1.1 Purpose

This policy covers the management of medical waste that is generated by health care, pharmaceutical and veterinary facilities. It outlines the regulatory and operational requirements so that medical waste is managed in manner to ensure that:

There is a safe environment for all employees, patients and visitors

There is compliance with national policies and regulations which govern waste management

Surrounding communities are protected from potential harm that may be associated with inappropriate handling, treatment and disposal of medical waste

Legal liability associated with the improper management of medical infectious waste is avoided

With increased environmental concerns about the handling, treatment and disposal of medical wastes in Jamaica as well as the numerous options for treatment and disposal available, it has become necessary for the Ministry of Health to establish this policy to guide the sector accordingly.

1.2 Definitions

Medical Waste is defined as any waste that is generated in the immunization, diagnosis, treatment and disposal of human beings or animals or parts thereof, in research pertaining thereto, or in the production or testing of biologicals, including but not limited to:

soiled or blood-soaked bandages

culture dishes and other glassware

discarded surgical gloves

discarded cultures, stocks, swabs used to innoculate cultures, specimens, vaccines and associated items likely to contain pathogenic organisms

discarded disease causing organisms

wastes from the production of biologicals and antibiotics likely to have been contaminated by pathogenic organisms

free-flowing human blood, blood products, and body fluids, including items containing or visibly contaminated with blood

human tissues or anatomical waste (body organs - tonsils, appendices, limbs, etc.)

sharps likely to be contaminated with pathogenic organisms including discarded surgical instruments and all discarded needles/syringes (used to give vaccinations or draw blood)

empty chemotherapy containers

remains of animals intentionally infected with human pathogens, including carcasses, body parts, bedding and related wastes

autopsy and mortuary wastes

residue from the cleanup of medical waste

pharmaceuticals

radioactive waste

any solid waste that is contaminated by or mixed with medical waste

Approximately 20% of the solid (medical) waste is considered to be infectious, toxic or radioactive. These wastes are generally governed by regulations due to the strict requirements needed to protect human health and the environment and are sometimes described as regulated medical waste. The remaining 80% is similar to regular municipal waste.

Regulated medical waste includes:
infectious waste
Anatomical/pathological waste (including waste from mortuary and autopsy centres)
Sharps
Chemical waste
Pharmaceutical waste
Genotoxic waste
Radioactive waste
Wastes containing heavy metals
Pressurized containers

The following are not considered to be medical waste and are generally not regulated:

Waste containing microbiological cultures used in food processing and any containers and devices used in the preparation and handling of these cultures

Urine, faeces, saliva sputum, nasal secretions, sweat, tears and vomitus, unless they contain fluid blood or are contaminated with cytotoxic drugs

Waste which is not bio-hazardous, such as paper towels, paper products, articles containing non-fluid blood, and other medical solid waste products commonly found in the facilities of medical waste generators

Biological products distributed for any other purpose other than treatment and disposal;

Diagnostic specimens directed for diagnosis

Laundry or medical equipment (that can be adequately disinfected)

A material, including waste that previously contained an infectious substance, that has been treated by an appropriate method, so that it no longer poses the hazard of an infectious substance

Any waste except sharps, derived from households, including but not limited to single and multiple residences and hotels

Corpses, remains and anatomical parts that are intended for ceremonial interment or cremation

Waste generated from normal veterinarian, agricultural and animal livestock management practices on a farm or ranch

Hazardous waste identified or listed in the Natural Resources (Hazardous Waste) (Control of Transboundary Movement) Regulation, 2002

Mixtures

Mixtures of solid waste (garbage) and regulated medical waste are considered regulated medical waste.

Mixtures of hazardous waste identified or listed in the Natural Resources (Hazardous Waste) (Control of Transboundary Movement) Regulation, 2002 and regulated medical waste are regulated medical waste unless the mixture is subject to provisions in the Natural Resources (Hazardous Waste) (Control of Transboundary Movement) Regulation, 2002.

Infectious Waste

Wastes generated during the different stages of health care (diagnosis, treatment, immunizations, research, etc.) that may contain pathogens. These wastes represent different levels of potential danger according to the degree of exposure to infectious agents.

Special Waste

Waste generated during auxiliary activities which pose health risks due to their aggressive characteristics such as being corrosive, reactive, inflammable, toxic, explosive and radioactive.

Common waste or garbage

Wastes generated by the administrative, auxiliary and general activities not considered to be infectious or special wastes. These wastes do not represent a risk and their characteristics are similar to common domestic waste.

2.0 SITUATIONAL ANALYSIS

The current status on medical waste management in Jamaica can be summarised as follows:

There is no specific legislation in place for the management of medical waste

There are not enough incinerators with or without the best available technology or other appropriate treatment facilities for treating and disposing of medical waste

There are no sanitary landfills for final disposal of treated medical waste

There is very little documentation on the quantities of waste that are generated, incinerated or sent for final disposal

Transportation of medical waste is not done by dedicated vehicles (or carriers) leaving room for risk of injury or contamination, either within the compound at the source of generation, during transportation or off-site at the location of final disposal

The labelling, storing and handling of waste at all stages of the cycle is inadequate

There is a low level of knowledge among waste handlers and treatment facility operators on the safe handling of medical waste

There is no isolation system in morgues and mortuaries; body waste goes either to the sewerage system or to the municipal disposal sites which are not appropriately designed with environmental control features to accept such waste

From observations, there is generally no large backlog of medical waste in the public health system awaiting treatment and disposal. This appears to be the case for the private sector as well because the offensive nature of the waste forces the institutions to seek a means of disposal (proper or improper) shortly after it is generated.

However from time to time there are media reports of a pile up of medical waste at certain healthcare and laboratory facilities when an incinerator is out of service and of body parts and needles being found at municipal disposal sites. This clearly suggests that there is significant room for improvement in the management of medical waste.

Healthcare institutions with incinerators provide assistance to other healthcare facilities without incinerators or with faulty units. Owners of incinerators have indicated that they continually receive requests for incineration from medical and other institutions and in many cases they have had to turn down the requests. This suggests that the waste goes to disposal sites untreated or are dumped illegally.

3.0 VISION STATEMENT

Successful implementation of a national medical waste management policy throughout the medical, pharmaceutical and veterinary sectors so that the generation of infectious waste is minimised, there is improved documentation and records on the types and quantities of medical waste generated and disposed and appropriate handling, treatment and disposal methods are employed for the different types of medical waste with minimal or no adverse impact on public health and the environment.

4.0 GOALS

Goal #1
To institute systems to record and document data on the quantities and types of medical wastes generated so that this information can be used to help optimise the management of medical waste.

The institution of regulatory and operational systems that will ensure that workers and patients in healthcare and other relevant sectors and the general public are protected from risks associated with the improper handling, treatment and disposal of medical waste.

Goal #3
The implementation of waste minimisation measures; effective storage, handling and transportation systems and appropriate treatment and disposal methods and technologies that will minimise or eliminate adverse impacts on public health and the environment.

Goal #4
To have persons working within the health care, pharmaceutical and veterinary sectors fully aware of the occupational health and safety requirements for managing medical waste and appropriately trained and empowered to understand and play their roles in the implementation of the medical waste management policy.

5.0 POLICY OBJECTIVES

To collect data related to medical waste management such as the types and quantities of medical waste generated by all health care facilities and to use this information to improve the management of medical waste at the local (facility) level and the national level.

To minimise the amount of hazardous waste generated by utilizing alternatives where possible that do not have harmful/adverse effects on human health and the environment

To minimise the amount of infectious/hazardous medical waste generated (when mixed with regular garbage) by segregating and treating this waste prior to disposal

To establish criteria for the sector to select appropriate handling, storage, transportation, treatment and disposal methods and technologies based on the characteristics and quantity of medical waste

To define the operational framework for medical waste treatment and disposal within the public sector

To promote a sustainable system, through cost recovery, for the provision of treatment and disposal services to facilities that do not have the equipment to effectively treat and dispose of their medical waste

To state the responsibilities of the generators, treatment facility operators, temporary storage operators, transporters, and disposal facility operators

To define legislative and enforcement mechanisms to facilitate the proper management of medical waste

To enable Jamaica’s compliance with local legislation and policies and international agreements and conventions related to medical waste management

To educate and train (where applicable) healthcare workers, waste handlers, collection and disposal service providers and the general public about their roles and responsibilities related to the management of medical waste, provide them with information on the appropriate options available for the management of different types of medical waste and the associated occupational health and safety requirements

6.0 STRATEGIES

Medical waste management is the responsibility of the Chief Executive Officer (CEO) and Managers of healthcare facilities from generation through to safe treatment and disposal.

6.1 Generation of Medical Waste

All health care facilities should identify the categories of medical waste that they have and classify them according to the risks they pose to humans and the environment. This will enable the preparation of a medical waste management plan that is specific to the location. The identification of medical waste categories and estimated quantities generated is best done by conducting a waste management audit.

All medical and healthcare facilities must institute measures to reduce the quantity and toxicity of medical waste as far as possible. This can best be done at the procurement stage. All facilities should prepare procurement guidelines to govern the procurement of goods and services and the guidelines must include:

clear specifications of items to be purchased and

a list the materials and equipment that must not be purchased

national and international environmental requirements that are applicable

Specifications for materials to be purchased must be carefully determined to reduce the generation of waste associated with the purchase of incorrect materials/equipment.

Assessment of the correct quantities should also be done, especially for items/ pharmaceuticals with an expiry date or a short shelf life. Over-purchasing will result in the generation of waste that can be difficult to dispose of.

If the supplier has a return policy for obsolete equipment or spent products, this would be a distinct asset particularly for hazardous and radioactive materials.

Procurement of goods and materials must be done in compliance with all national legislation and international agreements that Jamaica has signed. e.g. goods containing ozone depleting substances should not be purchased.

Donations must not be accepted unless they comply with local standards and legislation. Equipment that uses banned substances or are not energy efficient should not be accepted. Items and materials already expired or which cannot be utilised due to their short shelf life should not be accepted. The Ministry of Health’s Policy regarding donations must be adhered to (Appendix 1).

6.2 Tracking Waste Generation

All healthcare facilities must institute measures to capture data on the quantity of medical waste generated. This can be done by ensuring that waste is weighed prior to disposal. The necessary tools must be provided to facilitate data collection such as a scale and logbook (electronic or manual) to record the quantity of medical waste generated for treatment/disposal. A specific person should have responsibility to collect and analyse the data and to ensure that the tools are maintained in good working order. The data collected will enable the healthcare facility to institute appropriate systems to handle its medical waste and it will help to track progress of waste minimization programmes.

6.3 Segregation

Segregation is the action of separating different types of waste at the point of generation and keeping them isolated from each other. Single stage segregation is preferred; that is, segregation at source so that the waste stays in the same bag or container for storage, transportation and disposal. This helps to reduce the risk of human exposure to hazardous wastes and reduces the probability of human error when compared to a system that employs segregation at the point of disposal. By doing this, appropriate resource recovery and recycling techniques can be applied to each waste stream. The amounts of infectious waste, hazardous waste and low-level radioactive waste that must be treated according to special (and usually costly) requirements are minimised. This means that appropriate containers must be available for each type of waste and the size, weight, colour, form and material should guarantee appropriate identification, facilitate transportation and cleaning operations, be hermetic to avoid unnecessary exposure and be integrated into the physical and architectural conditions of the facility.

Standardising waste disposal bags and containers reduces human error in waste segregation which contributes to incidents of exposure of healthcare or waste handling personnel to medical waste that is toxic or infectious. It is important to make all relevant personnel aware of the segregation requirements as the success of this initiative depends on their understanding and acceptance of the requirements.

The following colour coding for disposal bags should be utilized:

Red and/or orange bags for medical/infectious wastes

Black, white, clear bags for common wastes

Green or yellow for special wastes

6.4 Provisions Applicable to Households and Other Small-quantity, Non-healthcare Facilities

Households and other small-quantity, non-healthcare facilities may dispose of their waste in the ordinary trash. The waste must be packaged to assure that there will be no leakage, even if the original package ruptures. Generally, this means double bagging or placing sharps containers in a second rigid disposal container. Sharps can either be encased in plaster or in another substance approved by the Ministry of Health, or placed in a sharps container of standard manufacture or other similar container of a type approved by the Ministry of Health. This sharps container should then be placed in another bag or other rigid container containing a greater volume of non-infectious waste. No labels or symbols are required on these containers.

6.5 Hazardous Substances

Where alternatives exist, equipment containing hazardous substances should be avoided. Additionally, since one of the most common methods of medical waste treatment is incineration, the use of plastic material and equipment which contain PVC and DEHP (di-2-ethylhexyl phthalate) should be eliminated where possible as materials containing these substances release toxic gases called dioxins and furans when burnt. This problem is further exacerbated when the incinerators are in poor working condition.

Mercury

Discarded or broken medical equipment such as mercury thermometers, sphygmomanometers, blood pressure devices, dilation and feeding tubes must not be incinerated. They should be placed in a sealed leak-proof package and arrangements should be made for their proper disposal in a secure disposal site.

Due to the lack of dedicated hazardous waste facilities in Jamaica, it is advisable to use alternatives to mercury-containing equipment as there are health and environmental hazards associated with the disposal of mercury. Healthcare facilities should:

identify all mercury containing equipment

implement a mercury free purchasing policy

implement a mercury reduction programme to phase out the use of mercury containing equipment over time

PVC and DEHP

Alternatives to materials that contain polyvinyl chloride (PVC or vinyl) and DEHP should also be employed due to health concerns associated with the incineration of wastes containing these substances.

PVC-free and DEHP-free alternatives are available for almost every use of PVC in the health care setting, including medical devices.

With the exception of the bags used for packed red blood cells, PVC-free intravenous and blood bags are available in Europe and the U.S. PVC-free bags are cost-effective and technically competitive with PVC bags. PVC-free or DEHP-free tubing is on the market for most medical applications. Additionally, alternatives for disposable PVC gloves are readily available.

To move away from PVC devices containing DEHP, hospitals should:

perform an audit to identify PVC and DEHP products;

identify and evaluate alternatives;

purchase PVC- or DEHP-free products of equivalent quality and performance.

Where no alternatives exist for a PVC product, one that does not contain a DEHP plasticizer should be selected.

Purchase orders and requests for bids or proposals to supply medical products should specify that PVC alternatives or PVC products without DEHP are required.

6.6 Radioactive Materials/Substances

Where alternatives exist for radioactive materials/substances, these should be used. Those radioactive materials and substances with short half-lives are preferred to those with long half lives. The materials/substances with short half lives can be stored under special conditions until they decay (that is, lose their radioactive properties) thereby facilitating disposal by normal means, whereas those with long half lives require special handling, storage and disposal. Low-level radioactive infectious waste (e.g. swabs, syringes for diagnostic or therapeutic use) may be disposed of with other infectious waste destined for incineration or treatment by a non-incineration technology.

Where applicable, arrangements should be made with the supplier of radioactive materials and substances to take back the spent or used product for recycling or safe disposal.

6.7 Waste Storage

Due to the hazardous nature of some medical wastes, appropriate methods of storing waste will help to prevent accidents and infections.

Storage locations should be:

Accessible

Exclusive

Secure

Hygienic and sanitary

Located as far as possible from patient treatment areas

Storage locations should be integrated with the physical and architectural infrastructure of the healthcare facility.

The following practices are generally recommended for medical wastes:

Sharps containers must be rigid, leak proof, tamper-proof

Where incinerators are not in operating according to the manufacturer’s specifications, plastic sharps containers should be avoided.

Bags with infectious waste should be marked with the international infectious substance symbol

Cytotoxic waste should be collected in strong leak proof containers, labelled “Cytotoxic waste” and should be stored separately from other medical wastes in a designated secure location

Radioactive waste should be contained within a lead box labelled with the radioactive symbol; waste that is stored during radioactive decay should be labelled with the type of radionuclide, the date and details of the required storage conditions; they should not be placed in an incinerator

There must be strict adherence to procedures for regular washing and disinfection of temporary and permanent infectious waste storage locations. The same is required for reusable receptacles used for infectious waste. Wastewater generated from washing should be directed to the sewerage system.

6.8 Internal Collection

There are carts designed specially for conveying medical waste within the compound of a healthcare facility. These should be used in keeping with the occupational health and safety requirements of the healthcare facility so as to reduce risk of injury and infection.

The carts should be impermeable, stable, facilitate easy cleaning and draining and be appropriately labelled. They should be dedicated to medical waste only and procedures for decontamination must be strictly applied. Wastewater generated from washing these receptacles should be directed to the sewerage system.

6.9 Transportation

Transporters/haulers of medical waste must be licenced and will only receive such a licence upon being able to demonstrate that they have the required systems to handle medical waste.

Medical waste must be transported in vehicles that are designed for that purpose. The vehicle transporting medical waste must be licenced to carry this waste and will only receive such a licence upon satisfying the licencing body that they meet the requirements.

Vehicles must be:

Leak proof

Vandal proof

Labelled as a vehicles transporting hazardous waste

Designed to facilitate washing and disinfection

The facilities for washing and disinfection must not pollute the environment, in fact wastewater from washing must be treated to the required national standards prior to discharge to the environment. NRCA Trade effluent standards are applicable and a licence to discharge effluent is required from the National Environmental and Planning Agency (NEPA).

The movement of medical waste from the point of generation to the point of treatment/disposal must be governed by a manifest system. As waste changes hands from person to person it is signed over. That means that the waste generator must have responsibility for the disposal of waste by ensuring that a licenced transporter moves their waste (in a licenced vehicle) and they must receive verification by the treatment plant/disposal facility that the waste has been received. Only then will the waste generator be relieved of their responsibility.

Unless a waste contractor can offer a generator of medical waste this service, the generator can never be sure of safe disposal and its liability is not discharged. It is therefore imperative that a healthcare waste generator uses a reputable contractor who has all the systems and safeguards in place.

6.10 Treatment

This policy will not prescribe specific treatment and disposal solutions; instead it will indicate the criteria that should be considered when selecting treatment and disposal options to meet the required standards.

There are a number of effective treatment and disposal options for medical waste, all with some limitations. These include:

Incineration
Autoclave and shredding
Microwave
Pyrolysis
Irradiation
Disinfection (with or without Chlorine)

6.10.1 Incineration

The most common treatment technology for medical waste over many decades has been incineration. It is the process of reducing combustible waste to inert residues by high temperature combustion. The incineration process does not destroy matter, it merely changes the chemical composition and toxicity of the substances burnt.

The process of incineration provides the advantage of volume reduction as well as the ability to dispose of recognisable waste and sharps. On site incinerators provide a quick and easy way of disposing of medical waste.

However, there are some potential negative environmental issues associated with the use of incinerators:

Emission control methods necessary

Potential pollution to landfill with fly and bottom ash

Temperature regulation necessary

Air pollution and the creation of hazardous emissions like dioxins and furans. The increased use of PVC materials causes dioxins to be generated during incineration and this pollutant is a human carcinogen and affects the immune and reproductive systems

Unable to deal with radioactive waste or pressurized containers

Potential health risks from:

o heavy metals in ash e.g. cadmium which is a neurotoxic chemical

o acid gases which cause eye and respiratory irritation and acid rain

o particulate emissions which cause chronic lung diseases

6.10.2 Alternative (Non-incineration) Treatment Methods

The increased awareness of the adverse environmental and health impacts of incineration and increasing availability of alternative non-incineration technologies have led to more treatment and disposal options being available.

Non-incineration treatment technologies can be categorised based on the fundamental processes used to decontaminate waste. The four basic processes are:

1. Thermal processes

2. Chemical processes

3. Irradiative processes

4. Biological processes

The majority of non-incineration technologies employ the first two processes listed above and are supplemented by mechanical processes. Table 2 provides a description of the four basic processes and the supplemental process used to treat medical waste with information on the advantages and disadvantages associated with each method.

Table 2 - Advantages and Disadvantages of Non-Incineration Technologies

TECHNOLOGY SIGNIFICANT ENVIRONMENTAL IMPACTS ADVANTAGES/DISADVANTAGES OF TECHNOLOGY

Thermal Processes (a) Low Heat

Wet Heat ·1 Autoclaves and Retorts ·2 Microwaves ·3 Autoclaving with shredding and compaction ·4 Odours related to process ·5 Potential release of toxic chemicals ·6 Potential release of toxic chemicals ·7 Offensive odours It is technically possible to treat human anatomical wastes using autoclaves and microwaves but ethical, legal, cultural, and other considerations may preclude their treatment using this technology unless the waste is shredded for unrecognisability. The autoclave technology has been improved by incorporating the shredding and compaction functions into the process making the end product unrecognisable. It will achieve the same volume reduction and sterilisation as incineration without the adverse impacts of hazardous emissions. The capital cost of the autoclave/shredder system is significantly less than the cost of an incinerator with the same waste throughput and the operating cost is about 1/5 of the cost of operating an incinerator. The following wastes should not be treated using these methods: 1 volatile and semi-volatile organic compounds 2 bulk chemotherapeutic wastes 3 mercury 4 other hazardous chemical wastes 5 radiological wastes

Dry Heat ·8 High Velocity Treated Air ·9 Potential release of toxic contaminants to the atmosphere and the landfill ·10 Slight odours It is technically possible to treat human anatomical wastes but ethical, legal, cultural, and other considerations may preclude their treatment in this technology unless the waste is shredded for unrecognisability. The following wastes should not be treated in the dry-heat sterilizer system: · volatile and semi-volatile organic compounds · chemotherapeutic wastes · mercury · other hazardous chemical wastes · radiological wastes

(b) Medium Heat Depolymerization Emissions from scrubbers and wastewater Grinding required to make waste unrecognisable. Relatively new technology

(c) High Heat Pyrolysis-Oxidation ·11 May emit dioxins ·12 Disposal of ash from processing Technically, this technology is capable of destroying bulk chemotherapeutic waste, pharmaceutical waste, hazardous waste, and controlled substances but treating these waste streams in a health care facility may be prohibited by regulations or require special permits. Radiological waste and waste contaminated with mercury should not be treated using pyrolysis -oxidation. Also the capital cost is very high in relation to its throughput capacity. Space requirements are large.

Advanced Thermal Oxidation ·13 May emit dioxins ·14 Disposal of ash from processing This technology can handle all wastes normally treated in an incinerator including cultures and stocks, sharps, materials contaminated with blood and body fluids, isolation and surgery wastes, laboratory wastes, soft wastes, blood and body fluids, pathological waste, animal waste, chemotherapeutic wastes, and dialysis waste. The following wastes should not be treated using this technology: 1 aerosol cans, 2 machine oils, 3 batteries, 4 large metal objects, 5 radioactive material, 6 x-ray film, 7 lead containers, 8 mercury, and 9 other materials containing toxic metals It is in the very initial stage of commercialisation.

Chemical Processes Chlorine and Non-chlorine Based Systems ·15 Worker exposure to effects of chemicals ·16 Release of pathogens through aerosol formation ·17 Spills and leakage of chemicals ·18 Toxic by-products released in wastewater ·19 Noise levels from any mechanical equipment used ·20 Offensive odours Grinding required to make waste unrecognisable. Large metal objects may damage internal shredders. Ethical, legal, cultural, and other considerations may preclude treatment of human anatomical wastes in chemical treatment systems. The following wastes should not be treated using this method: 1 volatile and semi-volatile organic compounds, 2 chemotherapeutic wastes, 3 mercury, 4 other hazardous chemical wastes, and 5 radiological wastes

Irradiation Processes ·21 Potential worker exposure to radiation ·22 Potential release of ozone gas E-beam technologies require shredders or other mechanical device in the post-processing stage to render the waste unrecognisable and reduce waste volume. Ethical, legal, cultural, and other considerations may preclude treatment of human anatomical wastes. The following wastes should not be treated in e-beam units: ·1 volatile and semi-volatile organic compounds, ·2 chemotherapeutic wastes, ·3 mercury, ·4 other hazardous chemical wastes, and ·5 radiological wastes This technology is highly automated and computer controlled.

Biological Processes Disposal of liquid and solid wastes The technology is suited for large applications (10 tons/day)

Mechanical Processes ·23 Worker exposure to pathogens ·24 Exposure to elevated noise levels ·25 Offensive odours ·26 Not aesthetically pleasing Mechanical processes such as shredding, grinding, hammermill processing, mixing, agitation, liquid-solid separation, conveying (using augers, rams, or conveyor belts), and compaction, supplement other treatment processes. Mechanical processes can add significantly to the level of maintenance required.

6.11 Factors to consider when selecting a Treatment Option

The following key factors should be considered by healthcare facility managers when determining the best technology or combination of technologies for their particular facility:

Throughput capacity

Types of waste treated

Microbial inactivation efficacy

Environmental emissions and waste residues

Regulatory acceptance

Space requirements

Utility and other installation requirements

Reduction of waste volume and mass

Occupational safety and health

Noise and odour

Automation

Reliability

Level of commercialization

Technology manufacturer/vendor background

Cost

Community and staff acceptance

6.11.1 Throughput Capacity

Select a treatment technology with throughput rates capable of handling the quantity and type of medical waste generated. When estimating/calculating the rate of generation of medical waste, all the strategies that need to be implemented to minimise the quantity of infectious waste for treatment should be considered. This ensures that the treatment technology is not oversized.

When matching throughput capacities with waste generation rates, the facility should take into account future anticipated growth and variabilities in waste generation. Some technologies may have a minimum feed rate to operate well or cost-effectively; technologies have a maximum design feed rate. Facilities should determine if their range of waste generation variability during the expected life of the equipment falls within the minimum and maximum feed rates of that equipment. A combination of technologies (e.g., a large technology for most of the waste, a small technology to handle difficult waste streams at the point of generation) may be suitable for a facility and should be examined as an option. Throughput rates cited by technology vendors are usually approximate and actual throughput rates depend on waste densities and other factors.

6.11.2 Types of Waste Treated

Broad categories are used to describe the types of waste that a technology can handle, generally based on manufacturers’ recommendations. After determining what constitutes regulated medical waste or infectious waste, facilities should make sure that the selected technology can treat each waste category from the perspective of mechanical destruction, microbial inactivation, emissions, regulatory acceptance, and safety.

When sizing the equipment, one must consider the types of waste that the technology can treat by subtracting the portion of the waste stream that the technology cannot handle (or is not permitted to handle due to regulations) from the regulated medical waste stream. The facility should make other arrangements for those excluded wastes.

The cost of treating the excluded waste should be accounted for when comparing overall costs of alternatives. The use of monitoring equipment, such as devices to detect low-level radioactive waste, can help keep specific waste streams out. Some technology vendors offer monitoring devices to exclude unwanted materials from the input stream. Others design their equipment to be able to interface with such devices.

6.11.3 Microbial Inactivation Efficacy

The main purpose for the treatment of medical waste is to decontaminate the waste by destroying pathogens. Healthcare and other facilities handling medical waste should make certain that the technology can meet the Ministry of Health’s criteria for disinfection.

The Ministry of Health will establish standards for the level of microbial inactivation that is expected from treatment technologies to guide healthcare facilities when selecting a new technology.

Reference can be drawn from the USA where the criteria for medical waste treatment efficacy outlined in Table 3 are used.

Table 3 - Levels of Microbial Inactivation

Level I Inactivation of vegetative bacteria, fungi, and lipophilic viruses at a 6 Log 10 reduction or greater

Level II Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses, parasites, and mycobacteria at a 6 Log 10 reduction or greater

Level III Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses, parasites, and mycobacteria (Mycobacterium phlei & Mycobacterium bovis (BCG) (ATCC 35743)) at a 6 Log 10 reduction or greater; and inactivation of B. stearothermophilus spores(ATCC 7953) and B. subtilis spores (ATCC 19659) at a 4 Log 10 reduction or greater This level is the recommended minimum by STAATT

Level IV Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses, parasites, and mycobacteria, and B. stearothermophilus spores at a 6 Log 10 reduction or greater

A 6 Log 10 reduction (or a 106 kill) is equivalent to a one millionth survival probability in a microbial population or a 99.9999 percent reduction of the given microorganism as a result of the treatment process.

Technology vendors should be able to provide documentation showing that their technology can meet applicable national standards and regulations and in the absence of these the recommended level in Table 3 can be used as a guide. If no documentation is available from the vendor, the healthcare facility should request that efficacy testing be conducted by an independent, qualified laboratory.

6.11.4 Environmental Emissions and Waste Residues

Facilities should consider discharges or emissions (including fugitive emissions) to all possible environmental media - indoor air, ambient air, waste residues, wastewater, landfills, etc. - and select technologies with the least impact on the environment.

Consideration should also be given to the environmental impacts of utility usage especially for technologies that consume large amounts of electricity or water. Vendors of high-heat thermal treatment systems should be able to demonstrate that their emissions meet NEPA’s air emission standards and regulatory requirements for existing and new incinerators and pyrolytic systems.

All liquid discharges should meet regulatory requirements set by NEPA including the NRCA Trade Effluent standards.

Solid waste residues should be acceptable to the National Solid Waste Management Authority (NSWMA) for disposal at a municipal solid waste landfill. Sharps waste should be made unusable during the treatment process.

The treatment technology should reduce the volume of waste and make the constituents unrecognisable.

6.11.5 Regulatory Acceptance

The Natural Resources Conservation Act, 1991 gives the Natural Resources Conservation Authority [NRCA](now embodied within the National Environment and Planning Agency [NEPA]) the power to take the necessary steps for the effective management of the physical environment of Jamaica to ensure the conservation, protection and proper use of its natural resources among other things. In performing its functions it may formulate standards and codes of practice to be observed for the improvement and maintenance of the quality of the environment generally, including the release of substances into the environment in connection with any works, activity or undertaking. Based on the powers and functions of the NRCA, medical waste treatment and disposal processes facilities fall within their jurisdiction.

Hazardous waste storage, treatment and disposal facilities is a category listed in The Natural Resources (Prescribed Areas) (Prohibition of Categories of Enterprise, Construction and Development) Order, 1996 as requiring a permit from NEPA. Since medical waste comprises some hazardous and toxic waste streams, medical waste treatment technologies require a Permit from NEPA.

The National Solid Waste Management Act, 2001 gives the National Solid Waste Management Authority (NSWMA) the power to take all steps as are necessary for the effective management of solid waste in Jamaica in order to safeguard public health, ensure that waste is collected, stored, transported, recycled, reused or disposed of in an environmentally sound manner and promote safety standards in relation to such waste. Medical waste treatment and disposal technologies must be approved by the NSWMA especially where residues will be disposed of at municipal disposal sites.

6.11.6 Space Requirements

Space is usually a premium at health care institutions. The space needed to operate a technology should fit the available space in the facility. That space is not only the footprint and height of the equipment but should also include additional space needed for opening waste entry doors, access to control panels, space for hydraulic lifts, conveyors, moving bins, storage areas, etc. Some treatment technologies have compact designs but others require a lot of room. Other possibilities include using mobile or portable units, trailer-mounted units, underground installations, or all-weather enclosed shelters at an outdoor site.

6.11.7 Utility and Other Installation Requirements

Some technologies only need an electrical outlet to operate; others require steam, compressed air, natural gas, drains and ventilation. Concrete pads, access paths, curb cuts, and other site preparations may be needed. The location may or may not be equipped with a loading dock, storage space, security fence, roll-off containers, etc. Not all facilities will have these utility services and other infrastructure available at the selected site. Some vendors include the cost of installation in the equipment price but facilities will have to provide some basic services. Processes that do not alter the physical characteristics of waste will need ancillary equipment such as shredders and compactors to reduce waste volume and make waste unrecognizable.

6.11.8 Reduction of Waste Volume and Mass

Volume and/or mass reduction is another important factor since facilities will have to pay by volume or mass for hauling the treated waste and disposing at a landfill. High heat thermal technologies offer the highest levels of volume and mass reduction. Other technologies may require an added shredder or compactor to reduce waste volume. By selecting a technology that achieves a high reduction in waste volume, facilities can reduce the cost of tipping fees for the disposal of solid waste at municipal landfills and contribute to longevity of the disposal facilities.

6.11.9 Occupational Safety and Health

When selecting a treatment technology, facilities should consider potential worker exposure to: hot surfaces, ionizing and non-ionizing radiation, chemicals released in the workspace, sharps that may fall out during conveying, pathogens from the waste that are aerosolized during shredding, blood splatter, etc.

It may be possible to obtain the safety record of a technology from facilities that have used or are using the technology for some time. Facilities should find out from technology manufacturers how their equipment will react if potentially dangerous materials, such as inflammable liquids, aerosol cans, large metal parts, low-level radioactive waste, etc., are fed into the equipment.

With high heat systems, large amounts of aqueous liquids may result in the rapid release of steam and a sudden rise in pressure. In other cases mixtures of certain chemicals may react to produce toxic gases.

Facilities should have emergency procedures in place and institute preventive measures. In the event of an equipment breakdown, the technology should have some way of protecting workers who may need to access internal parts of the equipment. Some technologies have a way of injecting chemical disinfectants on untreated waste and internal surfaces in these situations. Others have safety interlocks that prevent workers from opening a treatment chamber door if the treatment cycle has been interrupted. There must be strict adherence to the occupational health and safety requirements of the Factories Inspectorate in the Ministry of Labour and Social Security as contained in the Factories Act and the Occupational Safety and Health Regulations.

6.11.10 Noise and Odour

Where possible visits should be conducted to other healthcare facilities which utilise the treatment technology being considered to verify that it is noiseless and odour-free, particularly in instances where the vendor has indicated that these are features of the technology.

Reducing noise and noxious odours are important aspects of occupational health, patient health and community relations.

6.11.11 Automation (or Ease of Use) and Operator Training

A technology should be automated to minimise operator errors while allowing efficient and easy control of the process, safety interlocks, diagnostics, remote monitoring, alarms, and automatic documentation to meet record keeping requirements. Most modern treatment technologies are designed for ease of use and minimal operator time. Usually, the most labour-intensive task is introducing waste into the equipment. It is also a source of occupational injuries (e.g., back problems, needle-sticks).

Many technologies now include automatic feed assemblies such as cart lifters or bin dumpers to eliminate handling of red bags by workers. When selecting a technology, the level of required skills and necessary training of the operator should be considered. Vendors generally offer operator training when a new system is installed; the facility may need to arrange for ongoing training and education. Operator training should include a basic understanding of the systems, standard operating procedures, occupational safety and personal protection equipment, recordkeeping, identifying waste that should not be treated in the technology, recognizing technical problems, dealing with unusual conditions, periodic maintenance schedules, emergency procedures, and contingency plans. Records of operator training and qualification should be maintained by the facility.

6.11.12 Reliability

Reliability of equipment can be determined from past maintenance records (these may or may not be available for new technologies). Some vendors offer remote monitoring and diagnostics capabilities. High-maintenance items include major moving parts such as shredders, grinders, and feed systems, and parts that are subjected to high thermal stresses such as refractories. Facilities may be able to review maintenance records from other facilities that have used the equipment. For new technologies, facilities should find out how long the technology has been in full, continuous operation without having any problems.

Facilities should check to see if vendors are well-stocked with spare parts and staffed with technical people who can respond quickly to queries or provide urgent repair services. The availability of technical support is important, especially for newly commercialised technologies that may not have a long track record of operation. For technologies that have been in operation long enough, one may be able to obtain good estimates of equipment life.

6.11.13 Level of Commercialisation

Facilities should request a list of permanent installations and contact information for those sites where the treatment technology is in use. Technologies that are fully commercialised may have an extensive network of distributors and technical service centres. They may be able to respond quickly to urgent needs. These are some of the advantages of a fully commercialised system. On the other hand, it may be possible to get major reductions in capital costs from vendors whose technologies are in their initial stages of commercialisation. Some vendors of new technologies may be willing to offer large discounts in exchange for being able to demonstrate their technology at a health care facility. However, there are risks involved in being the first to use a technology with little or no track record.

6.11.14 Technology Manufacturer/Vendor-Background

Facilities could benefit from knowing how long a technology manufacturer and/or vendor has been in business, if they are financially stable, the backgrounds of key officers of the company, whether or not they have been cited for environmental or other violations, and any financial or legal liabilities. For new technologies, facilities may want to find out how the company plans to market the technology, how well they are capitalised, whether or not they can fill orders in a reasonable time, etc. Facilities should also find out if a technology developer is involved in legal disputes of intellectual property rights with other parties in relation to a new technology.

6.11.15 Cost

Healthcare institutions must be cost conscious. Therefore, after drawing up a list of technologies that meet the site-specific requirements of a facility, a comparison can be made to determine the most cost-effective option. Decision-makers may wish to determine whether a new treatment technology would save money in the long term compared to upgrading an existing incinerator, constructing a new incinerator that meets NEPA’s requirements, or contracting with a hauler to transport and treat medical waste at an off-site regional facility.

6.11.16 Community and Staff Acceptance

Educating the staff about the advantages and disadvantages of the treatment technology options and involving them in the selection process are important in order to gain support for a new technology. Notwithstanding regulatory approval of a technology, siting of a new system may be hampered by a lack of public acceptance especially if the site is located near residences, schools, and sensitive populations. Treatment processes with which the public is familiar may be accepted by the community more readily than lesser known technologies.

A programme to inform and engage the community in the selection of an alternative technology, allowing the community an opportunity to provide input into the decision-making process, would result in greater community satisfaction and improved standing of the health care facility as an environmental leader in the community.

6.11.17 Summary

In summary any treatment option applied should meet the following requirements:

Waste should be segregated so that only the infectious waste stream is treated

Volume reduction should be achieved

Air emissions and effluent discharge should be minimised

Where there are air emissions and effluent discharges they must be controlled and treated to meet national standards and regulatory requirements

The end product must not contain any recognisable components

It is preferable that the end product is inert and innocuous and at least a Level IV microbial inactivation should be achieved

6.12 Cost Considerations

The healthcare facility should conduct an analysis of the costs associated with suitable treatment technologies prior to selecting an option. Common techniques which can be applied include:

Annual cash flow projections

Net present value or Present Worth Method

Capitalised cost or Life Cycle cost Method

Annual Cost or Capital Recovery Method

Return on Investment method

Important in the analysis is to cover all direct and indirect costs.

6.13 Cost Items

6.13.1 Capital Costs

Total capital cost should include all direct and indirect costs related to siting and installation as well as the equipment purchase cost. Some technologies require little site preparation and installation, while others involve significant installation requirements.

The following list gives examples of direct costs that need to be taken into account. Not all of these items necessarily apply to a given technology.

Site preparation

Demolition and disposal (e.g. removal of an old incinerator)

Building (new construction or renovation)

Foundation and supports

Electrical service

Piping including steam and water lines

Heating and ventilation system

Air compressor

Lighting

Sanitary sewer

Sprinkler system

Painting and insulation

Handling and on-site fabrication

Equipment purchase cost (including auxiliary devices, instrumentation, carts for transporting waste, monitoring equipment, freight, sales tax, etc.).

The following are examples of indirect costs that should be considered:

Project management

Engineering

Construction fees

Permitting

Regulatory testing

Professional fees (including media fees to respond to public outcry, if the community does not like the technology choice)

Start-up

Performance testing

Contingencies

There are intangible costs that cannot be quantified, such as loss of good public perception if the chosen technology is unpopular in the community or among staff.

6.13.2 Annual Operating Costs

Annual operating costs are costs incurred every year due to the operation of the technology during the life of the equipment. Due to inflation, the magnitude of these costs may vary, but the same kinds of costs will be incurred.

Direct costs are those that are dependent on the throughput of the system, such as:

Labour (operating and supervisory)

Utilities:

o Electricity

o Steam

o LPG

o Water

o Compressed air

o Others

Supplies:

o Boxes or containers

o Autoclavable or steam permeable bags

o Labels

o Others

Consumables:

o Chemical disinfectants

o Electrodes or torches

o Others

Maintenance (scheduled and unscheduled)

Materials

Replacement parts (e.g. refractories, shredder blades, etc.)

Maintenance labour

Landfill disposal costs (including transportation and tipping fees)

Cost of disposing wastes not treated by the technology

Cost of treating waste during scheduled and unscheduled downtime

Indirect costs are costs that are not proportional to throughput, such as:

Overhead

Administrative costs

Insurance

Annual regulatory permit fees

Periodic verification or emission tests

Taxes

6.13.3 Haulage Costs

In addition to potential liabilities, the risk of a transportation accident, legal requirements when transporting regulated medical waste, and the uncertainty of how the waste is treated and ultimately disposed of, there is also the issue of hidden costs when one considers hauling. The full cost of hauling and off-site treatment are not limited to the price set by the hauler. The following are some of the hidden capital costs related to hauling:

Siting and construction of storage and loading areas including ramps and loading docks

Other infrastructure (fences, enclosures, refrigeration of storage area, etc.)

Transport containers

Personnel protection equipment, spill kits.

Additionally, annual costs that may not be included in the hauling price are:

Labour (related to packing, labelling, storage, loading, and waste tracking/documentation)

Labour (related to security, maintenance of storage areas, and pest management)

Supplies (boxes, biohazard labels, packing tape, etc.)

Maintenance materials (for cleaning of the storage area)

Liability insurance and other fees

Transportation charges and landfill disposal fees

Annual refrigeration costs

Costs related to disposal of waste not accepted by the hauler

Penalty fees (for containers not meeting the hauler’s specifications).

Some cost items, such as penalty fees, may turn out to be quite significant. These and any other costs not included in the hauling price should be taken into account when evaluating options from an economic perspective. Unfortunately, other issues, such as potential liability and uncertainty regarding how the waste is ultimately disposed of, cannot be assigned a dollar value.

6.14 Options For Acquisition

There are various ways of acquiring a new technology. Many health care organizations require competitive bidding for procuring items above a certain cost threshold. Competitive bidding according to the requirements of the National Contracts Committee is a requirement for public sector facilities.

The facility must first develop technical specifications and other bidding documents that are sent out. Bidders respond by submitting complete and detailed design and engineering submittals as well as price bids. Depending on the organisation’s policies, bidding by a sole source may be allowed.

Another approach is for the facility to issue a request for proposals (RFPs) which allows more flexibility than a sealed-bid process. Proposals generally involve negotiations with the selected firm prior to the final award of the contract. Having made a choice, the facility then purchases the equipment and, with advice from the manufacturer, the facility provides engineering and project management, builds or renovates the site where the equipment will be installed, putting in place the required utility and auxiliary services.

Alternatively, many technology vendors now offer a “turnkey” arrangement in which the contractor completes most or all the work necessary-project management, engineering design, construction, installation, supply requisitions, start-up, testing, etc.-so that the health care facility receives the entire package ready to operate.

Different financing options are also possible. A health care facility might pay for the technology and its installation through its own revenues allocated within its capital budget. Other facilities may raise funds through loans from banks or other financial institutions. Some technology vendors or financial institutions offer alternate financing arrangements. The following is a general description of several financing arrangements that allow health care facilities to acquire a technology without having to pay high capital costs. Many variations of these types of agreements exist.

Lease-purchase agreements allow the health care facility to select a technology and negotiate a purchase price and performance specifications. The lessor then purchases or provides the technology and allows the facility to use the technology for a specific period of time defined in the lease agreement. During the lease term, the facility makes pre-determined periodic payments including taxes and insurance. When the lease term ends, the facility purchases the technology for a pre-determined amount that is at or below its fair market value. Lease-purchase payments include both principal and interest, which may be slightly higher than those for loans, but leases require no down payment.

Another type of financing is a build-operate-transfer (BOT) arrangement. Under provisions of a BOT contract, the technology manufacturer (or a private financing entity) will use its own funds to install the technology at the host facility’s site. In return, the manufacturer or private entity is allowed to operate the technology commercially for a set number of years. During that time, the host facility pays the operator a fixed sum (usually a discounted price) per unit weight of medical waste treated. The BOT contract may allow the manufacturer or private entity to bring in medical waste from other health care facilities and to use the equipment to treat the waste at the host facility. Regulations will apply to the transportation of medical waste. After the allotted number of years, the technology and its operation are then transferred to the host facility.

A variation of this is a build-transfer-operate (BTO) agreement wherein the technology and infrastructure become the property of the facility immediately upon completion, but the manufacturer or private entity is granted the right to operate the technology for a certain period. Other variations include build-rent-operate transfer (BROT) or build-lease-operate-transfer (BLOT) arrangements in which the private entity rents the physical assets on which the equipment is located for the duration of the agreement. There is also a build-own operate (BOO) scheme, whereby the technology manufacturer or private financing entity retains ownership of the treatment facility and is not under obligation to transfer it to the host facility in the future.

It may also be possible for a group of hospitals to form a consortium and agree to share the capital and operating costs of the treatment technology. Strategic alliances may also be created between hospitals, nursing homes, clinics, medical offices, veterinary hospitals, and other facilities that generate regulated medical waste within a geographical area. Hospitals that are part of a large hospital chain may be able to negotiate with a vendor to get a reduced price for multiple units.

Performance contracting, an arrangement to provide incentives for achieving specific quantifiable outcomes and disincentives for non-performance should be considered to help cut costs and improve performance and quality of work. It is possible for the annual cost savings from the new treatment technology to be used to cover the cost of the technology (assuming the technology is expected to lower costs significantly).

A similar approach is a “shared savings” arrangement between a hospital that provides the site and the workers, the manufacturer that provides the technology, utilities that provide utility service, and other entities that contribute in cash or in kind to the project. The annual savings are computed based on a baseline cost of medical waste treatment and disposal before the technology is installed. Facilities may also be able to negotiate a highly discounted price for a new or emerging technology in return for allowing the vendor to use the hospital as a demonstration site for their technology. There are however risks associated with being the first facility to try a new technology but significant savings offered by the vendor may outweigh the risks. Health care organizations should explore these and other options for acquiring a non-incineration technology.

6.15 Disposal of Medical Waste within the Public Sector

There is no single treatment and disposal option that will be suitable for all types of medical waste. There are limitations associated with each method. It is therefore prudent within the public healthcare system to have more than one treatment and disposal option available.

The treatment and disposal options must minimise or eliminate the generation of waste bi-product which causes adverse impacts on public health and the environment. The facility must also be sized and designed appropriately for expected type and quantity of waste. The treatment and disposal facility must have a management plan in place to govern its operation and maintenance.

Spare parts must be easily available for the treatment and disposal facility. There should be documented procedures with the roles and responsibilities of the treatment/disposal facility operator. A sustainable source of funding must exist for the operation and maintenance. A maintenance fund for major maintenance and emergencies should be established and it is imperative that a contingency plan is in place for times when the facility is out of service.

Alternative means of disposal have to be identified for wastes which cannot be treated using recognised treatment methods. These include:

volatile and semi-volatile organic compounds, e.g. some pharmaceuticals

chemotherapeutic wastes,

other hazardous chemical wastes e.g. mercury

radioactive waste

Radioactive waste must be stored under appropriate conditions untl it decays. Heavy metals such as mercury should be packaged securely and disposed of at a secure disposal facility that can accept hazardous waste. Volatile chemicals and other toxic pharmaceuticals may be disposed of in specially designed incinerators or pyrolitic systems. Chemotherapeutic wastes are disposed of in the sewerage system with the exception of expired drugs which should be returned to the supplier.

In order to be more efficient and cost effective, a regional approach to medical waste treatment and disposal within the Public Sector should be taken. There should be some spare capacity to treat and dispose of medical waste generated by others who require that service within the framework of an appropriate cost recovery system. More than one type of technology should be used for waste treatment and disposal within the Public Sector with a reduction in dependence on incineration over time except where absolutely necessary.

The Ministry of Health should have at least one treatment facility for pharmaceutical waste. This facility should be available to the private sector within the framework of a cost recovery system.

There should be designated locations, appropriately designed for storing hazardous wastes and pharmaceuticals awaiting disposal/destruction locally or overseas. An inventory of the wastes in storage must be maintained and updated when items are added or removed from the storage facility.

Arrangements should be made with a facility overseas that has the capability to destroy chemical wastes that cannot be treated locally. This arrangement should be ongoing and within the context of the Basel Convention and the Natural Resources (Hazardous Waste) (Control of Transboundary Movement) Regulation, 2002.

6.16 Cost Recovery

The Ministry of Health must establish a cost recovery system applicable to the sector to allow for treatment facilities to charge for providing others with treatment services for medical waste. The cost of the service should be such that at least the additional costs associated with treating wastes from other locations are recovered. The Ministry should not determine the costs that should be charged for treatment services except in the case of its own treatment facilities. This system is best supported by legislation.

6.17 Accidents and Spills

There must a documented emergency response plan to address accidents and spills involving medical waste generally and in particular infectious waste. Any accident or spillage must be reported to the person with responsibility for the control of infection within the healthcare facility.

Information regarding the substance spilled (from signs/labels/MSDS), extent of the spill, persons injured must be noted until trained personnel arrive to contain and clean up the spill. Injured persons must receive immediate medical attention. No patient or visitor must be allowed to become involved in dealing with a medical waste spill.

Appropriate disinfection of the affected area must be conducted to the satisfaction of the person with responsibility for infection control within the facility.

Spilled waste must be re-contained in suitable bags or receptacles for disposal.

Persons containing and cleaning up spills must be attired in the appropriate personal protective equipment.

Spills and accidents should be investigated to ascertain the cause and corrective actions must be instituted to prevent reoccurrence of the incident.

6.18 Environmental Management and Quality Management Systems

All health care facilities should have procedures outlining the roles and responsibilities of those involved in the management of medical waste. The effectiveness of these procedures should be audited on a predetermined frequency both internally and externally. It may be useful for the healthcare facility to implement an Environmental Management System (EMS) and/or a Quality Management System (QMS). Implementing these systems can significantly improve the management of medical waste as they define a common goal that all persons are working towards, procedures must be developed outlining roles and responsibilities, there is a system of addressing non-conformances and there are requirements for periodic audits of the system to test its effectiveness. Regulators usually support the implementation of these systems as less rigorous monitoring is required. Where facilities become certified, they are recognised locally and internationally for superior practices.

6.19 Training

While each healthcare facility is obliged to ensure that stakeholders are trained to carry out their roles and responsibilities as it relates to medical waste management, the Ministry of Health should build capacity within the sector and facilitate the training of:

Persons responsible for waste management within healthcare and other facilities

Procurement personnel

Janitorial personnel (contracted or staff)

Waste collectors (public and private)

Health care, veterinary, pharmaceutical and other relevant professionals

7.0 PRINCIPLES

Environmental Audits And Taking Into Account All Ecological Consequences Principle

The environmental audit and ecological consequences principle requires the assessment of both the environmental costs of not converting to ecologically sound practices and the environmental costs of permitting ecologically unsound practices (including the costs to future generations of irreversible environmental degradation) and the environmental costs of potential mitigation, and restoration.

Use Of Best Ecologically Sound Techniques (Best)

It is important to support and promote the development of and the use of BEST (Best Ecologically Sound Techniques). In the event that there is no BEST technology which can prevent the release of persistent or bio-accumulative toxics then the extractive or productive activities which produce the product or substance process should be changed; the activities and product phased out/outlawed, or the demand for the product reduced through public education. In this case, the industry involved shall be assisted in the conversion to alternative processes or products.

Cradle to Grave

The "Cradle to Grave" concept means that the generator of waste is responsible for its safe disposal. The waste generators’ responsibility is not discharged until there is verifiable evidence that the waste was safely and securely disposed of.

The Polluter Pays Principle

The Polluter Pays Principle ensures that those who may release polluting substances into the environment pay the full-cost of environmentally safe handling, treatment, disposal, and remediation; in addition, permits shall be suspended and canceled, if the polluter has caused serious irreversible ecological damage.

The Precautionary Principle

One of the most important expressions of the precautionary principle internationally is the Rio Declaration from the 1992 United Nations Conference on Environment and Development, also known as Agenda 21. The declaration stated:

In order to protect the environment, the precautionary approach shall be widely applied by States according to their capabilities. 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.

“Right To Know” Principle

Environmental issues are best handled with the participation of all concerned citizens, at the relevant level. At the national level, each individual shall have appropriate access to information concerning the environment that is held by public authorities, including information on hazardous materials and activities in their communities, and the opportunity to participate in decision-making processes. Project proponents should facilitate and encourage public awareness and participation by making information widely available. Effective access to judicial and administrative proceedings, including redress and remedy, shall be provided.

8.0 KEY STAKEHOLDERS AND THEIR ROLES

The following table lists the key stakeholders that have roles and responsibilities related to medical waste management. These stakeholders range from those that have policy and regulatory roles to those that are required to comply with the policies and legislation based on the operations and activities that they are engaged in as shown in Table 4.

Table 4 - Role of Key Stakeholders in Medical Waste Management

ENTITY ROLE

1. The Ministry of Health (MOH); hospitals, clinics, labs etc. Regulator of medical waste (public and private sector); waste management operations of hospitals and labs regulated by NEPA and NSWMA

2. Ministry of Agriculture, Veterinary Division Regulator of the veterinary sector; waste management operations regulated by NEPA and NSWMA

3. Dental Association of Jamaica; Dental practices Umbrella association representing the dentists; members are generators of medical waste

4. Medical Association of Jamaica; Doctors Offices Umbrella association representing doctors; members are generators of medical waste

5. Ministry of Local Government, Community Development Sets national policy for solid waste management

6. National Solid Waste Management Authority Regulates all generators of solid waste and operates disposal facilities

7. Ministry of Land and Environment Sets national policy for hazardous waste management

8. National Environment and Planning Agency Regulates all activities such as waste treatment and disposal that can impact negatively on human health and the environment

9. Morticians Generators of medical waste

10. Private Hospitals Medical waste generated by these entities are regulated by MOH and NSWMA

11. Private Labs Medical waste generated by these entities are regulated by MOH and NSWMA

12. Nurses Association Umbrella association representing the nurses; members are generators of medical waste

13. Waste collection/treatment and disposal service providers Regulated by MOH and NSWMA

8.1 Applicable Legislation

The existing policies and legislation that relate to medical waste management primarily reside in regulatory agencies other than the Ministry of Health.

The existing legislation applicable to medical waste management includes:

The Natural Resources Conservation Act, 1991

The Natural Resources (Prescribed Areas) (Prohibition of Categories of Enterprise, Construction and Development) Order, 1996

The Natural Resources Conservation (Permits and Licences) Regulations, 1996

The Natural Resources Conservation (Air Quality) Regulations, 2002 (Draft)

The Natural Resources Conservation, (Ambient Air Quality Standards) Regulations, 1996

National Solid Waste Management Act 2001

The Clean Air Act, 1964

The Public Health Act, 1985

The Public Health (Nuisance) Regulations, 1995

The relevant policies are:

The Solid Waste Management Policy, 2000

The Draft Hazardous Waste Policy

The specific roles and responsibilities of key stakeholders as it relates to medical waste management are described as follows:

The Ministry of Health

The Ministry of Health (MOH) has jurisdiction over waste management under The Public Health Act (1975) and its amendment (1976). Their (MOH) focus is mainly at the point of generation of the waste but disposal as it relates to health also falls under their purview. The Ministry of Health establishes the policy governing the management of medical waste and enacts legislation and management plans for its implementation.

On the operational side, the MOH has responsibility for public hospital, clinics and laboratories.

The Clean Air Act, 1964 enables the Ministry of Health’s inspectorate to regulate emissions of gases such as smoke, fumes, other gases or dust.

Under section 5 of this Act an inspector upon verification of his authority if so required may enter any affected premises at any time while work is being carried on there, or while there is any discharge of smoke or fumes, gases or dust into the air from any part of such premises and may inspect and examine such premises or any part thereof and may make such enquiries, tests and take such samples of any substance, smoke, fumes, gas or dust as he considers necessary or proper for the performance of his duties.

The healthcare facilities would therefore have to ensure that emissions associated with medical waste treatment processes are of an acceptable quality to ensure that there are no legal repercussions under Section 5 of this Act.

Under section 20 (1) of the Public Health Act, 1985 a medical officer (health) or any other person authorised in writing in that behalf by the Minister or by a Local Board, or by the Medical Officer may at all reasonable times enter any premises for the purpose of ensuring compliance with the provisions of this Act, or any regulations made hereunder and shall, if required to do so by the person in charge of the premises, produce his authority for so entering to such person.

Under section 20(2) where a Medical Officer is satisfied that it is necessary in the interest of the public health so to do, he may by himself or by some other person duly authorised by him in that behalf enter any premises with or without the consent of the owner or occupier, and take such action as he considers necessary in the interest of the public.

Though not directly targeting medical waste, this Act is relevant to medical waste management since the waste being managed by healthcare facilities is infectious and toxic, thereby posing a potential hazard to staff, waste handlers and the wider public if it is not disposed of appropriately. Additionally some of the by-products of incineration (emissions and residues) are considered hazardous and require special equipment and management to protect the public.

In the Public Health (Nuisance) Regulations, 1995 nuisance includes any nuisance specified in the schedule to these Regulations. No person shall cause or permit a nuisance on any premises owned or occupied by him or aid and abet any other person to cause or permit nuisance on any premises.

Under section 4 (3) the Local Board, on receipt of a report may institute legal proceedings against the person for non-compliance with the notice or authorise in writing any person to enter upon the premises and to do such things as are necessary to abate or prevent a recurrence of the nuisance

Nuisances can include dust, smoke, fumes, gases or deposits of solid waste from any manufacturing process or caused by the carrying on of any trade or business or otherwise by the action of any person.

This regulation does not give the Ministry of Health direct jurisdiction over medical waste, it only regulates any nuisances that may arise from treatment and disposal of medical waste.

The Environmental Health Unit (EHU) in the Ministry of Health

The EHU is a technical department of the Ministry of Health that focuses on environmental health issues. It is responsible for approving proposed management plans for all healthcare facilities for the handling, storage, treatment and disposal of medical waste form an environmental health perspective. Proposals are assessed based on the following criteria:

Appropriateness of the design for the intended use

Maintenance Plan

Pollution control

The National Environment and Planning Agency (NEPA)

The Natural Resources Conservation Act, 1991 gives the Natural Resources Conservation Authority [NRCA](now embodied within the National Environment and Planning Agency [NEPA]) the power to take the necessary steps for the effective management of the physical environment of Jamaica so as to ensure the conservation, protection and proper use of its natural resources among other things. In performing its functions it may among other things, formulate standards and codes of practice to be observed for the improvement and maintenance of the quality of the environment generally, including the release of substances into the environment in connection with any works, activity or undertaking. Based on the powers and functions of the NRCA, the management of medical waste as it relates to the potential adverse effect it could have on the environment falls within their jurisdiction.

Hazardous waste storage, treatment and disposal facilities is a category listed in the Natural Resources (Prescribed Areas) (Prohibition of Categories of Enterprise, Construction and Development) Order, 1996 as requiring a permit from NEPA. Since medical waste comprises some hazardous and toxic waste streams, the establishment of facilities to treat and dispose of medical waste will require a Permit from NEPA. In cases where the treatment/disposal option for medical waste results in air emissions from point sources such as incinerators or effluent discharge, a licence would also be required.

A Permit Application and a Project Information Form are to be submitted to NEPA in accordance with the Natural Resources Conservation (Permits and Licences) Regulations, 1996 for the construction and operation of hazardous waste storage, treatment and disposal facilities. An Environmental Impact Assessment (EIA) may be requested by NEPA for the proposed activity. This regulation is applicable to medical waste treatment and disposal facilities.

In cases where the treatment and disposal option will require the release of air emissions from a point sources, the Natural Resources Conservation Authority (Air Quality) Regulations, (currently being drafted) would apply. These regulations require industrial sources (with emissions greater than a specified amount) to obtain air pollutant discharge licences. It also establishes stack emission standards for new sources and ambient air quality guideline concentrations for a wide range of toxic air pollutants. These regulations complement the National Ambient Air Quality Standards for common air pollutants.

The Natural Resources Conservation, (Ambient Air Quality Standards) Regulations, 1996 set the acceptable limits for common air pollutants in ambient air. Since the treatment of medical waste in some cases could emit air pollutants, this regulation would be applicable to ensure that controls are in place to ensure that emissions do not contribute negatively to ambient air quality.

The National Solid Waste Management Policy 2000 indicates that the Ministry of Health has responsibility for establishing policy for the management of medical waste. It also indicates that there will be collaboration with the National Solid Waste Management Authority (NSWMA) on the operational aspects governing the management of medical waste to ensure the best use of the Government’s scarce resources.

National Solid Waste Management Act, 2001 gives the NSWMA the power to take all steps as are necessary for the effective management of solid waste in Jamaica in order to safeguard public health, ensure that waste is collected, stored, transported, recycled, reused or disposed of in an environmentally sound manner and promote safety standards in relation to such waste. The NSWMA would therefore have to be satisfied that the management of medical waste meets their required operational standards for segregation, storage, collection, treatment and disposal. These operational standards are set by the NSWMA to ensure safety to the persons collecting garbage and working at disposal sites. Also operational standards for the vehicles transporting medical waste are established to ensure that there is no cross contamination of wastes by using a municipal garbage truck to collect medical waste and to prevent leachate from contaminating the environment from vehicles not designed for the purpose of transporting medical waste.

Standards and procedures for the handling of residues from treated medical waste such as ash from incinerators and shredded autoclaved residues are established by the NSWMA to ensure safe handling and disposal of these wastes at disposal sites. Disposal of parts from decommissioned medical waste treatment and disposal facilities would also be an operational aspect that would come under the purview of the NSWMA.

Other agencies

The Jamaica Fire Brigade is interested in the incineration process, particularly the height of the flue and the disposal of ash. A proposal for the installation of an incinerator must be submitted to the Jamaica Fire Brigade for approval. Therefore in cases where incineration is being considered as the treatment technology for medical waste, the Jamaica Fire Brigade must approve of the equipment.

The Veterinary Services Division in the Ministry of Agriculture oversees national health, animal status and welfare through its various services offered island wide. Included in this would be standards and guidelines for the safe disposal of veterinary wastes.

The Ministry of Local Government, Community Development and Sport is responsible for the policy direction and guidance of the NSWMA, the agency responsible for solid waste management nationally. The Local Authorities (Parish Councils and the Kingston and St. Andrew Corporation) are also a part of this Ministry and they have a monitoring role as it relates to:

effective management of solid waste within their jurisdiction and

effective management of medical waste among other things through the Local Boards of Health.

The Hazardous Waste (Control of Transboundary Movement) Regulations explicitly address the Transboundary movement of hazardous wastes. The regulations were developed to further Jamaica’s accession to the Basel Convention and are the responsibility of NEPA. The regulations include a definition for hazardous wastes and address the international movement (import and export) of hazardous waste. Radioactive and shipping wastes are not covered by these regulations. The regulations include mechanisms for approving the export of hazardous wastes. The Ministry of Land and Environment is the designated national focal point for this convention and they are responsible for filing annual reports to the Secretariat of the Basel Convention.

Since there are some medical wastes that are designated hazardous, this regulation would be applicable if medical wastes were either imported or exported for treatment and disposal.

There are plans to develop regulations to address the movement of hazardous wastes within the island which would be applicable to the movement of medical wastes.

8.2 New Legislation

The existing legislation under the jurisdiction of the Ministry of Health is weak, outdated in many instances and not specific to medical waste management. While NEPA and the NSWMA are able to regulate some aspects of medical waste management based on their legislation, there are issues specific to medical waste that are not covered. It is therefore imperative that the Ministry of Health develop legislation specifically applicable to the sector. The new legislation should be developed in accordance with this policy to establish enforceable standards and operational criteria that will lead to acceptable management of medical waste.

The Ministry of Health will need to liaise with the NSWMA regarding the mechanism for regulating medical waste haulers. The Ministry Health should define the health and infection control criteria and the NSWMA should address the operational requirements since they already have the operational, administrative and legislative systems to deal with licencing regular garbage collectors. The health and operational criteria from both agencies should be used to develop a licencing system for the operators and the vehicles as well.

This new legislation to be developed by the Ministry of Health must be complementary to the National Solid Waste Management Act and associated regulations; the Natural Resources Conservation Authority Act and its regulations including those related to hazardous waste and the Occupational Health and Safety Regulations being developed by the Ministry of Labour.

The potential conflict the Ministry of Health will have as the regulator for medical waste management and as an entity being regulated, should be addressed through legislative instruments along with and changes to the organisational structure. The Ministry of Health should not be in a position where it has to regulate itself.

Legislation is not the only tool that can be used to regulate activities within the sector. Codes of Practice and Guidelines should be developed and utilised where applicable to support the policy goals and objectives.

8.3 Incentives

Incentives such as reduction in duties and taxes will be provided to entities interested in importing equipment using “clean technology” to treat medical waste. This can be considered due to the potential cost savings that will accrue to the Government from the reduced negative impact of pollution on human health and environment.

9.0 MONITORING AND EVALUATION

The effectiveness of the implementation of the policy goals and objectives will be monitored by the Central Health Committee (CHC). The Environmental Health Unit in the Ministry of Health will be responsible for the implementation of the policy. They will develop a 5 year plan for the implementation of the policy with annual updates and report on the status of its implementation to the CHC. Table 5 provides an example of the information that should be included in the medical waste management plan. The indicators must be realistic and measurable. One of the first actions is to establish baselines by collecting data so that progress can be measured from a particular point in time against an established baseline. Without this information it will be impossible to monitor the effectiveness of the implementation of the policy. When the actions are completed and targets are met, then the objectives and ultimately the goals will be achieved.

Table 5 - Sample Medical Waste Management Action Plan

Objectives Actions Targets

To collect data related to medical waste management such as the types and quantities of medical waste generated by all health care facilities and to use this information to improve the management of medical waste at the local (facility) level and the national level ·1 Conduct a waste audit and classify the types of wastes generated according to risk ·2 Acquire equipment or services to weigh segregated waste on an ongoing basis ·3 Document information ·4 Analyse information and use it to develop waste management plan and to set targets ·5 Set timelines for activities to be completed

To minimise the amount of hazardous waste generated by utilizing alternatives where possible that do not have harmful/adverse effects on human health and the environment ·6 Quantify amount of hazardous waste generated ·7 Develop new specifications for materials and services to be purchased ·8 Amend procurement procedures ·9 Ask suppliers to take back spent items that are hazardous where applicable ·10 Avoid accepting donations of outdated and expired products ·11 X % reduction in year 1 ·12 Y% reduction in year 2 etc.

To minimise the amount of infectious/hazardous medical waste generated (when mixed with regular garbage) by segregating and treating this waste prior to disposal ·13 Quantify the quantity of infectious waste generated ·14 Institute segregation procedures ·15 Have appropriate and adequate numbers of receptacles and colour coded bags available ·16 X % reduction in year 1 ·17 Y% reduction in year 2 etc.

To establish criteria for the sector to select appropriate handling, storage, transportation, treatment and disposal methods and technologies based on the characteristics and quantity of medical waste ·18 Develop Codes of Practice and Guidelines to govern aspects of medical waste management where those tools would be applicable ·19 Develop regulations that define the treatment standards for medical waste ·20 Liaise with the NSWMA to develop regulations for transporting medical waste ·21 Liaise with NEPA and the NSWMA to ensure regulations, Codes of Practice and Guidelines are complementary with their policies and regulations ·22 Set timelines for these regulations, guidelines and Codes of Practice to be developed

To define the operational framework for medical waste treatment and disposal within the public sector ·23 Determine the treatment technologies to be utilised ·24 Phase out dependence on incineration over a specified time ·25 Determine the strategy for cost effective provision of medical waste treatment services within the public sector e.g. regional approach ·26 Set timelines for activities to be completed

To define a framework for cost recovery for public and private facilities that provide medical waste treatment/disposal services to others ·27 Develop guidelines and/or regulations to govern cost recovery system for providing 3rd party treatment services ·28 Establish scale of fees for public sector healthcare facilities that can provide 3rd party treatment services ·29 Establish mechanism to review and revise scale of fees ·30 Set timelines for activities to be completed

To state the responsibilities of the generators, treatment facility operators, temporary storage operators, transporters, and disposal facility operators ·31 Develop Codes of Practice, guidelines and regulations ·32 Implement EMS and/or QMS ·33 Conduct seminars and workshops for specific target groups ·34 Set timelines for activities to be completed

To define legislative and enforcement mechanisms to facilitate the proper management of medical waste ·35 Develop Codes of Practice, guidelines and regulations ·36 Identify and train enforcement personnel ·37 Conduct seminars and workshops for specific target groups ·38 Set timelines for activities to be completed

To enable Jamaica’s compliance with local policies and regulations and international agreements ·39 Develop Codes of Practice, guidelines and regulations ·40 Conduct seminars and workshops for specific target groups ·41 Set timelines for activities to be completed

To educate and train (where applicable) healthcare workers, waste handlers, collection and disposal service providers and the general public about their roles and responsibilities related to the management of medical waste, provide them with information on the appropriate options available for the management of different types of medical waste and the associated occupational health and safety requirements ·42 Implement EMS and or QMS ·43 Develop procedures ·44 Conduct seminars and workshops for specific target groups ·45 Implement applicable provisions of the Occupational Health and Safety Regulations ·46 Set timelines for activities to be completed

10.0 POLICY REVIEW

Unless otherwise mandated by the Minister of Health, the policy should be reviewed by the CHC every 4 years to ensure its relevance. Additions to and/or deletions from the policy should only occur after consultation with the stakeholders.

11.0 CONCLUSION

There is clearly a need to improve medical waste management in Jamaica and the stakeholders need information and guidance. This policy provides guidance to the sector to enable the development of the necessary systems, legislation and partnerships to improve and optimise the management of medical waste so that the vision stated herein can be achieved.

APPENDIX 1

GIFTS AND DONATIONS POLICY AND PROCEDURES

as of 1998 November 12

Groups or individuals wishing to donate equipment or medical supplies etc. to public sector institutions in Jamaica should submit the list of suggested items to the Jamaican Embassy or Consulate in the area.

Jamaica’s representatives overseas will then submit the list to the Procurement Manager at the Ministry of Health, who will then determine the appropriateness of the donation after consultation with the Director of Health Facilities, Maintenance Unit the Pharmaceutical Services Division and/or the respective Technical Officers (Director- Standards & Regulation, Director- Health Services Planning & Integration, Director- Health Promotion & Protection)

Equipment offered must be accompanied by specifications and information in accordance with the guidelines for medical equipment maintenance (see below). Of special importance in determining acceptability of equipment is information regarding age of the item availability of spare parts, operator and service manuals, and availability of maintenance services in Jamaica.

Once equipment/medical supplies have been found to be acceptable then the donor would arrange for the shipment, which should be addressed to the Permanent Secretary, Ministry of Health for attention of the Procurement Manager. Arrangements will be made for the handing over and distribution of the items, in consultation with the donor. Ministry of Health reserves the right to direct gifts to the area of greatest need. The donated Institution will be informed accordingly.

The final list of items showing values being shipped along with the letter from the donor should be sent two weeks in advance to the Ministry of Health so that the appropriate duty waivers and permits can be obtained, prior to the arrival of the goods on the island.

The donor must supply for the Procurement Manager the packing list and other invoices and relevant shipping documents so that arrangements can be made for Customs clearance.

A matter of particular concern is the unrestrained generosity of various benefactors who ship large quantities of supplies and equipment to the Ministry or its institutions. Apart from the problem of obsolete or incompatible goods, equipment requiring costly infrastructure, and occasional requests for reimbursement of shipping costs or payment for items, gifts and donations often pose other problems for speedy clearance. Practices include:

shipping of goods without advising the Ministry

failure to provide packing lists

failure to provide invoices showing values and other pertinent data

failure to consign goods correctly to the MOH.

LIST OF ITEMS DONORS CAN SUPPLY

HOSPITAL LINEN (new)

HOSPITAL GOWNS (new)

PREP PADS OR SOLUTION - POVIDONE IODINE

GAUZE (X Ray detectable and non-detectable)

BANDAGES (All sizes)

DISPOSAL SURGICAL MASKS

DISPOSAL EXAMINATION GLOVES (All sizes)

STERILE SURGICAL GLOVES (All sizes)(especially size 7-71/2)

SYRINGES (5 and 10cc)

NEEDLES (20,21,22g)

VACUTAINER/VENOJECT (red and lavender)

VACUTAINER/VENOJECT NEEDLES

INSULIN SYRINGES (1cc)

SURGICAL SCISSORS

SCALPEL BLADES AND HANDLES

SMALL ARTERY FORCEPS (Criles)

TISSUES FORCEPS

NEEDLE HOLDERS

SUTURES (SPECIFICS TO BE PROVIDED)

X-RAY FILM (SPECIFICS TO BE PROVIDED)

PLASTER OF PARRIS

INSTRUMENT TRAYS (small, medium, large)

SOLUTION & SWAB BOWLS (small, medium, large)

KIDNEY DISHES (medium, large)

OTHER SUITABLE ITEMS

EQUIPMENT

UNIVERSAL OXYGEN CROUPETTE WITH CANOPY

INSTRUMENT/DRESSING TROLLEYS

EMERGENCY STRETCHES

WHEELCHAIRS - Adult & Pediatric

MOBILE SCREENS

DELIVERY BEDS

MAJOR OPERATING THEATRE TABLES

MAJOR OPERATING THEATRE LIGHTS

INCUBATORS

PHYSIOLOGICAL MONITORS

ELECTROCAUTERY MACHINES

SPHYGMOMANOMETERS (MOBILE AND WALL MOUNTED)

EMERGENCY CRASH CARTS

EMERGENCY/TRAUMA BEDS

PNEUMATIC TOURNIQUETS

ELECTRIC CAST CUTTER/

ELECTRIC DRILL

DEFIBRILLATOR

ECG MACHINE

SURGICAL INSTRUMENTS FOR OPTHALOMOLOGY

ORTHOPAEDICS

PAEDIATRIC SURGERY

GENERAL SURGERY

AMBULANCES

AUTOCLAVES

THE DETAILED LIST OF PHARMACEUTICALS WHICH CAN BE DONATED WHICH IS ACCEPTABLE TO THE MINISTRY OF HEALTH HAS BEEN CATALOGUED IN THE PUBLISHED VEN LIST ENTITLED "LIST OF VITAL ESSENTIAL AND NESSARY DRUGS AND MEDICAL SUNDRIES" FOR PUBLIC HEALTH INSTITUTIONS 1998, WHICH IS AVAILABLE AT ALL OUR EMBASSIES AND CONSULATES AND FROM THE MINISTRY OF HEALTH

MEDICAL GASES

All equipment using medical gas must use the colour code system as specified by the Jamaica National Formulary (and the British Pharmacopoeia). NO other colour code system is permitted. ALL hoses, connections, sockets, probes, pipes flowmeter, suction controllers and gauges must be marked in accordance with the colour code system.

Equipment for connection to medical gas cylinders must be screw threaded fitting for size J/M cylinders and medical pin-index fitting for all other cylinder sizes.

Medical equipment using gases for patient inhalation and operating from the central medical gas pipeline system must be suitable for operation at mains line pressure up to 4 BAR. Orthopedic power tool equipment should use compressed air and be suitable for operation at line pressures up to 7 BAR. Suction equipment should be suitable for pressures of -0.9 BAR. All equipment must be supplied with a permanently crimped BOC/OHMEDA Marked IV medical gas probe.

All cylinder mounted pressure reducing controllers must include an over-pressure safety valve, and be so adjusted as to prevent the delivery of pressures in excess of 4.5 BAR.

All flexible hoses from the mains gas supply system or cylinder regulators must be attached to equipment and probes with permanent medical gas crimps. The use of Jubilee clips friction nipples or fixing wires is NOT permitted.

All cylinder mounted/using equipment, including regulators, must