Managing Sharps Waste In Cambodia

SIGN Meeting, 25 October 2002Cambodiana Hotel, Phnom Penh Dr. Chea Kim Ly, Deputy DirectorNational Immunization Program

Current safe injection interventions in Cambodia

Relatively new still in Cambodia – since 1999Ensuring safe injection and waste management is a collaborative effort in Cambodia, involving:

Safe Injection CommitteeHIV Prevention ProgrammeEssential DrugsNational Immunization ProgrammeReproductive HealthHealth System –

National, Operational District, Province, Health Centres, Village and Commune levels

Ministry of Environment

1 2 3

4 5 6

Cambodia management of sharps waste by proper use of safe injection equipment in all levels of the health system

7

Three key safe injection equipment: A-D syringes

Three key safe injection equipment: Local safety boxes

SICIM – 13 in CAM VULCAIN

DISTRICT REFERRAL HOSPITAL BURNERS - Safety boxes not burned

here, only medical waste

Three key safe injection equipment: Incinerators

Overview: NIP goals for safe injection interventions

Every immunization is done with a sterile needle and syringe

All used injection material is properly disposed of in an appropriate way

The program discourages the use of disposable equipment that can be re-packaged without proper sterilization

The NIP will transition to auto-disable syringes and safety boxes for all immunization by the end of 2002

NIP has implemented the national safe injection policy by developing the following into its strategic plan:

Introduction and distribution of donated A-D syringes and safety boxes into immunization programme activities

Supplementary immunization activities (SIAs)Routine immunization activities

Training for SIAs and routineA-D syringesSafety boxesIncineratorsDistribution: Exchange system

Monitoring and supervision into integrated supervision activities

NIP role

Safe injection equipment introduction plan

A-D syringes and safety boxes are already being used for all supplementary immunization activities (SIAs) – since 1999

A-D syringes and safety boxes have been introduced to the routine program in Kg. Chhnang OD with the DPT-Hep B introduction – since 4Q 2001

A phased introduction of A-D syringes and safety boxes will follow after Kg. Chhnang so that all areas will have A-D syringes by the end of 2002!

First shipment of A-D syringes arrived in May, 1998Training for A-D syringes were provided from August to October 2002A-D syringes will be expanded for use to all provinces in November and December

Incinerators in all provinces

No. of A-D syringes used in NIP activities (1999 - 2002)

10,000376,741

1,838,616

2,404,274

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

1999 2000 2001 2002

Year

Nu

mb

er o

f A

-D s

yrin

ges

Includes syringes used in all SIA activities and SIAs and routine activities in K. Chhnang (data from K. Chhnang from January to June 2002)Includes both 0.5 cc and 0.1 cc syringesAll A-D syringes were sent to incineratorsNumber of A-D syringes used higher than number of injections given due to:

Staff new to use A-D syringesSystem to use safety boxes newSome A-D syringes were of not good quality

A-D syringes used from 1999 - 2002

No. of Safety boxes used in NIP activities (1999 - 2002)

1003,134

15,322

20,035

0

5000

10000

15000

20000

25000

1999 2000 2001 2002

Year

Nu

mb

er o

f S

afet

y b

oxe

s

Safety boxes are now used in supplementary immunization activities, hospitals, blood collection sites, and HIV/AIDS Treatment Centers

Average number of A-D syringes in safety boxes: 120

Safety boxes: 5-litre capacity

Safety boxes used from 1999 - 2002

Distribution system of A-D syringes and safety boxes

Referral Hospitals – only disposable syringesCentral level distributes safety boxes to district pharmacists for use at referral hospitalsDistrict pharmacists store new and used safety boxes Each department of referral hospitals collects and change old safety boxes from district pharmacists when safety boxes are fullFull safety boxes are sent to the incinerator

K. Chhnang – Bundling of A-D syringes & exchange systemHealth centre workers take full safety boxes from the health centre to the district centres during monthly meetings at the district centresFull safety boxes are exchanged for new A-D syringes and new safety boxes

SIAs – Bundling of A-D syringes & exchange systemFor provinces with incinerators

Safety boxes are burned every day during the campaignFor provinces with no incinerators

Safety boxes are stored at one place, the designated sub-district site, until transported to the nearest incinerator at the end of the campaign

Training materials•Injection safety movie produced•Immunization safety movie (in progress)•Posters (see pictures)•Guidelines for injection safety in routine immunization and SIAs and for referral hospitals

Training materials

Conduct training activities to assemble, use and prevent recapping of A-D syringe to all health workers

Training for use and assembly of A-D syringe

•Training for assembly and use of safety boxes and A-D syringes is provided to all health workers

•Training is also given on the exchange system – full safety boxes are exchanged for new safety boxes and A-D syringes (when available)

Training for use and assembly of safety boxes

•Training on operational use and maintenance of incinerators is provided to the appropriate incinerator operator (one for each incinerator)

Training of preparation, use and maintenance of incinerators

Problems still encountered…

…however, much better than before…

View of waste before safety boxes were introduced before the waste management system in 1998

View of waste from a typical medical waste disposal pit – prior 1998

…however, much better than before…

Ongoing improvement through monitoring and supervision

Future activities

Conduct national assessment of injection safety system to include:

Assessment of operational capacity and conduct any necessary

maintenance of incinerators in each province

Ongoing training

Ongoing monitoring and supervision of use of safe injection equipment, and distribution and exchange system

Final note: Waste management system for the first five year time period in K. Chhnang – Overview of costs

14%

15%

6%

28%

16%

10%

6%5% Sicim Incinerator

Housing & other adjustments

Technical Assistance

Safety Boxes

Training

Supervision

Personnel, Maintenance &Equipment

Other

Waste Management Costing in Cambodia(% distribution by funding source)

*Data Source: Estimates based on information provided by the WHO Cambodia Country Office, Ministry of Health EPI Department and field visits to Kompong Chnang and Takeo