic drugs.
Hospital staff should ensure that the families of patients undergoing
chemotherapy at home are aware of the risks and know how they can be minimized
or avoided. The senior pharmacist at the HCF should be made responsible for
ensuring the safe use of cytotoxic drugs. Large oncological hospitals may appoint a
full-time genotoxic safety officer, who should also supervise the safe management
of cytotoxic waste.
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11.2.2 Other Health Hazards
Actual cases of non-sharps waste being demonstrated to cause an infection in

health care personnel and waste workers are rarely documented. HCW handlers are
at greatest risk from infectious hazards, which include chemical exposures such as
chemotherapeutic drugs, disinfectants, and sterilants; physical hazards such as
ionizing radiation; and ergonomic hazards. The risk of acquiring a secondary
infection following needle-stick injury from a contaminated sharp depends on the
amount of the contamination and nature of the infection from the source patient.
The risk of infection with hepatitis B is more than 10 times greater than for hepatitis C,
and up to 100 times greater than for HIV.
Table 9: Hazards to health care workers

Hazards Health Effects Control Measures
Sharps injuries  Infections with hepatitis B or  Immunization against Hepatitis B virus
and resulting C, HIV, malaria or other (WHO, 2009)
exposure to bloodborne infections  Appropriate disposal of sharps at site of
bloodborne (Prüss-Ustün, Rapiti & Hutin, use into a puncture-resistant container
pathogens 2005) without recapping (Hutin et al., 2003; WHO,
2010);
 Use of engineered needles that
automatically retract, blunt re-sheath, or
disable the sharp (CDC, 1997;
Lamontagne et al., 2007
Other  SARS (WHO, 2007a, 2009b)  Exhaust ventilation (natural or mechanical)
biological  Tuberculosis, Influenza (WHO, 2009c,2009d)
hazards
Chemicals  Skin and respiratory  Substitute soap and water for cleaning
Chlorine sensitization (International chemicals
disinfectants Programme on Chemical  Avoid soaking of sharps in chlorine when
(sodium Safety, 1999; Zock et al., they will receive autoclaving or
hypochlorite) 2007) Eye and skin irritation, incineration before disposal Dilute
weakness, exhaustion, chemicals appropriately according to
drowsiness, dizziness, manufacturer for less toxic exposure (Zock,
numbness and nausea Vizcaya & Le Moual, 2010
High-level  Irritation of the eyes, nose  Substitute steam sterilization except for
disinfectant and throat Skin sensitization pressure sensitive instruments (Harrison,
glutaraldehyde Occupational asthma 2000; Pechter et al., 2005)
where the symptoms in  Ensure appropriate dilution and use in
affected individuals include closed, ventilated system
chest tightness and difficulty
in breathing (Mirabelli et al.,
2007)
Sterilants:  Eye and skin irritation,  Substitute steam sterilization for ethylene
ethylene oxide difficulty breathing, nausea, oxide except for pressure-sensitive
(International vomiting, and neurological instruments (EPA, 2002)
Programme in problems such as  Use only in a closed and ventilated system
Chemical headache and dizziness.
Safety, 2003  Reproductive hazard, linked
to nerve and genetic
damage, spontaneous
abortion and muscle
weakness Carcinogen
(IARC, 1999)
Heavy lifting  Back injuries and  Reduce mass of objects or number of
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Handling heavy musculoskeletal disorders loads carried per day (Nelson, 2003)
loads over long (Schneider & Irastorza, 2010)
Use waste carts with wheels, automated

periods Degenerative diseases of waste transfer from cart to truck and
the lumbar spine treatment Use lifts and pulleys to assist in
transferring loads
Ionizing  Irreversible damage of cells,  Safe waste management, in full
radiation anemia, leukemia, lung compliance with all relevant regulations.
cancer from inhalation (Niu, must be considered and planned for at
Deboodt & Zeeb, 2010) the early stages of any projects involving
radioactive materials It should be
established from the outset that the waste
can be properly handled, treated and
ultimately disposed of See International
Atomic Energy Agency for national
regulatory standards and safety guidance
(IAEA, 1995)
Source: Safe Management of Wastes from Health-Care Activities, 2nd Edition (WHO, 2014)
11.3 Exposure Prevention and Control

A proper and safe segregation system for hazardous waste is the key to
occupational safety and environmental sound handling. Implementing a proper
segregation system must be accompanied by safe and standardized handling
procedures.
11.3.1 Hierarchy of Controls for Bloodborne Pathogens
Methods to control occupational hazards have traditionally been discussed in

terms of hierarchy and presented in order of priority for their effectiveness in
preventing exposure to the hazard or preventing injury resulting from exposure to the
hazard. Controlling exposures to occupational hazards is the fundamental method
of protecting workers. Hierarchy of controls has been used as a means of determining
feasible and effective controls. One representation of this hierarchy can be
summarized as follows.
11.3.1.1 Elimination and Substitution
Complete removal of a hazard from the work area. Elimination is the method
preferred in controlling hazards and should be selected whenever possible. While
most effective at reducing hazards, also tend to be the most difficult to implement
in an existing process. If the process is still at the design or development stage,
elimination of hazard and substitution of control may be inexpensive and simple to
implement.
On existing process, major changes in equipment and procedures may be
required to eliminate hazards or substitute control. Examples include removing sharps
and needles and eliminating all unnecessary injections. Jet injectors may substitute
for syringes and needles. All unnecessary sharps, such as towel clips, should also be
eliminated, and needleless systems should be used.
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11.3.1.2 Engineering Control
Engineering control is used to remove a hazard or place a barrier between the

worker and the hazard. This includes designing the facility, equipment and processes
to eliminate or minimize the hazards; substituting the processes, equipment, devices,
materials or other factors to lessen the hazards; isolating the hazard by enclosing the
source or putting barriers between the source of hazard and the exposed workers;
using interlocks, machine guards, blast sheets, protective curtains and/or other
means; removing or redirecting the hazard using local exhaust ventilation; and
adopting complete mechanization or computerization.
Well-designed engineering controls can be highly effective in protecting workers
and are typically independent of worker interactions. The initial cost of engineering
controls can be higher than the cost of administrative controls or PPE, but over the
long term, operating costs are frequently lower, and in some instances, can provide
cost savings in other areas of the process.
11.3.1.3 Administrative Control
Policies to limit exposure to a hazard (e.g., universal precautions). Includes

assessment of risks, medical controls including provision of PPEs, establishment of
waste management policies, procedures, guidelines, and activities, conduct of
regular and effective training, management of human resources and procurement
of appropriate equipment and supplies. Administrative controls and PPE are
frequently used with existing processes where hazards are not particularly well
controlled. While relatively inexpensive to establish, it can be very costly to sustain
over the long term.
Examples include allocation of resources demonstrating a commitment to staff
safety, an infection-control committee, an exposure control plan, replacement of all
unsafe devices and consistent training on the use of safe devices. These methods for
protecting workers have also proven to be less effective than other measures,
requiring significant effort by the affected workers. Medical control includes written
policies with standard operating procedures on the following:
 Patient Safety which includes proper patient identification, assurance of
blood safety, safe clinical and surgical procedures, provision and
maintenance of safe quality drugs and technology, strengthening of
infection control, maintenance of environment care standards and
energy/waste management standards. Administrative Order 2008-0023 of
the DOH requires Patient Safety program to have the key elements of
leadership, institutional development, reporting system, feedback and
communication, adverse event prevention and risk management,
disclosure of reported serious events, professional development, and a
patient centered care and empowerment.
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 Occupational Health and Safety which includes physical examination

(pre-employment and annual), regular immunization, health education
and wellness, and continuous medical monitoring and periodic evaluation
of safety measures.
11.3.1.4 Work Practice Controls
These are controls that reduce exposure to occupational hazards through the
behavior of workers. Examples include no needle recapping, placing sharps
containers at eye level and at arm’s reach, emptying sharps containers before they
are full, and arranging for the safe handling and disposal of sharps devices before
beginning a procedure.
11.3.1.5 Personal Protective Equipment (PPE)
This refers to specialized clothing or equipment worn by a worker designed to

protect against infectious materials or from exposure to infectious agents thus,
preventing injury or illness from a specific hazard. Adequate and appropriate PPE
shall be provided to HCF workers who are exposed to hazardous waste. This includes
protection for the whole body – head, face, body, arms, legs, and feet.
The most effective PPE in reducing risk of injury are gloves to protect from
exposure to blood, other potentially infectious materials, and chemicals; particulate
masks (respirators) to protect from respiratory infections hazards and particulates
from burning waste; and boots for waste handlers to protect from sharps injuries to
the foot. Availability and access to soap and water, and alcohol hand rub, for hand
hygiene are also important to maintain cleanliness and inhibit the transfer of infection
via dirty hands.
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Box 41: Required PPEs for health care workers
The type of protective clothing used will

depend to an extent upon the risk associated
with the HCW, but the following should be
made available to all personnel who collect or
handle waste:
Obligatory
 disposable gloves (medical staff) or heavy-
duty gloves (waste workers)
 industrial aprons
 overalls (coveralls)
 leg protectors and/or industrial boots
Depending on type of operation

 eye protectors (safety goggles)
 face masks (if there is risk of splash into
eyes)
 helmets, with or without visors.
Industrial boots and heavy-duty gloves are

particularly important for waste workers. The
thick soles of the boots offer protection in the
storage area, as a precaution from spilt sharps, and where floors are slippery. If segregation is
inadequate, needles or other sharps items may have been placed in plastic bags; such items
may also pierce thin-walled or weak plastic containers.
If it is likely that HCW bags will come into contact with workers’ legs during handling, leg
protectors may also need to be worn.
HCF workers should know the correct usage and maintenance of the equipment.
PPE shall conform to established standards. Training on PPE shall include:
 Description on the type of hazard and the condition of the work
environment – determination of waste management concerns, working
conditions, materials, equipment, and substances used, the exposed
populations and conditions of exposure, taking into account the adverse
effects on human health and to the environment.
 Explanation on why a certain type of PPE has been selected – based on
the hazards present, the type of materials used and the manner in which
they will be handled.
 Explanation on its proper use, maintenance, and storage – PPE shall be
kept safe and in good condition. Defective PPE shall be discarded. Since
PPEs have limitations and useful life, these must be regularly inspected for
its effectiveness.
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11.4 Hospital Hygiene and Infection Control

Management of HCW is an integral part of hospital hygiene and infection control.
HCW can be considered as a reservoir of pathogenic microorganisms, which – if
someone is exposed – could give rise to an avoidable infection. If waste is
inadequately managed, these microorganisms can be transmitted by direct
contact, by inhalation or by a variety of animal vectors (e.g., flies, rodents, roaches),
which could come into contact with waste.
A basic infection-control principle is to know the chain of infection and identify
the most effective points to prevent potential disease transmission. Transmission of
infectious diseases in an HCF requires at least six elements: an infectious agent, a
reservoir, a portal of exit, a means of transmission, a portal of entry, and a susceptible
host. This concept has been discussed in Chapter 3 of this Manual.
11.4.1 Epidemiology of nosocomial infections
Nosocomial infections (also known as hospital-acquired infections, hospital-

associated infections, and hospital infections) are infections that are not present in
the patient at the time of admission to the HCF but develop during the course of the
patient’s stay.
Nosocomial infections occur as a result of medical procedures performed on
patients that lead to infections from a patient’s own (endogenous) flora or as a result
of exposure to items contaminated with infectious agents. Additionally, the risk of
acquiring an infection increases for patients with altered or compromised immunity.
11.4.1.1 Transition from exposure to infection
Whether an infection will develop after an exposure to microorganisms depends

upon the interaction between the microorganisms and the host. Healthy individuals
have a normal general resistance to infection. Patients with underlying disease,
newborn babies and the elderly have less resistance and are at greater risk to
develop an infection after exposure.
Local resistance to infection also plays an important role: the skin and the mucous
membranes act as barriers in contact with the environment. Infection may occur
when these barriers are breached. Local resistance may also be overcome by the
long-term presence of an irritant, such as a cannula or catheter. The likelihood of
infection increases daily when a patient has a catheter attached.
The most important determinants of infection are the nature and number of the
infectious agents. Microorganisms range from the completely innocuous to the
extremely pathogenic; the former will never cause an infection even in
immunocompromised individuals, while the latter will cause an infection in virtually
every case of exposure.
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When only a few organisms are present, an infection will not necessarily develop.
However, when a critical number is exceeded, it is very likely that an infection will
become established. For every type of microorganism, the minimal infective dose
can be determined. This is the lowest number of bacteria, viruses or fungi that cause
the first clinical signs of infection in a healthy individual. For most causative agents of
nosocomial infections, the minimal infective dose is relatively high.
11.4.1.2 Sources of infection
In an HCF, the sources of infectious agents may be the personnel, the patients, or
the inanimate environment.
 The hospital environment can be contaminated with pathogens.
Salmonella or Shigella spp., Escherichia coli O157:H7 or other pathogens
may be present in the food and cause an outbreak.
 Waterborne infections may develop if the water-distribution system breaks
down.
 Pharmaceuticals may become contaminated during production or
preparation; an outbreak of infection by Pseudomonas aeruginosa,
Burkholderia cepacia or Serratia marcescens may occur as a
consequence.
 The source of a nosocomial infection may also be a health care worker
who is infected or colonized (a carrier) with an infectious agent.
 The source of most hospital epidemics is infected patients; that is, patients
infected with pathogenic microorganisms are often released into the
environment in very high numbers exceeding the minimal infective dose,
and exposing other patients, who subsequently develop hospital-acquired
infections.
11.4.1.3 Routes of transmission
In health care settings, the main modes of transmission from a source to a new
host are as follows:
 Contact Transmission
o Direct contact (e.g., a surgeon with an infected wound on a finger
performs a wound dressing);
o Indirect contact (e.g., secretions transferred from one patient to
another via hands in contact with a contaminated waste item);
o Fecal–oral via food
 Bloodborne Transmission
o Blood is transferred via sharps or needle stick injuries, transfusion, or
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injection.
 Droplet Transmission
o Infectious droplets expelled into the air or onto a surface (e.g., when
sneezing, coughing, vomiting); the droplets are too heavy to remain
in suspension in the air and typically fall <2 meters from the source;
o Direct droplet transmission – droplets reach mucous membranes or
are inhaled;
o Droplet-to-contact transmission – droplets contaminate
surfaces/hands and are transmitted to another site (e.g., mucous
membranes); indirect droplet transmission is often a more efficient
transmission route than direct transmission (examples are the
common cold, respiratory syncytial virus)
 Airborne Transmission
o Small particles carrying microbes are transferred as aerosols via air
currents for >2 meters from the source (e.g., droplet nuclei or skin
scales); direct airborne transmission can be from particles in
suspension in air (e.g., varicella zoster) or from deposition on to
contaminated wounds (e.g., staphylococcus aureus) (Siegel et al.,
2007).
 Vector Transmission
o Typical in areas where insects, arthropods and other pests are
widespread; these vectors become exposed to a disease organism
(such as on the feet of flying insects) through contact with excreta
or secretions from an infected patient and transmit the infective
organisms directly to other patients.
11.4.2 Prevention of Nosocomial Infection
Two basic principles govern the main control measures to prevent the spread of
nosocomial infections in HCFs: 1) Separate an identified source of infection from
other patients and medical areas; and 2) Eliminate all obvious routes of transmission.
The separation of the source has to be interpreted in a broad sense. It includes
the isolation of infected patients and implements aseptic conditions by introducing
measures intended to act as a barrier between infected or potentially contaminated
tissue and the environment, including other patients and medical staff.
11.4.2.1 Standard Precautions
These should be taken with every patient, independent of any known condition
(e.g., infected or colonized), to protect health care workers from exposure to
infectious disease. It is impossible to avoid all contact with infected tissue or
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potentially contaminated body fluids, excreta, and secretions. Even when they are
not touched with the bare hands, they may come in contact with instruments,
containers, linen or similar items.
11.4.2.2 Isolation
The first measure in preventing the spread of nosocomial infections is the isolation
of infected patients. Maintaining isolation is expensive, labor-intensive, and usually
inconvenient for both patients and health care personnel. Its implementation should
be adapted to the severity of the disease and to the causative agent.
11.4.2.3 Cleaning
Cleaning is one of the most basic measures for maintaining hygiene in the health
care environment. It is essentially a mechanical process whereby the dirt is dislodged
from a surface, suspended, or dissolved in a water film, diluted until it is no longer
visible, and rinsed off. Soaps and detergents act as solubility-promoting agents.
Cleaning should be carried out in a standardized manner and preferably by
automated means that will guarantee an adequate level of cleanliness. Diluting and
removing the dirt also removes the breeding ground or culture medium for bacteria
and fungi. Most non-sporulating bacteria and viruses survive only when they are
protected by dirt or a film of organic matter; otherwise, they dry out and die.
11.4.2.4 Sterilization and disinfection
The effectiveness of disinfection and sterilization is increased by prior or

simultaneous cleaning. Self-evidently, an object should be sterile (i.e., free of
microorganisms) after sterilization. However, sterilization is never absolute; by
definition, it reduces the number of microorganisms by a factor of more than 106 (i.e.,
more than 99.9999% of microorganisms are killed).
The term “disinfection” is difficult to define, because the activity of a disinfectant
process can vary widely. The guidelines for environmental infection control in HCFs
(CDC, 2003) allow the following distinctions to be made:
 High-Level Disinfection: can be expected to destroy all microorganisms,
except for large numbers of bacterial spores;
 Intermediate Disinfection: inactivates Mycobacterium tuberculosis,
vegetative bacteria, most viruses, and most fungi; does not necessarily kill
bacterial spores;
 Low-Level Disinfection: can kill most bacteria, some viruses, and some
fungi; cannot be relied on to kill resistant microorganisms such as tubercle
bacilli or bacterial spores.
There is no ideal disinfectant, and the best compromise should be chosen
according to the situation. A disinfectant solution is considered appropriate when
the compromise between the antimicrobial activity and the toxicity of the product
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is satisfactory for the given application. The principal requirements for a good
antiseptic are absence of toxicity, rapid action, and adequate activity on natural
flora and pathogenic bacteria and other microorganisms after a very short exposure
time. Essential requirements for a disinfectant are somewhat different. There must be
adequate activity against bacteria, fungi and viruses that may be present in large
numbers and protected by dirt or organic matter. In addition, since disinfectants are
applied in large quantities, they should be of low ecotoxicity. In general, use of the
chosen disinfectant, at the appropriate concentration and for the appropriate time,
should kill pathogenic microorganisms, rendering an object safe for use in a patient,
or rendering human tissue free of pathogens to exclude cross-contamination. An
overview of the list of different disinfectants are given on ANNEX B 6.
11.4.3 Measures for Improving Infection Control
Infection control can be improved in three ways: 1) avoiding wasteful practices;

2) using good infection-control practices; and 3) using good cost-effective practices.
Table 10: Ways to improve infection control

Eliminate Wasteful Practices Use Good, No-Cost Infection Use Good, Low-Cost Infection
That Just Increase Costs Control Practices Control Practices
Avoid: You should: You should:
 routine swabbing of health  use aseptic technique for  provide education and
care environment to all sterile procedures practical training in
monitor standard of  remove invasive devices standard infection control
cleanliness when no longer needed (e.g., hand hygiene,
 routine fumigation of  isolate patients with aseptic technique,
isolation rooms with communicable diseases or appropriate use of PPE, use
formaldehyde a multidrug-resistant and disposal of sharps)
 routine use of disinfectants organism on admission  provide hand-washing
for environment cleaning,  avoid unnecessary vaginal material throughout the
e.g., floors and walls examination of women in HCF (e.g., soap and
 inappropriate use of PPE in labor alcoholic hand
intensive-care units,  minimize the number of disinfectants)
neonatal units and people in operating  use single-use disposable
operating theatres theatres sterile needles and syringes
 use of overshoes, dust-  place mechanically  use sterile items for invasive
attracting mats in the ventilated patients in a procedures
operating theatres, and semi-recumbent position  avoid sharing multi-dose
intensive-care and vials and containers
neonatal units between patients
 unnecessary intramuscular  ensure equipment is
and intravenous (IV) thoroughly
injections decontaminated between
 unnecessary insertion of patients
invasive devices (e.g., IV  provide hepatitis B
lines, urinary catheters, immunization for health
nasogastric tubes) care workers
 inappropriate use of  develop a post-exposure
antibiotics for prophylaxis management plan for
and treatment health care workers
 improper segregation and  dispose of sharps in robust
disposal of clinical waste containers
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11.4.4 Minimum Approach to Hygiene and Infection Control
Infection control is a team effort. Therefore, at a minimum, a multidisciplinary

infection-control committee must be organized, comprising (but not limited to): a
senior physician to provide leadership; a clinical microbiologist; an infection-control
nurse; an antibiotic specialist; and a director of environmental services.
The committee should set clear aims that are time specific and measurable, and
that target a specific population of patients, location, or employees. Aims could
include implementing a hand hygiene program and implementing an
environmental cleaning and disinfection program. In summary, the minimum
approach to good hospital hygiene and infection control includes:
 setting modest aims;
 establishing baseline rates;
 implementing evidence-based interventions shown to be effective
elsewhere;
 carrying out daily process surveillance (or clinical audit) throughout the
project period to monitor compliance with the interventions by staff;
 measuring rates again at the end of the project period;
 if desired improvements have not occurred, analyzing the reasons (e.g.,
poor compliance with the interventions); and
 implementing necessary changes and repeating the cycle.
11.5 Occupational Health and Safety Program

11.5.1 Immunization
A. Pre-employment Immunization
HCF workers shall be given immunization to prevent or ameliorate the effects of

infection by many pathogens such as virus causing hepatitis B and tetanus infection.
Many HCF workers are at risk of exposure to and possible transmission of vaccine-
preventable diseases because of their contact with infectious materials from patients
such as HCW. Maintenance of immunity is therefore an essential part of the
prevention and infection control programs for HCF workers.
B. Post-exposure Prophylaxis (PEP)
Post-exposure prophylaxis (PEP) is short-term antiretroviral treatment (for HIV) or

immunization (for hepatitis B) to reduce the likelihood of infection after potential
exposure. Within the health sector, PEP should be provided as part of a
comprehensive universal precautions package that reduces staff exposure to
infectious hazards at work. PEP for HIV comprises a set of services to prevent
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development of the infection in the exposed person. These include first-aid care;
counselling and risk assessment; HIV blood testing; and, depending on the risk
assessment, the provision of short-term (28 days) antiretroviral drugs, with follow-up
and support. Most incidents linked to occupational exposure to bloodborne
pathogens occur in HCFs.
Box 42: Summary of PEP recommendations
The WHO and the International Labor Organization have published guidelines on PEP to
prevent HIV infection. A summary of PEP recommendations from these guidelines are as
follows:
 PEP should be provided as part of a package of prevention measures that reduce staff
exposure to infectious hazard.
 PEP should be available to health care workers and patients.
 Occupational PEP should also be available to all workers who could be exposed while
performing their duties (such as social workers, law enforcement personnel, rescue
workers, refuse collectors).
 Countries should include occupational PEP in national health care plans.
11.5.2 Hand Hygiene
The hands of health care workers are the most frequent transmission route for
nosocomial infections. Hand hygiene, both hand washing and hand disinfection,
should be seen as the primary preventive measure that is the responsibility of all
health care personnel. Provision for washing facilities (with soap and warm water)
and instruction shall be made available at the point needed to ensure that proper
handwashing is observed.
Thorough hand washing with adequate quantities of water and soap removes
more than 90% of the transient (i.e., superficial) flora, including all or most
contaminants. An antimicrobial soap will further reduce the transient flora, but only if
used for several minutes. Hand washing with (non-medicated) soap is essential when
hands are dirty and should be routine after every physical contact with a patient.
Killing all transient flora within a short time (a few seconds) necessitates hygienic hand
disinfection: only alcohol or alcoholic preparations act sufficiently fast. Hands should
be disinfected with alcohol when an infected tissue or body fluid is touched without
gloves.
The WHO guidelines on hand hygiene in health care (WHO, 2009) include a
recipe for alcohol hand rub. The WHO (2009) guidelines also include the following
guidance for hand washing and use of alcohol-based hand rubs:
 If hands are not visibly soiled, use an alcohol-based hand rub for routine
antisepsis (hygienic hand disinfection). Rub until hands are dry.
 Wash hands before starting work, before entering an operating theatre,
before eating, after using a toilet, and in all cases where hands are visibly
soiled.
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 Keep nails short and clean.

 Do not wear artificial fingernails, nail polish or jewelry.
 Do not wash gloves between uses with different patients.
 Multiple-use cloth towels of the hanging or roll type are not recommended
for health care establishments.
 When bar soap is used, soap racks that facilitate drainage and only small
bars should be used; liquid detergents in dispensers are preferred.
 To prevent contamination, do not add soap to a partially empty liquid-
soap dispenser. Empty the dispenser completely and clean it thoroughly
before refilling.
 Hand hygiene products should have low skin irritation, particularly in
multiple-use areas, such as intensive care or operating rooms.
 Ask personnel for their views regarding the tolerance of any products
under consideration.
 For surgical scrub, preferably use an alcohol-based hand rub.
 When using an alcohol-based surgical hand rub, pre-wash with soap, and
dry hands and forearms completely (including removal of debris from
underneath the nails using a nail cleaner) once a day before starting
surgery and when hands become soiled (e.g., glove perforation) or
sweaty. Brushes are not necessary and can be a source of contamination.
Hand washing immediately before every rub does not improve its efficacy
and should be abandoned. Rub for 1–5 minutes according to the
manufacturer’s recommendation after application and rub until hands
are dry before donning sterile gloves.
 Hands must be fully dry before touching the patient or patient’s
environment/equipment for the alcohol hand rub to be effective. This will
also eliminate the extremely rare risk of flammability.
 Use hand lotions frequently to minimize the possibility of irritant contact
dermatitis.
See ANNEX C 2 and ANNEX C 3 for sample information materials on proper hand
rubbing and handwashing, respectively.
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Box 43: “My Five Moments of Hand Hygiene” in HCF
The “My Five Moments for Hand Hygiene” approach defines the key moments when health care
workers should perform hand hygiene. This evidence-based, field-tested, user-centered
approach is designed to be easy to learn, logical and applicable in a wide range of settings.
This approach recommends health-care workers to clean their hands: 1) before touching a
patient; 2) before clean/aseptic procedures; 3) after body fluid exposure/risk; 4) after
touching a patient; and 5) after touching patient surroundings.
Reference: “WHO Guidelines on Hand Hygiene in Health Care” (WHO, 2009)
11.6 Education, Communication, Training and Awareness

Everyone within the HCF plays a vital role in the management of HCW, for this
reason, the training program shall cast a wide network. Every HCF worker shall be
made aware of the policy, the significant health and environmental impacts of their
work activities, their roles and responsibilities, the procedure that apply to their work
and the importance of conformance with the requirements. The worker shall
understand the potential consequences of NOT following the requirements.
Training and continuing education are integral parts of the HCWM system. When
health care personnel are properly sensitized to the importance of waste
management, they become advocates for best practices and help to improve and
sustain a good waste management system. Importantly, training should be
institutionalized and become part of the standard functions of the HCF.
A training module shall be part of the Orientation/Re-orientation Program for
newly hired and existing workers to ensure consistency in compliance by all HCF
workers. The use of IEC materials, issuances and advisories shall be utilized to raise
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awareness and ensure effective implementation of the program. The overall goals
of training are to:
a) Prevent occupational and public health exposures to the hazards
associated with HCW;
b) Raise awareness of the health, safety, and environmental issues relating to
HCW;
c) Ensure that health care personnel are knowledgeable about best
practices and technologies for HCWM and are able to apply them in their
daily work; and
d) Foster responsibility among all health care workers for HCWM.
11.6.1 Training of Health Care Workers
Training is essentially the transferring of knowledge, skills, and capacity building of

targeted participants. In any HCF, it is mandatory to implement education and
training programs to make all the HCF workers aware of the hazards involved in HCW
and their specific roles. All HCF workers shall receive training tailored to their different
needs at various levels or functions in the HCF.
The overall aim of the training is to develop awareness on the health, safety and
environmental issues relating to HCW, and how these can affect HCF workers in their
daily work. It shall also highlight the roles and responsibilities of the HCF workers.
Separate training activities shall be designed for each of the following targeted
categories of personnel:
 HCF managers and administrative staff responsible for implementing
regulations on HCWM;
 Medical doctors;
 Nurses and assistant nurses; and
 Cleaners, porters, auxiliary staff, and waste handlers.
The training for waste generators as well as waste handlers is equally important.
Medical doctors may be educated through senior staff workshops and general
hospital staff through formal seminars. The training of waste managers and regulators
could take place outside the hospital at public health schools or university
departments. Basic education program for HCF worker shall include:
 Information on and justification for all aspects of the HCW policy;
 Information on the role and responsibilities of each HCF worker in
implementing the policy; and
 Technical instructions, relevant for the target group, on the application of
waste management practices.
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All HCF workers must receive initial and annual training. A trained individual must
be available during training sessions. The instructors shall have experience in
teaching and training and be ideally familiar with the hazards and practices of
HCWM; they should also have experience in waste handling.
11.6.2 Integrating Public Education on Risk Awareness
Promotion of safe and sensible waste handling and disposal is relevant both to
users of HCFs and to the wider community as one approach to achieve a better
understanding of health public. All HCFs, the DOH and the EMB-DENR have the
responsibility and a “duty of care” for the environment and public health.
The need to promote appropriate handling and disposal of HCW is important to
public health. Every member of the HCF and the community has the right to be
informed about the potential health hazards associated with HCW. Inadequate
handling of HCW may have serious public health consequences and impacts on
environmental health protection. Public awareness through formal or informal
education plays an important role in HCWM. Development of information,
education, and communication (IEC) programs and materials shall be given due
course with the following objectives: 1) to transmit the basic skills and knowledge in
establishing a healthy, secure, and safe environment for HCW and the general
public; 2) to inform the public about the risks linked to HCW, focusing on people either
living or working near or visiting HCF, families of patients being treated at home and
scavengers on waste dumps; 3) to foster responsibility among hospital patients and
visitors to HCF regarding hygiene and HCWM; 4) to prevent exposure to HCW and
related health hazards, this exposure may be voluntary in the case of scavengers or
accidental as a consequence of unsafe disposal methods; 5) to increase awareness
of the impact of HCW on environment and ecology; and 6) to influence behavior of
patients, watchers, HCF workers to implement proper HCWM.
In developing the education, training, information and communication tools,
there are several concerns that need to be addressed. These are specific targeted
subjects or participants, including their level of understanding and involvement in the
implementation of the HCWM Plan; availability of funds and logistics to sustain the
program; and support of the HCF management to the program. Training package
suggestions for each target group are provided in ANNEX B 9.
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Box 44: Methods of communication and training
Various methods can be used to promote public education on HCW. Commonly used
approaches include the following:
 Graphics and audio-visuals which may be in the form of brochures, posters, display
boards, video tapes, slides, CD/DVDs, flyers, flip charts, leaflets, etc.
 Use of tri-media such as announcements or commercial ads featured in radios, movies,
television, newspaper, magazines, and the internet.
 Orientation/re-orientation seminars, training, and workshops; community and health
teachings for hospital patients, watchers and other clients using IEC materials and
didactic exercise.
 Issuance of written HCF policies to disseminate the information and awareness among
HCF workers. There shall be corresponding sanctions to be implemented for non-
compliance with issued policies.
For maximum effectiveness, all information should be displayed or communicated in an

attractive manner to hold people’s attention and increase the likelihood they will remember
the important messages to be conveyed by an information campaign. In medical areas,
general HCW bins should be easily accessible for patients and visitors, and signs should explain
clearly what they should do with other categories of waste. HCFs should set an example to
society by demonstrating that they are managing their waste in a manner designed to
protect health and the environment.
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Fourth Edition Chapter 12: Health Care Waste Management in Emergencies
12 Health Care Waste Management in

Emergencies
Natural disasters and conflicts, by their nature, are highly disruptive and
dangerous events. Their consequences are unpredictable, and it is inevitable that
many essential public services will be interrupted. HCFs, public health and municipal
services, such as waste management, may totally or partially cease due to
destroyed buildings, damaged equipment, dislocation of staff and blocked roads.
In such situations, all forms of wastes including hazardous HCW remains
uncollected and untreated. It is inevitable that wastes will accumulate, and serious
environment and health hazards (e.g., hepatitis B and C) may affect communities.
Therefore, measures need to be taken to remove wastes as soon as possible after an
emergency. The purpose is to reduce the proximity of people to accumulated
wastes and so reduce the potential for disease transmission.
12.1 Emergency Management Plan

As defined by the WHO “contingency planning and emergency preparedness is
a program of long-term development activities whose goals are to strengthen the
overall capacity and capability of a country to manage efficiently all types of
emergency and to bring an orderly transition from relief through recovery and back
to sustain development. The phases for the safe management of HCW in
emergencies are described in the succeeding sub-sections.
12.1.1 Phase 1: Rapid Initial Assessment
Rapid assessments immediately following a disaster or other emergency are

designed to be swift and to inform emergency responders about critical and
immediate needs. An initial rapid assessment is likely to be unrefined and should be
updated as more data become available. An assessment team shall conduct this
initial phase which may include relief or awareness activities.
To work effectively, the team shall have a clear-cut disposition and priority
whether to gather information or perform relief actions. Personnel carrying out
assessments are likely to provide initial advice and awareness-raising activities
simultaneously. However, a pragmatic balance must be found between the need
to act quickly and the need to gather sufficient information to ensure assistance is
effective, appropriate to the problems found and sustainable into the future.
Issues to remember when collecting information in emergencies:
 Collect information from as many sources as possible to reduce bias and
inaccuracies;
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 Be aware of local conditions so as not raise unrealistic expectations;

 Use the data collected as evidence to inform the decisions that must be
made;
 Keep good records of what has been learned and from whom; and
 Situations change rapidly in an emergency, and the solutions proposed
should be robust and flexible.
More detailed assessments are required during the later disaster management
phases as the needs and capabilities of local communities and public organizations
evolve. The purpose is to prepare the contributors to the wider relief effort to change
over from short-term initial response activities to longer term rehabilitation.
Table 11: Key issues in rapid initial assessment

Aspect Key Issues
General  Nature and history of the emergency
information  Organization carrying out the assessment
 Name and position of assessors
 Dates of the assessment
 Location of the affected area
 Logistical resources available
 Government involvement
 Existing potential donors
 Other organizations working in the area, including current and planned
activities
 Institutions and NGOs providing emergency medical care
 Existing policies, regulations, or guidelines on HCW management
 Locations and nature of emergency medical care interventions (in tents,
field hospitals, mobile HCFs, non-damaged hospitals and health care
centers, HCFs outside of the affected area)
Demographic data  Total population in the affected area
 Approximate number of affected people
Geographical  A sketch should be produced, and the following features identified and
information located:
o Location and type of existing operational medical care activities
o Location and type of existing operational waste treatment and
disposal facilities
o Burial or cremation sites
o Location of emergency dumping of HCW
o If possible, groundwater water levels near the locations of the
operational health care operations
General description  The categories of HCW generated by medical care activities
of the  Provide any information about HCW quantities. If none exists, make a
management of rough estimation
HCW in the  Describe the process of HCW handling in the location of the emergency
affected area medical activities
 Describe the type and number of waste-related equipment available for
managing HCW
 Explain how HCW is disposed
 Identify any sites near the emergency health care activities for controlled
burial of HCW
 Identify who is involved in the handling and disposal of HCW
 Identify financial resources allocated for handling and disposal of HCW
 Describe any reported injuries related to HCW (e.g., sharps injuries)
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12.1.2 Phase 2: Emergency Response
Based on the rapid initial assessment, a simple action plan with clear roles and
responsibilities for individuals and emergency response organizations (international
bodies, national authorities, civil society) can be developed and resources allocated
from the aid effort for implementation. The purpose of HCWM in an emergency is to
avoid wastes from being scattered indiscriminately around medical buildings and
their grounds and reduce the likelihood of secondary infections.
As a basic starting point and to avoid sharps injuries, HCW generated by
emergency medical care activities (in tents, field hospitals, mobile hospitals) should
be segregated using a “two-bin solution” – that is, sorting waste into used sharps and
non-sharps wastes (including general wastes and infectious, pathological and
pharmaceutical residues). The two bins should be kept segregated until final
disposal.
Basic considerations in emergency response in HCWM:
 All non-sharps wastes, without exception, should be collected in medical
areas in rigid containers, such as plastic buckets with a cover, to prevent
waste items from being exposed to disease transmission by contact by
hand, airborne particles, and flying insects.
 Containers and covers should be washed and disinfected daily after being
emptied.
 Reuse of rigid waste containers after disinfection with a chlorine (0.2%)
solution may be the most practical option to introduce quickly in an
emergency and is low cost at a time when resources for better forms of
waste segregation and storage may be scarce.
 Sharps wastes should be stored safely in puncture-proof and leak-proof
containers.
 Burial of non-sharps and sharps wastes in pits or trenches may be
considered as a pragmatic option in emergency situations. Burning of
HCW is less desirable, but if it is genuinely the only realistic option in an
emergency it should be undertaken in a confined area (burning within a
dugout pit, followed by covering with a layer of soil).
The following preventive measures can also be implemented during an
emergency response phase to reduce public and occupational health risks:
 Provide hepatitis B vaccination to all health care personnel and waste
handlers;
 Encourage hand hygiene (washing, preferably followed by disinfection);
 Use gloves for handling HCW;
 Raise the awareness of staff about simple post exposure prophylaxis in the
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event of an occupational injury (e.g., needle-stick injury);

 Contain and promptly clean up spillages of infectious materials and
disinfect quickly to avoid pathogen transmission;
 Disinfect body fluids before their discharge; and
 Conduct on-site awareness-raising activities (whenever possible) to remind
health care personnel about occupational exposures and the safe
practices for managing HCW.
As an emergency response progresses and more aid resources become
available, the management of HCW can be improved by establishing a three-bin
system (see Box 23).
Table 12: Segregation of HCW in emergencies

Waste Typical Waste Items Type of Container Color or Mark/Sign
Category
Non-sharps Infectious, pathological Leak-proof container or plastic Yellow or special
wastes waste and some bag in a holder mark or sign
pharmaceutical and
chemical residues
Used sharps Syringes with needles, Leak- and puncture proof Yellow or special
sutures, blades, broken sealable container, box or mark or sign
glass drum bearing the word
“contaminated sharps”
General waste Similar to municipal wastes, Container or plastic bag in a Black or special
not contaminated by holder mark or sign
hazardous substances
Segregated waste should be kept separated until final disposal. General waste
should follow a municipal waste disposal route, if available, and sharps and non-
sharps wastes should be treated and disposed of using the best available practices
based on the minimum options described in the preceding chapters of this Manual.
12.1.2.1 Minimum treatment and disposal options
A. On-site burial in pits

Dig a pit 1–2 meters wide and 2–3 meters deep. The bottom of the pit should be
at least 2 meters above the groundwater. Line the bottom of the pit with clay or
permeable material. Construct an earth mound around the mouth of the pit to
prevent water from entering. Construct a fence around the area to prevent
unauthorized entry. Inside the pit, place alternating layers of waste, covered with
10cm of soil (if it is not possible to layer with soil, alternate the waste layers with lime).
When the pit is within about 50cm of the ground surface, cover the waste with soil
and permanently seal it with cement and embedded wire mesh. See ANNEX E 9 for
illustration of pit construction for on-site waste burial.
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B. Burial in special cells in dumping sites (if available in the affected area)
Cells to contain waste can be used when burying waste in dumping sites. The cell
should be at least 10 meters long and 3 meters wide, and 1–2 meters deep. The
bottom of the cell should be at least 2 meters above the groundwater. The bottom
of the cell should be covered by soil or a material with low permeability. The waste
in the cell should be covered immediately with 10-cm layers of soil to prevent access
by people or animals (in diseases outbreaks, preferably spread lime on waste before
covering with the soil). It is strongly recommended that HCW be transported in a safe
manner to minimize public exposure to bio-contaminated wastes.
C. Low-cost double-chamber incinerators
Double-chamber incinerators may reach a temperature of about 800°C with a
residence time of more than one second in the second chamber to kill pathogens
and break down some of the particulates in the outlet gases. The incinerators should
be built at a convenient distance away from buildings. Such incinerators need to be
heated with paper, wood, or dry non-toxic waste (small quantities of kerosene may
be added, if available) before adding infectious wastes.
D. Encapsulation
Place sharps wastes or pharmaceutical wastes in hard containers, such as metal

drums, and add an immobilizing material, such as cement, bituminous sand, or clay.
When dry, the drum or container can be sealed and buried in local landfill or a pit in
the HCF.
Table 13: Summary of pharmaceutical disposal methods in and after emergencies

Disposal Method Type of Pharmaceutical Comments
Return to donor or All bulk waste Usually not practical- transfrontier
manufacturer, pharmaceuticals, particularly procedures may be time consuming
transfrontier transfer for antineoplastics
disposal
Highly engineered Limited quantities of Immobilization of waste
sanitary landfill untreated solids, semi-solids pharmaceuticals is preferable before
and powders PVC plastics disposal
Engineered landfill Waste solids, semi-solids and Immobilization of solids, semi-solids and
powders PVC plastics powders is preferable before disposal
Open, uncontrolled, non- Untreated solids, untreated As last resort, untreated solids, semi-
engineered dump semi-solids and untreated solids and powders must be covered
powders immediately with municipal waste
Immobilization is preferable before
disposal.; Not for untreated controlled
substances
Immobilization: waste Solids, semi-solids, powders, Immobilization: not applicable;
encapsulation or liquids, antineoplastics and Chemical decompositions are not
inertization controlled substances recommended unless special expertise
and materials are available
High-temperature Solids, semi-solids, powders, Expensive, particularly for purpose-built
incineration (>1200°C) antineoplastics and incinerators; Use of existing industrial
controlled substances plants may be more practical
Medium-temperature In the absence of high- Antineoplastics best incinerated at high
incineration with two- temperature incinerators, temperatures
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Disposal Method Type of Pharmaceutical Comments

chamber incinerator, min. solids, semi-solids, powders
temperature of 850°C and controlled substances
Burning in open Packaging, paper and As last resort; Not acceptable for PVC
containers cardboard plastics or pharmaceuticals
Sewer or fast-flowing Diluted liquids, syrups, Not recommended for antineoplastics,
watercourses intravenous fluids, small undiluted disinfectants or antiseptics
quantities of diluted
disinfectants (supervised)
Chemical decomposition NA Not recommended unless special
expertise and materials are available
Not practical for quantities of more than
50kg
Table 14: HCWM practice in emergencies

Aspect Measures
Segregation and  All containers and bags should be filled to three-quarters of their
packaging capacities to avoid spillage and kept covered to prevent casual
access by people or disease vectors.
 Should color coding of plastic bags and containers not be possible,
signs or marks can be put on containers to differentiate between
hazardous HCW and general waste.
 Segregated waste should be regularly removed and safely stored to
reduce the risk of transmission of pathogens and improve general
standards of cleanliness and hygiene in medical areas.
 If plastic bags are not available, containers for non-sharps wastes
should be washed and disinfected after being emptied.
 Body parts should be safely stored and disposed of according to local
culture and customs.
Collection  Exclusively allocated carts or trolleys with lids should be used to collect
and transport HCW. Carts should be regularly cleaned and
disinfected.
 Highly infectious wastes (e.g., laboratory wastes and wastes from
persons with contagious diseases) should be collected quickly and
carried to a single, secure central storage area; on no account should
collected waste be left anywhere other than at a central storage
point.
Storage  Segregated waste should preferably be stored in specific restricted
areas. The storage area should be a locked room or guarded
enclosure.
 If this is not available, large containers with lids may be used for
temporary storage of segregated waste and should be placed in
restricted areas to minimize contact with people and animals.
 Mark the storage area with the biohazard symbol or put a sign or mark
that is understood locally to differentiate between hazardous and
non-risk wastes.
Treatment and Disposal  Should resources not be available, minimal treatment and disposal
practices should continue to be used as follows:
 onsite burial in pits or trenches;
 disposal in special cells in municipal dumping sites;
 burning in pits and then covering with soil;
 incineration in low-cost double-chamber incinerators;
 encapsulation of sharps waste or small quantities of pharmaceuticals
followed by onsite burial or burial in special cells in municipal dumping
sites;
 incineration in high-temperature industrial incinerators (provided that
there is a safe means of transportation);
 disinfection of infectious and sharps wastes with a small autoclave
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Aspect Measures
(when resources are available); non-sharps disinfected wastes should
join the general waste stream.
12.1.2.2 Spill control
Spillages require clean-up of the area contaminated by the spilt waste. For
spillages of highly infectious material, it is important to determine the type of
infectious agent, because immediate evacuation of the area may be necessary in
some cases.
In general, the most hazardous spillages occur in laboratories rather than in
medical care departments. The Infection Control Officer can be asked for assistance
regarding proper management and clean-up of the spill due to infectious waste.
Procedures for dealing with spillage (refer to ANNEX C 4 and ANNEX C 5) shall specify
safe handling operation and appropriate protective clothing. In case of skin and eye
contact with hazardous substance, there shall be immediate decontamination. The
exposed person shall be removed from the area of the incident for decontamination,
generally with copious amounts of water. Special attention shall be paid to the eyes
and any open wounds. In case of eye contact with corrosive chemicals, the eyes
shall be irrigated continuously with clean water for 10 – 30 minutes; the entire face
shall be washed in a basin, with the eyes being continuously opened and closed. An
eye wash assembly can be installed in the unit for immediate response.
Emergency response procedures for specific waste spills are provided in ANNEX C 6.
12.1.3 Phase 3: Recovery Phase
The recovery phase can be characterized as a longer-term program of

assistance to return an affected community to a normal situation similar to that which
existed before the disaster or, potentially, better. As resources become available, a
more detailed assessment can be conducted for planning and fundraising for future
improvements, and for setting priorities in the affected area.
The results of the assessment and the identified needs and priorities are the
starting point for ensuring that a sustainable approach to HCWM is created after an
emergency. Start by preparing simple, locally applicable action plans to define the
improvements to be achieved, and gradually improve these action plans whenever
the resources become available. Key points to address during a recovery phase:
 Existing procedures and practices of HCWM;
 Responsibility for the management of HCW;
 Presence of an infection-control committee to oversee improvements and
training;
 Dedicated equipment for storage, collection, and on-site and off-site
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transportation of HCW;
 Availability of on-site and off-site HCW treatment facilities;
 Availability of on-site and off-site disposal facilities;
 Level of health care personnel awareness about the risks associated with
HCW;
 Staff health protection (protective clothing, vaccination); and
 Financial aspects related to HCWM and associated infection-control
procedures, and a means to sustain funds to operate waste management
in the future.
Recovery phase activities in the HCF after an accident, incident and
emergencies can include the following:
 Preparation of incident/accident report (Refer to ANNEX D 6 for a sample
Occupational Incident/Accident Report (OIR) Form);
 Inventory of used items;
 Provision of new supplies to replace the used items in the kit; and
 Psychosocial debriefing of the injured person, as necessary.
All waste management staff should be trained in emergency response and made
aware of the correct procedure for prompt reporting. Accidents or incidents,
including near misses, spillages, damaged containers, inappropriate segregation,
and any incidents involving sharps, should be reported to the WMO (if waste is
involved) or to another designated person. The report should include details of:
 The nature and magnitude of the accident or incident;
 The place, date and time of the accident or incident;
 The staff who is directly involved;
 Immediate response taken;
 Any other relevant circumstances; and
 Recommendations, if any.
The WMO or other responsible officer, who shall take possible action to prevent
recurrence, shall investigate the cause of the accident or incident. The records of
the investigation and recommendations must be submitted to the management for
review and approval. Any amendment in the policies and procedural guidelines
must be integrated in the HCWM Plan of the HCF. Updates shall be disseminated to
all HCF workers for information and guidance. All records of spill management must
be kept for future reference. A sample flowchart on the management of
occupational accident/incident for tertiary hospitals is provided in ANNEX A 9.
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There shall be an established reporting system in all HCWM-related incidents. A

clear investigating system must be ensured, and effective corrective action must be
employed.
12.2 Contingency Planning and Emergency Preparedness

At the HCF level, action plans on HCWM should include temporary measures to
apply during emergency situations.
The contingency plans should address the following questions:
 What standards will be used to guide a response?
 What are the current capacities of the agencies or organizations to
respond?
 What initial assessment arrangements are needed?
 What actions will be taken as an immediate response to the situation?
 Who does what and when? Who is coordinating and leading?
 What resources would be needed?
 How will information flow between the various levels (local and national)?
 Have specific preparedness actions be agreed on and practiced?
Contingency planning needs to be seen as a continuing process that is regularly
reviewed and updated to ensure that all partners are familiar with their various roles,
responsibilities and actions to be undertaken. Contingency plans should be in line
with existing national policies and legislation.
Box 45: Emergency contingency plan for HCW transporter
The development of a plan of action shall be considered in the event of an accidental spill,
loss of containment, equipment failure or other unexpected circumstances. The
owner/operator of vehicles used in the transport of HCW shall carry contingency plans for
emergencies that address the following:
 Emergency response intervention cards (ERICards or ERICs) kept inside the driver’s cab
provide guidance on initial actions for responders and fire crews, because they are often
the first to arrive at the scene of a hazardous waste transport accident. These cards
provide reliable product-specific emergency information that otherwise may not be
immediately available. Sample is provided in ANNEX --- of this Manual.
 Plan for the disinfection of the truck and any contaminated surface if a leaking container
is discovered.
 A notification list of individuals or agencies to be contacted in the event of a transport
accident.
 Clean-up and decontamination of potentially contaminated surfaces, designation of
back-up transport for the HCW, a description of the plans for the repackaging and
labelling of HCW where bins are no longer intact.
 Procedures for the management of leaking container/s.
 Other EMB-DENR requirements.
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12.3 Emerging Issues

12.3.1 Emerging Diseases and Multidrug-resistant Organisms
Among the most important diseases are those becoming increasingly resistant to
the established medical treatments. These include extremely drug-resistant
tuberculosis, methicillin-resistant and vancomycin-resistant Staphylococcus aureus,
and malaria (chloroquine-resistant Plasmodium falciparum, and strains that are
resistant to the antifolate combination drugs and to atovaquone). Clostridium
difficile too has recently caused much concern as a resistant nosocomial infection
(Loo et al., 2005).
Waste-treatment practices may need to be adapted to ensure that novel
organisms are inactivated properly. Standardized test strips containing heat-resistant
bacterial spores are assumed to demonstrate that processes to inactivate the spores
will also be effective with other pathogens. However, some pathogens – such as
prions – are difficult to inactivate. Testing protocols, including test strip design, need
to be updated regularly in the light of new data on pathogen resistance.
12.3.2 Pandemics
Pandemics have always occurred periodically. They may be catalyzed by factors

including the increase in international travel and movement of populations or
disease vectors. It is generally assumed that the amount of HCW will increase during
pandemics, but if non-emergency medical operations and other treatments are
postponed, the amount of wastes may be lower. The mode of transmission will be
another significant factor. If a pandemic is spread by contact, even general waste
from medical areas may potentially have to be classified as infectious HCW.
Where a vaccine is available, the quantity of sharps waste and empty vials will
increase significantly. Fortunately, these wastes are comparatively easy to store and
so should not create an insurmountable HCW problem, unless produced in
underdeveloped regions. Any increase in vaccination waste may be partially offset
by a reduction in routine injections. The status of waste management staff should be
considered. Unlike health workers, they are generally not included in lists of essential
workers who should be prioritized for vaccination. Consequently, there may be
significant staff shortages and subsequent loss of capacity for waste management
staff. This would be most acute where HCW treatment and disposal are conducted
at centralized plants away from HCFs.
In their contingency plans to address medical emergencies, HCFs should include
the use of HCW engineering advice, realistic transportation and disposal
arrangements, and the regular vaccination of waste workers. This is a prudent
approach to maintaining a sufficient level of public health protection through
prompt waste removal and processing during an emergency.
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12.3.3 Climate Change
Climate change is likely to affect all aspects of life, and waste management is no
exception. Gradual climatic trends and extreme weather events can disrupt services
in the short term and affect long-term capacity requirements. Waste-disposal sites
are often built on marginal sites, such as marshlands, flood plains and coastal areas,
and many may become increasingly vulnerable to flooding where average sea and
river levels rise, or more frequent extreme weather events inundate the land.
Shorter duration weather changes, such as seasonal floods and heatwaves, may
be particularly problematic in rural areas, where resilience in waste-collection
systems may be lower. This can be countered by decentralizing waste treatment and
increasing storage capacity, as well as undertaking contingency or continuity
planning at the facility and national levels. Fuel and power costs are predicted to
rise, and power shortages may become more common. Planners should promote
the adoption of lower energy technologies wherever possible. Installation of
renewable energy generation capacity, particularly at remote installations, would
reduce vulnerability.
Table 15: Key points relating to climate change

Issues Response Options
 Sea level rise and increased flooding will  Avoid siting waste-handling and disposal
affect routine waste-collection and sites on locations that are vulnerable to
treatment services and access to sites. flooding.
 Heatwaves and other extreme weather  Ensure extra clearance during planning and
events will increase the burden on HCFs, design between subsurface constructions
increase waste production, and lengthen (landfills, septic systems, composting pits)
storage times for wastes before disposal. and the subsurface water table.
 Fuel and energy costs will increase.  Consider the possibility of being cut off from
 Geographical disease patterns will change. waste-collection services by floods when
 Greater health consequences will result from planning waste-storage and treatment
an increasing likelihood of more large-scale needs for remote facilities.
population movements.  Plan for reduced storage periods during
heatwaves.
 Install temperature controls in waste-storage
areas, noting that extreme weather events
may result in power failures.
 Select low-energy waste-treatment options.
 Install renewable energy sources where
possible.
 Reduce overall resource requirements
through waste-minimization practices.
 Develop contingency plans for impacts likely
at facility, regional, national, and
international levels.
12.3.4 Other Environmental Issues
The list of pharmaceuticals, other hospital-derived chemicals and disinfection by-

products present in wastewater and the environment is increasing. Their impacts on
human and ecosystem health vary but are becoming more widely understood.
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Overuse of antimicrobials can simultaneously drive bacterial resistance and cause

pollution. Glutaraldehyde, triclosan and silver are among the best known. Silver is
now found in many medical devices, soaps, textiles, furnishings, and construction
materials targeted at hospitals. However, some bacteria rapidly build up resistance
to silver by a mechanism that could also make them resistant to antibiotics,
particularly the beta-lactams.
Resistance can also build up in bacteria in sewage treatment works and the wider
environment if they are polluted with antimicrobials released from products. The only
way to avoid these twin problems is through the segregation and treatment of wastes
containing these antimicrobials, or their recovery from wastewaters. Since this is
currently not practiced and is unlikely to be feasible in the near future, use of these
products should be kept to a minimum.
Chlorine-based disinfectants are widely used. However, chlorine can cause
pollution through reacting with organic chemicals in liquid wastes to create toxic
organochlorines. If materials such as infected plastics have been soaked in chlorine
before incineration, the amount of chlorinated dioxins and furans produced will be
elevated. Alternatives that can be equally or even more effective as disinfectants
include hydrogen peroxide or ozone, either alone or in combination with ultraviolet
light.
Table 16: Key points relating to environmental issues

 There is a need to reduce toxic chemicals in
 Prioritize pollution prevention over pollution
wastewater and in other emissions from HCW control and avoid the use of toxic materials
disposal. wherever possible.
 Overuse of antimicrobials increases  Improve wastewater treatment and avoid
pathogen resistance. disposing of chemicals to the sewer.
 The availability of authorized landfill  Avoid overuse of microbial chemicals,
capacity is decreasing, and the costs of especially silver triclosan and
operation are increasing. glutaraldehyde.
 Environmental protection requirements and  Replace chlorine as a disinfectant with
costs will increase. hydrogen peroxide, ozone, and ultraviolet
alternatives.
12.3.5 Waste Technology
The use of more complex medical procedures and the continuing trend towards
single-use products in medical practice will lead to marked changes in the
composition of waste. Using single-use products would necessitate disposal of the
device itself and its packaging, neither of which may be recyclable. Increases in
waste volumes can be guarded against by selecting reusable products where
possible without compromising patient care or worker safety.
New and environmentally friendly technologies for HCW treatment include
microwave and ozone for sterilizing, and alkaline hydrolysis and supercritical water
oxidation for treating chemical and pharmaceutical wastes. Their implementation is
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hampered by cost and sometimes a reluctance by decision-makers to invest in

technologies without a history of successful operation. Another factor limiting the
widespread implementation of these technologies is the paucity of models available
for smaller facilities and those in remote areas.
Controlling pollution through technological means is a costly process and costs
will inevitably rise as national and international pollution control legislation is
tightened. Avoiding pollution through upstream measures such as better design of
products will be more cost-effective. Procurement policies should favor products that
are reusable or recyclable, are non-toxic and have a lower environmental impact
when disposed of.
Table 17: Key points relating to waste technology

 Little independent information is available on
 Improve information dissemination for an
new waste-treatment technologies. informed debate on technology evaluations.
 Many products are not recyclable.  Set standards for waste treatment that relate
 Increased use of disposables will increase to the level of microbial inactivation
waste production. required.
 Some products (e.g., polyvinyl chloride  Phase out mercury and PVC products used
[PVC], broken mercury thermometers) in health care.
produce toxic emissions if incinerated.  Replace disposable products with reusable
 Technologies for low-income or remote and recyclable options wherever it can be
regions need further development. achieved without affecting patient care or
worker safety.
 Design new products for easier reuse and
recycling.
 Improve segregation of wastes so that each
waste stream is sent to the most appropriate
waste-treatment system.
12.3.6 Social, Cultural, and Regulatory Changes
As countries develop economically, populations tend to gravitate to the cities,

increasing the pressure on all types of infrastructure. The movement to the cities is
likely to be exacerbated by climate change, as people may be driven off the land
by drought, flooding or other changes that cause the failure of previously stable
environments and agricultural systems. This will also increase the possibility of conflict
and cross-border migration and exert pressure on disposal systems.
The Stockholm Convention aims to eliminate pollution from persistent organic
pollutants, including dioxins and furans, which are produced by the combustion
process in HCW incinerators. Capacity-building plans should consider alternatives,
such as autoclaving of infectious waste, which may become cheaper in the future.
Regulations are also tightening on the use and disposal of mercury-containing
products, PVC, diethylhexyl phthalate (DEHP), pharmaceuticals, hazardous wastes
and scrapped electronic equipment. In the future, “extended producer
responsibility” legislation may make more product and waste producers legally
responsible for ensuring the proper disposal of many types of waste.
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The range of alternatives to medical products that pose elevated pollution risks
during disposal is increasing, while the cost of many is decreasing. For example, more
PVC- and DEHP-free devices are being brought to market. The price of mercury-free
electronic thermometers and retractable syringes has decreased significantly, and
syringe manufacturers are redesigning their products to make them more easily
recyclable. Careful procurement can reduce the effort and expense of waste
disposal. Improved information technology also makes it easier for decision-makers
to identify and source the best available technologies from across the world.
HCWM currently suffers in many areas from a lack of attention by decision-makers
and a lack of funding. Hopefully, this lack will be remedied as the health and
environmental benefits of proper treatment are better appreciated. Minimization of
the amount and toxicity of waste should take ever greater priority at all stages of the
medical product design, manufacture, procurement, use and disposal cycle. At the
same time, more recycling of non-hazardous wastes and the wider use of efficient
and less polluting waste-disposal practices should reduce the impact on the
environment and wider community health and maintain protection from transmission
of infections.
Table 18: Key points relating to social, cultural, and regulatory changes
 The Stockholm Convention and other  Develop and implement non-incinerator
regulations may restrict incinerator use. technologies.
 Hazardous chemicals will be increasingly  Build capacity for technology transfer and
tightly regulated. knowledge sharing.
 New designs of medical equipment (e.g.,  Encourage health care providers to
retractable syringes, digital thermometers) cooperate to bulk purchase improved
are more costly than established products. designs of medical products that are less
 Pressure on health care services will increase expensive to dispose of.
as urban populations increase.  Build research collaborations to design and
 There will be increasing globalization of promote new environmentally beneficial
medical device manufacture and products for the health care sector.
procurement.
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Health Care Waste Management Manual PART IV—GLOSSARY, ANNEXES, AND REFERENCES
Fourth Edition Definition of Terms
PART IV—GLOSSARY, ANNEXES, AND

REFERENCES
167
Definition of Terms
Unless otherwise specified, the following terms shall have the meaning provided
for in this Manual:
Ambulatory Surgical A specialized health facility that is primarily organized, constructed,
Clinic (ASC) renovated, or otherwise established for the purpose of providing elective
surgical treatment of outpatients whose recovery, under normal and
routine circumstances, will not require inpatient care. (DOH AO No. 183, s.
2004; DOH AO No. 24, s. 1994)
See related: Specialized Health Facility.
Antineoplastic Inhibiting the development of neoplasms or abnormal tissue growth.
Autoclaving Method of sterilization using an equipment for effective sterilization by
steam under pressure and temperature.
Barangay Health Station A government primary health facility that provides primary care services at
(BHS) the barangay level; is focused on preventive and promotive population-
based health service; assists in patient navigation as a satellite health facility
of the Rural Health Unit (RHU) and Urban Health Unit (UHU); and follows the
standards set by the DOH. The BHS is equivalent to the Barangay Health
Center of the Local Government Code of 1991. The term ‘health center’ is
sometimes used by communities to refer to these facilities. (DOH-HFDB
Health Facilities Dictionary)
See related: Primary Care Facility.
Birthing Home A short-stay non-hospital-based health facility that provides maternity
services including prenatal and postnatal care, normal spontaneous
delivery, and care of newborn babies to low-risk mothers and babies. (DOH-
HFDB Health Facilities Dictionary)
Blood Service Facility A unit, agency, or institution providing blood products. The types of BSF are
(BSF) Blood Station (BS), Blood Collecting Unit (BCU), Hospital Blood Bank (BB),
and Blood Center (BC)—regional, sub-national, and national. (DOH AO No.
2008-008)
Clinical Laboratory A health facility where tests are done on specimens from the human body
to obtain information about the health status of a patient for the prevention,
diagnosis, and treatment of diseases. These tests include, but are not limited
to, the following disciplines: clinical chemistry, hematology,
immunohematology, molecular biology, and cytogenetics. The total testing
process includes pre-analytical, analytical, and post-analytical procedures.
(RA 4688; DOH AO No. 2007-0027)
a) General Clinical Laboratory—provides the following minimum service
capabilities such as, but not limited to, routine hematology, qualitative
platelet determination, routine urinalysis, routine fecalysis, blood typing,
etc.
b) Specialized Clinical Laboratory—offers highly specialized laboratory
services that are not provided by a General Clinical Laboratory.
See related: Diagnostic Facility.
Collection Act of safe transporting of HCW from source or from a central storage area.
168
Custodial Care Facility A health facility that provides long-term care, including basic human
services like food and shelter to patients with chronic or mental illness,
patients in need of rehabilitation owing substance abuse, people requiring
ongoing health and nursing care due to chronic impairments and a
reduced degree of independence in activities of daily living. (DOH AO No.
2012-0012)
See related: Transitional Care Facility.
Cytotoxic A substance possessing a specific destructive action on certain cells; used
particularly in referring to the lysis (disintegration or dissolution) of cells
brought about by immune phenomena and to antineoplastic drugs that
selectively kill dividing cells.
Decontamination Reduction of microbiological contamination to a safe level.
Dental Clinic A section or clinic in a hospital or non-hospital-based facility with standard
dental equipment, instruments, and supplies plus all the anesthetic and
sterilization apparatus that provides basic and/or expanded outpatient
services for oral health education, oral examination, fluoride application,
oral prophylaxis, tooth filling, tooth extraction, root canal, minor surgeries.
May also offer specialized dentistry services such as orthodontic treatment,
cosmetic dentistry, prosthodontic dentistry, and diagnostic dental services.
(DOH-HFDB Health Facilities Dictionary)
Diagnostic Facility A type of health facility that examines the human body or specimens from
the human body (except laboratory for drinking water analysis) for the
diagnosis, sometimes treatment, of diseases. The test covers the pre-
analytical, analytical, and post-analytical phases of examination. (DOH AO
No. 2012-0012)
Dialysis Clinic A health facility where a cleansing process using dialyzing equipment
(artificial kidney) and appropriately recognized procedures are performed.
(DOH AO No. 2012-0001)
Disinfection Reduction or removal of disease-causing microorganisms (pathogens) in
order to minimize the potential for disease transmission.
Disposal Discharge, deposit, placing or release of any HCW into or on any air, land,
or water.
Drug Abuse Treatment A health facility that provides comprehensive patient drug treatment and
and Rehabilitation Center rehabilitation services that range within a spectrum of medical and
psychological management. This is further classified into: (DOH-HFDB Health
Facilities Dictionary)
a) Non-residential Treatment and Rehabilitation Center / Outpatient
Center—a health facility that provides diagnosis, treatment, and
management of drug dependents on an outpatient basis. It may be a
drop-in/walk-in center, recovery clinic, or any other facility with
consultation and counseling as the main services provided; or may be
an aftercare service facility. Patients diagnosed with moderate
substance use disorder are oftentimes referred to this center.
b) Residential Treatment and Rehabilitation Center / Inpatient Center—a
health facility that provides comprehensive and rehabilitation services
utilizing any of the accepted modalities as described in the Manual of
Operations towards the rehabilitation of a person with substance use
disorder in an inpatient basis. Patients diagnosed with severe substance
use disorder are oftentimes admitted to this center.
c) Residential Treatment and Rehabilitation Center with Outpatient
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Service Capability—a health facility that provides both outpatient and

inpatient services.
Drug Testing Facility A health facility that is capable of testing a specimen to determine the
presence of dangerous drugs therein. (DOH-HFDB Health Facilities
Dictionary)
a) Screening Laboratory—a laboratory capable of drug screening test to
eliminate negative specimen from further consideration and to identify
the presumptively positive specimen.
b) Confirmatory Laboratory—a laboratory that performs qualitative and
quantitative examination of a specimen independent from that of a
drug screening test.
General Hospital A type of hospital that provides services for all kinds of illnesses, diseases,
injuries, or deformities. A general hospital shall provide medical and surgical
care to the sick and injured, maternity, newborn, and child-care. It shall be
equipped with the service capabilities needed to support board-
certified/eligible medical specialist and other licensed physicians rendering
services in, but not limited to, clinical services (family medicine; pediatrics;
internal medicine; obstetrics and gynecology; surgery), emergency
services, outpatient services, ancillary and support services such as clinical
laboratory, imaging facility, pharmacy. (DOH AO No. 2012-0012)
a) Level 1 Hospital—Non-departmentalized hospital that provides clinical
care and management on the prevalent diseases in the locality with
clinical services that include general medicine, pediatrics, obstetrics
and gynecology, surgery and anesthesia. Provides appropriate
administrative and ancillary services (clinical laboratory, radiology,
pharmacy) and provides nursing care for patients who require
intermediate, moderate, and partial category of supervised care for 24
hours or longer.
b) Level 2 Hospital—Departmentalized hospital that provides clinical care
and management on the prevalent diseases in the locality, as well as
particular forms of treatment, surgical procedures, and intensive care.
Same clinical services provided in Level 1 Hospital, as well as specialty
clinical care. Provides appropriate administrative and ancillary services
(clinical laboratory, radiology, pharmacy), gives total nursing and
intensive skilled care.
c) Level 3 Hospital—Teaching and training hospital that provides clinical
care and management on the prevalent diseases in the locality, as well
as specialized forms of treatment, surgical procedure, and intensive
care. Same clinical services provided in Level 2 Hospital, as well as sub-
specialty clinical care. Provides appropriate administrative and
ancillary services (clinical laboratory, radiology, pharmacy), nursing
care, and continuous and highly specialized critical care.
See related: Hospital.
Genotoxic A substance that can interact directly with genetic material, causing DNA
damage that can be assayed. It may refer to carcinogenic, mutagenic, or
teratogenic substances.
Half-life Specific period that a radiation element decays.
Halfway House A community-based, short-term, housing facility for those in recovery from
physical, mental, and emotional disabilities, including those suffering from
mild to moderate drug and alcohol dependence, with a structured
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environment and crucial support in reintegrating into society. (DOH-HFDB

Hazardous Waste All waste generated by HCF except general waste.
Health Care Facility An institution that has health care as its core service, function, or business.
(HCF) / Health Facility Health care pertains to the maintenance or improvement of the health of
individuals or populations through the prevention, diagnosis, treatment,
rehabilitation, and chronic management of disease, illness, injury, and other
physical and mental ailments or impairments of human beings. (DOH-HFDB
Health Care Workers All staff in the HCF, i.e., doctors, nurses, administrative staff, paramedical,
ancillary workers, institution workers, nursing attendants, dental aides,
laboratory aides, janitors, maintenance, radiology aide, social workers, etc.
Health Office A barangay, municipal, city, province, regional government or private
office that does not provide direct health services or with health services
not defined as its core service, function, or business. These include
administrative and management offices of municipal, city, provincial, and
regional health units. Examples: Municipal Health Office, City Health Office,
Provincial Health Office, Regional Health Office, research offices, etc.
Highly Infectious Waste Cultures and stocks of highly infectious agents; waste from autopsies,
animal bodies, and other waste items that have been inoculated, infected
or in contact with such agents; wastes contaminated with organisms
belonging to Biosafety Levels 3 and 4; wastes contaminated with
pathogens mentioned in DOH AO 2010-0033.
Human A health facility credited by the Health Facilities and Services Regulatory
Immunodeficiency Virus Bureau (HFSRB), capable of performing HIV Testing by medical
(HIV) Testing Center technologists that have undergone the training on HIV Testing Proficiency.
(DOH AO No. 2014-0005)
Hospice A health facility that provides hospice care defined as a component of
palliative care of a chronically ill, terminally ill, or seriously ill patient’s pain
and symptoms, otherwise known as end-of-life care that consists of
medical, psychological, spiritual, and practical support or patients unable
to perform self-care and with declining conditions despite definitive
treatment and other disease-modifying interventions. (IRR of RA 11215)
Hospital A place devoted primarily to the maintenance and operation of facilities
for the diagnosis, treatment, and care of individuals suffering from illness,
disease, injury, deformity, or in need of obstetrical or other medical and
nursing care. The term ‘hospital’ shall also be construed as any institution,
building, or place where there are installed beds, or cribs, or bassinets for
24-hour use or longer by patients in the treatment of diseases, diseased-
conditions, injuries, deformities, or abnormal physical and mental states,
maternity cases, and all institutions such as those for convalescence,
sanitaria or sanitaria care, infirmaries, nurseries, dispensaries, and such other
names by which they may designated. (RA 4226)
Household Waste Wastes produced from activities within the household.
Human Stem Cell Clinic A facility that may act as an entity providing the service of cellular therapy
(Cellular Therapy product collection and a location where cellular therapy product
Facility) processing activities are performed in support of its clinical program. The
facility may also serve as the storage area for cellular therapy product for
171
future processing, distribution, or administration. (DOH AO No. 2013-0012)

Infectious Waste Waste that contains pathogens like bacteria, viruses, parasites or fungi in
sufficient concentration or quantity to cause disease in susceptible hosts.
Infirmary A health facility that provides emergency treatment and care to the sick
and injured, as well as clinical care and management to mothers and
newborn babies. It provides basic, non-complex inpatient, diagnostic, and
treatment services usually by general practitioners. The need for infirmaries
is decided according to the local context. (RA 4226; DOH AO No. 2012-
0012)
Leachate Liquid produced when HCW undergoes decomposition, and when water
percolates through solid waste undergoing decomposition. It is a
contaminated liquid that contains dissolved and suspended materials.
Medical Facilities for A health facility that conducts Pre-Employment Medical Examination
Overseas Workers and (PEME), which refers to a complete medical examination during screening
Seafarers to determine physical and mental fitness to work for overseas workers and
seafarers for inter-island/overseas employment. (DOH AO No. 101-2004)
Medical Outpatient Clinic A health facility that provides ambulatory general or specialized outpatient
care to patients with injuries or infirmity requiring the range of non-urgent to
immediate care, commonly addressing minor and non-life-threatening
illness and injuries. Examples: Family Planning Clinic, HIV Clinic, Social
Hygiene Clinic, School Clinic, Office Clinic, etc. (DOH-HFDB Health Facilities
Dictionary)
Mental Health Facility Any establishment or unit of an establishment, which has as its primary
function the provision of mental health services. (RA 11036)
National Reference The highest level of laboratory in the country, mandated to provide
Laboratory laboratory confirmatory services, provide training, perform surveillance, do
outbreak response, provide External Quality Assurance, perform kit
evaluation, and do research. NRL may have designated Sub-National
Laboratories (SNL).
Newborn Hearing The central facility at the National Institutes of Health (NIH) that defines
Screening Reference testing and follow-up protocols, maintains an external laboratory
Center proficiency testing program, oversees the national testing database and
case registries, assists in training activities in all aspects of the program, and
oversees content of educational materials. (RA 9709)
Newborn Screening The central facility at the National Institutes of Health (NIH) that defines
Reference Center (NSRC) testing and follow-up protocols, maintains an external laboratory
proficiency testing program, oversees the national testing database and
case registries, assists in training activities in all aspects of the Newborn
Screening (NBS) program, oversees content of educational materials,
recommends establishment of Newborn Screening Centers (NSCs) and acts
as the Secretariat of the Advisory Committee on Newborn Screening. (IRR
of RA 9288)
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Non-Hazardous Waste Waste that has not been in contact with infectious agents, hazardous
chemicals, or radioactive substances, and that does not pose a sharps
hazard.
Nuclear Medicine Facility A health facility, presently regulated by Philippine Nuclear Research
Institute (PNRI), embracing all applications of radioactive materials in
diagnosis, treatment, or in medical research, with the exception of the uses
of sealed radiation sources in radiotherapy. (DOH AO No. 2012-0012)
Nursing Home A residential facility providing a high level of long-term custodial, personal,
or nursing care for persons such as the aged or the chronically ill. The facility
may also provide palliative and/or hospice care at the end of life. (DOH-
Off-site Collection Collection and transfer of segregated HCW from the HCF-Central Storage
Area (CSA) to DENR Accredited Transporter/Municipal Waste
Collector/Supplier.
Off-site Transport Transport of segregated HCW from HCF to Treatment Facilities or to Final
Disposal on-site collection area.
Office Clinic A medical outpatient clinic inside a professional work or employment
environment that provides primary care services including treatment of
minor ailments, immediate management of emergency cases, health
education, health promotion, and referral to an appropriate facility. (DOH-
On-site Collection Collection of segregated HCW from the point of generation to designated
color-coded bins.
On-site Transport Transport of collected segregated HCW from the designated color-coded
bins to CSA.
Pharmaceutical Outlet Refer to entities licensed by appropriate government agencies, and which
are involved in compounding and/or dispensing and selling of
pharmaceutical products directly to patient or end-users. (RA 10918)
Physical Therapy and A health facility concerned with the maximal restoration or development of
Rehabilitation Facility physical, physical, psychological, social, occupational, and vocational
functions in persons whose abilities have been limited by disease, trauma,
congenital disorders, or pain to enable people to achieve their maximum
functional abilities. It involves the diagnosis, evaluation, and management
of people of all ages physical and/or cognitive impairment and disability
(DOH AO No. 2012-0012)
Primary Care Facility A type of health facility that provides population- and individual-based
health services that accessible, continuous, comprehensive, and
coordinated care that is accessible at the time of need, including a range
of services for all presenting conditions. It also serves as the initial point of
contact for individual-based services, through its ability to navigate and
coordinate referrals to other health care providers in the health care
delivery system, when necessary. (DOH-HFDB Health Facilities Dictionary)
Pyrolysis Thermal decomposition of substance and materials in the absence of
supplied molecular oxygen in the destruction chamber in which the said
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material is converted into gaseous, liquid, or solid form.

Quarantine Clinic A designated health facility for referral of suspect/s or probable case/s of
public health emergency of international concern where people who have
been exposed to an illness, usually an infection, but are not ill or have not
yet shown any sign of the illness are restricted to. (IRR RA 9271)
Radioactive Waste Material that contains, or is contaminated with, radionuclides at
concentrations or activities greater than clearance levels.
Radiologic Facility A health facility concerned with the use of imaging techniques in the study,
diagnosis, and X-ray guided treatment of disease. This includes the use of x-
rays in in general radiography and fluoroscopy, interventional radiology,
lithotripsy, computed tomography, mammography, bone densitometry,
and tumor localization and simulation. (DOH-HFDB Health Facilities
Dictionary)
Re-use Process of recovering materials intended for the same or different purpose
without the alteration of physical and chemical characteristics.
Recovery Clinic A non-residential treatment facility where specialized consultations,
evaluations, and treatment may be provided for those recovering from
drug use. (DOH-HFDB Health Facilities Dictionary)
Recyclable Any waste material retrieved from the waste stream and free from
contamination that can still be converted into suitable and beneficial use
or for other purposes, including, but not limited to cardboard, glass, office
paper, drink cans, newspapers, magazines and polyethylene or
polypropylene plastics (PE and PET).
Recycling Processing of used materials (waste) into new products to prevent waste of
potentially useful materials, reduce the consumption of fresh raw materials,
reduce energy usage, reduce air pollution and water pollution (from land
filling) by reducing the need for ‘conventional’ waste disposal, and lower
greenhouse gas emissions as compared to virgin production.
Rural Health Unit (RHU) / A government primary health facility that serves as first contact primary
Urban Health Unit (UHU) care services in the municipality or city delivering health promotion, disease
prevention, health maintenance, counseling, patient education, diagnosis,
management, and treatment of acute and chronic illnesses and referrals.
It ensures a follow-through course of treatment of a person as a whole and
provides both population- and individual-based health services. It provides
leadership in patient navigation and coordination in a network and follows
the standards set by the DOH. The RHU/UHU is equivalent to the Municipal
or City Health Center of the Local Government Code of 1991. The term
‘health center’ is sometimes used by communities to refer to these facilities.
Sanitarium An institution established to make available hospital services specifically for
Hansenites (Hansen’s Disease). The sanitarium serves as the referral center
for the management of complications, patient and family counseling, and
community education for leprosy and also for the integration of its Multi-
Drug Therapy (MDT) treatment. (DOH AO No. 2005-2013)
Sanitary Landfill Facility An engineered method designed to keep the waste isolated from the
(SLF) environment.
174
School Clinic A medical outpatient clinic inside school, college, or university premises that
provides primary care services including, but not limited to, oral care, health
education, health promotion, treatment of minor ailments, immediate
management of emergency cases, and referral to an appropriate facility,
following the standards set by the DOH. (DOH-HFDB Health Facilities
Dictionary)
Segregation Separating the waste generated by the HCF according to the specific
treatment and disposal requirements.
Sludge Accumulated solids that separate from liquids such as water or wastewater
during processing, or deposits on the bottom of streams or other bodies of
water.
Specialized Health A type of health facility that provides highly specialized care addressing
Facility particular conditions and/or providing specific procedures and
management of cases requiring specialized training and/or equipment.
Specialized health facilities within hospitals are recognized as a service/unit
and not as a separate stand-alone facility. (DOH-HFDB Health Facilities
Dictionary)
Specialty Hospital A hospital that specializes in a particular disease or condition or in one type
of patient. A specialized hospital may be devoted to any of the following:
a) Treatment of a particular type of illness or for a particular condition
requiring a range of treatment. Examples: Philippine Orthopedic
Center, National Center for Mental Health, San Lazaro Hospital
b) Treatment of patients suffering from diseases of a particular organ or
groups of organs. Examples: Lung Center of the Philippines, Philippine
Heart Center, National Kidney and Transplant Institute
c) Treatment of patients belonging to a particular group such as children,
women, elderly, and others. Examples: Philippine Children’s Medical
Center, National Children’s Hospital, Dr. Jose Fabella Memorial Hospital
See related: Hospital.
Sterilization Destruction of all microbial life
Storage Area or place where HCW is temporarily stored after generation and prior
to collection for ultimate recovery or disposal.
Traditional and A health facility that provides a broad set of health care practices that are
Complementary Medicine not integrated into dominated the dominant health care system. Examples
Clinic are, but not limited to, the following services: acupuncture; chiropractic;
naturopathy, etc. (PITAHC Order No. 2018-109)
Transitional Care Facility A type of heath facility that oversees the continuity of care during the
course of chronic or acute illness. The transitional care facilities also
encompass both the sending and receiving aspects of transfers including,
but not limited to, logistical arrangements, patient and family health
education, and coordination among health professionals involved in the
transition. (DOH-HFDB Health Facilities Dictionary)
Waste Disposal Refers to the intentional burial, deposit, discharge, dumping, placing, or
release of any waste material into or on air, land, or water.
Waste Generator Any person, organization, or facility engaged in activities that generate
waste.
Waste Management All the activities, administrative and operational, involved in the handling,
treatment, storage, collection, transportation, and disposal of wastes.
175
Waste Treatment Any method, technique, or process for altering the biological, chemical, or
physical characteristics of waste to reduce the hazards it presents and
facilitate or reduce the costs of disposal. The basic treatment objectives
include volume reduction, disinfection, neutralization, or other change of
composition to reduce hazards including removal of radionuclides from
radioactive wastes.
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Fourth Edition ANNEX A: Process Flow Diagrams
ANNEX A: Process Flow Diagrams

Annex A 1: Health Care Waste Management per Type of Waste
Annex A 2: Process Flow for Waste Minimization for Urban Area With Access to a
Legally Approved Modern Waste Treatment Facility
Annex A 3: Process Flow for Waste Minimization for Urban Area Without Access to a
Legally Approved Modern Waste Treatment Facility
Annex A 4: Process Flow for Waste Minimization for Rural Area Without Access to a
Legally Approved Modern Waste Treatment or Disposal Facility
Annex A 5: Process Flow for Needle-Syringes Waste Management – Immunization at
PHC
Annex A 6: Process Flow Needle-Syringes Waste Management - Outreach
Immunization Activities
Annex A 7: Incineration Process with Flue Gas
Annex A 8: Wastewater Process Flow
Annex A 9: Sample Flowchart on the Management of Occupational
Accident/Incident for Tertiary Hospitals
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Annex A 1: Health Care Waste Management per Type of Waste

Sharps Waste
178
Chemical Waste
179
Pharmaceutical Waste
180
Radioactive Waste
181
Pathological Waste
182
Anatomical Waste
183
Highly Infectious Waste
184
General Waste (Non-hazardous)
185
Annex A 2: Process Flow for Waste Minimization for Urban Area With Access to a Legally Approved Modern Waste
Treatment Facility
Source: Management of solid health-care waste at primary health-care centres (WHO 2005)
186
Annex A 3: Process Flow for Waste Minimization for Urban Area Without Access to a Legally Approved Modern
Waste Treatment Facility
187
Annex A 4: Process Flow for Waste Minimization for Rural Area Without Access to a Legally Approved Modern
Waste Treatment or Disposal Facility
188
Annex A 5: Process Flow for Needle-Syringes Waste Management – Immunization at PHC
189
Annex A 6: Process Flow Needle-Syringes Waste Management - Outreach Immunization Activities
190
Annex A 7: Incineration Process with Flue Gas
191
Annex A 8: Wastewater Process Flow
Flow of wastewater from HCF departments to WWTP
Flow of wastewater within the WWTP
192
Annex A 9: Sample Flowchart on the Management of Occupational Accident/Incident for Tertiary Hospitals
193
Fourth Edition ANNEX B: Requirements and Guides
ANNEX B: Requirements and Guides

Annex B 1: Duties and Functions of HCWM Committee Members
Annex B 2: Requirements for Consignment Notes
Annex B 3: Requirements of Off-site Transport Vehicles
Annex B 4: Guide Questions for Selection of Treatment Technology
Annex B 5: Advantages and Disadvantages of Different Treatment Technologies
Annex B 6: Characteristics of the Main Disinfectant Groups
Annex B 7: Advantages and Disadvantages of Different Types of Wastewater
Treatment Plant
Annex B 8: Factors to Consider for Establishment of On-Site WWTP
Annex B 9: Suggested Training Package for HCWM Target Group
194
Annex B 1: Duties and Functions of HCWM Committee Members
CORE TEAM
A. Waste Management Officer (WMO) – designated as Co-Chair of the HCWM Committee will be
responsible for the day to day operation and monitoring of the waste management system in
the hospital. The WMO is directly responsible to the Head/Administrator of the HCF. He or she
shall establish linkage with the Infection Control Officer, the Chief Pharmacist and the Radiation
Officer in order to become familiar with the correct procedures for handling and disposing of
pathological, pharmaceutical, chemical and radioactive waste. The duties and responsibilities
of the WMO shall include the following:
 Ensure that the internal regular collection of waste observe the proper waste
segregation, collection and transport policies and guidelines;
 Observe and direct the provision of continuous availability of waste bins, plastic liners,
personal protective equipment and collection bins/carts and direct supervision of
collection crews;
 Check and direct correct use of central storage facility, which shall be kept locked but
accessible to authorized staff at all times;
 Coordinate and monitor waste treatment, disposal operations, waste transport for both
on-site and off-site;
 Coordinate with the Senior Nursing Officer and Department Heads to ensure that nursing
staff and medical assistants as well as doctors and other qualified clinical staff are aware
of their responsibilities for segregation and storage of waste; and
 Ensure that written emergency procedures are available and that personnel are aware
of the action to be taken in the event of an emergency. Investigate and review
reported incidents concerning the handling of HCW.
B. Designated Pollution Control Officer (PCO) – shall be responsible for the HCF compliance to the
requirements mandated by EMB-DENR and other regulatory agencies. He/she shall be
responsible for the following duties and responsibilities:
 Attend to requirements of the HCF prior to the construction or installation of pollution
control facilities including the application and securing of necessary pollution permits
and renewal;
 Monitor activities pertaining to the installation or construction of pollution source and
control facilities with the end in view of ensuring their compliance with air, noise and
water quality standards; the PCO and the head of the HCF shall be held responsible for
any violations of PD 984 and its IRR committed by the establishment where the officer is
employed;
 Supervise the proper operation and maintenance of pollution control facilities of the
establishment or agency;
 Report within reasonable time to the EMB-DENR the breakdown of any pollution control
facility and the estimated and actual date of completion/repair and operation;
 Promptly submit validated/certified as correct by the HCF Administrator periodic reports
as required by the EMB-DENR;
 Act as liaison officer and maintain linkage with the DOH, DENR, EMB and designated
PCO of other agencies including the local government unit;
 Keep himself abreast with the requirements of DENR-EMB and the latest available
technology on the prevention, control and abatement of pollution; and
 Attend the meetings for PCO’s which may from time to time be called by the monitoring
agency.
C. Designated / Appointed Infection Control Officer (ICO) / Safety Officer (SO) shall be responsible
for the following duties and responsibilities:
 Maintain linkage with the WMO on a continuous basis and provide advice concerning
the control of infection and the standards of the waste disposal system.
 Identify training requirements according to staff grade and occupation;
 Organize and supervise staff training courses on safe waste management;
 Liaise with the department heads and Senior Nursing Officer regarding the training of
their staff;
195
 Handle the overall responsibility for chemical disinfection, sound management of

chemical stores and chemical waste minimization.
 Ensure that all chemical used in the HCF has a Material Safety Data Sheet (MSDS).
D. Finance / Budget Officer and Supply Officer -shall be responsible in assuring the provision of
continuous logistics, maintaining and sustaining the programs and activities of the HCWM
Committee and including them in the annual procurement plan:
 Liaise with the WMO to ensure a continuous supply of the items required for waste
management (plastic liners and bins of the right specifications, spare parts for the on-site
waste treatment equipment, etc.). These items shall be ordered within a reasonable time
to ensure that these are readily available at the HCF at all times. However, excessive
accumulation of these items should be avoided.
 Investigate the possibility of purchasing environmental-friendly products (e.g. PVC-free
plastic items) by adopting the principles of Green Procurement Policy.
HCWM COMMITTEE MEMBERS
All HCF management and support staff play a vital part in the success of the program. Equally
important are the specific roles and contribution of the following specific key personnel in any HCF:
A. Division Heads of the Medical, Nursing and Administrative Services shall:

 Ensure strict compliance of their respective staff with the policies and guidelines being
implemented by the HCWM Committee;
 Disseminate polices and guidelines down the line including all the support staff in the
HCF;
 Conduct regular orientation and reorientation among their HCF workers;
 Maintain linkage with designated WMO
B. Department Heads are responsible within their respective areas of concern to ensure that all
members of their department are aware of the hospital waste management plan as to
segregation and storage procedures and that strict compliance is observed. They shall also:
 Ensure that all doctors, nurses, clinical and non-clinical professional staff in their
departments are aware of the segregation and storage procedures and that all
personnel comply with the highest standards in HCWM;
 Liaise with the WMO to monitor working practices against failures or mistakes;
 Ensure that key staff members in their department are given training in waste
segregation and disposal procedures; and
 Encourage medical and nursing staff to be vigilant to ensure that hospital attendants
and ancillary staff follow correct procedures at all times.
C. The Senior Nursing Officer is responsible for the training of the nursing staff, medical assistants,
hospital attendants and ancillary staff on the correct procedures for the segregation, storage,
transport and disposal of waste. He/she shall:
 Liaise with the WMO and the advisers (Infection Control Officer, Chief Pharmacist, and
Radiation Officer) to maintain the highest standards in HCWM;
 Participate in staff introduction to and continuous training in the handling and disposal
of waste; and
 Liaise with the Department Heads to ensure coordination of training activities, other
waste management issues specific to particular departments.
D. The Chief Pharmacist is responsible for the sound management of pharmaceutical storage and
for pharmaceutical waste minimization. Hs/she shall:
 Liaise with the Department Heads, the WMO, the Senior Nursing Officer and give advice,
in accordance with the national policy and guidelines, on the appropriate procedures
for pharmaceutical waste disposal;
 Coordinate continuous monitoring of compliance with procedures for the storage and
disposal of pharmaceutical waste;
 Ensure that personnel involved in pharmaceutical waste handling and disposal receive
adequate training; and,
 Ensure safe utilization of genotoxic products and safe management of genotoxic waste.
196
E. The Radiation Officer shall:

 Ensure proper waste management of radioactive waste;
 Liaise with the Department Heads, the WMO, the Senior Nursing Officer and give advice,
in accordance with the national policy and guidelines, on the appropriate procedures
for radioactive waste disposal including its continuous monitoring;
 Ensure that personnel involved in radioactive waste handling and disposal receive
adequate training.
F. The Head of the General Services including the unit heads of housekeeping and janitorial
services shall:
 Maintain cleanliness and orderliness of the HCF premises for aesthetic reasons;
 Assist in the preparation of the HCWM Plan;
 Initiate a sanitary manner of implementing the pre-treatment process, appropriate
collection system/procedures and disposal of waste either by TSD or municipal system;
 Establish baseline data, ensure generation of data for regular recording and monitoring;
and maintain proper filing system and update program records;
 Maintain constant good working relationship with all HCF workers for their support and
full participation in implementing the program;
 Enhance or provide continuous training for housekeeping/janitorial services on waste
management and government policies.
G. Maintenance and Ground Services shall:

 Assist in the proper collection, pre-treatment and disposal of HCW;
 Carry out directly the activities related to the operation and maintenance of pre-
treatment, collection and disposal system with importance to the drainage system and
plumbing facilities of the establishment;
 Attend immediately to problems arising from the repair/installation of waste equipment.
H. The Motor Pool and Ground Services shall:

 Assist in the provision of vehicle for transporting HCW to transfer station or disposal sites;
 Prepare and plan the collection system routes and frequency of collection of HCW;
 Inspect and schedule maintenance work on vehicles used for transporting HCW;
 Observe proper infection control measures in the maintenance of vehicles used for the
transportation of HCW
I. The HCF Engineer or the designated in-charge of engineering services shall:

 Be responsible for installing and maintaining waste storage facilities and comply with the
specifications of the national guidelines;
 Be accountable for the adequate operation and maintenance of any on-site waste
treatment equipment;
 Be responsible for compliance with mandatory requirements of pollution control;
 Be responsible for the staff involved in waste treatment; ensure that the staff designated
to operate the on-site waste treatment facilities are trained in their operation and
maintenance.
197
Annex B 2: Requirements for Consignment Notes
 All HCW to be transported to an approved off-site waste treatment facility shall be

transported only by a DENR-accredited transporter or carrier, except non-hazardous
HCW which are collected by the municipal collection system.
 The authorized transporter/carrier shall maintain a completed consignment note of
all HCW for treatment or disposal and an updated transport permit.
 Upon the receipt of the wastes, the transporter shall provide the waste generator
with a copy of the consignment note for the generator’s waste records.
 The transporter and generator shall separately maintain a copy of the consignment
note. The consignment note shall include, but is not limited to the following
information:
o The name, address, telephone number and accreditation number of the
transporter, unless the transporter is the generator.
o The type and quantity of HCW transported;
o The name, address, and telephone number of the generator;
o The name, address, telephone number, permit number and the signature of
an authorized representative of the approved facility receiving the HCW.
o The date that the HCW is collected or removed from the generator’s facility,
the date that the HCW is received by the transfer station or point of
consolidation (if applicable) and the date that the HCW is received by the
treatment facility.
 If the HCW generator transports the waste or directs a member of its staff to transport
the HCW to an approved waste treatment and disposal facility, the consignment
note for the HCW shall show the name, address and telephone number of the HCW
generator when the HCW are transported to the waste treatment and disposal
facility.
 The transporter or generator transporting the HCW shall have the consignment note
in his or her possession in the vehicle while transporting the waste. The tracking
document shall be available upon demand by any traffic enforcement agency
personnel. The transporter shall provide the facility receiving the waste with a copy
of the original tracking document.
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Annex B 3: Requirements of Off-site Transport Vehicles
A. Logistic Staff Requirements

Drivers of vehicles carrying hazardous HCW should have appropriate training about risks and
handling of hazardous waste. Training on the following issues should be included:
 relevant legal regulations
 waste classifications and risks
 safe handling of hazardous waste
 labelling and documentation
 emergency and spillage procedures.
In addition, drivers should be declared medically fit to drive vehicles. In case of accident,
contact numbers or details of the emergency services and other essential departments
should be carried in the driver’s cab. For safety reasons, vaccination against tetanus and
hepatitis A and B is recommended, and vaccination and training details of staff should be
recorded.
B. Requirements for Off-site Transport Vehicles

 Transport vehicles for HCW shall not be used for the transport of any other materials
that could be seriously affected by contamination such as food, livestock, or retail
goods.
 The vehicle shall have an enclosed leak-proof body and capable of being locked
to secure the HCW. Open-topped skips or containers are unsuitable because they
fail to isolate waste from the general public during transportation and should not be
used for HCW.
 HCW can be loaded directly to a specially designed vehicle, but it is safer to place
them first in containers (e.g. cardboard boxes or wheeled, rigid, lidded plastic or
galvanized bins).
o The design of the collection vehicle must conform to the following:
o The body shall be of suitable size commensurate with the design of the
vehicle.
o It shall have a totally enclosed car body with the driver’s seat separated from
the load to prevent coming into contact with the HCW in the event of a
collision/ accident.
o The body of the vehicle shall display the international biohazard sign
including emergency telephone number.
o The body shall be marked with the name and address of the waste carrier.
o It shall have a suitable system for securing the load during transport.
o It shall be easy to clean. The internal surface of the body shall be smooth
enough to allow it to be cleaned with wet steam or hot water.
o The internal finish of the vehicle and internal angles should be rounded to
eliminate sharp edges to permit more thorough cleaning and prevent
damage to waste containers.
o It shall be equipped with a separate compartment containing empty plastic
bags, suitable protective clothing, cleaning equipment, tools, disinfectants
and special kits for dealing with liquid spills.
o It shall strictly comply with EMB-DENR requirements.
o The same safety measures should apply to the collection of hazardous HCW
from scattered small sources, such as clinics and general practice surgeries.
 The transport vehicle should be labelled according to the type of waste that is being
transported. The label that is displayed will depend on the United Nations
classification of the waste. No specific vehicle labelling is required if less than 333kg
(i.e. the “gross dangerous goods charge”) of infectious waste (UN 3291) is
transported – although labelling is recommended. Vehicles transporting more than
199
333kg gross weight of infectious waste must be provided with warning plates.
 A warning plate should:
o be not less than 250mm by 250mm, with a line of the same color as the symbol
running 12.5mm inside the edge and parallel with it;
o correspond to the label required for the dangerous goods in question with
respect to color and symbol;
o display the numbers prescribed for the dangerous goods on the
corresponding label, in digits not less than 25mm high.
C. Emergency Contingency Plan for HCW Transporter

The development of a plan of action shall be considered in the event of an accidental spill,
loss of containment, equipment failure or other unexpected circumstances. The
owner/operator of vehicles used in the transport of HCW shall carry contingency plans for
emergencies that address the following:
 Emergency response intervention cards (ERICards or ERICs) kept inside the driver’s
cab provide guidance on initial actions for responders and fire crews, because they
are often the first to arrive at the scene of a hazardous waste transport accident.
These cards provide reliable product-specific emergency information that otherwise
may not be immediately available. (PROVIDE SAMPLE OF ERICs in the Annex)
 Plan for the disinfection of the truck and any contaminated surface if a leaking
container is discovered.
 A notification list of individuals or agencies to be contacted in the event of a
transport accident.
 Clean-up and decontamination of potentially contaminated surfaces, designation
of back-up transport for the HCW, a description of the plans for the repackaging and
labelling of HCW where bins are no longer intact.
 Procedures for the management of leaking container/s.
 Other EMB-DENR requirements.
200
Annex B 4: Guide Questions for Selection of Treatment Technology
 How important is volume reduction in choosing a technology? What is the ratio of

HCW produced by your HCF to the HCW treated by the treatment technology? Is
the technology dependent on the volume of waste?
 How would waste reduction programs affect the process? If the waste volume
changes radically for any reason (e.g., reduced patient-days, merger, better waste
minimization efforts) will this technology still be the treatment needed?
 Have workers from your HCF talked to colleagues at other HCFs about their treatment
options, made comparisons, discussed technologies, contracts and services, as well
as violation histories and ranges of service costs?
 What is the Philippine regulatory climate for on-site treatment technologies? (Some
types of technologies require more complicated permits than others)
 Does your HCF have workers on-site that are trained and certified to fulfil the testing
requirements, time, etc. involved in these permits? If not, consider those staffing and
testing costs in your evaluation.
 How long has the treatment technology been effectively in use and where?
 What is the estimated “life” of this equipment?
 What volume of waste can the technology handle and treat?
 Will it always be operating at peak capacity or will there be wide variations in the
amount of HCW treated?
 What are the operational cost implications of using this technology?
 What are the environmental and fiscal impacts of utilities usage (electricity, water,
and sewer)?
 What is the safety and repair history of the waste treatment equipment?
 What worker safety and on-going equipment education are required and who
provides it?
 What is/are the cost/s of equipment failure and need for a back-up or alternative
system?
 Is waste fed into the treatment system automatically (by machine) or by hand (stop
feed)?
 What impact does this have on your HCF workers limitations?
 Can equipment repair be completed within 24 hours without an emergency clause
and/or additional costs?
 Does the technology require ancillary equipment such as shredders? Are they an
integral part of the treatment process?
 What are the total associated costs for this equipment?
 Are there any worker-safety concerns with this equipment?
 How is the volume and weight of the HCW measured? Who measures it? Is it cost-
effective to weigh the wastes on-site?
201
Annex B 5: Advantages and Disadvantages of Different Treatment Technologies

ADVANTAGES DISADVANTAGES HEALTH AND ENVIRONMENTAL IMPACT
Autoclave
 Low environmental Reliable solid waste
 Autoclaving is an environmentally
impacts collection required friendly technology. Low-heat thermal
 No hazardous  Reliable water and processes like autoclaving produce
residues electricity connection significantly less air pollution than
 Complies with needed incineration processes, therefore there
Stockholm  Water needs to be of are no specific pollutant emission limits
Convention certain quality to protect for autoclaves. However, the air
 Some treated the equipment evacuated from the treatment
wastes can be  Temperature resistant chamber needs to be filtered and the
recycled waste bin or bags are condensate decontaminated to
needed prevent occupational health hazards.
 Residue recognizable,
can cause injuries (e.g.,
sharps)
Autoclaves with Integrated Shredding
 Low environmental  Reliable water and Since low-heat thermal processes like
impacts electricity connection hybrid autoclaves produce significantly
 No hazardous needed less air pollution than incineration
residues  Water needs to be of processes, there are no specific
 Complies with certain quality to protect pollutant emission limits for hybrid
Stockholm the equipment autoclaves. The system needs to be
Convention  Higher cost and completely enclosed to prevent
 Reduction of maintenance emitting aerosols during the waste
Volume  Requires skilled operator shredding process
 Residue is
unrecognizable
Batchwise Microwave
 Low environmental  Reliable solid waste Microwaving is an environmentally
impacts collection required friendly technology. Wastewater is
 No hazardous  Reliable electricity decontaminated during the process. Air
residues connection needed emissions from microwave units are
 Complies with  Waste needs a minimum minimal. There are no pollutant emission
Stockholm humidity or water needs limits specific for microwaves.
Convention to be added
 Special waste bins are
needed
Continuous Microwave
 Low environmental  Reliable electricity Microwaving is an environmentally
impacts connection needed friendly technology. Wastewater is
 No hazardous  Waste needs a minimum decontaminated through the process.
residues humidity or water needs Air emissions from microwave units are
 Residue is to be added minimal. There are no pollutant emission
unrecognizable  Higher cost and limits specific for microwaves. The
 Reduction of waste maintenance system needs to be completely
volume enclosed to prevent emission of
 Complies with aerosols during the waste shredding
Stockholm process.
Convention
Incineration
 Reduction of waste  High environmental and Incinerators release a wide variety of
volume health impact (air pollutants, including dioxins and furans,
 Residue is emissions and risk of burns) into the atmosphere. Pollutants vary
unrecognizable * according to the composition of the
 Fully destroys  Bottom and fly ash is waste. Bottom ash residues are also
infectious and potentially hazardous generally contaminated with dioxins,
sharps wastes  Not in accordance with leachable organic compounds, and
202
ADVANTAGES DISADVANTAGES HEALTH AND ENVIRONMENTAL IMPACT

 Applicable to some the Stockholm heavy metals and must be treated as
pharmaceutical Convention* hazardous waste. The ash should be
and chemical disposed in sites designed for hazardous
wastes  *If no flue gas treatment wastes, e.g., designated cells at
engineered landfills, encapsulated and
placed in specialized monofill sites, or
disposed in the ground in ash pits.
203
Annex B 6: Characteristics of the Main Disinfectant Groups

SPECTRUM ADVANTAGES DISADVANTAGES
Alcohols (60–90%) including ethanol or isopropanol
 Used for some semicritical and noncritical items (e.g., oral and rectal thermometers
and stethoscopes)
 Used to disinfect small surfaces such as rubber stoppers of multidose vials
 Alcohols with detergent are safe and effective for spot disinfection of countertops,
floors and other surfaces
Low- to  Fast acting  Volatile, flammable, and irritant
intermediate  No residue to mucous membranes
level  No staining  Inactivated by organic matter
disinfectant  Low cost  May harden rubber, cause glue
 Readily available in all countries to deteriorate, or crack acrylate
plastic
Chlorine and chlorine compounds: the most widely used is an aqueous solution of sodium
hypochlorite 5.25– 6.15% (household bleach) at a concentration of 100–5000 ppm free chlorine
 Used for disinfecting tonometers and for spot disinfection of countertops and floors
 Can be used for decontaminating blood spills
 Concentrated hypochlorite or chlorine gas is used to disinfect large and small
water-distribution systems such as dental appliances, hydrotherapy tanks, and
water-distribution systems in hemodialysis centers
Low- to high-  Low cost  Corrosive to metals in high
level  Fast acting concentrations (>500 ppm)
disinfectant  Readily available in most  Inactivated by organic material
settings  Causes discoloration or
 Available as liquid, tablets or bleaching of fabrics
powders  Releases toxic chlorine gas
when mixed with ammonia
Irritant to skin and mucous
membranes
 Unstable if left uncovered,
exposed to light or diluted; store
in an opaque container
Glutaraldehyde: ≥2% aqueous solutions buffered to pH 7.5– 8.5 with sodium bicarbonate
Novel glutaraldehyde formulations include glutaraldehyde, phenol-sodium-phenate, potentiated
acid glutaraldehyde, stabilized alkaline glutaraldehyde.
 Used in automated endoscope reprocessors
 Can be used for cold sterilization of heat-sensitive critical items (e.g.,
hemodialyzers)
 Also suitable for manual instrument processing (depending on the formulation
High-level  Rapid sterilization cycle time at  Corrosive to some metals
disinfectant/ low temperature (30–45 min. at  Unstable when activated
sterilant 50–55°C)  May be irritating to skin,
 Active in presence of organic conjunctiva and mucous
matter membranes
 Environment friendly byproducts
(oxygen, water, acetic acid)
Orthophthalaldehyde (OPA) 0.55%
 High-level disinfectant for endoscopes
High-level  Excellent stability over wide pH  Expensive
disinfectant/ range  Stains skin and mucous
sterilant  No need for activation membranes
 Superior mycobactericidal  May stain items that are not
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SPECTRUM ADVANTAGES DISADVANTAGES

activity compared with cleaned thoroughly
glutaraldehyde Does not  Eye irritation with contact
require activation  May cause hypersensitivity
reactions in bladder cancer
patients following repeated
exposure to manually
processed urological
instruments
 Slow sporicidal activity
 Must be monitored for
continuing efficacy levels
Hydrogen peroxide 7.5%
 Can be used for cold sterilization of heat-sensitive critical items
 Requires 30 min at 20°C
High-level  No odor  Material compatibility concerns
disinfectant/  Environment friendly byproducts with brass, copper, zinc,
sterilant (oxygen, water) nickel/silver plating
Hydrogen peroxide 7.5% and peracetic acid 0.23%
 For disinfecting hemodialysis
High-level  Fast-acting (high-level  Material compatibility concerns
disinfectant/ disinfection in 15 min) with brass, copper, zinc, and
sterilant  No activation required lead
 No odor  Potential for eye and skin
damage
Glucoprotamin
 Used for manual reprocessing of endoscopes
 Requires 15 min at 20°C
High-level  Highly effective against  Lack of effectiveness against
disinfectant mycobacteria some enteroviruses and spores
 High cleansing performance
 No odor
Phenolics
 Have been used for decontaminating environmental surfaces and noncritical
surfaces
 Should be avoided
Low to  Not inactived by organic matter  Leaves residual film on surfaces
intermediate  Harmful to the environment
level  No activity against viruses
disinfectant  Use in nurseries should be
avoided due to reports of
hyperbilirubinemia in infants
Iodophores (30–50 ppm free iodine)
 Have been used for disinfecting some non-critical items (e.g., hydrotherapy tanks);
however, they are used mainly as an antiseptic (2–3 ppm free iodine)
Low-level  Relatively free of toxicity or  Inactivated by organic matter
disinfectant irritancy  Adversely affects silicone tubing
 May stain some fabrics
205
Annex B 7: Advantages and Disadvantages of Different Types of Wastewater Treatment Plant

WWTP ADVANTAGES DISADVANTAGES
TECHNOLOGY
Anaerobic  Suitable for smaller and larger  Experts are required for the
Baffled settlements design and supervision
Reactor (ABR)  Little space required due to  Master mason is required for
underground construction water-tight plastering
 Low investment costs  Effluent is not completely
 Very low operation and odorless
maintenance costs. No moving  Slow growth rate of
parts power needed. Hardly any anaerobic bacteria means
blockage long start-up period
 Simple and durable  Less efficient with weak
 High treatment efficiency wastewater
Waste  Simple to build, reliable and easy  Large area requirement
Stabilization to maintain  Poor quality of treated
Ponds  Provides pathogen removal which effluent
is better than the conventional  May promote breeding of
treatment insects in the pond
 Used in small communities  Needs to be located far from
 Low in construction and operating communities
cost
Engineered  Easy and simple to maintain and  Requires larger land area
Reed Bed operate  Low treatment efficiency
 Low-cost secondary treatment  Professional/specialist
option needed in design and
 Pleasant landscaping is possible construction
Sequencing  Efficient treatment  Most of the component parts
Batch  Tolerates hydraulic and organic are patented and comes
Reactor (SBR) shock loads (high inlet variation) from abroad
 Modular construction facilitates  Capacities are fixed and no
future expansion Provides a simple, flexibility
reliable, automatic, wastewater  More expensive than other
treatment process with a basin treatment methods
(simple design and construction)  In case of power failure,
 Fully automatic (simple and easy reactor may overflow
control and operation)  Requires more skilled
 Relatively small space requirement attention
Rotating  Low space requirement  Contact media are not
Biological  Can withstand hydraulic and readily available in the
Contractors organic surges more effectively market
(RBC)  High treatment efficiency  High capital cost of
 Low energy and maintenance equipment
requirement  Must be covered for
 Well drainable excess sludge protection against rain, wing,
sunlight, and vandalism
 Failures in shaft and media
 Odor problems
Sludge Drying  Simple to operate  Filtrate/seepage water must
Bed  Lowest cost option among sludge be treated
dewatering methods  Requires solar power
 Energy-saving  May produce odor and flies
nuisance
206
Annex B 8: Factors to Consider for Establishment of On-Site WWTP

a) Regulatory Requirements: Prior to application for Discharge Permit, the following shall be
secured:
b) Environmental Compliance Certificate (ECC) or Certificate of Non-Coverage
c) Application Form from DENR or LLDA
d) Designated and Accredited Pollution Control Officer (PCO - Curriculum Vitae - Undergo 40 hours
accreditation training course by DENR or LLDA 4. Working Plan signed by Professional
Mechanical Engineer (PME)
e) Engineer’s Report
f) Submission of Quarterly Self-Monitoring Report to LLDA
g) Location of the treatment and disposal facility: Under the latest Fire Code of the Philippines,
underground or basement WWTP must be avoided for the following reasons:
h) Possible accumulation of methane gas during breakdown
i) Difficult to access, thus delaying the response during emergency
j) Risk on the part of the full time WWTP operator due to the poor indoor air quality in basements
k) Space Availability: This determines the technology/type or treatment given the volume and
characteristic of wastewater. Smaller space available requires a more compact type of WWTP.
l) infrastructure Requirements: Generally, upon construction, WWTP chambers shall be
waterproofed and can withstand pressure of air blowers and pumping during operation. It is
necessary to provide an air vent in air diffusers to avoid fatigue of the blower component. Proper
ventilation and lighting illumination are also necessary. Proper warning and signage in strategic
areas must be provided.
m) Locally available equipment and parts: In selecting WWTP technology, the Terms of Reference
(TOR), should include the criteria that the equipment parts must be readily available in the local
market for at least five (5) years. This will ensure that there will be a supply of equipment parts in
cases when repairs are needed.
n) Treatment Efficiency: The main objective of treating wastewater is to prevent pollution and
protect the receiving body of water. This can be achieved by maintaining treatment efficiency
that meets the DENR/EMB/LLDA effluent standards.
o) Quantity of Wastewater for Treatment and Disposal: The influent of wastewater for treatment and
disposal depends on the day to day consumption of water.
p) Reuse of Treated Wastewater: Treated wastewater can be used for cooling towers, watering of
ornamental plants and trees, cleaning of hospital buildings and grounds and for flushing of
urinals and toilets. Separate piping for toilets is necessary in using treated wastewater. By using
treated wastewater, over extraction of groundwater and preserved water resources can be
prevented.
q) Characteristic of Wastewater for Treatment: In order to select the best technology option, there
is need to know the characteristics of the HCF’s wastewater through water analysis.
r) Sludge and Septage Disposal: Disposal of accumulated sludge and septage shall be included in
the selection of WWTP technology in compliance with the IRR of Chapter 17 of PD856 and the
Operational Manual on Sludge and Septage Treatment.
s) Operation and Maintenance: It is important to hire a WWTP Operator or a service provider for the
efficient operation and maintenance, monitoring and recording of parameters. It is a must to
have a readily available consumable stock of needed equipment and treatment materials for
continuous WWTP operation.
t) Training Requirement for Operation: It is the responsibility of the awarded contractor to conduct
the on-site or off-site training for the service, operation and proper preventive maintenance of
the WWTP. In compliance with the DENR requirements, the WWTP operator shall undergo training
before renewal of the discharge permit. A newly hired or newly assigned operator must first
undergo training with the DENR.
u) Investment and Operating Cost: Since it is a mandatory requirement of the government, the
management of the HCF shall allocate a budget for the acquisition and maintenance of the
WWTP. Maintenance cost, manpower and operational (electrical and water) costs of the WWTP
shall be included in the annual budget of the HCF.
207
Annex B 9: Suggested Training Package for HCWM Target Group
The development of a training package shall be suitable for the various types of HCFs.
For Personnel Providing Health Care

The training course shall provide an overview of the waste management policy and underlying
rationale and information on practices relevant to trainees’ responsibilities. Waste segregation is a
key element for this training in waste management. All HCF workers that generate HCW shall be
responsible for its segregation and shall therefore receive training in the basic principles and
practical applications of segregation. Training shall make the staff aware of the potentially serious
implications of the mismanagement of waste to the health of waste handlers and patients; provide
them with an overview of the fate of waste after collection and removal from the ward and teach
them the importance of proper segregation.
For Waste Handlers

Topics covered may include the waste management policy, health hazards, on-site transportation,
storage, safety practices and emergency response. Among staffs who routinely handle HCW,
awareness of the need for safety may decrease with time, which will increase the risk of injury.
Periodic refresher course is therefore recommended.
For Health Care Waste Management Operators

The training course shall include:
 Information of the risk associated with the handling of HCW;
 Procedures for dealing with spillage and other accidents;
 Correct use of protective clothing.
For Staff Who Transport the Waste

In carrying out the responsibility of waste transportation, the drivers and waste handlers shall be
aware of the nature and risk of the transported waste. Transport staff shall be able to carry out all
procedures for:
 Handling, loading and unloading of waste bags and bins;
 Dealing with spillage or accidents;
 The use of PPE; and
 Documentation and recording of HCW, e.g. by means of consignment note system to allow
waste to be traced from the point of collection to the final place of disposal.
For Treatment Plant Operators

HCFs shall make arrangements to provide training to prospective treatment plant operators
specifically on the following areas:
 General operations of the treatment facility;
 Health, safety and environmental implications of treatment operations;
 Technical procedures for plant operations;
 Emergency response, in case of equipment failures and/or alarms;
 Maintenance of the plant and record keeping;
 Surveillance of the quality of emissions and discharges, according to the specifications.
Orientation Module for Patients

HCF shall provide patients and watchers an orientation of the HCWM policies and system of the
hospital as part of the admission procedure. The orientation will include, at the minimum:
 Policies on HCWM relevant to patients and watchers such as the ban on Styrofoam and non-
reusable plastic food containers, proper segregation of waste
 Impact of improper segregation and Styrofoam/non-reusable plastic food containers on
health, safety and environment.
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Fourth Edition ANNEX C: Procedures
ANNEX C: Procedures
Annex C 1: Standard Precaution in Health Care
Annex C 2: Procedure for Proper Hand Rubbing
Annex C 3: Procedure for Proper Hand Washing
Annex C 4: Procedures for Spill Control
Annex C 5: General Procedure for Emergency Response to Spills
Annex C 6: Procedures for Emergency Response to Specific Waste Spills
Annex C 7: Procedure for Emergency Response to Needle Prick Injury
209
Annex C 1: Standard Precaution in Health Care
210
211
Annex C 2: Procedure for Proper Hand Rubbing
212
Annex C 3: Procedure for Proper Hand Washing
213
Annex C 4: Procedures for Spill Control
General procedure for dealing with spillages:

a) Vacate and secure the area to prevent further exposure of other individuals.
b) Provide first aid and medical care to injured individuals.
c) Inform WMO who shall coordinate the necessary actions.
d) Determine the nature of the spill. Refer to the MSDS if necessary.
e) Provide appropriate clothing to personnel involved in cleaning-up.
f) Limit the spread of the spill.
g) Activate exhaust system or keep the area well-ventilated particularly if the spill is due
to volatile organic solvents or corrosive agents.
h) Neutralize or disinfect the spilled or contaminated material if indicated.
i) Collect all spilled and contaminated materials (sharps shall never be picked up by
hand; brushed and pans or other suitable tools shall be used). Spilled materials and
disposable contaminated items for cleaning shall be placed in appropriate waste
bags or containers and properly labelled and documented before final disposal.
j) Decontaminate or disinfect the area, wiping with absorbent cloth. The cloth (or other
absorbent material) shall NOT be turned during this process, because this will spread
the contamination. Work from the least to the most contaminated part of the spill
while changing cloth at each stage to carry out the decontamination. Dry cloth shall
be used in the case of liquid spillage and spillage of solids, while wet cloth shall be
used for acidic, base or neutral chemicals.
k) Decontaminate or disinfect all tools used.
l) Seek medical attention if exposure to hazardous material has occurred during the
operation.
m) Normal operation may continue once the disinfected area is thoroughly cleaned
and dried.
The clean-up kit for spill shall contain the following items:
a) One (1) pair of latex gloves
b) One (1) N95 mask (for blood, body fluids and chemotherapeutics/cytotoxics
c) spills)
d) Respirator with specific filter for the type of chemicals
e) One (1) Zip lock bag – small
f) One (1) Zip lock bag – big
g) Absorbable cloth
h) Appropriate disinfectant solution for spills due to blood, body fluids and
chemotherapeutics/cytotoxics
i) Neutralizing solution specific for acids or alkali
j) Eye goggles (for big spill)
k) Labeling materials
l) Small pail with putty clay at the bottom (for chemical spill)
m) Miscellaneous items which the HCF may require to meet their need
214
Annex C 5: General Procedure for Emergency Response to Spills
215
Annex C 6: Procedures for Emergency Response to Specific Waste Spills

TYPE OF IMMEDIATE RESPONSE FOLLOW-UP PERSON IN-
WASTE SPILL PROCEDURES CHARGE
Biohazardous Waste Spill
Minor spill -  Make sure that the biosafety  Know the nature Infection
occurs inside cabinet continues to operate of the organism Control
biosafety  If only a small quantity is spilled, involved Office
cabinet, no decontaminate the surfaces  Report to the
one is within the cabinet, wearing person-in-
exposed gloves and using 16% bleach charge
solution
 If a large quantity is spilled,
entire cabinet including fans,
filters, airflow plenums, will need
to be decontaminated (40%
solution required)
Major spill –  Evaluate the room, breathing  Know the nature Infection
occurs as little as possible of any of the organism Control
outside the aerosols involved Office
biosafety  Close the door of the room.  Report to the
cabinet, Remove any and all person-in-
people are contaminated clothing and charge
exposed place it in sealed plastic
containers
 Thoroughly wash hands and
face with disinfectant soap.
Shower if necessary.
Chemical Waste Spills
Corrosive  If corrosive gets contact with  Do not apply Safety Officer
(acids and eyes, go immediately to any neutralizers
bases) eyewash stations or ointments to
 Remove contact lenses, if any the eyes
 Flush eyes for 15-20 minutes  Seek medical
attention
Reactive  Leave the area quickly  Inform person-in- Safety Officer
(explosives,  Close the doors charge
oxidizers,  Go directly to the eyewash  Seek medical
unstable stations, shower or fresh air area attention
chemicals)
Toxins and  If inhaled, go to fresh air area  Get medical Safety Officer
Poisons right away help.
 If swallowed, seek medical help  If swallowed, do
immediately not induce
 If it got into your eyes, go to the vomiting nor
nearest eyewash station. eat/drink
Remove contact lenses, if any. anything unless
Flush eyes for 15-20 minutes. instructed to do
 If on skin, don’t rub the so in the MDS or
affected area. Rinse with by medical
running water for 15-20 minutes. personnel.
 Remove all contaminated
clothing.
216
Annex C 7: Procedure for Emergency Response to Needle Prick Injury
Needle stick safety shall always be a priority. The following steps in handling a needle stick
injury are highly recommended.
Cleaning the Report the

Testing Retesting
Wound incident
•Clean the wound •It is critical that the •In order to maintain •Injured HCF worker
with soap and injured HCF worker is needle stick safety, shall be retested for
water. Do not pinch tested for HIV, always report hepatitis C six (6)
or squeeze blood hepatitis B and incidence of needle weeks after the
out of the wound or hepatitis C as soon stick injury through needle stick injury
apply bleach. as possible. an incident report and after four to six
according to (4 – 6) months for
infection control hepatitis C virus
protocol antibodies and
elevated liver
enzymes.
•After HIV exposure,
the injured shall get
tested at the sixth
(6th) week and
again on the third
(3rd), sixth (6th) and
twelfth (12th) month
for antibodies to HIV.
The frequency will
vary depending on
the risk of
transmission.
217
Fourth Edition ANNEX D: Sample Checklists and Forms
ANNEX D: Sample Checklists and Forms

Annex D 1: Sample Assessment Checklist for Small HCFs for the Development of HCWM
Annex D 2: Sample Sheet for Assessment of Waste Generation
Annex D 3: Sample Consignment Note Template
Annex D 4: HCWM Program Self-Monitoring Sheet
Annex D 5: Sample Monitoring Tool for Waste Collector
Annex D 6: Occupational Incident/Accident Report (OIR) Form
218
Annex D 1: Sample Assessment Checklist for Small HCFs for the Development of HCWM
Name of HCF:
Type of HCF:
Location:
General Information
Number of employees/workers
Bed capacity
Bed occupancy rate
List all medical and supporting departments of the
facility. (including pharmacy, laboratories, kitchen
etc.)
Health Care Waste Management
What are the wastes generated daily be each ______ General non-infectious wastes
department or ward/lab in the HCF? ______ Sharps
(Please check) ______ Pharmaceutical wastes
______ Chemical wastes
______ Pathological wastes
______ Anatomical wastes
How much is generated per type of waste by ______ General non-infectious wastes
each department or ward/lab in the HCF? ______ Sharps
(kg/day) ______ Pharmaceutical wastes
______ Chemical wastes
______ Pathological wastes
______ Anatomical wastes
Is the HCF practicing segregation at point source?
Are there functional waste collection containers in
close proximity to all waste generation points for
non-infectious wastes, infectious waste and sharp
wastes?
How and where is the facility’s HCW stored before
collection?
Are the wastes stored separately?
Are all the infectious wastes stored in a protected
area before treatment for no longer than the
default and safe time?
How is hazardous liquid waste handled? Specify
for chemical waste, cytotoxic waste, reagents,
and used x-ray film processing liquids.
If the liquid waste is discharged in the sanitation
system, where does the latter discharge and what
is its capacity?
HCWM Treatment and Disposal
What acceptable treatment technology (if any)
are done to the wastes before disposal?
Is the HCW disposed of at the HCF or off-site?
If the wastes are disposed at the facility:
Are concrete vaults used for the disposal of sharp
wastes?
Are placentas disinfected prior to disposal to
placenta pit?
Are treated infectious wastes, sharps, chemical
and pharmaceutical waste
encapsulated/inertisized and disposed through
219
safe burial?
If any waste is taken off-site, are the wastes
transported for treatment by a DENR-accredited
transporter? How is the waste packaged? What
types of vehicles are used to transport the waste?
Is any of the waste taken to a dump or landfill
site?
If so, what happens to the waste at this facility?
Is the HCW buried immediately after arriving at the
landfill/dump?
Is it burned on the site?
Is it left unattended at any time after being
unloaded?
Do waste pickers, children, or others have access
to the HCF?
Wastewater Management
What are the uses of water in the facility?
What departments/wards in the HCF that
generate wastewater? Estimate volume
generated.
Is the wastewater treated on-site or treated in a
centralized wastewater treatment facility?
Management
Is there a trained person responsible for the
management of health care wastes in the health
care facility?
How many people are involved in waste
collection and are special skills required by the
HCF? What sort of worker safety measures are in
place?
What are the current operational standards for
HCW and what are the applicable national,
regional, and local policies?
Are there any written standard operating
procedures for the segregation, storage,
treatment and disposal of the health care wastes?
Are appropriate protective equipment provided
to all staff in charge of the waste management?
Is procurement of new health care materials
reviewed to reduce the waste stream and to
avoid potential treatment problems (such as
PVC)?
What are the daily waste collection routines,
including waste packaging?
How much does HCW management cost the
facility? Does the budget provision cover these
costs?
Risks of the current waste management system
Does the management of the HCF have concerns
about the facility’s current HCW practices? If so,
what problems do they identify?
Does the assessment above indicate that the
facility’s current waste management practices
220
pose any health risks to patients, nurses or doctors,

other staff, or visitors? If yes, what kind of risks?
Does the waste pose any risk to waste collectors?
If yes, what kind?
Source:
Health Care Waste Management Guidance Note (World Bank, 2000)
Water and Sanitation for Health Facility Improvement Tool (WHO, 2018)
221
Annex D 2: Sample Sheet for Assessment of Waste Generation

Name of the facility:
Week:
Waste collection Waste Quantity of waste generated per day (weight/volume)
point: category Mon Tue Wed Thurs Fri Sat Sun
Department/location
222
Annex D 3: Sample Consignment Note Template
A. TRANSPORTER
Name: ____________________________
Address: _____________________________
Telephone No.: _____________________ Accreditation No.: _________________
Type of Waste Transported: __________________________ Quantity (kg): _________
B. GENERATOR
Name: ____________________________
Address: ________________________________
Telephone No.: ___________________________
C. TREATMENT FACILITY
Name of Manager/Authorized Representative: __________________________________

Address: _______________________________Telephone No.: ____________________
Permit to Operate: (Permit No.) _____________________________________________
Signature of Manager/Authorized Representative:
____________________________________
D. DATE WASTES ARE COLLECTED/TRANSPORTED/RECEIVED
Date Collected/Removed from Generator’s Facility:

___________________________________
Date Received by the Transfer Station (Point of Consolidation):
_________________________
Date Received by the Treatment Facility:
___________________________________________
223
Annex D 4: HCWM Program Self-Monitoring Sheet

AREA OF THE HOSPITAL:
DATE OF INSPECTION: MONITORING RATING:
SCORE INDICATORS
Reference Actual
A. WASTE MINIMIZATION PRACTICES 20%
1. Re-uses/recycles used containers, articles, 10 % of recyclable wastes that
papers, etc. were recycled multiplied to 0.10
2. Use of only environment friendly products 10 No Styrofoam (polystyrene) and
and materials plastic (PVC) = 5, otherwise, the
score is 0; and
No mercury containing devices
used = 5, otherwise, the score is
0
B. WASTE SEGREGATION 25%
1. Waste properly segregated in correct 5 No mixed wastes seen at all
plastic liners times= 5, otherwise, the score is
 Black/Clear: Non-Biodegradable 0
General Waste
 Green: Biodegradable General Waste
 Yellow: Infectious Waste
2. Color-coded plastic liners with proper 4 Color coding and proper
tagging and labeling tagging and labeling strictly
followed at all times= 4,
otherwise, the score is 0
3. Use puncture-resistant and leak- proof 4 Only puncture-resistant and
sharps container for sharps leak-proof sharps container
used for sharps waste = 4,
otherwise the score is 0
4. Waste bins strategically placed in 4 Waste bins are placed in
designated area strategically designated areas =
4, otherwise, the score is 0
5. Proper segregation of recyclable items 4 Proper segregation practiced
at all times= 4, otherwise, the
score is 0
6. Empty vials brought to the pharmacy 4 Proper management of empty
section by the nursing attendant/personnel- vials practiced at all times= 4,
in-charge for proper recording and crushing otherwise, the score is 0
(logbook available)
C.WASTE ON-SITE COLLECTION, TRANSPORT 20%
AND STORAGE
1. On-site collection scheduled strictly 2 Strict adherence to on-site
followed collection schedule = 2,
2. Janitorial Service uses standard trolley with 3 Standard trolley is used to
enclosure in collecting waste collect waste on- site= 3,
3. Janitorial Service directly transports waste 3 Waste is directly transported to
collected to Central Storage Area Central Storage Area= 3,
4. No presence of spillage during collection 3 No occurrence of spillage
and transport during collection and
transport= 3, otherwise, the
score is 0
5. Waste bins thoroughly cleaned/ washed 3 Waste bins thoroughly cleaned
by janitors at all times= 3, otherwise, the
score is 0
6. Waste transportation route followed 3 Waste transportation route
224
strictly followed at all times= 3,

7. Final disposal of waste in approved DENR 3 Final disposal of waste in
facility accredited DENR facility= 3,
D.WASTE TREATMENT ON SITE (If applicable) 10%
1. Treatment of highly infectious waste 4 Highly infectious waste treated
conducted at all times= 4, otherwise, the
score is 0
2. In case of chemical disinfection, used only 3 Only the allowed chemicals are
allowed chemicals such as Sodium used for chemical disinfection=
Hypochlorite, Chlorine Dioxide and 3, otherwise, the score is 0
Hydrogen Peroxide
3. In case of the use of microwave or 3 Equipment has passed the
autoclave, the equipment has passed the validation test= 3, otherwise, the
validation test score is 0
E. WASTEWATER MANAGEMENT (Personnel 15%
in- charge)
1. Regular testing of effluents 5 Effluents tested regularly= 5,
2. Preventive maintenance schedule for 10 Strict adherence to STP
Sewage Treatment Plant (STP) followed maintenance schedule= 10,
F. ADMINISTRATIVE 10%
1. Staff with formal training and education 2 Staff had undergone formal
on proper health care waste management training and education on
(HCWM) proper HCWM= 2, otherwise,
the score is 0
2. Infection control protocol observed and 4 Strict adherence to infection
practiced control protocols at all times= 4,
3. Posters and other IEC materials available 2 On-site presence and visibility of
on-site posters and other IEC materials=
2, otherwise, the score is 0
4. Accident/incident reports submitted if any 2 Prompt submission of complete
accident/ incident reports, if
any= 2, otherwise, the score is 0
TOTAL PERCENTAGE 100%
Monitoring Team: ___________________________________________________
Signature of Area Supervisor: __________________________________________
Monitoring Rating
Grade/Actual Score/Interpretation
100% Excellent with full compliance
91%-99% Highly satisfactory with highly adequate compliance
81%-90% Satisfactory with adequate compliance
75%-80% Fair with compliance
74% and below Poor with low compliance
225
Annex D 5: Sample Monitoring Tool for Waste Collector

Part 1
AREA OF THE HOSPITAL: ________________________________________________________________
MONTH OF COLLECTION: ___________________ AREA SUPERVISOR: ________________________

Date Time Volume of Waste
I S P A PH PH PH C Hg R G(A) G(B) G(C) G
(A) (B) (C) (D)
Legend
I – Infectious Waste C – Chemical Waste
S – Sharps Hg – Mercury and Other Heavy Metals
P – Pathological Waste R – Radioactive Waste
A – Anatomical Waste G (A) – Biodegradable/ Food Waste
PH (A) – Pharmacological Waste (Expired/Used Drugs) G (B) – Non-biodegradable/ Recyclable Waste
PH (B) – Pharmacological Waste G (C) – Non-biodegradable/ Non-Recyclable Waste
(Cytotoxic/Genotoxic/Antineoplastic)
PH (C) – Pharmacological Waste (Empty G (D) – Aerosol and Pressurized Containers
Vials/Ampoules)
226
Part 2
DATE TIME CHECK IF “YES” IF NOT, PROVIDE EXPLANATION NAME AND
SIGNATURE OF
COLLECTOR
Is proper segregation practiced?
If not Improper practice/s:
Is the supply of liners adequate?
# of liners left:
Yellow: ___ Green: ___ Black: ___ Brown: ___
If not, # liners needed:
Are bins cleaned after collection?
If not:
Are trolleys cleaned after collection?
If not:
Is disinfectant used?
Type of disinfectant:
Concentration of disinfectant:
Are the bins in good condition?
If not, repairs needed:
Are PPEs used?
If not:
Are the PPEs in good condition?
If not, repairs/new equipment needed:
Is proper segregation practiced?
If not Improper practice/s:
Is the supply of liners adequate?
# of liners left:
If not, # liners needed:
Are bins cleaned after collection?
If not:
Are trolleys cleaned after collection?
If not:
Is disinfectant used?
Type of disinfectant:
Concentration of disinfectant:
Are the bins in good condition?
If not, repairs needed:
Are PPEs used?
If not:
Are the PPEs in good condition?
If not, repairs/new equipment needed:
227
Annex D 6: Occupational Incident/Accident Report (OIR) Form

Part 1 (NOTE: ALL MEDICAL DATA IS CONFIDENTIAL)
1. Name: ________________________ Date of Incident/Accident: _________Time: ________
2. Describe the incident fully
a. Actual task during the incident: _______________________________
b. Area of assignment during the incident: _________________________
c. Type of Exposure: (tick only the box that apply)
 Sharp Injury  Blood/body fluids  Chemicals  Others, please
 Needle  Splash  Splash specify:
 Surgical Instrument  Spillage  Spillage
 Glass  Vomitus  Others, specify:
 Other sharp item,  Sputum
specify:  Saliva
 Blood/blood
products
 CSF
 Pleural Fluids
 Urine
 Feces
 Others, specify:
d. Location of Exposure/Injury of the body part (tick only the box that apply)
 Intact Skin  Eyes  Mouth  Others, specify:
 Wound  Nose
e. Personal Protective Equipment worn at the time of exposure (tick all the boxes that apply)
 Gloves, single pair  Goggles  Disposable gown  Others, specify:
 Gloves, double  Face983620 shield  N95 respirator
pair  Surgical mask  Lab coat/gown
f. Immunization Status:
 _____ Hep B  _____ Tetanus  _____ Unknown  Others, specify:
3. Risk Assessment (tick one only)

 High Risk Exposure (source of exposure from HIV x ans HBV/air-borne diseases)
 Low Risk Exposure (source of exposure from HIV x ans HBV/air-borne diseases)
Corrective actions undertaken: _____________________________________________________
Plans to prevent similar incidents from occurring in the future: ___________________________
______________________________________________________________________________________
4. Referred to Emergency Medical Service/Emergency Room Physician?

 Yes Date: _______________
 No Reason: __________________________________
Accomplished by:
Name and Signature: ___________________________________ Date: ________
Department/Section: ________________________________________________
Part 2 (To be filled-up by ICN)
Name of Attending Physician: _________________________________________
Advice/Treatment Given: _____________________________________________
Additional recommendation/suggestions: _______________________________
Note: For HIV exposure, refer to HACT for further evaluation and management.
228
Fourth Edition ANNEX E: Drawings and Illustrations
ANNEX E: Drawings and Illustrations

Annex E 1: EMB and Other Universally Accepted Hazard Symbols
Annex E 2: Sample Transport Route Plan
Annex E 3: Sample Layout of Chemical Storage Room
Annex E 4: Sample Layout of Waste Storage Area
Annex E 5: Sample Placard for Off-Site Transport Vehicle
Annex E 6: Sample Schematic Diagram of Encapsulation
Annex E 7: Sample Design of Concrete Vault
Annex E 8: Sample Design of Placenta Pit
Annex E 9: Sample Design of Safe On-site Waste Burial Pit
Annex E 10: Schematic Diagram of a Horizontal Reed Bed System for Wastewater
System
Annex E 11: Schematic Diagram of a Natural Pond System for Wastewater Treatment
Annex E 12: Schematic Diagram of a Sequencing Batch Reactor (SBR) System for
Wastewater Treatment
229
Annex E 1: EMB and Other Universally Accepted Hazard Symbols
RECYCLABLE SYMBOL BIOHAZARD SYMBOL
OLD RADIATION SYMBOL NEW RADIATION SYMBOL / IONIZING RADIATION SIGN
CYTOTOXIC INFECTIOUS SYMBOL
FLAMMABLE LIQUID FLAMMABLE SOLID
CORROSIVE EXPLOSIVE
REACTIVE POISON/TOXIC
230
Annex E 2: Sample Transport Route Plan
231
Annex E 3: Sample Layout of Chemical Storage Room
232
Annex E 4: Sample Layout of Waste Storage Area
233
Annex E 5: Sample Placard for Off-Site Transport Vehicle
Reference: Safe management of wastes from health-care activities (WHO, 2014)
234
Annex E 6: Sample Schematic Diagram of Encapsulation
Source: https://www.who.int/water_sanitation_health/facilities/waste/module15.pdf
235
Annex E 7: Sample Design of Concrete Vault
236
Annex E 8: Sample Design of Placenta Pit
237
Annex E 9: Sample Design of Safe On-site Waste Burial Pit
238
Annex E 10: Schematic Diagram of a Horizontal Reed Bed System for Wastewater System
239
Annex E 11: Schematic Diagram of a Natural Pond System for Wastewater Treatment
Source: LCI Envi Corporation
240
Annex E 12: Schematic Diagram of a Sequencing Batch Reactor (SBR) System for Wastewater Treatment
Source: LCI Envi Corporation
241
Fourth Edition ANNEX F: Links
ANNEX F: Links
Annex F 1: Online Links to Relevant Legislations, Policies, and Guidelines
Annex F 2: List of Necessary Forms and Reports to be submitted by the HCF
242
Annex F 1: Online Links to Relevant Legislations, Policies, and Guidelines

Laws/Policies/Guidelines Links
INTERNATIONAL AGREEMENTS
The Montreal Protocol on Substances that https://unep.ch/ozone/pdf/Montreal-
Deplete the Ozone Layer (1987) Protocol2000.pdf
The Basel Convention on the Control of https://www.basel.int/Portals/4/Basel%20Conven
Transboundary Movements of Hazardous Wastes tion/docs/text/BaselConventionText-e.pdf
and Their Disposal (1989)
The United Nations Framework Convention on https://unfccc.int/resource/docs/convkp/conve
Climate Change (1992) ng.pdf
The Kyoto Protocol to the United Nations https://unfccc.int/resource/docs/convkp/kpeng.
Framework Convention on Climate Change pdf
(1997)
The Stockholm Convention on Persistent Organic https://www.wipo.int/edocs/lexdocs/treaties/en/
Pollutants (2001) unep-pop/trt_unep_pop_2.pdf
The Minamata Convention on Mercury (2013) http://www.mercuryconvention.org/Portals/11/d
ocuments/Booklets/COP3-version/Minamata-
Convention-booklet-Sep2019-EN.pdf
World Health Assembly Resolution on Water, https://apps.who.int/gb/ebwha/pdf_files/WHA72
Sanitation and Hygiene (WASH) in Health Care /A72_R7-en.pdf
Facilities (2019)
NATIONAL LAWS AND POLICIES
Republic Acts
Republic Act 4226 “Hospital Licensure Act”
(1965)
Republic Act 6969 “An Act to Control Toxic https://www.officialgazette.gov.ph/1990/10/26/r
Substances and Hazardous and Nuclear Wastes epublic-act-no-6969/
(1990)
Republic Act 8749 “The Philippine Clean Air Act” https://emb.gov.ph/wp-
(1999) content/uploads/2015/09/RA-8749.pdf
Republic Act 9003 “Ecological Solid https://www.officialgazette.gov.ph/2001/01/26/r
Waste Management Act” (2000) epublic-act-no-9003-s-2001/
Republic Act 9275 “The Philippine Clean Water https://www.officialgazette.gov.ph/2004/03/22/r
Act” (2004) epublic-act-no-9275/
Republic Act 11223 “Universal Health Care Act” https://www.officialgazette.gov.ph/2019/02/20/r
(2018) epublic-act-no-11223/
Presidential Decrees
Presidential Decree 856 “The Code of Sanitation https://www.officialgazette.gov.ph/1975/12/23/
of the Philippines” (1975) presidential-decree-no-856-s-1975/
Presidential Decree 984 “Providing for the http://r12.emb.gov.ph/wp-
Revision of Republic Act 3931, Commonly known content/uploads/2016/04/presidential-decree-
as the Pollution Control Law, and for Other no984.pdf
Purposes” (1976)
Presidential Decree 1586 “Environmental Impact https://emb.gov.ph/wp-
Statement System” (1978) content/uploads/2015/09/PD-1586.pdf
Executive Orders
Executive Order 301 “Establishing a Green https://www.officialgazette.gov.ph/2004/03/29/e
Procurement Program for all Departments, xecutive-order-no-301-s-2004/
Bureaus, Offices, and Agencies of the Executive
Branch of the Government”
DOH Administrative Orders
Joint DENR-DOH AO No. 2005-02 “Policies and
Guidelines on Effective and Proper Handling,
Transport, Treatment and Disposal of Health Care
Waste”
DOH AO No. 2007-0014 “Guidelines on the
Issuance of Certificate of Product Registration for
243
Equipment or Devices Used for Treating Sharps,

Pathological and Infectious Waste”
DOH AO No. 2007-0027 “Revised Rules and http://lcp.gov.ph/images/Admin_Order_2007_00
Regulations Governing the Licensure and 27.pdf
Regulation of Clinical Laboratories in the
Philippines”
DOH AO No. 2008-0021 “Gradual Phase-Out of https://ww2.fda.gov.ph/index.php/issuances-
Mercury in All Philippine Health Care Facilities 2/others-laws-and-regulations-not-applicable-to-
and Institutions” the-above-categories/others-administrative-
order/15780-ao2008-21
DOH AO No. 2008-23 “National Policy on Patient
Safety”
DOH AO No. 2010-0033 “Revised Implementing
Rules and Regulations of PD 856 Code on
Sanitation of the Philippines”
DOH AO No. 2012-012 “Rules and Regulations https://hfsrb.doh.gov.ph/wp-
Governing the New Classification of Hospitals content/uploads/2019/07/ao2012-0012-1.pdf
and Other Health Facilities in the Philippines”
DOH AO No. 2019-0047 “National Standard on https://www.scribd.com/document/434777656/
the Design, Construction, Operation and DOH-AO-2019-0047-National-Standard-on-the-
Maintenance of Septic Tank Systems” Design-Construction-Operation-and-
Maintenance-of-a-Septic-Tank-System
DENR Administrative Order
DENR AO No. 2001-34 “Implementing Rules and
Regulations of Republic Act 9003”
DENR AO No. 2006-10 “Guidelines on the https://server2.denr.gov.ph/uploads/rmdd/dao-
Categorized Final Disposal Facilities (Sanitary 2006-010_706.pdf
Landfills)”
DENR AO No. 2013-22 “Revised Procedures and https://server2.denr.gov.ph/uploads/rmdd/dao-
Standards for the Management of Hazardous 2013-22.pdf
Wastes (Revising DAO 2006-036)”
DENR AO No. 2014-02 “Revised Guidelines for https://server2.denr.gov.ph/uploads/rmdd/dao-
Pollution Control Officer Accreditation” 2014-02.pdf
DENR AO No. 2016-08 “Water Quality Guidelines https://server2.denr.gov.ph/uploads/rmdd/dao-
and General Effluent Standards of 2016” 2016-08.pdf
OTHER RELEVANT ISSUANCES AND GUIDELINES
BFAD Circular No. 16 series of 1999 “Amending https://ww2.fda.gov.ph/attachments/article/171
BFAD MC #22 dated September 8, 1994 06/bc%2016%20s%201999.pdf
regarding Inventory, Proper Disposal and/or
Destruction of Used Vials or Bottles”
Bench book on performance improvement of https://www.philhealth.gov.ph/partners/provider
health services (Philippine Health Insurance s/benchbook/QualityAssuranceProgram_Benchb
Corporation, 2004) ook.pdf
Operations Manual on the Rules and Regulations http://open_jicareport.jica.go.jp/pdf/11948882_2
Governing Domestic Sludge and Septage 4.pdf
(Department of Health, 2008)
Health Care Waste Management Manual – 3rd
edition (Department of Health, 2011)
Safe management of wastes from health-care https://apps.who.int/iris/bitstream/handle/10665/
activities, 2nd edition (World Health Organization, 85349/9789241548564_eng.pdf?sequence=1
2014)
Water and Sanitation for Health Facility https://apps.who.int/iris/bitstream/handle/10665/
Improvement Tool (WASH FIT) (World Health 254910/9789241511698-eng.pdf?sequence=1
Organization, 2018)
Overview of technologies for the treatment of https://apps.who.int/iris/bitstream/handle/10665/
infectious and sharp waste from health c 328146/9789241516228-eng.pdf?ua=1
are facilities (World Health Organization, 2019)
244
Annex F 2: List of Necessary Forms and Reports to be submitted by the HCF

Forms and Reports Needed Links
Environmental Compliance Certificate (ECC) eia.emb.gov.ph
EMB Quarterly Self-Monitoring Report Please refer to the website of your respective
regional DENR-EMB office.
LLDA Clearance http://llda.gov.ph/llda-clearance/
LLDA Discharge Permit http://llda.gov.ph/discharge-permit-dp-new/
http://llda.gov.ph/discharge-permit-dp-renewal/
LLDA Self-Monitoring Report http://llda.gov.ph/wp-
content/uploads/dox/forms/smr/frm_smr.pdf
Hazardous Waste Generator Registration Form https://emb.gov.ph/wp-
content/uploads/2018/09/Form_Generator_ver2
018.pdf
Hazardous Waste Transporter Registration Form https://emb.gov.ph/wp-
content/uploads/2018/09/Form_Generator_ver2
018.pdf
Hazardous Waste Treater Registration Form https://emb.gov.ph/wp-
content/uploads/2018/09/Form_TSD_ver2018.pdf
Hazardous Waste Generator Quarterly/ Annual Please refer to the website of your respective
Report Form regional DENR-EMB office.
Hazardous Waste Transporter Checklist https://emb.gov.ph/wp-
content/uploads/2018/09/checklist_Generator20
18.pdf
Hazardous Waste Treater Checklist https://emb.gov.ph/wp-
content/uploads/2018/06/checklist_TSD2018.pdf
Hazardous Waste Transporter Affidavit https://emb.gov.ph/wp-
content/uploads/2018/06/affidavit_HWtransport
er.pdf
Hazardous Waste Treater Affidavit https://emb.gov.ph/wp-
content/uploads/2018/06/affidavit_TSDFacility.p
df
245
References
 AEA Technology, “Metro Manila Solid Waste Management Project Final Report” ADB, September 2003
 American Society for Hospital Engineering: “Safety Policies and Procedures for Health Care Facilities”
by John S. Klare, 1992
 Asian Institute of Technology: “Healthcare Waste in Asia: Intuitions and Insights”, 2008
 Basel Convention on the Control of the Trans-boundary Movements of Hazardous Wastes and Their
Disposal (1989)
 BFAD Memorandum Circular No. 22 Series of 1994, “Inventory, Proper Disposal and/or Destruction of
Used Vials or Bottles” and BFAD Bureau Circular No. 16 Series of 1999: “Amending BFAD MC No. 22
dated September 8, 1994, Regarding Inventory, Proper Disposal and/or Destruction of Used Vials or
Bottles”
 Center for Disease Control and Prevention: “Handwashing: Clean Hands Save Lives”
http://www.cdc.gov/handwashing/
 DENR Administrative Order No. 34, Series 1990 – “Revised Water Usage and Classification/ Water
Quality Criteria Amending Section Nos. 68 and 69, Chapter III of the 1978 NPCC Rules and
Regulations”
 DENR Administrative Order No. 35, Series 1990, “Effluent Regulations”
 DENR Administrative Order No. 36, Series 2004, “Revising DENR Administrative Order No. 29, Series 1992,
to Further Strengthen the Implementation of Republic Act 6969 and Prescribing the Use of the
Procedural Manual”
 DOH-DENR Joint Administrative Order No. 02 series of 2005 dated August 24, 2005 “Policies and
Guidelines on effective and Proper Handling, Collection, Transport, Treatment, Storage, and Disposal
of HCW”
 DOH Administrative Order No. 70-A series of 2002 “Revised Rules and Regulations Governing the
Registration, Licensure, and Operation of Hospitals and Other Health Facilities in the Philippines”
 DOH Administrative Order No. 2005-0029 dated December 12, 2005, “Amendment to Administrative
Order No. 70-A series of 2002 re: Revised Rules and Regulations Governing the Registration, Licensure
and Operation of Hospitals and Other Health Facilities in the Philippines
 DOH Administrative Order No. 2007-0014, “Guidelines on the Issuance of Certificate of Product
Registration for Equipment or Devices Used for Treating Sharps, Pathological and Infectious Waste
 DOH Administrative Order No. 2007-0027 dated August 22, 2007 “Revised Rules and Regulations
Governing the Licensure and Regulation of Clinical Laboratories in the Philippines”
 DOH Administrative Order No. 2008-0021 dated July 30, 2008, “Gradual Phase out of Mercury in all
Philippine Health Care Facilities and Institutions”
 DOH Administrative Order No. 2008-0023 dated July 30, 2008, “National Policy on Patient Safety”
 DOH Administrative Order 2010-0033 “Revised Implementing Rules and Regulations of PD 856 Code
on Sanitation of the Philippines Chapter XXI Disposal of Dead Persons” December 2010
 DOH Department Memorandum 2011-0145, “Guidelines for the Temporary Storage of Mercury
Wastes in Health Care Facilities in Accordance with AO No. 0021 s. 2008 on the Gradual Phase-out
of Mercury in All Philippine Health Care Facilities and Institutions”
 DOH “Health Care Waste Management Manual” in 2004 (Revising the 1997 Hospital Waste
Management Manual)
 DOH: Operation Manual on the Rules and Regulations Governing Domestic Sludge and Septage,
June 2008
 Executive Order No. 301 (2004) “Establishing a Green Procurement Program for All Departments,
Bureaus, Offices, and Agencies of the Executive Branch of Government”
 ISO 14001 Environmental Management Guide
 Kyoto Protocol to the United Nations Framework Convention on Climate Change (1997)
 McCay, P.H., Ocampo-Sosa, A.A. & Fleming, G.T.A. (2010). Effect of subinhibitory concentrations of
benzalkonium chloride on the competitiveness of Pseudomonas aeruginosa grown in continuous
culture. Microbiology 156: 30-38
 Montreal Protocol on Substances that Deplete the Ozone Layer (1987)
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(PNRI) from Off-Site Waste Generators
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 Presidential Decree 856 “The Code on Sanitation of the Philippines” (1975)
 Presidential Decree No. 984 “Providing for the Revision of Republic Act No. 3931, Commonly Known
246
as the Pollution Control Law, and for Other Purposes” (1976)

 Presidential Decree No. 1586 “Environmental Impact Statement (EIS) System” (1978)
 Republic Act No. 4226 “Hospital Licensure Act” (1965)
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(1990)
 Republic Act No. 8749 - “The Philippine Clean Air Act of 1999”
 Republic Act No. 9003 - “Ecological Solid Waste Management Act of 2000”
 Republic Act No. 9275 – “The Philippine Clean Water Act of 2004”
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Working Group on Solid and Hazardous Wastes, 2008
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Edition, 2009
 United Nations Framework Convention on Climate Change (1997)
 WB Water and Sanitation Program: “Philippine Sanitation Sourcebook and Decision Aid”, 2005
 WHO: Safe Management of Wastes from Health Care Activities, 1999
 WHO: Safe Management of Wastes from Health Care Activities, draft second edition
 WHO: Practical Guidelines for Infection Control in Health Care Facilities, 2004
 WHO: Laboratory Safety Manual, Third Edition, 2004
 WHO: Guidance Manual for the Preparation of National Health Care Waste Management Plans in
Sub-Saharan Countries
 WHO: Guidelines for the Safe Use of Wastewater, Excreta, and Greywater, Volume II, Wastewater Use
in Agriculture, 2006
 WHO Guidelines on Hand Hygiene in Health Care, 2009
 WHO: http://www.who.int/gpsc/5may/How_To HandWash_Poster.pdf
 WHO: http://www.who.int/gpsc/5may/How_To_HandRub_Poster.pdf
 WHO: “Risks and Costs Associated with the Management of Infectious Wastes” by L.F. Diaz and G.M.
Savage, 2003
 WHO: Philippines: Environmental Health and Country Profile, 2005
247
248

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COVER PAGE

HEALTH CARE WASTE

The signing of the UHC Act is a remarkable achievement as it marks the

FRANCISCO T. DUQUE III

Department of Environment and Natural Resources

Department of Science and Technology

Local Government Units

Medical Association, Regulators, NGO, Academe

World Health Organization

1.2 Purpose and Intent ........................................................................................................................................ 2

1.3 Scope and Limitations .................................................................................................................................. 2

1.4 Contents of the Manual .............................................................................................................................. 3

1.5 Approach ............................................................................................................................................................ 3

1.6 Key Concepts .................................................................................................................................................... 4

1.7 Expected Outcomes....................................................................................................................................... 6

2 Health Care Waste Source, Categorization, and Characterization ........................................... 7

2.2 Categorization of HCW ................................................................................................................................ 7

2.3 Generation of HCW .....................................................................................................................................15

2.4 Waste Assessment Approaches .............................................................................................................20

3 Risks Associated with Health Care Waste ....................................................................................... 23

3.2 Types of Hazard and Mode of Transmission ..................................................................................23

4 Legislative, Regulatory, and Policy Aspects of Health Care Waste ....................................... 37

4.2 International Agreements/Conventions ..............................................................................................38

4.3 National Policies and Related Issuances ...........................................................................................39

4.4 Other Relevant Issuances and Guidelines .........................................................................................44

PART II—HEALTH CARE WASTE MANAGEMENT SYSTEM ........................................................ 47

5.2 Health Care Waste Management Committee .................................................................................50

5.3 Health Care Waste Management Plan ...............................................................................................51

6 Health Care Waste Minimization ........................................................................................................... 57

6.2 Benefits of Waste Minimization .............................................................................................................60

6.3 Waste Minimization Techniques ...........................................................................................................61

6.4 Administrative Control Measures ..........................................................................................................68

7 Health Care Waste Segregation, Collection, Storage, and Transport .................................. 70

7.2 HCW Segregation .........................................................................................................................................71

7.3 Collection and Transport within the HCF .........................................................................................79

7.4 On-site Storage of HCW ...........................................................................................................................82

7.5 Off-site Collection ........................................................................................................................................88

7.6 Off-site Transport .........................................................................................................................................89

8 Health Care Waste Treatment and Disposal ................................................................................... 90

8.2 Basic Treatment Processes .......................................................................................................................91

8.3 Treatment Technologies ............................................................................................................................94

8.4 On-site HCW Treatment Facilities ...................................................................................................... 103

9 Managing Wastewater Generated by Health Care Facilities ................................................. 114

9.2 Sources and Characteristics of HCF Wastewater ........................................................................ 115

9.3 Collection of HCF Wastewater ............................................................................................................ 115

9.4 Treatment of HCF Wastewater ............................................................................................................ 116

PART III—ADMINISTRATIVE CONTROLS AND REQUIREMENT ............................................ 124

10.2 Administrative Requirements at the Facility Level .................................................................. 126

10.3 Budgetary Requirements to Implement the HCWM Program .......................................... 128

10.4 Options for Financing ........................................................................................................................... 132

11 Health and Safety Practices .................................................................................................................. 134

11.2 Occupational Health Risks .................................................................................................................. 135

11.3 Exposure Prevention and Control ................................................................................................... 137

11.4 Hospital Hygiene and Infection Control ...................................................................................... 141

11.5 Occupational Health and Safety Program .................................................................................. 146

11.6 Education, Communication, Training and Awareness ........................................................... 149

12 Health Care Waste Management in Emergencies ...................................................................... 153

12.2 Contingency Planning and Emergency Preparedness ........................................................... 161

12.3 Emerging Issues....................................................................................................................................... 162