Plan of Health Waste Management

VIETNAM HIV/AIDS PREVENTION PROJECT E1055 v3

PLAN OF HEALTH WASTE MANAGEMENT VIETNAM HIV/AIDS PREVENTION PROJECT

HANOI, 2010 ABBREVIATIONS

BCC Behavior change communication

CPMU Central project management unit

CSW Commercial sex worker

IDU Injecting drug user

M&E Monitoring and evaluation

OI opportunistic infection

PLWHA People living with HIV/AIDS

Prevention of mother to child transmission (of PMTCT HIV)

PPMU Provincial project management unit

S&N Syringe and needle

STI Sexually transmitted infection

VCT Voluntary and testing

2 TABLE OF CONTENT

SUMMARY...... 4 Part I. Update of adjustments of the project...... 5 1. Project sites...... 5 2. Adjustments of activities of the project...... 5 Part II. Update of legal documents related to health waste management...... 9 1. Decision No. 43 of Minister of health on December 30th, 2007, promulgating the regulation on management of health wastes...... 9 2. Guidance on managing health waste arising from project services...... 10 3. Other legal documents related to health waste management...... 11 Part III. Assessment of Health waste management in project sites...... 11 I. Resources of waste arising from the project services...... 11 II. Actual situation of waste management...... 13 1. Dissemination of guidance of health waste management...... 13 2. Training on health waste management...... 14 3. Health waste management transferred to annual provincial action plans...... 14 4. Supervision of health waste management...... 15 5. Forms of treatment of used S&N in project sites...... 15 6. Waste treatment from other activities...... 19 7. Conclusion...... 20 Part IV. Proposed plan for health waste management...... 21 I. Description of the plan...... 21 II. Proposal budget for plan of health waste management...... 22 III. Monitoring and evaluation framework...... 26 Annex 1: Map of project provinces...... 28 Annex 2. Specific requirements of safe used S&N containers...... 29 Annex 3. Result of questionnaire analysis...... 31 Annex 4. Content of Decision 43/QD-BYT...... 35

LIST OF FIGURES

Map 1. Resources of waste arising from project services...... 12

Table 1. Summary of adjustments of the project...... 6 Table 2. Budget allocated by programs...... 7 Table 3. Estimated size of high risk population in 12 new provinces...... 8 Table 4. Percentage of used S&N collected annually...... 13 Table 5. Estimated number of tons of used S&N collected annually...... 13 Table 6. Providing essential equipments for used S&N collection...... 14 Table 7. Form of treatment of used S&N at commune level...... 15 3 SUMMARY

In order to expand project sites from 20 participating provinces to 32, the project implements an assessment as well as develop a plan of health waste management, that occurred from project services.

The assessment results show that management of health waste, especially contaminated needles are essential, according to report in 2009, in 20 project provinces, there were 17 million clean needles and syringes (S&N) distributed, and 10 million of used units collected, these figures will increase further when the project is increased coverage of geographical areas and target interventions. Currently the project has no uniform process for managing used S&N as well as other health waste generated from project services; supervising health waste management has not been fulfilled, and become a major content of supervision; providing training for staffs of project network has not been conducted sufficiently.

The main difficulty in the implementation process and health waste management is lack of specific guidance, lack of training and guidance of related payment. Units, that have qualified incinerators only concentrated in urban areas, towns, townships, therefore signing contracts of used S&N destruction is unable to apply to all project sites, particularly in rural areas, remote areas…

Based on result of assessment, the project proposes a plan of health waste management, that includes: (1) developing detailed guidance of health waste management; (2) organizing training courses on related topic; (3) purchasing and distributing essential equipments for collection, transport of health waste; (4) supervising health waste management; (5) allocating budget for health waste management; (6) assigning staffs for this activity.

4 Part I. Update of adjustments of the project

1. Project sites

In 2010, participating provinces will be expanded from 20 to 32:

20 provinces/cities currently belong to WB project: An Giang, Bac Giang, Ben Tre, Cao Bang, Dong Nai, Hai Phong, Hau Giang, Ho Chi Minh City, Khanh Hoa, Kien Giang, Lai Chau, Nam Dinh, Nghe An, Son La, Thai Binh, Thai Nguyen, Thanh Hoa, Tien Giang, Vinh Long, Yen Bai

12 new provinces: Hanoi, Langson, Quangninh, Hatinh, Thuathienhue, Danang, Tayninh, Baria Vungtau, Binhthuan, Can tho, Soctrang, Dong thap

(See map of project provinces in Annex 1)

2. Adjustments of activities of the project

Content of the project Adjustments Component I. Provincial HIV/AIDS Participating provinces will be expanded from 20 to action plan 32

Component II. National HIV/AIDS policy and program (Activities at central level) Sub component 1. Policy and 1. Model of integrated harm reduction activities with program development and care and support will be taken over by PPMU. implementation Technical assistant will be provided by CPMU 2. Innovation is not changed. CPMU will cooperate with relevant agencies to conduct 2010 innovation day 3. Capacity building is not changed, CPMU will continuously provide short training courses and postgraduate courses for staffs worked in HIV/AIDS field 4. To increase Methadone program, expectantly extend this program in more 6 provinces 5. To increase condom promotion program, including freely condom distribution and social marketing

5 Subcomponent 2. Monitoring and Not change evaluation Subcomponent 3. Behavior change This program will be implemented in provincial level. communication CPMU will provide technical assistance and monitoring and evaluation

Component III. Project management To establish 12 PPMUs and maintain current 20 PPMUs

Table 1. Summary of adjustments of the project

2.1. According to original proposal, CPMU implements interventions in 06 center and integration with community interventions in Hanoi, Haiphong and Khanhhoa. However, since 2009, Khanhhoa site has been transferred to Khanhhoa PPMU with only communication activities focused; Haiphong site has been taken over by GF project. With Hanoi site, it will be taken over by Hanoi PPMU when it is established.

2.2. In the extended project, Methadone will be implemented in Namdinh, Thainguyen and Thanhhoa provinces. Plan of extension of Methadone sites belongs to National program of Methadone chaired by the Government.

2.3. Regarding to provincial level, harm reduction among high risk population will be prioritized with over 60% of budget allocated annually. According to orientations of plan, harm reduction program includes:

- Behavior change communication among IDUs and CSWs - S&N exchange program among IDUs - Freely distribute condom to CSWs - Voluntary counseling and testing (VCT) - Sexually transmitted infection (STI) management and treatment - Care and opportunistic infection (OI) treatment

- Allocated budget in provinces: The budget allocation for the program of harm reduction interventions (S&N exchange and condom distribution) accounted for the highest rate of 59.77%, followed by program monitoring and evaluation (15:56%)

No Program Budget % 1 BCC 559.041 9.4

6 2 Harm reduction (S&N exchange and 3.556.817 59.77 condom distribution) 3 Care and support 131.929 2.22 4 STI management and treatment 266.131 4.47 5 Capacity building 428.570 7.2 6 M&E 925.499 15.56 7 PMCT 17.845 0.3 Contingencies 64.168 1.08 Total 5.949.000 100 (2010 provincial action plan – WB project)

Table 2. Budget allocated by programs

2.4. Summary of interventions implementation

2.4.1. Harm reduction - This program is being implemented in 20 provinces and cities. Number of communes in implementing interventions among IDUs is increased annually, specifically, in 2009, 1084 communes, and 1169 in 2010; related to intervention among CSWs, 626 communes in 2009 and 709 communes in 2010 - Peer educator network is established. One of their tasks is distribution of condom and clean S&N and collection of used S&N. - Target applied for peer educators: each IDU receives at least 30 S&N/month and each CSW receives at least 60 condom/month

2.4.2. Care and support: - Implement in 10 provinces - Major model is establishment of club of PLWHAs. Activities of the clubs are provision of counseling about care and personal health protection, compliance with treatment (if any), and practicing safe behaviors to prevent HIV transmission toward community - Wound care and treatment of opportunistic infections are conducted in clinics by medical staffs

2.4.3. STI management and treatment - Implemented in 17 provinces - There are two type of implementation, including mobile teams and fixed clinics - Mobile team is major type. With this type, quarterly, provincial and district health staffs integrate with commune collaborators to be a mobile team. Place of STI examination is regularly commune health station in this site. - Fixed sites are located in commune health stations or STI clinics or reproductive health clinics

7 2.4.4. VCT

- In 2009, there are 14 provinces implementing VCT with 37 VCT rooms. In which, 9 rooms belong to 05, 06 centers (8 in HCM city and 1 in Hanoi). Regarding other VCT rooms, there are 6 in provincial level and 20 in district level - 100% of VCT rooms is located in health clinics such as provincial AIDS centers, hospitals or district preventive medicine centers - VCT rooms in rehabilitation centers don’t provide HIV testing

2.4.5. Action plan of new 12 provinces

According to orientations of plan, 12 new provinces will focus on interventions among high risk populations. Interventions include: harm reduction, capacity building, M&E and STI treatment. Estimated size of high risk population in these provinces:

No 12 provinces Estimated size of Estimated size of Total IDU CSW 1 Hanoi 22,066 1,882 23,948 2 Langson 2,313 615 2,928 3 Quangninh 2,025 1,585 3,610 4 Hatinh 1,477 5,051 6,528 5 Hue 250 990 1,240 6 Danang 1,087 1,205 2,292 7 Tayninh 796 1,355 2,151 8 Ba ria – Vungtau 1,252 992 2,244 9 Binhthuan 545 1,100 1,645 10 Cantho 1,195 1,932 3,127 11 Soc trang 708 616 1,324 12 Dong thap 782 1,467 2,249 Total 34,496 18,790 53,286

Table 3. Estimated size of high risk population in 12 new provinces Part II. Update of legal documents related to health waste management

1. Decision No. 43 of Minister of health on December 30th, 2007, promulgating the regulation on management of health wastes

8 On 30th December, 2007, Ministry of Health has promulgated Decision No 43/2007/QĐ- BYT on management of health waste. The Decision has replaced Decision No 2575/1999/QĐ- BYT, dated August 27, 1999 of Ministry of Health on the same issue. Content of the Decision No 43/QD-BYT is summarized as below:

1.1. According to Article 6, health waste is categorized as below:

1. Contagious wastes: a) Sharp and pointed wastes (Type A) are those which can cause cuts or punctures and may be infected, including injection needles, sharp and pointed ends of transfusion tubes, scalpels, nails and saws, injection ampoules, broken glass pieces and other sharp and pointed instruments used in medical activities. b) Non-sharp and non-pointed contagious wastes (Type B) are those stained with blood or body biological fluids and wastes from isolation wards. c) Highly contagious wastes (Type C) are those generated at laboratories such as swabs and containers stained with swabs. d) Surgery wastes (Type D), which include human tissues, organs, body parts, placentas, fetuses and tested animal carcasses. 1. 2. Hazardous chemical a) Expired or poor-quality pharmaceuticals which are no longer wastes usable b) Hazardous chemicals used in medical activities (Appendix 1 to this Regulation)

c) Tissue intoxicants, including drug bottles and pots, instruments stained with tissue intoxicants or substances secreted from patients treated with chemicals (Appendix 2 to this Regulation). d) Wastes containing heavy metals: mercury (from broken thermometers, blood pressure meters, wastes from dental treatment), cadimi (Cd (from batteries, accumulated batteries, lead (from lead-coated boards or material used to prevent X-rays from image diagnosis or X-ray treatment rooms). 3. Radioactive wastes: Radioactive wastes: include solid, liquid and gaseous ones, which are generated from diagnostic, therapeutic, research and production activities. The list of radioactive drugs and marked compounds used in diagnosis and therapy was promulgated together with decision No. 33/2006/QD-BYT of October 24, 2006, of the Minister of Health.. 4. Pressure containers: which include oxygen, CO2 or gas cylinders, prone to cause fires 9 and explosion when put on the fire

1.2. Other content mentioned in the Decision:

No Content Note 1 Standard of containers and transportation of solid waste in health Article III facilities 2 Sorting, collection and transportation of solid waste stored at the Article IV health facility 3 Transporting solid waste from the medical health facilities Article V 4 Model, treatment technologies and disposal of medical waste Article VI 5 Treatment of wastewater and waste gas Article VII 6 Organization of implementation Article VIII

1.3. However, to similar finding mentioned in health waste management plan, that was developed in 2005, currently it still lacks legal documents guiding management of health waste, particularly used needles and syringes arising from HIV/AIDS transmission prevention interventions in community.

2. Guidance on managing health waste arising from project services

2.1. Guidance on implementing harm reduction (issued in 2005 by CPMU) and training documents of harm reduction (developed in 2009) only give guidance of distribution and collection of used S&N. These documents don’t mention about transporting, storing and treating used S&N

2.2. To similar S&N exchange program, guidances related to other intervention services such as VCT, STI treatment, care and support … don’t mention health waste management

3. Other legal documents related to health waste management

Name of document Summary of content Circular No 12/2006/TT-BTNMT, dated Guide practice conditions and procedures, December 26, 2006 of MORE registration, providing license, and codes for hazardous waste management

QCVN 02:2008/BTNMT National technical regulation on the emission of health care solid waste incinerators)

10 TCVN 5937:2005 Air quality – ambient air quality standards TCVN 5938:2005 Air quality – maximum allowable concentration of hazardous substances in ambient air TCVN 5939:2005 Air quality – industrial emission standards – inorganic substances and dusts TCVN 5940:2005 Air quality – industrial emission standards – organic substances TCVN 7380 : 2004 Health care solid waste incinerators – technical requirements

Part III. Assessment of Health waste management in project sites

The assessment is done through: (1) data collected by questionnaire; that is sent to Provincial AIDS center of 12 new provinces and 20 PPMUs of WB project (see Annex questionnaire in the appendix. (2) Field visit in Nam Dinh and Hai Phong (direct observation and interviewing some key informants). In two provinces, assessment team visits peer educators, collaborators, club of PLWHAs, VCT, commune health stations, STI clinics, Methadone site and Trangcat waste treatment plant in Hai Phong.

I. Resources of waste arising from the project services

According to the above description, sources of the waste generated by project services as follows:

11 Project services Waste

Used S&N, and tubes containing S&N exchange distilled water

Condom distribution Used condom

STI management STI examination equipments, gloves, cotton, gauze, samples WB project

VCT used S&N, gloves, cotton gauze

Care and support used S&N, gloves, cotton gauze …

Methadone Methadone drug containers

Map 1. Resources of waste arising from project services

According to the analysis of characteristics related to the implementation of intervention programs, except N&S exchange and condom distribution programs, all other interventions (examination STI treatment, VCT, Care and support, and Methadone) are provided in health clinics with health staffs.

Therefore, the main source of hazardous contamination waste of the project is used S&N. As the content of the plans and annual reports, number clean S&N distributed and used needles collected is very large, its data is demonstrated in below:

12 Years Clean S&N Used S&N % of used S&N distributed collected collection (units) (units) 2005-2006 895.040 500.459 55.90 2007 4.213.989 2.320.855 55.07 2008 10.558.141 5.978.678 56.62 2009 17.103.582 10.621.099 62.09

Table 4. Percentage of used S&N collected annually

According to estimates, each safe box contains approximately used 160 S&N (about 150-180 used S&N/ safe box), estimated weight for a box full of used S&N is about 0.8 kg (about 0,7-0.9 kg/box), so estimated number of used S&N containers and contaminated waste is:

Years Used S&N Number of used Number of tons of used collected (units) S&N containers S&N stored in containers 2005-2006 500.459 3.127 4 2007 2.320.855 14.505 18 2008 5.978.678 37.366 46 2009 10.621.099 66.381 82

Table 5. Estimated number of tons of used S&N collected annually

II. Actual situation of waste management

1. Dissemination of guidance of health waste management

20/20 PPMUs have received Decision No 43/2007/QD-BYT on regulation of health waste management. With the exception of Khanh Hoa and An Giang have received the above decision since 2008 (Department of Health provided), others have received from CPMUs in March, 2010.

Prior to March 2010, all PPMUs were not known any guidance of health waste management, especially 2575/1999/QD-BYT Decision dated August 27, 1999 of the Ministry of Health issued regulations on health waste management (this decision was replaced by Decision No 43/QD- BYT mentioned above).

2. Training on health waste management

13 Staffs of PPMUs are not attended to formal training courses on health waste management of (0% rate by survey results).

Training courses for member of implementing network: - Peer educators: 3/20 provinces (An giang, khanhhoa and Namdinh) - Collaborators: 5/20 provinces (An Giang, HCM, Khanhhoa, Nam dinh and Thaibinh) - VCT: 3/14 provinces (bentre, Namdinh and Thaibinh) - Collaborators of STI teams: 3/17 provinces (bentre, khanh hoa and Namdinh) - Care and support for PLWHAs: 1/10 province (Bentre)

However, the above training courses are not specifically referred to the transport and treatment of health waste and used S&N.

During conducting assessment, subjects, who have knowledge about health waste management, are laboratory staffs (they are involving in VCT activities). Reason of gained knowledge of health waste management is that laboratory staffs have been participated in testing courses, or trained in learning process in medical secondary schools/medical colleges. However, it notes that not all staffs of laboratory have this knowledge because they don’t graduate from medical schools or regularly receive refresh training

3. Health waste management transferred to annual provincial action plans

All project provinces, that are implementing S&N exchange program, allocate budget to purchase essential equipments for used S&N collection. The essential equipments include gloves, clamps, and safe boxes. Results of assessment shows:

No Essential equipments Number of provinces meets requirements 1 Safe containers provided timely 20 2 Safe containers provided sufficiently 20 3 Protective equipments to be provided timely 19 (except Thaibinh)

4 Protective equipments to be provided sufficiently 19 (except Thaibinh)

Table 6. Providing essential equipments for used S&N collection

14 4. Supervision of health waste management

Used S&N collection is one of contents of supervision done by PPMU staffs and district collaborators (20/20 provinces). However, these activities don’t include supervision of destruction of used S&N, or management of health waste arising from other services such as VCT, STI treatment and care and support.

5. Forms of treatment of used S&N in project sites a. Result collected from questionnaire

No Form of treatment Number of % communes 1 Heat sterilization 0 0 2 Microwave sterilization 0 0 3 Burned without incinerators 415 43% 4 Burned in incinerators 269 28% 5 Burying 35 4% 6 Collecting and treated by other units 241 25% 7 Others 0 0

Table 7. Form of treatment of used S&N at commune level

- The data summarized in the table above shows that 43% of communes and wards have burned used S&N without incineration, 28% burned in incinerators, 4% burying and 25% collecting and treated by other units

- Regarding form of collecting and treated by other units: in rural areas, used S&N, collected and stored in containers, is transferred to district hospitals; in urban areas, it is transferred to Urban Environmental Company or provincial hospital, TB hospitals or dermatology hospitals. b. Process of collecting, storing used S&N in community: through field visit, this process is below:

Peer educators are tasked with collecting used S&N in community (most of the provinces don’t require peer educators to collect tubes containing distilled water was used).

To ensure safety for used S&N collection, all PPMUs buy some essential equipment for peer educators, including: clamps, protection gloves, boots, and safe containers. These equipments

15 are distributed sufficiently for peer educators. Assessment team doesn’t get complaint of distribution shortage during field visit.

Containers are usually placed in house of peer educator. When storing fully used S&N, containers are assembled at commune health stations. c. Destruction of used S&N:

- Burying: in some mountainous communes, used S&Ns are destroyed by burying. Regulations related to this form of treatment (mentioned in Decision No 43) are not guided for performance.

- Treatment in commune health stations: most of communes are applying form of burned without incinerators and form of burned in incinerators. Smoke and dust pollution must be considered, particularly, burned in cities/town areas because these stations are located near residential areas, high population density, and numerous numbers of used S&N.

Picture: used S&N burned with simple incinerator in commune health station

Picture: used S&N burned without incinerator in commune health station

d. Moved and processed in other units

16 - District hospital/provincial hospital: used Suns are stored and moved to district hospital/provincial hospital. Some hospitals require payment for treatment but also not required in others. There isn’t any cost norm related to treatment of used S&N, therefore budget allocated for treatment is different in provinces.

Picture: Used S&N gathered on commune health stations, then moved to district hospitals for treatment

- Urban Environment Company: this form is applied for urban areas (areas are covered by urban environment company). PPMU signs contract with this company. Used S&N, which are placed in health stations, are moved monthly to Urban Environment Company and processed in its own incinerators. Budget is estimated according to price of Urban Environment Company.

Picture: Health waste placed and processed in Haiphong URENCO

Notes of waterproof, moisture-proof standards of container

These standards are very important. Through the assessment, there are 3 types

17 of container used in project sites, including two types of paper containers and one type of plastic container.

Picture: plastic container and paper container that is made of cardboard coated waterproof material

Picture: Container made of cardboard without waterproof material

Waterproof, moisture-proof standards of container are very important because: (1) Collecting used S&N is done in community; (2) places, where gather containers such as house of peer educators or corners of commune health stations, are outdoor therefore it doesn’t prevent containers from rain, wet condition.

6. Waste treatment from other activities

Result of the assessment indicated that: a. VCT activity: - This activity generates wastes, including used S&N, samples, gloves, cotton gauze

18 - Used S&N is destroyed by S&N destruction machine or stored in safe containers. Used glove, gauze is still stored in safe containers or plastic bags. Tube containing sample or blood is treated according to requirements of laboratory. - Regulations of bag containing health waste are not yet interested - The VCT rooms are located in health facilities so that waste is treated together with waste of health facilities. Forms of waste treatment include: burned without incinerator or burned in incinerator in health facilities or transferred to other processing units according to contract signed between health facilities and service providers. b. STI management:

- Mobile STI examination team is major mode, in which there is participation of provincial specialists and commune health staffs - Major waste of this activity include: examination equipments, gloves, cotton, gauze, samples - Examination equipments are sterilized in place and moved to provincial STI facilities for treatment. gloves, cotton, gauze, samples are moved and treated in commune health stations (burned without incinerators or with incinerators) - Fixed STI clinics are located in health facilities such as hospitals therefore waste is treated with general medical waste generated from other activities of the hospital c. Care and support PLHWAs: this activity doesn’t generate health waste because of only providing communication and counseling d. Methadone: this activity is implemented in Ngoquyen center of preventive medicine. Major waste is used Methadone bottle. Currently, these bottles are stored in this center, and then moved to provincial AIDS center in order to burning with its incinerator.

7. Conclusion

7.1. According to new proposal, number of participating provinces will extend from 20 to 32. Interventions will mainly implement in community and concentrate on high risk populations (IDUs and CSWs). Care and support including ART will be taken by other donors.

7.2. Ministry of health has promulgated Decision No 43/2007/QĐ-BYT dated December 03, 2007 on health waste management. However, dissemination of this Decision for project implementing network is still not met requirement. Technical guidance, developed by CPMU, don’t sufficiently mention about health waste management.

7.3. With revised orientations of intervention mentioned above and result of the assessment, main waste, generated from project services, is used S&N.

19 7.4. The project is lacking of uniform process of managing health waste, particularly used S&N arising from S&N exchange program.

7.5. Supervision of health waste management is not done sufficiently and not yet become a content of regular supervision, monitoring and evaluation program.

7.6. Provincial action plans only focus on purchasing and distributing essential equipments for used S&N collection. Only half of project provinces allocate budget for transport and treatment of used S&N in facilities, where have standard incinerators.

7.7. Major difficulties of health waste management include: lack of specific guidance, lack of training and cost norm related to waste treatment. On the other hand, facilities having standard incinerators only locate in cities, towns, therefore signing contract with these facilities is unable to apply for rural areas, remote areas.

20 Part IV. Proposed plan for health waste management

I. Description of the plan

1. To develop specific guidance on managing health waste, particularly managing used S&N arising from S&N exchange program: this activity will be done by CPMU with assistance of individual consultant. Based on Decision No43, the document will give specific guidance in accordance with intervention implementation;

2. To organize training courses, workshops on health waste management: a. At central/regional and provincial level: health waste management will be integrated in schedule of courses/workshops on planning, harm reduction, VCT, STI management, care and support and Methadone. And health waste management is even integrated in courses/workshops organized by CPMU in 2010; b. At district and commune level: health waste management will be integrated with courses/workshops organized by PPMU in 2010 action plan and coming action plans

3. To purchase and provide essential equipments for collecting and transporting health waste: this activity will be developed in provincial action plan and provincial procurement plan.

4. Supervising, monitoring health waste management: it will be a content of regular supervision and monitoring implemented by CPMU, regional units, PPMUs as well as district and commune collaborators. CPMU will develop supervision tools, monitoring forms and organize training courses for relevant agencies.

5. To allocate budget for transporting and treating used S&N and other health waste: budget will be allocated annually in provincial action plan. CPMU will discuss and sign contract with relevant agencies providing service of health waste treatment

6. To supplement task of monitoring and supervising health waste management for M&E staffs, harm reduction staffs of CPMU, PPMUs. Clauses related to health waste management will be supplemented in annual contract between CPMU and implementing units.

21 II. Proposal budget for plan of health waste management No Activities Expected output Implementin Timeline Estimate Estimate Note g units d budget d budget in 2010 during plan 2011- (USD) 2012 (USD) 1 To develop specific guidance on 01 guidance developed CPMU 6-8/2010 10,000 - managing health waste, particularly managing used S&N arising from S&N exchange program 2 To organize training courses, workshops on health waste management 2.1. At central level: this content is integrated with existing 50,000 courses/workshops approved in 2010 action plan of CPMU:

- Course on plan development 32 provinces/cities: CPMU 7/2010 40,000 Integrated participants include activity leader of PPMUs, coordinators, and staffs in charge of planning Leaders and staffs of regional institutes

22 No Activities Expected output Implementin Timeline Estimate Estimate Note g units d budget d budget in 2010 during plan 2011- (USD) 2012 (USD) - Course on VCT implementation Participants include: CPMU 6/2010 48,000 Integrated counselors, managers, activity lab staffs, and staffs of mobile VCT - Workshop on reviewing harm 32 provinces: CPMU 8/2010 25,000 Integrated reduction program for 32 project participants include activity provinces staffs in charge of harm reduction; leaders of PPMUs; and representatives of regional institutes

- Course on monitoring and 32 provinces: CPMU 6/2010 30,000 Integrated evaluation participants include activity staffs in charge of M&E; leaders of PPMUs; and representatives of regional institutes

23 No Activities Expected output Implementin Timeline Estimate Estimate Note g units d budget d budget in 2010 during plan 2011- (USD) 2012 (USD) - Course on STI management Provinces implementing CPMU 5/2010 30,000 Integrated STI management; activity participants include staffs of PPMUs, staffs of STI mobile teams and staffs of fixed clinics

- Semi reviewing workshop 32 provinces, CPMU 7/2010 30,000 Integrated participants include activity leaders, coordinators and accountants of PPMUs; representatives of relevant agencies

- Annual reviewing meeting in 2010 32 provinces, CPMU 12/2010 35,000 Integrated and signing contracts between participants include activity CPMU and project provinces Chairman of Provincial steering committee, Directors, coordinators of PPMUs; representatives of

24 No Activities Expected output Implementin Timeline Estimate Estimate Note g units d budget d budget in 2010 during plan 2011- (USD) 2012 (USD) relevant agencies

2.2. Provincial courses will be integrated 100% of implementing PPMU 2010 and 64,000 Integrated with courses/workshops approved in network trained on coming activity provincial action plans managing health waste years 3 Purchasing and contributing Essential equipments PPMU 2010 and Integrated essential equipments for collecting, distributed timely and coming activity transporting health waste sufficiently years 4 Supervision of health waste management 4.1 Supervision of WB 01 time/year WB Annually 15,000 30,000

4.2 Supervisions, done by CPMU and 01 time/province/year CPMU Annually 64,000 128,000 Integrated regional institutes, will be integrated activity with regular supervision of CPMU and regional institutes 4.3 Supervisions done by PPMU All project sites will be PPMU Annually 128,000 256,000 Integrated supervised at least one activity time a year

25 No Activities Expected output Implementin Timeline Estimate Estimate Note g units d budget d budget in 2010 during plan 2011- (USD) 2012 (USD) 5 To allocate budget for processing 32 project provinces PPMU Annually used S&N and other health waste allocate sufficiently budget for this activity Total 455,000 528,000

26 III. Monitoring and evaluation framework

No Activities Expected output Indicators Measurement Timeline Responsibility

1 To develop specific 01 guidance developed Guidance Report of CPMU 6-8/2010 CPMU guidance on managing developed health waste, particularly managing used S&N arising from S&N exchange program 2 To organize training 100% staffs of Number/percentage - Training reports Annually CPMU and courses, workshops on implementing units of staffs having - Supervision PPMU health waste management having knowledge of knowledge of reports health waste management health waste management 3 Purchasing and Essential equipments Number of project - Supervision Annually CPMU and contributing essential contributed timely and provinces reports PPMU equipments for collecting, sufficiently contributed timely transporting health waste and sufficiently 4 Supervising health waste management 4.1 Supervision of WB 01 time/year Number of Mission report Annually WB supervision done 4.2 Supervisions, done by 01 time/province/year Number of Supervision reports Annually CPMU CPMU and regional supervision done

27 No Activities Expected output Indicators Measurement Timeline Responsibility

institutes, will be integrated with regular supervision of CPMU and regional institutes 4.3 Supervisions done by All project sites will be Number of Supervision reports Annually PPMU PPMU supervised at least one supervision done time a year 5 To allocate budget for 32 project provinces Budget allocated Report of action plan Annually CPMU and processing used S&N and allocate sufficiently sufficiently in PPMU other health waste budget for this activity annual action plans

28 Part V. Annexes

Annex 1: Map of project provinces

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VÜnh Long

Sãc Tr¨ng

29 Annex 2. Specific requirements of safe used S&N containers

(According to guidance of CPMU)

I Requirements

Boxes can safely store sharp used objects used: - in place of use; - during temporary storage; - During transportation.

II Detailed specific requirements

1. Box is made of cardboard, able to contain used S&N with types of 1 ml, 3 ml, 5 ml and other sharp objects

2. Can be folded for easily transporting

3. Capacity: 05 l + 10%

4. Diameter of hole inserting sharp objects into the box is 38 mm + 10%. Hole have lid to close the box when it contain sharp objects

5. There are straps above remark line of maximum amount of waste. The straps must not make difficult for inserting sharp objects and ensure sustainment for transportation

6. box is able to be portable with one hand and not make sharp objects inside falling out

7. Print clearly bio-hazard warning with not less than 50 mm of diameter, with black or red color on the front and back of the box

8. Mark line of maximum amount of waste must be clearly printed on both side of the box with black or red color. 9. Minimum force to penetrate the box from any point must be not less than 12.5 N.

10 When dropped, the box is not torn and not be penetrated by sharp objects .

11 Boxes don’t collapse when placed on the inclined plane of 15 degrees. In the case . of collapsing, hole must minimize the risk of sharp objects falling out.

30 12 Able to waterproof from inside .

13 Minimum height from floor to marline is 230 mm. .

14 The minimum distance from the hole inserting sharp objects and marline is 40 mm. .

15 User Guide Photos are printed on 2 sides box, including: . - How to assemble the box; - How to use the box to contain sharp objects; - Direction of inserting needles into the box - How to close the hole when the box is full.

31 Annex 3. Result of questionnaire analysis

Form 1 Yes: 1 No: 0 1 2 3 4 5 6 7 8 9 10

Receiving Safe guidance on PPMU Training for staffs of implementing network (1: Yes, 0: Supervisi Destroye box Essential health waste trained not yet) HWM is on of Safe box d Essential provid equipmen no Provinces management included HWM is provided machine equipments ed ts in plan included timely provided provided sufficie provided in plan for VCT sufficiently Answer Note Answer PE Col C&S PMCT organizer ntly timely VCT STI

1 An Giang 1 1.2008 0 1 1 PPMU 1 1 1 1 1 1 CPMU 2 Bacgiang 1 0 0 0 0 0 0 1 1 1 1 1 1 1 10.3.10 CPMU 3 Bentre 1 0 0 0 1 1 1 0 1 1 1 1 1 1 1 10.3.10 CPMU 4 Caobang 1 0 0 0 1 1 1 1 0 1 1 10.3.10 CPMU 5 Dongnai 1 0 0 0 0 0 0 0 1 1 1 1 0 1 1 10.3.10 CPMU 6 Haiphong 1 0 0 0 0 0 0 0 1 1 1 1 0 1 1 10.3.10 CPMU 7 Haugiang 1 0 0 0 0 0 1 1 1 1 1 1 1 10.3.10 CPMU 8 HCM city 1 0 0 1 1 1 1 1 1 1 10.3.10 CPMU 9 Kiengiang 1 0 0 0 0 1 1 1 1 1 1 10.3.10 CPMU 10 Lai chau 1 0 0 0 0 1 1 1 1 1 1 1 10.3.10 From DoH Monthly 2008 11 Khanhhoa 1 0 1 1 1 meeting 1 1 1 1 1 1 and of PPMU CPMU 10.3.10

32 CPMU 12 Namdinh 1 0 1 1 1 1 1 1 1 1 1 1 1 10.3.10 CPMU 13 Nghean 1 0 0 0 0 1 1 1 1 0 1 1 10.3.10 CPMU 14 Sonla 1 0 0 0 0 0 0 0 1 1 1 1 0 1 1 10.3.10 CPMU 15 Thaibinh 1 0 0 1 1 0 0 1 1 1 1 0 0 10.3.10 CPMU 16 Thainguyen 1 0 0 0 0 0 1 1 1 1 0 1 1 10.3.10 CPMU 17 Thanhhoa 1 0 0 0 0 0 0 1 1 1 1 0 1 1 10.3.10 CPMU 18 Tiengiang 1 0 0 0 0 0 0 1 1 1 1 0 1 1 10.3.10 CPMU 19 Vinhlong 1 0 0 0 0 0 0 1 1 1 1 1 1 1 10.3.10 CPMU 20 Yenbai 1 0 0 0 0 0 0 1 1 1 1 0 1 1 10.3.10

Total 20 0 3 5 3 3 1 20 20 20 20 6 19 19

PE: peer educators Col: collaborator C&S: care and support

33 Form 2. Forms of treatment of used syringe and needles in project provinces

Sharp object (Type A): yes and no Form of treatment of used S&N

TT Provinces Used S&N C&S Note

1 2 3 4 5 6 7 1 An Giang 1 15

2 Bacgiang 1 51 11 Burned with incinerators of TB hospital

3 Bentre 1 35 4 Caobang 1 22 10

5 Dongnai 1 22 82 Burned with incinerators of TB hospital

6 Haiphong 1 3 60 Burned with incinerators of environment company

7 Haugiang 1 12

8 HCM city 1 15 Burned with incinerators of environment company

9 Kiengiang 1 10 Provincial hospital

34 10 Laichau 1 23 11 Khanhhoa 1 35 10 20 Dematology hospital 12 Namdinh 1 11 128 13 Nghean 1 71 14 Sonla 1 24 15 Thaibinh 1 14 9 16 Thainguyen 1 13 21 17 Thanhhoa 1 101 71

18 Tiengiang 1 6 4 District hospital

District hospital 19 Vinhlong 1 20

20 Yenbai 1 21 10 District hospital Total 20 0 0 415 269 35 241 0

Forms of treatment 1 Heat sterilization 2 Microwave sterilization 3 Burned without incinerators 4 Burned in incinerators 5 Burying 6 Collecting and treated by other units 7 Others

35 Annex 4. Content of Decision 43/QD-BYT

Minister of health The Socialist Republic of Viet Nam ______Independence – Freedom- Happiness ______

Decision No. 43 of Minister of health on november 30th, 2007, promulgating the regulation on management of medical wastes

Chapter I General provisions

Article 1. Governing scope 1. This Regulation provides for the management of medical wastes, the rights and responsibilities of organizations and individuals in the management of medical wastes. 30TH 2. Medical establishments and organizations as well as individuals participating in the treatment and destruction of medical wastes shall, apart from implementing this Regulation, implement current state regulations on management of wastes.

Article 2. Subjects of application This regulation applies to medical examination and treatment establishments, maternity homes, health stations, establishments engaged in medical and pharmaceutical research, preventive medicine, training of health workers, production of and trading in pharmaceutical products, vaccines, medical biologicals (collectively referred to as medical establishments) and organizations as well as individuals involved in the transportation, treatment or destruction of medical wastes.

Article 3. Interpretation of terms In this Regulation, the terms below are constructed as follows: 1. Medical wastes means materials in solid, liquid or gaseous form, discharged from medical establishments, including hazardous medical wastes and ordinary medical waster. 2. Hazardous medical wastes means medical wastes containing elements hazardous to human health and environment such as contagiousness, intoxication, radiation, flammability, explosiveness, corrosiveness or other hazardous characters if these wastes are not safely destroyed. 3. Management of medical wastes means activities of managing the classification, preliminary treatment, collection, transportation, storage, minimization, re-use, recycle,

36 treatment, and destruction of medical wastes, and inspecting as well as overseeing the implementation. 4. Minimization of medical wastes means activities of restricting to the utmost the discharge of medical wastes, including reduction of medical waste volumes at their sources, use of recyclable or re-usable products, good managements and strict control of the process of accurate classification of wastes. 5. Re-use means the use of a product for many times until the end of its lifetime or the use of products for a new function of a new purpose. 6. Recycle means the re-production of discarded materials into new products. 7. Collection of wastes at their sources means the process of classifying, gathering, packing, and temporarily storing wastes at places where wastes are generated in medical establishment. 8. Transportation of wastes means the process of transporting wastes from their sources to places of preliminary treatment, storage or destruction. 9. Preliminary treatment means the process of disinfecting or sterilizing highly contagious wastes at their sources before the transportation thereof to places of storage of destruction. 10. Waste treatment and destruction means the process of using technologies to deprive the wastes of their hazard to human health and environment.

Article 4. Prohibited acts 1. Discharging hazardous medical wastes, which are not yet treated or destroyed up to prescribed standards, into the environment. 2. Treating and destroying hazardous medical wastes not according to the prescribed technical process and not at the prescribed place. 3. Delivering medical wastes to organizations or individuals having no legal person status for operation in the domain of waste management. 4. Trading in hazardous wastes. 5. Recycling hazardous medical wastes.

Chapter II Identification of medical wastes

Article 5. Groups of medical wastes Based on their physical, chemical and biological properties and hazards, wastes in medical establishments are classified into the following 5 groups: 1. Contagious wastes 2. Hazardous chemical wastes 3. Radioactive wastes 37 4. Pressure containers 5. General wastes

Article 6. Types of medical wastes 2. Contagious wastes: a) Sharp and pointed wastes (Type A) are those which can cause cuts or punctures and may be infected, including injection needles, sharp and pointed ends of transfusion tubes, scalpels, nails and saws, injection ampoules, broken glass pieces and other sharp and pointed instruments used in medical activities. b) Non-sharp and non-pointed contagious wastes (Type B) are those stained with blood or body biological fluids and wastes from isolation wards. c) Highly contagious wastes (Type C) are those generated at laboratories such as swabs and containers stained with swabs. d) Surgery wastes (Type D), which include human tissues, organs, body parts, placentas, fetuses and tested animal carcasses. 3. Hazardous chemical wastes: a) Expired or poor-quality pharmaceuticals which are no longer usable. b) Hazardous chemicals used in medical activities (Appendix 1 to this Regulation) c) Tissue intoxicants, including drug bottles and pots, instruments stained with tissue intoxicants or substances secreted from patients treated with chemicals (Appendix 2 to this Regulation). d) Wastes containing heavy metals: mercury (from broken thermometers, blood pressure meters, wastes from dental treatment), cadimi (Cd (from batteries, accumulated batteries, lead (from lead-coated boards or material used to prevent X-rays from image diagnosis or X-ray treatment rooms). 3. Radioactive wastes: Radioactive wastes: include solid, liquid and gaseous ones, which are generated from diagnostic, therapeutic, research and production activities. The list of radioactive drugs and marked compounds used in diagnosis and therapy was promulgated together with decision No. 33/2006/QD-BYT of October 24, 2006, of the Minister of Health. 4. Pressure containers, which include oxygen, CO2 or gas cylinders, prone to cause fires and explosion when put on the fire 5. General wastes are those which do not contain contagious elements, hazardous chemicals, radioactive substances, inflammable or explosive elements, including: a) Garbage from patients’ rooms (excluding isolation wards). b) Wastes generated from medical activities such as glass bottles and pots, serum bottles, plastic materials, assorted plasters for broken bone cast, which are not stained with blood, biological fluids and hazardous chemicals. c) Wastes generated from administrative activities: papers, newspapers, documents, packing materials, cardboard boxes, plastic bags and film bags. 38 d) External wastes: leaves and garbage from external areas.

Chapter iii Standards of instruments and bags from containing and transporting solid wastes in medical establishments

Article 7. Color coding 1. Yellow for contagious wastes. 2. Black for hazardous chemical and radioactive wastes. 3. Green for ordinary wastes and small pressure cylinders. 4. White for recycled wastes.

Article 8. Waste bags 1. Yellow and black bags must be made of PE or PP, not PVC plastic. 2. Medical waste bags must be at least 0.1 mm thick and have sizes suitable to waste volume and the maximum volume of 0,1 m3. 3. The bag outside must be printed with a line at the 3/4 height of the bag and the phrase “KHONG DUOC DUNG QUA VACH NAY” (NOT CONTAINED ABOVE THIS LINE). 4. Waste bags must comply with the color system specified in Article 7 of this Regulation and be used for proper purposes.

Article 9. Sharp and pointed waste containers 1. Sharp and pointed waste containers must suit the final destruction methods. 2. Sharp and pointed waste containers must satisfy the following standards: a) Their walls and bottoms are hard enough so as not to be punctured. b) They can resist infiltration. c) They have proper sizes. d) They have lids which are easy to open and close. ®) Their mouths are big enough for putting sharp and pointed objects without push. e) The bag outside must be printed with a line at the 3/4 height of the bag and the phrase “KHONG DUOC DUNG QUA VACH NAY” (NOT CONTAINED ABOVE THIS LINE). g) They are in yellow. h) They have handles or are attached with a fixed system. i) The contained sharp and pointed objects do not fall outside upon transportation. 3. For medical establishment using injection needle-cutters, sharp and pointed waste containers must be made of metal or hard plastic, which can be usable and must constitute a part of the injection needle and syringe destroying machines or cutters. 39 4. For re-usable sharp and pointed waste plastic containers, before their re-use, they must be cleansed and disinfected under the medical instrument-disinfecting process. The disinfected plastic containers for re-use must retain all their original properties

Article 10. Waste bins a) To be made of high-density plastic with thick and hard bottoms or made of metal with pedal lids. Collection bins of 50 litters or larger should be wheeled. b) Yellow bins are used for gathering yellow waste bags and boxes. c) Black bins are used for gathering black waste bags. For radioactive wastes, bins must be made of metal. d) Green bins are used for gathering green waste bags. e) White bins are used for gathering white waste bags. f) Bin capacity depends on generated waste volumes, ranging from 10 liters to 250 liters. g) The bin’s outside must be printed with a signal line at the 3/4 height and with the phrase “KHONG DUOC DUNG QUA VACH NAY” (NOT CONTAINED ABOVE THIS LINE).

Article 11. Waste type symbols The outside of bags and bins storing assorted hazardous waste and to-be-recycle wastes must bear symbols indicating proper waste types (Appendix 3 to this Regulation, not printed herein): a) Yellow bags and bins storing contagious wastes display the symbol of biological hazard. b) Black bags and bins storing tissue-intoxicating wastes display the symbol of tissue intoxicants and the phrase “CHAT GAY DOC TE BAO” (RADIOACTIVE). c) Black bags and bins storing radioactive wastes display the symbol of radioactive substance and the phrase (RADIOACTIVE WASTES). d) White bags and bins storing to-be-recycled wastes display the symbol of recyclable wastes.

Article 12. Waste-carrying vehicles Vehicles carrying wastes must meet the standards of having walls, lids and tight bottoms, being convenient for loading and unloading wastes, for cleaning, cleansing and drying.

40 Chapter IV Classification, collection, transportation and storage of solid wastes at medical establishments

Article 13. Classification of solid wastes

1. Waste generators must classify wastes right at their sources. 2. Wastes must be stored in bags and bins with prescribed color codes and symbols.

Article 14. Collection of solid wastes in medical establishments 1. Waste bin locations. a) Departments and sections must clearly identify places for bins to store each type of medical waste; waste sources must have corresponding collection bins. b) Waste bin locations must have classification and collection instructions. c) Waste bins must be up to prescribed standards and cleaned daily. d) Clean bags for waste collection must be always available at places where wastes are generated for replacement of bags of the same kinds, already transported to temporary waste storage places of medical establishments. 2. Each type of waste must be gathered into collection tools according to the prescribed color code and affixed with labels or inscriptions on the outside of waste bags. 3. Hazardous medical wastes must not be stored together with general wastes. If hazardous medical wastes are accidentally stored together with general wastes, such waste mixtures must be treated and destroyed like hazardous medical wastes. 4. The waste volume in each bag is only 3/4 full, and then the bags must be tied up. 5. Collection frequency: Nurses or assigned employees shall collect hazardous medical wastes and general wastes from their sources to the concentrated waste places of departments at least once a day and when necessary. 6. Highly contagious wastes, before being collected to the concentrated waste places of medical establishments, must be preliminarily treated at their sources.

Article 15. Transportation of solid waste in medical establishments 1. Hazardous wastes and general wastes generated at departments/sections must be separately transported to the waste storage places of medical establishments at least once a day and when necessary. 2. Medical establishments must prescribe the waste transport routes and time. The transportation of wastes through patients’ areas and other clean zones must be avoided. 3. Waste bags must be closely tied up and transported by special vehicles; wastes and waste liquid must not be dropped en route and their strong smells must not be dispersed in the course of transportation.

Article 16. Solid waste storage in medical establishments 41 1. Hazardous medical wastes and general wastes must be stored in separate chambers. 2. Re-usable and recyclable wastes must be stored separately. 3. Waste storage places in medical establishments must satisfy the following conditions: a) Being at least 10 meters away from dining halls, patients’ room, public passages, and crowded places. b) Being accessible to waste-carrying vehicles from the outside. c) Waste storage houses must have roofs, protection fences, doors and locks and must not be intruded freely by animals, rodents or unconcerned persons. d) Their areas suit the volume of waste generated at medical establishments e) Having hand-washing facilities and protection devices for personnel, having cleansing tools and chemicals. f) Having culvert systems, walls and anti-seepage floors, being weel ventilated. g) Medical establishments are encouraged to store waste in cold houses. 4. Duration for hazardous medical waste storage in medical establishments. a) The duration for storage of hazardous wastes in medical establishments must not exceed 48 hours. b) The duration for waste storage in cold houses or boxes may reach 72 hours. c) Surgery wastes must be transported for daily burial or destruction. d) For medical establishments with a volume of less than 5 kg of medical waste a day, the collection frequency must be at least twice a week.

Chapter v

Transportation of solid medical wastes From medical establishments

Article 17. Transportation 1. Medical establishments shall sign contracts with establishments having the legal person status for transportation and destruction of wastes. Where there are no establishments with the legal person status for transportation and destruction of medical wastes in localities, medical establishments shall report such to local administration for solution. 2. Hazardous medical wastes must be transported by special vehicles meeting the requirements stated in Circular No. 12/2006/TT-BTNMT of December 26th 2006, of the Ministry of Natural Resources and Environment, guiding conditions for professional practice and procedures for making dossiers, registration, grant of practice licenses and hazardous waste management codes. 3. Hazardous medical wastes, before being transported to destruction places, must be packed in bins to avoid cracks of breaks en route.

42 4. Surgery wastes must be stored in two yellow bags, packed separately in bins or boxes closely tied up and displaying the phrase “chat thai giai phau” (SURGERY WASTES) before being transported for destruction.

Article 18. Dossiers on waste monitoring and transportation

Each medical establishments must establish a system of books to monitor the daily waste volume; keep records of hazardous medical wastes and general wastes carried for destruction, made according to a set form in Circular No 12/2006/TT-BTNMT dated December 26th 2006, of the Ministry of Natural Resources and Environment, guiding conditions for professional practice and procedures for making dossiers, registration, grant of practice licenses and hazardous waste management codes.

Chapter VI Solid medical waste treatment and destruction models and technologies

Article 19. Hazardous solid medical waste treatment and destruction models and the application thereof: 1. Hazardous solid medical waste treatment and destruction models include: a) Model 1: Concentrated hazardous medical waste treatment and destruction centers. b) Model 2: Hazardous medical waste treatment and destruction facilities for clusters of medical establishment. c) Model 3: On-spot treatment and destruction of hazardous solid medical waste. 2. Medical establishments shall base themselves on plans, geological elements, economic and environmental conditions to apply one of the medical waste treatment and destruction models specified in Clause 1 of this Article.

Article 20. Hazardous medical waste treatment and destruction technologies 1. The selection of hazardous medical waste treatment technologies must ensure environmental standards and satisfy the requirements of treaties to which Vietnam is a contracting party.

2. Hazardous medical waste treatment technologies include incineration in furnaces reaching environmental standards; hot-steam disinfection; microwave and other treatment technologies. The application of environment-friendly technologies is encouraged.

Article 21. Methods of preliminary treatment of highly contagious wastes 1. Highly contagious wastes must be safely treated near their sources. 2. Highly contagious wastes can be preliminarily treated by one of the following methods: 43 a) Chemical disinfection: highly contagious wastes are soaked in 1-2% cloramin B or 1- 2% Javel water for at least 30 minutes or other disinfectant chemicals under the use instructions of producers and regulations of the Health Ministry. b) Hot-steam disinfection: highly contagious wastes are put into disinfection steamers which are operated under producers’ instructions. c) Non-stop boiling for at least 15 minutes. 3. Highly contagious wastes, after being preliminarily treated, can be buried or wrapped in yellow plastic bags for mixture with contagious wastes. If these wastes are preliminarily treated by autoclave or microware methods or other modern technologies up to prescribed standards, they can be later treated like general wastes and be recycled.

Article 22. Contagious waste treatment and destruction methods 1. Contagious wastes can be treated and destroyed by one of the following methods: a) Autoclave disinfection b) Microwave disinfection c) Incineration d) Hygienic burial: Being only temporarily applied to medical establishments in mountain and midland areas where local standard hazardous medical waste treatment facilities are not yet available. The burial sites are designated by local administrations and approved by local environment management bodies. Burial pits must meet the requirements: being surrounded by fences, at least 100m away from water wells and residential houses; their bottoms are at least 1.5m below the surface water level, their mouths are above the ground and temporarily roofs against rain water, each waste layer must be covered by an earth layer of 10- 25 cm thick and the final earth layer must be 0.5m thick. Contagious wastes must not be buried together with general wastes. Contagious wastes must be disinfected before being buried. e) Where contagious wastes are treated by autoclave, microwave method or other modern technologies up to the prescribed standards, they can be later treated, recycled or destroyed like general wastes. 2. Sharp and pointed wastes: One of the following destruction methods can be applied: a) Incineration in special furnaces together with other contagious wastes. b) Direct burial in cement holes exclusively used for burial of sharp and pointed objects: the holes are built with concrete bottoms, walls and lids. 3. Surgery wastes: One of the following methods can be applied: a) The contagious waste treatment and destruction methods mentioned in Clause 1 of Article 22. b) They are wrapped in two yellow bags, packed in cases and buried in cemeteries. c) Burial in concrete pits with tight bottoms and lids.

Article 23. Chemical waste treatment and destruction methods 44 1. General methods for treatment and destruction of hazardous chemical wastes: a) Returning them to suppliers under contracts. b) Incinerating them in high blast furnaces. c) Destroying them by method of alkali neutralization or hydrolysis. d) Pre-burial Inertization: Mixing wastes with cement and a number of other materials in order to fasten hazardous substances in wastes. The mixture ratios will be as follows: 65% pharmaceutical, chemical wastes, 15% lime, 15% cement, 5% water. After a unique block is created, it is transported for burial. 2. One of the following methods can be applied to the treatment and destruction of pharmaceutical wastes: a) Incinerating them in furnaces, if any, together with contagious wastes. b) Burying them at hazardous waste burial sites c) Inertization. d) Liquid pharmaceutical wastes are diluted and discharged into waste water treatment systems of medical establishments. 3. One of the following methods can be applied to the treatment and destruction of tissue-intoxicating wastes: a) Returning them to suppliers under contracts. b) Incinerating them in high-temperature furnaces (Appendix 2: a number of tissue- intoxicating drugs frequently used in medical activities and the minimum temperature for destruction of tissue intoxicants).

c) Using a number of oxides such as KMnO2, H2SO4, etc. degrading tissue intoxicants into non-hazardous compounds. d) Inertization then burial at concentrated waste burial sites. 4. Treatment and destruction of wastes containing heavy metals: a) Returning them to producers for recovery of heavy metals. b) Destroying them at places for safe destruction of industrial wastes. c) If these two methods cannot be applied, the method of packing wastes tight in metal or high-density polyethylene cans or boxes, then adding fastening substances (cement, lime, sand), letting them dry and packing them tight, then discharging them to waste dumping sites.

Article 24. Radioactive waste treatment and destruction Medical establishments using radioactive substances and radioactive substance-related instruments or equipment must comply with current legal provisions on radiation safety.

Article 25. Pressure cylinder treatment and destruction One of the following methods can be applied: a) Returning them to producers. b) Re-using them. c) Burying them like pressure cylinders of small capacity.

45 Article 26. General solid waste treatment and destruction 1. Recycling, re-use a) The list of general wastes to be recycled or re-used complies with Appendix 4 to this Regulation. b) To-be-recycled general wastes must not contain contagious elements and hazardous chemicals affecting human health. c) Wastes allowed for recycling and re-use are only supplied to organizations or individuals licensed for such operation and having the function of recycling wastes. d) Medical establishments assign one unit to organize, inspect and strictly supervise the treatment of general wastes according to regulations for recycling and re-use. 2. Treatment and destruction: Burial at local waste burial sites.

Chapter IX Treatment of waste water and gaseous waste Article 27. General provisions on treatment of waste water 1. Each hospital must have a synchronous waste water collection and treatment system. 2. Those hospitals, which do not have waste water treatment systems, must build complete waste water treatment systems. 3. Those hospitals already having waste water treatment systems which are, however, out of order or have operated inefficiently, must repair and upgrade them for operation up to environmental standards. 4. Newly build hospitals must include waste water treatment systems into construction items approved by competent agencies. 5. Hospital waste water treatment technologies must satisfy environmental standards and conform to topographical conditions, investment, and transportation and maintenance costs. 6. Waste water treatment must be qualitatively examined periodically and waste water treatment dossiers must be kept.

Article 28. Waste water collection 1. Hospitals must have separate systems for collecting surface water and waste water from various departments, rooms. Waste water culvert systems must run underground or be covered with lids. 2. Waste water treatment systems must have mud-gathering tanks.

Article 29. Requirements on hospital waste water treatment systems 1. They are structured with an appropriate technological process for treatment of waste water up to environmental standards; 2. Their capacity suit the volume of hospitals’ waste water; 3. Waste water discharge gates must be convenient for inspection and supervision;

46 4. Mud discharged from waste water treatment systems must be managed like solid medical wastes. 5. Waste water treatment must be qualitatively inspected periodically. There must be books on management of operation and results of relevant quality inspection.

Article 30. Treatment of gaseous wastes 1. Laboratories, chemicals or pharmaceuticals storehouses must constructed with air ventilation systems and toxic gas-gathering cabinets up to the prescribed standards. 2. Equipment using toxic chemical gas must have systems for treating gas up to prescribed standards before it is discharged into environment. 3. Gas discharged from solid medical waste incinerators must be treated up to Vietnams’ environmental standards.

Chapter X Organization of implementation

Article 31. Responsibilities for management of medical wastes 1. Heads of medical establishments: a) To manage medical wastes from the time they are generated to the time they are finally destroyed. b) To possibly contract the transportation, treatment and destruction of medical wastes to organizations or individuals having the legal person status. c) To formulate plans on management of medical wastes and work out schemes for investment in and upgrading of infrastructure for management of their units’ medical wastes and submit them to competent authorities for approval. Investment projects on construction of infrastructure for medical waste treatment and destruction must comply with current regulations on management of capital construction investment. d) To purchase and supply adequate special means up to standards for the classification, collection, transportation and treatment of wastes; to coordinate with local environment bodies and waste treatment establishment in treating and destroying medical wastes according to regulations. e) To apply measures to reduce the volume of to-be-destroyed medical wastes through minimization, collection, recycling and re-use activities after they are treated according to regulations. 2. Directors of provincial/municipal Health Services shall manage and formulate plans on treatment of medical wastes in their respective localities and submit them to provincial/municipal People’s Committee presidents for consideration, approval and implementation organization. 3. Heads of medical establishments under the Health Ministry and heads of branches’ health sections shall manage, draw up plans on disposal of medical wastes of their

47 establishments and attached units, and submit them to the minister of the managing ministry for consideration, approval and implementation organization. 4. Bureaus, departments and the Inspectorate of the Health Ministry shall manage medical wastes according to their respective functions and tasks prescribed by the MoH.

Article 32. Training and Research 1. The Health Ministry shall formulate programs and documents for uniform application to medical establishments, incorporate medical waste management into training programs in medical and pharmaceutical schools, research into and apply modern technologies suitable to the treatment and destruction of medical wastes. 2. Medical establishments shall guide the implementation of the Regulation on management of medical wastes to their staff members and concerned subjects, guide patients and their families in classification of medical wastes according to regulations.

Article 33. Registering owners of waste sources and waste treatment Medical establishments shall register to be owners of waste sources and waste treatment under the guidance in Circular No. 12/2006/TT-BTNMT dated on Dec, 26th 2006, of the Ministry of Natural Resources and Environment, guiding conditions for professional practice and procedures for making dossiers, registration, grant of practice licenses and hazardous waste management codes.

Article 34. Fund 1. Medical establishments shall arrange funds for medical waste management. 2. Funds invested in the construction of infrastructure, operation and management of medical wastes come from the following sources: a) State budget: - Health non-business budget - Environmental protection non-business budget b) Capital sources of international organizations, foreign governments, non- governmental organizations. c) Other lawful capital sources. Minister of health Nguyen Quoc Trieu

48 Appendix 1

Hazardous chemical frequently used in medical activities

Formaldehyde Photochemical substances: Hydroquinone; Kali hydroxide; Silver; Glutaraldehyde Dissolvent: Halogen compounds: methylene chloride, chloroform, freons, trichloro ethylene vµ 1,1,1-trichloromethane Evaporating anesthetics: halothane (Fluothane), enflurane (Ethrane), isoflurane (Forane) Sans-halogen compounds: xylene, acetone, isopropanol, toluen, ethyl acetate, acetonitrile, benzene Oxite ethylene Chemical compounds: Phenol Grease Cleansing dissolvent Ethanol alcohol; methanol Acide

49 Appendix 2

Some tissues intoxicants frequently used in medical activities and minimum temperatures for destruction thereof

Drug Destruction temperature (oC) Asparaginase 800 Bleomycin 1000 Carboplatin 1000 Carmustine 800 Cisplatin 800 Cyclophosphamide 900 Cytarabine 1000 Dacarbazine 500 Dactinomycin 800 Daunorubicin 700 Doxorubicin 700 Epirubicin 700 Etoposide 1000 Fluorouracil 700 Idarubicin 700 Melphalan 500 Metrotrexate 1000 Mithramycin 1000 Mitomycin C 500 Mitozantrone 800 Mustine 800 Thiotepa 800 Vinblastine 1000 Vincristine 1000 Vindesine 1000

50 Appendix 3 Some symbols

Symbol of hazardous biological wastes:

Symbol of radioactive substance: (Black picture on red-floor picture)

Symbol of tissue intoxicants:

Symbol of recyclable wastes:

51 Appendix 4 List of wastes to be gathered for recycling

General waste materials neither stained with nor-containing hazardous elements (contagious element, hazardous chemicals, radioactive substances, tissue intoxicants), which are allowed to be collected for recycling, including: a) Plastic: - Plastic bottles containing solutions without hazardous chemicals, such as NaCl 0.9% solution, Bicarbonatenatri, ringer lactic, molecular paste solution, kidney filtering fluid and plastic bottles containing other non-hazardous solutions. - Other plastic materials not stained with hazardous; b) Glass: - Glass bottles containing solutions without hazardous elements - Glass ampoules containing injection drugs not containing hazardous elements; c) Paper: paper, newspapers, cardboard, cardboard boxes, drug boxes and paper materials. d) Metal: Metal materials not stained with hazardous elements.