AUGUST 2013 This publication was made possible through the support of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under contract number GHH-I-00-07-00059-00, AIDS Support and Technical Assistance Resources (AIDSTAR-One) Project, Sector I, Task Order 1.

Uganda National Guidelines: Managing Healthcare Waste Generated from Safe Male Circumcision Procedures | i

Acronyms

ACP AIDS Control Programme

HCW health care waste

HCWM health care waste management

IP implementing partner

MoH Ministry of Health

NDA National Drug Authority

NEMA National Environmental Management Authority

PEPFAR U.S. President’s Emergency Plan for AIDS Relief

PHC primary health center

PMTCT prevention of mother-to-child transmission

POP persistent organic pollutants

SMC safe male circumcision

STI sexually transmitted infections

UAC AIDS Commission

UNBOS Uganda National Bureau of Standards

USG U.S. Government

WHO World Health Organization

ii | Uganda National Guidelines: Managing Healthcare Waste Generated from Safe Male Circumcision Procedures

Table of Contents

Acronyms ...... ii Preface ...... v 1.0 BACKGROUND ...... 1 1.1 HIV Situation in Uganda ...... 1 1.2 National Response to the Epidemic ...... 1 1.3 Male Circumcision ...... 1 1.4 Supply Chain Considerations ...... 2 1.5 Health Care Waste Management as a Challenge to Achieving Desired Targets ...... 3 2.0 GENERAL OVERVIEW OF HEALTH CARE WASTE MANAGEMENT ...... 4 2.1 Introduction ...... 4 2.2 Risks Caused by Poor Management of Health Care Wastes ...... 4 2.3 Basic Elements for Safe Management of Health Care Waste for PHC Centers ...... 5 2.3.1 Waste Minimization and Segregation ...... 6 2.3.2 Recommended Techniques for Treatment of Infectious Waste ...... 8 2.3.3 Storage and Transportation of Waste ...... 8 2.3.4 Final Disposal ...... 9 2.4 Roles and Responsibilities of Stakeholders ...... 10 3.0 GENERAL OVERVIEW OF HEALTH CARE WASTE MANAGEMENT ...... 12 3.1 Identifying SMC Waste Generation Points ...... 12 3.2 Mapping the Flow of HCW within the Health Facility or Outreach Site ...... 13 3.3 Considerations for All Streams of SMC Waste ...... 14 3.3.1 How to Select a Waste Handling Service Provider ...... 14 3.3.2 Segregating SMC Waste ...... 15 3.3.3 Treatment of SMC Waste Streams ...... 17 3.3.4 Decontamination and Disposal of Used Instruments ...... 18 3.3.5 Summary of Treatment and Disposal Methods for SMC Kit Components ...... 20 4.0 REFERENCES ...... 23 5.0 ANNEXES ...... 24 5.1 List of Health Facilities Participating in SMC Supported by IPs ...... 24 5.2 Laws and Regulations - Health Care Waste Management ...... 30 5.3 Estimated Volumes of Waste ...... 31 5.4 Managing HCW Using a Centralized System ...... 32 Uganda National Guidelines: Managing Healthcare Waste Generated from Safe Male Circumcision Procedures | iii

5.5 List of General Hospitals with Installed Incinerators (March 2013)...... 32 5.6 Licensed Waste Handling Service Providers (March 2013) ...... 33 5.7 Decontamination Process ...... 35 List of Figures Figure 1: Distribution of Health Facilities Providing SMC Services ...... 2 Figure 2: Critical Steps in Health Care Waste Management ...... 6 Figure 3: Colour-Coding for Waste Segregation ...... 6 Figure 4: Waste Segregation Chart ...... 7 Figure 5: Roles of Stakeholders ...... 10 Figure 6: SMC Health Facility Client Flow and Waste Generation ...... 12 Figure 7: Flow Chart for SMC Waste Generated at an Outreach Site ...... 13 Figure 8: Safe Male Circumcision Waste Segregation Chart ...... 16 Figure 9: Handling and Treatment of SMC Waste ...... 17 Figure 10: How to Decontaminate Instruments ...... 19 Figure 11: SMC Sites and HCWM Availability ...... 22 List of Tables Table 1: Elements for Safe Management of HCW for Primary Health Care Centers ...... 5 Table 2: Recommended Techniques for Treatment of Infectious Waste ...... 8 Table 3: Waste Treatment and Disposal Methods ...... 9 Table 4: Male Circumcision Kit Component Disposal Methods: Health Care Facility Level ...... 20 List of Boxes Box 1: A Minimum Package of Service for SMC ...... 3 Box 2 : Definitions ...... 4 Box 3: Key Messages ...... 11 Box 4: Criteria for Selecting a Waste Handling Service Provider ...... 14 Box 5: Waste Collection Supplies for SMC procedure ...... 15

iv | Uganda National Guidelines: Managing Healthcare Waste Generated from Safe Male Circumcision Procedures

Preface

These guidelines have been put together to guide health service providers when managing waste generated from safe male circumcision (SMC). The guidelines will go a long way in mitigating risks of exposure and subsequent transmission of infections to health service providers, patients, and the community. In addition, the guidelines will protect the environment against undesirable effects that can result from using less than optimal methods of waste disposal. The document provides guidance on management of SMC waste at both static and outreach service delivery points. It highlights that waste produced during SMC activities carries a high risk of infection if not managed properly. To avoid serious public health consequences and substantial environmental impact, it is essential to promote use of safe and reliable methods for handling and treating health care waste.

At a stakeholder`s meeting held 26-27 February 2013 at Central Inn Hotel , it was noted that different USG implementing partners who support scaling up of SMC in Uganda reported unsafe waste handling practices. The stakeholders recommended that the Ministry of Health urgently develop guidelines to be followed when handling increasing volumes of waste generated from SMC. We hope that these guidelines will help to fill the current information gap on specific issues related to handling waste generated from SMC. The wider scope of health care waste management (HCWM) in this document is reflected in the title “General Overview of Health Care Waste Management.” The Ministry of Health however, recommends that readers interested in understanding general management of HCW read the broader health workers’ guide, “Approaches to Health Care Waste Management,” developed by the Making Medical Injections Safer (MMIS) project.

These guidelines have been developed in consultation with government implementers at regional and district levels, health training institutions, USG implementing partners, and representatives from the private sector. The AIDSTAR-One Project, which is funded by PEPFAR through USAID, provided technical guidance throughout the process.

Dr. Isaac Ezati Ag. Director General of Health Services

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1.0 BACKGROUND

1.1 HIV Situation in Uganda

The population of Uganda is approximately 34 million people. The national HIV prevalence rate in the general population was initially estimated at 21% in the 1980s but dropped significantly over a 15-year period to 6.4% [1], although recent estimates show a slight increase to 7.3% [2]. Continuous assessment at sentinel sites shows stagnation in the prevalence with some sites registering a rise in the number of new cases [2]. Most of the new cases reportedly are occurring among couples in stable heterosexual relationships [2]. This changing trend in HIV prevalence calls for additional strategies as well as objective review of existing behavioral change models.

1.2 National Response to the Epidemic

Uganda’s strategic plan for HIV/AIDS control recommends several strategies for reducing the incidence of new cases of HIV in the population. Such strategies include: creating a high level of awareness among communities on the risk factors for HIV transmission; the ABC approach promoting abstinence, being faithful in relationships, and condom use; prevention of mother-to-child transmission of HIV (PMTCT); and disclosure of serostatus following successful counseling and testing. Using these strategies, the country set a target of preventing 165,000 new infections under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) [3].

1.3 Male Circumcision

Male circumcision is the process of removing all or part of the foreskin of the penis. It is a common surgical procedure worldwide that can be performed for medical, social, cultural, or religious reasons. Several sociological studies highlight the benefits of male circumcision [4, 5]. Studies have shown that male circumcision can interrupt transmission of HIV among men contracting the virus through heterosexual intercourse. Clinical trials done in various settings in sub-Saharan Africa found that male circumcision groups had over 60% reduction in HIV in South Africa and over 50% reduction in Uganda and Kenya [6-8]. Based on these studies, the World Health Organization (WHO) recommends safe male circumcision (SMC) as an additional strategy in the fight against HIV [9].

In 2010, the Ministry of Health (MoH) in Uganda under the AIDS Control Programme adopted a national SMC policy that recommends provision of voluntary circumcision services for all men. The programme targeted to reach 4.2 million men by extending SMC services to 1 million men annually from 2012-15. According to the Uganda AIDS Commission’s (UAC) annual performance review of the national HIV and AIDS strategic plan (2011-12), 380,000 men were circumcised by March 2012. According to the national SMC National Coordinator, the U.S. Government (USG) has provided funds and commodities to circumcise 750,000 men through PEPFAR.

In 2012, PEPFAR supported a total of 263 facilities providing SMC services in Uganda. In addition, there is commitment to reviewing the work of all implementing partners (IPs) to ensure that the services offered are of the highest medical standards. The goal is to provide quality services at a mix of facilities, including clinics, health centers, and hospitals as well as mobile sites. All PEPFAR partners in Uganda are accelerating their scale-up of SMC services in order to contribute to the national target of 1 million procedures in 2013—which will help Uganda to reach its national target of 4.2 million eligible men undergoing the procedure by 2015.

The map below illustrates the distribution of health facilities providing SMC services in Uganda through IPs. Annex 1 lists all SMC facilities by partner organization.

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Figure 1: Distribution of Health Facilities Providing SMC Services

1.4 Supply Chain Considerations

To provide safe male circumcision procedures, a minimum package of services is required (WHO, 2007). Because of the broad programme needs, supply chain issues carry significant planning implications, both in terms of matching demand with supply and making sure that financial resources are available to ensure a full supply of required supplies and commodities, including resources for managing resulting waste.

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Box 1: A Minimum Package of Services for SMC

1. HIV testing and counseling 2. Screening and treatment for sexually transmitted infections (STIs) 3. Condom provision and promotion 4. Counseling on risk reduction and safer sex

1.5 Health Care Waste Management as a Challenge to Achieving Desired Targets

Waste management is the collection, handling, treatment, transportation, processing, recycling or disposal, and monitoring of waste materials [10]. The term usually relates to materials produced by human activity, and is generally undertaken to reduce their effect on health, the environment, or aesthetics. Waste management is also carried out to recover resources. Waste management can involve solid, liquid, gaseous, or radioactive substances, with different methods and fields of expertise for each.

Despite the availability of many laws related to health care waste management (HCWM) in Uganda (Annex 2), unsafe waste management practices in health facilities continue to put health workers, patients, and communities at risk for injuries as well as potential exposure and subsequent transmission of HIV, hepatitis, and other blood-borne diseases. Scaling up safe male circumcision to 80% of eligible males in Uganda, especially while using single use disposable kits, will generate high quantities of hazardous waste. It is estimated that on average a single SMC procedure generates 0.5 kg of waste [11]. With a projected target of 1 million SMC procedures in 2013 alone, it is estimated that 500 tons of hazardous waste will be generated across Uganda. Of this, PEPFAR will generate an estimated 191 tons (Annex 3).

This additional volume of waste in settings without proper infrastructure for managing HCW will significantly add to the burden of HCWM at individual health facilities, and also to district leaders, USG implementing partners, and to the entire health sector.

Purpose of the manual: To provide guidance to USAID implementing partners (IPs) on how to prevent and

mitigate risks associated with unsafe management of the high quantities of waste generated from safe male circumcision procedures.

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2.0 GENERAL OVERVIEW OF HEALTH CARE WASTE MANAGEMENT

2.1 Introduction

Health care activities lead to the production of waste that may lead to adverse health effects. Most of this waste is not more dangerous than regular household waste. However, some types of HCW represent a higher risk to health.

Box 2: Definitions

Health Care Waste This is the total waste stream from health care service delivery or research (HCW) facilities and includes both potential risk and non-risk waste materials. Hazardous Health This is waste with a potential to cause harm to both humans and the environment Care Waste if exposed or improperly handled or disposed of. Approximately 20% of all HCW is estimated to be hazardous and 1% is estimated to be sharps waste.

Non-hazardous The largest component of HCW (80%) is non-hazardous waste. However, this can Waste cause a nuisance or create breeding sites of disease vectors like flies and rats. It includes domestic waste, office or compound sweepings and wrappings, and containers of medicines.

Infectious Has living organisms in it that are capable of causing disease. Pathological These are parts of the human body that are removed because they are diseased, usually for identifying the cause of disease. Sharps These are objects that can penetrate skin easily and include needle/syringes. Pharmaceuticals Related to manufacturing, dispensing, and disposing of unusable medicines and consumables.

2.2 Risks Caused by Poor Management of Health Care Wastes

Poor management of HCW causes serious risk to personnel, HCW handlers, patients, and the community. Sources of illness from infectious waste include injuries from used needles, reuse by other people, and diseases that may result from contact with this dangerous waste.

Occupational Risk During handling of waste, health care personnel and waste handlers (within and outside the health facility) can come into contact with this waste if it has not been packaged safely. Needle stick injuries arising from improperly stored needles and syringes may occur. At landfills or waste dumps, waste recyclers or scavengers may come in contact with infectious waste if the waste has been disposed of without prior segregation and treatment.

Risk to the Public The reuse of syringes by the general public represents a significant public health problem in developing countries. Worldwide, an estimated 10-20 million infections of hepatitis B, hepatitis C, and HIV occur annually from reuse of discarded syringes and needles without prior sterilization [12]. In Uganda, an injection safety study conducted in 2003 among 80 primary health care (PHC) facilities in ten randomly selected districts indicated a prevalence of reuse of needles and syringes of 19% [13].

Indirect Risks via the Environment As opposed to direct contact with HCW, waste can also contaminate the environment, water, air, or land and therefore can indirectly impact on health.

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When waste is disposed of in a pit that is not lined, the groundwater may become contaminated. The same water may be used as a source for drinking water.

Burning plastics with organic matter leads to production of toxic gases called persistent organic pollutants (POPs), such as dioxins. These gases are produced mainly when waste is burnt at low temperatures. Their toxic effects have been found to cause cancer among human beings.

If waste is burned or incinerated in an incinerator without emission control, the air may become contaminated by a large number of pollutants and cause serious illness in people who inhale this air. Alternatively, plant life that is important to human life may be destroyed. When choosing a treatment or disposal option, environmental friendliness is an important criterion.

Considering these health impacts, HCWM is an integral part of health care service delivery. Creating harm through inadequate waste management reduces the benefits of health care. Health care centers must be responsible for management of all waste they generate.

2.3 Basic Elements for Safe Management of Health Care Waste for PHC Centers

Table 1: Elements for Safe Management of HCW for PHC Centers

Comprehensive System Awareness and Training Selection of Options

 Assignment of focal person for waste  Awareness raising for all  Identification of available management staff about risks related to waste management and sharps and other infectious disposal resources  Allocation of sufficient resources (financial waste and human)  Choice of sustainable  Training of health workers management and disposal  Waste minimization, including purchasing regarding segregation options according to: policies & stock management practices practices - Affordability  Segregation of waste at point of  Training of waste handlers - Environmental generation: sharps, non-sharps, infectious regarding safe handling, friendliness - Efficiency waste, and non-infectious waste storage, and operation and - Workers’ safety maintenance of treatment  Implementation of safe handling, storage, - Social acceptability technologies transportation, treatment, and disposal

options.  Display of written guidelines and job aids for personnel  Tracking of waste production and destination

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2.3.1 Waste Minimization and Segregation

Figure 2: Critical Steps in Health Care Waste Management

Recommended Colour-Coding

Sharps waste can lead to accidental needle stick injury if not properly stored in a safety box, and infectious waste can lead to exposure to infectious fluids through abraded or intact skin. However, approximately 80% of HCW is non-infectious (domestic) and easy to handle or recycle or dispose of in a domestic waste pit. Domestic waste or non-infectious waste does not need special treatment, storage, or expensive methods of disposal. To prevent health risks and to increase efficiency and cost savings, waste must be segregated at the point of generation using colour-coded bins [14].

Figure 3: Colour-Coding for Waste Segregation

Yellow sharps Red = Highly Yellow = Infectious container = Sharps infectious waste waste waste only

Black = General Brown = waste (wet and dry pharmaceutical and waste may be chemical waste further segregated)

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Figure 4: Waste Segregation Chart

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2.3.2 Recommended Techniques for Treatment of Infectious Waste

Table 2: Recommended Techniques for Treatment of Infectious Waste

Recommended treatment technique

Steam High Burning and Chemical Thermal sterilization temperature low-temp disinfection inactivation Type of waste incineration incineration (autoclaving)

Isolation waste Highly Highly Not Not Recommended recommended recommended recommended recommended

Cultures and stocks of Highly Highly Not Not infectious agents Highly recommended recommended recommended recommended recommended and associated biologicals

Human blood Highly Highly Not Recommended Recommended and products recommended recommended recommended

Pathological Highly Highly Not Not Recommended waste recommended recommended recommended recommended

Contaminated Highly Highly Not Recommended Recommended sharps recommended recommended recommended

Carcasses and Highly Highly Not Not Not recommended body parts recommended recommended recommended recommended

Bedding Not Highly Recommended Recommended Not recommended recommended recommended

Blunt surgical Not Not Recommended Recommended Highly recommended instruments recommended recommended

2.3.3 Storage and Transportation of Waste

An appropriate waste storage area must be available until waste can be transported for disposal (or disposed of on-site). During storage, waste must remain segregated and in the appropriate colour-coded containers. Waste should be disposed of as soon as possible, but when stored, it must be kept away from reach of children, animals, and the general public. The storage area should also protect the waste from the elements, particularly rain. The storage area should be maintained clean and free of loose waste. Special transportation vehicles must be identified; transportation companies must be licensed to transport health care waste. Waste must be properly secured during transport to disposal sites in order to avoid spills and waste handler injury. It is important to clean the vessel or vehicle after transporting waste.

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2.3.4 Final Disposal

Table 3: Waste Treatment and Disposal Methods

Waste treatment and disposal methods Description Autoclave Steam treatment of waste at high temperature and pressure for sufficient amount of time for sterilization. Autoclave with shredding or grinding A metal chamber where steam is introduced at an elevated pressure so it reaches a saturation temperature and produces saturated steam. Incorporated into the design of the autoclave is a grinder or shredder, which reduces the size of the waste by shearing the material between knives or blades. The waste is then rendered unrecognizable. Disinfect with bleach, autoclave for Soak stainless steel instruments in a mixture of bleach and water. If reuse necessary, use a cleaning brush to remove organic material from the instruments’ surface. Once instruments are disinfected, and all organic material is removed, instruments are safe for transport to an autoclave for sterilization and subsequent reuse. Encapsulation Containers are filled three-quarters full with hazardous waste. Material such as cement mortar, clay, bituminous sand, or plastic foam is used to fill the container. When capping material is dry, the container is buried or landfilled. Microwave irradiation Waste is shredded, humidified, and irradiated with microwaves. Heat destroys microorganisms. Municipal landfill Municipal solid waste landfills (MSWLFs) are able to receive household waste, non-hazardous waste, industrial solid waste, and construction and demolition debris. Open air burning Burning of waste in or next to a pit where it will be buried. May need to add kerosene or similar fuel to maintain combustion. Not recommended as a permanent solution, but better than burying untreated. Propane fueled incinerator A mobile incinerator fueled by a replaceable propane tank. Double-chamber “pyrolitic” incineration A permanent furnace of masonry/concrete, refractory materials, and metal. Waste thermally decomposes in the first chamber, an oxygen- poor (pyrolitic) chamber that operates at 800-900 degrees centigrade. The second chamber, a post combustion chamber, burns the gases produced in the first chamber at 900-1200 degrees centigrade. Safe burying Burial of waste in a pit on the site. Access to the pit should be limited. Pit lined with clay, if available. Single chamber incinerator A permanent simple furnace of solid construction (e.g., concrete). Waste is placed on a fixed grate. Burning is maintained by the natural flow of air. Operating temperature reaches <300 degrees centigrade. May need to add kerosene or similar fuel to maintain combustion.

Source: EGSSAA. 2009. The African Bureau’s Environmental Guidelines for Small Scale Activities in Africa. (EGSSAA) Chapter 8. Washington, DC: USAID.

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2.4. Roles and Responsibilities of Stakeholders

Figure 5: Roles of Stakeholders

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Box 3: Key Messages

National regulations must be observed when planning and implementing waste treatment and disposal guidelines.

It is essential that every health facility develop a HCWM plan and designate a focal person and/or committee to coordinate its management.

Infectious waste must be treated properly to eliminate the potential hazards that this waste poses to the health of staff, clients, communities, and the environment.

All health care workers must receive orientation, continuous in-service training, and supportive supervision on health care waste management.

All health care facilities and settings have a responsibility to dispose of waste in a manner that poses minimal hazard to patients, visitors, health workers, and the community.

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3.0 PLANNING FOR WASTE GENERATED FROM SMC PROCEDURES

3.1 Identifying SMC Waste Generation Points

For planning purposes, it is important that each implementing partner fully understands the range of steps that a SMC client goes through during the safe male circumcision process. Figure 4 provides a brief summary of the steps. Since each step generates waste, it is important to plan for the management of waste at each individual service delivery point.

It is necessary to identify the commodities and supplies required to safely contain and, where appropriate, treat the generated waste. Such items include: waste bins, bin liners, sharps containers (safety boxes), and disinfectants. When a facility is running multiple similar service stations, effort should be made to plan for management of waste generated at each additional station.

Figure 6: SMC Health Facility Client Flow and Waste Generation

Key: Blue Service stations generate only ordinary waste; purple service stations generate ordinary, infectious and highly infectious waste; orange service stations generate ordinary, infectious, highly infectious, and sharps waste.

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3.2 Mapping the Flow of HCW within the Health Facility or Outreach Site Health Facility

Each SMC team should map the flow of HCW within the health facility. The flow will depend on the type of system that is being used for handling and disposing the waste. Waste segregation requirements are identified in 3.1 above, and Figure 5 will help the planning team to identify additional requirements needed to ensure safe handling of waste as it flows through the subsequent steps. In addition, Annex 5.4 provides an example of a waste flow system used by health facilities in eastern Uganda—a centralized waste transportation, treatment, and disposal system.

Outreach Sites

Outreach sites are located within the community at sites such as schools and churches. These sites lack facilities for conventional waste disposal, such as incinerators and placenta pits. Partners offering SMC procedures through outreach must consider what provisions must be made in order to properly collect then transport the waste generated.

Figure 7: Flow Chart for SMC Waste Generated at an Outreach Site

Non infectious Burn at site of Waste Waste segregation generation waste (paper) outreach

Infectious & Highly Infectious Yes waste Used disposable Disposable metal instruments (metal) instruments? No

Infectious and highly Disinfect with sodium infectious waste hypo chloride

Put sharps in safety box /Double bag other waste and seal

Temporary storage

Transport to health facility Transport to near to Yes Human No near by HC with parts for further management placenta pit (foreskin)

yes Glass, No Autoclave metal, incinerate Dispose of Human parts in hand over to plastics placenta pit and place the used recycling plant liner in a red bag

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3.3 Considerations for All Streams of SMC Waste

3.3.1 How to Select a Waste Handling Service Provider

Health care waste must be transported and treated by a licensed provider. The criteria in Box 3 can help in selecting a reliable waste handling service provider.

Box 4: Criteria for Selecting a Waste Handling Service Provider

• An existing company with knowledge and skills in disposing of HCW.

• Recognition and current registration with regulatory bodies like National Environmental Management Authority (NEMA), National Drug Authority (NDA), and Uganda National Bureau of Standards (UNBOS).

• Good previous record in bio-safety and bio-security; the company should show good evidence that their employees are adequately protected while at work. Protection can include: provision of vaccinations, protective gear, health insurance, and insurance against accidents. Workers should be well trained in HCWM.

• Previous history of safely disposing large quantities of HCW using national recommended disposal methods.

• Previous history of safely disposing of pharmaceutical waste.

• Competence of the management team.

• A company that offers cost-effective rates.

Annex 5.6 provides a list of waste handling service providers approved by the National Environment Management Authority (NEMA).

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3.3.2 Segregating SMC Waste

To ensure both safety and cost-efficiency, it is essential to segregate SMC waste at the point of generation using recommended colour-coded waste bins with corresponding liners.

Box 5: Waste Collection Supplies for SMC procedure

• Black waste bin with corresponding liner • Safety box for sharps* • Three red containers with corresponding liners: o blunt surgical instruments o highly infectious waste generated from used items o the removed skin (pathological waste) • Brown container for immediate disposal of used pharmaceuticals

*For sharps waste, the used sharp should be placed into a proper sharps container immediately after use; do not temporarily rest the used sharp on any surface or in a kidney dish

Figures 6 and 7 summarize how SMC waste should be segregated and treated prior to disposal. Note that each category of waste will need differing treatment and disposal methods.

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Figure 8: SMC Waste Segregation Chart

SMC Waste Streams

Higly infectious Blunt Highly infectious pathological General Waste Sharp instruments instruments waste waste Pharmaceuticals

Paranet Gauze

Forceps Surgical gloves

Mosquito Packaging Gauze (12 ply) forceps materials (curved) (uncontaminated) Multi-purpose tray Sutures

Forceps Examination Non- Needle and (straight) Removed gloves Lignocaine contaminated attached syringe foreskin

plastic containers Mosquito Alcohol swabs Scalpel forceps

Cans/bottles for (straight) O-drape towel soft drinks and

water Needle holder Surgical tape and scissors plaster combo

Apron

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3.3.3 Treatment of SMC Waste Streams

Figure 9: Handling and Treatment of SMC Waste

Treatment of SMC Waste Streams

Higly infectious Sharp Blunt Highly infectious (pathological General Waste instruments instruments waste waste) Pharmaceuticals

Does not need Seal the sharps Disinfection Double bag when Seal and store in At static facility special treatment box when ¾ full ¾ full a secure dispose of tissue in temporary a placenta pit Seal the bag storage area immediately after when ¾ full completing daily

surgery (pour out from bin liner). Dispose of the used bin liner with

infectious waste

Store in a secure Store in a secure followed by Store in a secure If at an outreach Hand over to temporary temporary autoclaving temporary (non-static): double licensed HCW storage area storage area storage area bag and place in a handling service tightly closed rigid provider red container. Dispose of in a placenta pit at the nearest static health facility

Manage as metal scrap

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3.3.4 Decontamination and Disposal of Used Instruments

Before final disposal of disposable instruments (metal scrap), decontamination is required. Regardless of what final disposal method is chosen, this step is essential. Decontamination is achieved by presoaking and manually cleaning disposable non-sharp metal instruments in a sodium hypochlorite solution. After decontamination, the instruments must be thoroughly rinsed of all chemicals with potable water and dried before undergoing sterilization or transport. Figure 8 provides step by step information on the processes for mixing the sodium hypochlorite solution (disinfectant) and the cleaning procedure. It is important to note that hypochlorite is available in various solutions. Figure 10 provides information on how to produce a 0.5% solution for concentrations in the ranges of 3-5%, and 6-10%. For solutions outside this range, you can use the formula provided below to make the 0.5% solution for use during disinfection of equipment.

Formula for dilution of JIK (hypochlorite solution)

• Check the container for information on the concentration of the hypochlorite you have as provided by the manufacturer. Let us assume that this concentration is A%.

Concentration availed by the manufacturer (A %) - 1 = parts of water needed for dilution

Desired solution (0.5%)

If A = 6% then 6% = 6/100 = 0.06; 0.5% = 0.5 /100 = 0.005.

(A %) - 1 = 0.06 - 1 = 12-1 = 11 parts of water.

(0.5%) 0.005

This means that for every one cup of JIK with a concentration 6%, 11 cups of water are required to achieve the correct (0.5%) solution for use during disinfection. Please note that the number of cups of water needed will change depending on the hypochlorite concentration provided by the manufacturer.

Once the disposable metal instruments have been decontaminated, they can then be autoclaved to render them non- hazardous. Once autoclaved, the instruments can be transported in a vehicle that also carries usable products, provided the instruments are safely containerized and labeled correctly for identification purposes. They should be handled, packed, and stacked with care such that they cannot topple or break during transit, with all packaging and containers remaining wholly intact en route to their destination. For instruments that are disinfected but not autoclaved, a licensed company must be contracted to transport, autoclave, and then properly dispose of the instruments.

Internationally recognized methods of disposal for disposable non-sharp metal instruments include smelting (recycling) and encapsulation. Smelting (recycling) is the process of turning used materials (waste) into new products; the metal is melted down for reuse. Encapsulation involves immobilizing the metal instruments in a solid block within a plastic or steel drum. The drums are filled to 75% capacity with non-sharp metal instruments, and the remaining space is filled by pouring in a medium such as cement, plastic foam, or bituminous sand.

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6) 5.exnnAn igesimaed garnlee eS( garnlee igesimaed 5.exnnAn 6) sntumertnse Iatnmiaonteco Dt Iatnmiaonteco sntumertnse

)SMCS( metsy SnteanagemMn hai CyupplS hai SnteanagemMn metsy )SMCS( w Ho w : 01 erugiF ce: ruoS ce:

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3.3.5 Summary of Treatment and Disposal Methods for SMC Kit Components

Table 4: Male Circumcision Kit Component Disposal Methods: Health Care Facility Level

Compo- Disinfect Autoclave Auto- Micro- Encap- Safe High Single Open nent with with clave– wave sulation bury- temperature cham- air bleach, shredding– munici- irradia- ing (850oC ) ber– burn- auto- Municipal pal tion– incineration bury ing– clave Landfill landfill municipal –bury ashes ashes bury landfill or municipal or ashes landfill munici- pal landfill Plastic Most Most X X X Least contain- preferred preferred pre- er tray ferred O-drape Most Most X X X Least preferred preferred pre- ferred Surgical Most Most X X X Least crepe preferred preferred pre- paper ferred Surgical Most Most X X X Least paper preferred preferred preferr tape ed Plastic Most Most X X X Least apron preferred preferred pre- ferred Alcohol Most Most X X X Least swab preferred preferred pre- ferred Gauze Most Most X X X Least swab preferred preferred pre- ferred Paraffin Most Most X X X Least gauze preferred preferred pre- ferred Surgical Most Most X X X Least gloves preferred preferred pre- ferred Exam- Most Most X X X Least ination preferred preferred pre- gloves ferred Syringe Most X X X with preferred needle Injection Most X X X needle preferred Suture Most X X X with preferred needle Scalpel Most X with preferred handle

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Compo- Disinfect Autoclave Auto- Micro- Encap- Safe High Single Open nent with with clave– wave sulation bury- temperature cham- air bleach, shredding– munici- irradia- ing (850oC ) ber– burn- auto- Municipal pal tion– incineration bury ing– clave Landfill landfill municipal –bury ashes ashes bury landfill or municipal or ashes landfill munici- pal landfill Needle Most X X X holder preferred Suture Most X X X scissors preferred Circum- Most X X X cision preferred forceps, haemo- static Mosqui- Most X X X to preferred clamp, straight Mosqui- Most X X X to preferred clamp, curved Plastic Most X X X X X forceps preferred Tissue Most X X X waste preferred

Note: After successful autoclaving, reusable stainless steel instruments can be centrally collected and reallocated to hospitals and health care facilities in need of this instrumentation.

Single use instruments should be handed to licensed vendors dealing in steel re-processing.

Key: [X] Can be used as alternative option

21 | Uganda National Guidelines: Managing Healthcare Waste Generated from Safe Male Circumcision Procedures

Figure 11: SMC Sites and HCWM Availability

22 | Uganda National Guidelines: Managing Healthcare Waste Generated from Safe Male Circumcision Procedures

4.0 REFERENCES

1. Ministry of Health (MOH) [Uganda] and ORC Macro, Uganda HIV/AIDS Sero-behavioural Survey 2004-2005, 2006: Calverton, Maryland, USA: Ministry of Health and ORC Macro.

2. Uganda Bureau of Statistics (UBOS) and ICF International Inc, Uganda Demographic and Health Survey 2011, 2012, UBOS and Calverton, Maryland: ICF International Inc.; , Uganda.

3. Office of the United States Global AIDS Coordinator and PEPFAR, U.S. President’s Emergency Plan for AIDS Relief Five-Year Strategy, 2004. Washington, DC: PEPFAR.

4. Weiss, HA, Quigley, MA, and Hayes, RJ, Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS, 2000. 14(15): p. 2361-70.

5. Siegfried, N, et al. HIV and male circumcision—a systematic review with assessment of the quality of studies. Lancet Infectious Diseases, 2005. 5: p. 165-173.

6. Auvert, B, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Medicine 2(11): e298. 2005. 2(11): p. e298.

7. Wawer, MJ, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. The Lancet, 2009. 374(9685):p. 229-237.

8. Bailey, RC, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. The Lancet, 2007. 369: p. 643-56.

9. WHO/UNAIDS, WHO/UNAIDS Technical Consultation on Male Circumcision and HIV Prevention: Research Implications for Policy and Programming, Montreux, 6-8 March 2007. New data on male circumcision and HIV prevention: policy and programme implications. Accessed on 03/29/2013: http://www.who.int/hiv/pub/meetingreports/mc_montreux_march07/en/, 2007.

10. Waste management, “What is Waste Management?” accessed on 03-30-2013, www.docstoc.com/docs/6460637/ what_is_waste_management.html, 2009.

11. SCMS, Recommendation Options for the Disposal of Decontaminated Surgical Instruments, 2012.

12. Hutin, Yvan JF, Hauri, AM , and Armstrong, GL. Use of injections in healthcare settings worldwide, 2000: literature review and regional estimates. British Medical Journal, 2003; 327(7423): p.1075.

13. MoH [Uganda], A study on improvement of health care waste management in Uganda, 2003, Infrastructure Department, Kampala, Uganda.

14. MoH [Uganda], Approaches to Health Care Waste Management: Health Workers Guide, 2009, Making Medical Injections Safer (MMIS) Project: Kampala, Uganda.

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5.0 ANNEXES

Annex 5.1 List of Health Facilities Participating in SMC Supported by USG IPs

S/No. NAME OF FACILITY LEVEL OF FACILITY LOCATION OF THE FACILITY SPEAR UGANDA POLICE FORCE (UPF) 1. Kibuli Police Training School HCIII Kampala 2. Naguru Police Kampala HCIII Kampala 3. Kabalye Police Training HCIII 4. Police HCIII Masaka 5. Mbale Police Clinic Mbale 6. Gulu Police Clinic Gulu 7. Arua Police Clinic Arua UGANDA PRISONS SERVICES (UPS)

1. Muchsion Bay Hospital Kampala

2. Masaka Prison HCIII Masaka 3. Mbarara Prison HCIII Mbarara 4. Gulu Prison HCIII Gulu 5. Mbale Prison HCIII Mbale 6. Masindi Prison HCIII Masidi 7. Fortportal (Katojo) Prison Kabarole 8. Arua Prison Arua 9. Jinja Prison Jinja STAR-EC

1. Bugiri Hospital Bugiri

2. Kamuli Hospital Kamuli 3. Iganga Hospital Iganga 4. Kigandalo HC IV 5. Kityerera HC IV 6. Kiyunga HC IV 7. Nsinze HCIV 8. Bugono HC IV 9. Busesa HC IV 10. Bujinja HC IV 11. Namwendwa HCIV 12. Nankandulo HCIV 13. Kidera HCIV 14. Nankoma HCIV 15. Mayuge HCIII Mayuge 16. Namugalwe HCIII 17. Bulesa HCIII 18. Mway HCIII

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S/No. NAME OF FACILITY LEVEL OF FACILITY LOCATION OF THE FACILITY 19. Bumanya HCIV

STAR-E 1. Budaka HCIV Budaka 2. Kaderuna HCIII Budaka 3. Bududa Hospital Hospital Bududa 4. Bukwa HCIV Bukwa 5. Bukwa Hospital Hospital Bukwa 6. Bulumbi HCIII Busia 7. Dabani Hospital Hospital Busia 8. Busia HCIV Busia 9. Lumino Busia 10. Masafu Hospital Hospital Busia 11. Busolwe Hospital Hospital Butaleja 12. Nabigande HCIII Butaleja 13. Kapchorwa Hospital Hospital Kapchorwa 14. Kibuku HCIV Kibuku 15. Kapchorwa HCIV Kween 16. Bujambo HCIV Mbale 17. Busiu HCIV Mbale 18. Butebo HCIV Pallissa 19. Pallisa Hospital Hospital Pallissa 20. Budadiri Sironko 21. Buwasa HCIV Sironko 22. Muyembe HCIV Bulambuli HIPS 1. Scoul Buikwe 2. Mabonge Buikwe 3. Breweries Clinic Buikwe 4. Bulisa HCIV Bulisa 5. McHood Russels Clinic Bushenyi 6. Kyehoro- HC III Hoima 7. Kakira Sugar Hospital Jinja 8. Busirasgama (Rwenzori C) Kabarole 9. Mpanga Tea Kabarole 10. SIMLS Medical Center Kampala 11. Kitintale Medical Center Kampala 12. Old KAMPALA Hospital Kampala 13. Kyadondo Medical Center Kampala 14. Philomena Health Center Kampala 15. St Joseph's Clinic Wandegeya Kampala 16. Safe Guard Nursing Home Kampala 17. Uganda Baati Clinic Kampala 18. Mirembe Medical Care HC Kampala 25 | Uganda National Guidelines: Managing Healthcare Waste Generated from Safe Male Circumcision Procedures

S/No. NAME OF FACILITY LEVEL OF FACILITY LOCATION OF THE FACILITY 19. Community Health Plan Kampala 20. Hima Cement Kampala 21. KCCL Kasese 22. St Ambrose Kibale 23. EMESCO Kibale 24. New Format Clinc-l Kiboga 25. Kiruhura Engain Community Kiruhura 26. Family Health Resource Center Kiruhura 27. Nyero Health Center Kumi 28. Malata Tea Kyenjojo 29. Kigumba Rwenzori Tea Kyenjojo 30. Mwenge HCIII Kyenjojo 31. Ayira Nirango Home Lira 32. Lambu HCIII Masaka 33. Kinyara Sugar Works masindi 34. Double care Mpigi 35. People’s Medical Centre 36. Luwero Industries Ltd Nakasongola 37. Kyolera Community-Based Health Rakai 38. Executive Medical Centre Wakiso 39. St. Marys Medical Centre Wakiso 40. Wagagai Clinic Wakiso 41. SDA Wakiso 42. Boots Medical Wakiso 43. Uganda Clays Clinic Wakiso UEC 1. Aber Hospital 2. Kalongo Hospital 3. Kamwokya Christian Caring C it 4. Kasanga Primary Health Care 5. Nkozi Hospital 6. Nsambya home care 7. Nyenga Hospital 8. St Daniel Comboni Kyamuhunga 9. St Joseph Kitgum 10. St Mary's Lacor 11. 12. Virika Hospital UPMB

1. Amai Hospital 2. Azur HCIV Hoima 3. Bushenyi Medical Centre Bushenyi 4. Family Hope Centre - Kampala Kampala 26 | Uganda National Guidelines: Managing Healthcare Waste Generated from Safe Male Circumcision Procedures

S/No. NAME OF FACILITY LEVEL OF FACILITY LOCATION OF THE FACILITY 5. International Hospital - Kampala Kampala 6. Kabarole Hospital Kabarole 7. Kabwhowe Clinical R h t (KCRC) 8. Ruharo Hospital BAYLOR EASTERN REGION

1. Amuria HCIV Amuria

2. Bukedea HCIV Bukedea 3. Kaberamaido HCIV Kaberamaido 4. Katakwi HCIV Katakwi 5. Atutur Hospital Kumi 6. Mukongoro HIII Kumi 7. Nyero HCIII Kumi 8. Ngora hospital Ngora 9. Serere HCIV Serere 10. Princes Diana HCIV Soroti WEST NILE REGION 11. Omugo HCIV Arua 12. Oli HCIV Arua 13. Adumi HCIV Arua 14. Rhino Camp HCIV Arua 15. Koboko HCIV Koboko 16. Pakwach HCIV Nebbbi 17. Adjumani hospital Adjumani 18. Yumbe Hospital Yumbe 19. Maracha Hospital Maracha 20. Obongi HCIV Moyo 21. Midingo HCIV HCIV Moyo 22. Paidha HCIV Zombo AIC

1 Kabale Region Centre Kabale 2 Mbarara Region Centre Mbarara 3 Kampala Region Centre Kampala 4 Jinja Region Centre Jinja 5 Mbale Region Centre Mbale 6 Soroti Region Centre Soroti 7 Lira Region Centre Lira 8 Arua Region Centre Arua AMREF 1 Apac Hospital (Nu-Hites) Hospital Apac

2 Apwori (Nu-Hites) HCIII 3 Bukasa HCIII 4 HC Bukuya 27 | Uganda National Guidelines: Managing Healthcare Waste Generated from Safe Male Circumcision Procedures

S/No. NAME OF FACILITY LEVEL OF FACILITY LOCATION OF THE FACILITY 5 Bulondo HCIII 6 Buwambo HCIV 7 Bwendero HCIII 8 HCIII Bweyogere 9 Chawente (Nu-Hites) HCIII 10 Entebbe Hospital Hospital Entebbe 11 HCIII Kajjansi 12 Kalagala HCIV 13 Kalangala HCIV 14 Kasaala HCIII 15 Kasambya HCIII 16 HCIV 17 HCIII Kassanda 18 Kiganda HCIV Kiganda 19 Kigungu HCIII 20 Kinyogoga HCIII 21 Kiwoko Hospital Hospital 22 Kiyuni HCII 23 Kiziba HCIII 24 Kyabbagu HCIII 25 Kyantungo HCIII 26 Lulamba HCIII 27 Luwero HCIV Luwero 28 Mazinga HCIII 29 Mildmay Uganda 30 Hospital 31 Hospital 32 Mwera HCIV 33 Nabiswera HCIII 34 Nabweru HCIII 35 Nakaseke Hospital Hospital 36 Nakasongola HCIV Nakasongola 37 Nakasongola Military Hospital Hospital Nakasongola 38 Naluvule 39 HCIV Namayumba 40 Nambieso (Nu-Hites) HCIII 41 Ndejje HCIV Ndejje 42 Ngoma HCIV 43 Nyimbwa HCIV 44 Semuto HCIV 45 Teboke (Nu-Hites) HCIII 46 Wakiso HCIV Wakiso 47 Zirobwe HCIII

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S/No. NAME OF FACILITY LEVEL OF FACILITY LOCATION OF THE FACILITY STAR-SW 1 Bushenyi HCIII Bushenyi 2 Kyabujimbi HCIV Bushenyi 3 Kitgata Hospital Sheema 4 Kabwohe HCIV Sheema 5 Kisoro Hospital Kisoro 6 Mutorere Hospital Kisoro 7 Rubuguli Kisoro 8 Nsiika HCIV Buhweju 9 Rugazi HCIV Rubirizi 10 Kebisoni HCIV Rukungiri 11 Bugangari HCIV Rukungiri 12 Nyakibale Rukungiri 13 Rukungiri HCIV Rukungiri 14 Rwashamaire HCIV Ntugamo 15 Rubaare HCIV Ntungamo 16 Kitwe HCIV Ntungamo 17 Ntungamo 18 Mparo HCIV Kabale 19 Rubaya HCIV Kabale 20 Hamura HCIV Kabale 21 Kamwezi HCIV Kabale 22 Rugarama HCIV Kabale 23 Muko HCIV Kabale 24 Maziba HCIV Kabale 25 Kamukira HCIV Kabale 26 Mitooma HCIV Mitooma 27 Rushere Hospital Hospital Kiruhura 28 Kazo HCIV Kiruhura 29 Isongoro HCIV Ibanda 30 Ruhoko HCIV Ibanda 31 Ibanda Hospital Ibanda 32 Kambuga Hospital Kanungu 33 Kihihi HCIV Kanungu 34 Bwindi Hospital Kanungu 35 Kabuyanda HCIV Isingiro 36 Rwekobo HCIV Isingiro 37 Ruhiira HCIII Isingiro 38 Nshungyezi HCIII Isingiro 39 Nakivale HCIV Isingiro 40 Rubondo HCII Isingiro 41 Nyamuyanja HCIV Isingiro

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Summary of SMC Facilities (March 2013)

No Project No. Health Facilities 1 SPEAR Project 16 2 STAR-EC 19 3 STAR-E 22 4 HIPS Project 43 5 UCE 12 6 UPMB 8 7 BAYLOR 22 8 AIC 8 9 AMREF 47 10 STAR-SW 41 Total 238

As submitted by USAID and CDC implementing partners – March 2013

Annex 5.2 Laws and Regulations - Health Care Waste Management

 The Uganda Constitution (1995) under Article 17, “it is the duty of every citizen of Uganda to create and protect a clean environment,” Article 50 (2) stipulates controls as to what should be done in case of rule violations.

 The National Environment Act (1995) makes NEMA responsible for protection of the environment.

 The Water Act of 1995 – stipulates rights in water, planning for water use, control on use of Water Resources and Water Works. It prohibits pollution of water sources.

 The Land Act of 1998 protects land resources and stipulates regulations against misuse.

 The Public Health Act 2000 prohibits the existence of a nuisance on any premises and stipulates the penalties to defaulters.

 The Local Government Act and the Urban Authorities Acts 1997: - Gives the mandate of operation of local health units under the mandate of local government or urban authorities - Authorizes the local authorities to remove all waste from towns and municipal councils.

 Basel Convention 1992 (UN) signed by 100 nations – polluter pays principle. Controls trans-boundary movement of hazardous waste. Calls for environmentally sound disposal methods.

 Stockholm Convention (2001) - global treaty to protect human health and environment from persistent organic pollutants (POPs), specifically dioxins and furans. Commits all parties to reduce release of dioxins with goal of continued minimization and where feasible, ultimate elimination.

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Annex 5.3 Estimated Volumes of Waste

The table shows the estimated volumes of waste that will be generated by SMC IPs supported by PEPFAR in the year 2013.

Total number Number of Number of Number of Estimated volume projected SMC procedures procedures disposable kits (kg) of waste that procedures in (Static health (Outreach that will be used will be generated FY 2012/2013 facilities) settings) in the district

STAR-E 90,000 90,000 -- 90,000 45,000 STAR SW 100,420 80,336 20,084 90,378 50,210 NU-HITES 100,000 45,000 55,000 80,000 50,000

Uganda HIV/AIDS 21,011 3,200 17,811 22,000 10,506 in military project

HIPS 22,640 5,720 16,920 18,150 11,320

SPEAR 48,596 8,565 40,031 36,626 24,298

382,667 232,821 239,846 337,154 191,334 TOTAL

Note: It is estimated that each SMC procedure generates 0.5 kg of waste.

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Annex 5.4 Managing HCW Using a Centralized System

This is a sample flow chart of managing HCW using a privately contracted centralized transportation, treatment and disposal service.

Waste Double Loading on Weighing segregation bagging trucks Transporting and and containment recording

Treating waste, Invoicing Data Disposal including Off loading compilation disinfecting waste bins

Procurement of waste handling Distributing waste Receiving materials / handling payment Fueling of materials to the vehicles health facilities

Annex 5.5 List of General Hospitals with Installed Incinerators (March 2013)

Hospitals with Recently Installed Incinerators

REGIONAL GENERAL REGION HOSPITAL STATUS HOSPITALS STATUS

LOT 1 Mubende Installed Kigadi Installed Mityana Installed Kawolo Installed

Kayunga Installed

Fort Portal Installed Bundibugyo Installed

LOT 2 Masaka Installed Kalisizo Installed Lyantonde Installed Gombe Installed

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LOT 3 Hoima Being Installed Masindi Installed Kilyandongo Being Installed Nakaseke Installed

LOT 4 Lira Being Installed Kitgum Being Installed Anaka Being Installed

LOT 5 Mbarara March 2013 Itojo March 2013 Kabale March 2013 Kambuga March 2013 Kitagata March 2013

LOT 6 Moroto April 2013 Abim April 2013 Soroti April 2013 Kapchorwa April 2013 Mbale April 2013 Pallissa May -2013

Iganga May -2013

Tororo May -2013

LOT 7 Arua June 2013 Nebbi June 2013 Yumbe June 2013 Moyo June 2013

With permission from the MoH Infrastructure Department.

Annex 5.6 Licensed Waste Handling Service Providers (March 2013)

NO. LICENSEE ADDRESS/CONTACT TYPE OF WASTE HANDLED INFORMATION LICENSE TRANSPORTATION OF DOMESTIC / MUNICIPAL SOLID WASTE 1 T&D Cleaning Ltd Plot 16, Entebbe Kitoro Transportation Domestic waste Road P.O. Box 10146 Tel: 414669860 Mob: 0712 839237 2 Green Hope Uganda P.O Box 9244 Kampala Transportation Domestic waste Ltd Mobile:0772 486398 0712 776622 3 Kibanyi and Sons Plot14 Kanjokya Street Transportation Domestic waste Company Ltd P.O Box 7668 Kampala Tel: 0702 366790 0775 424855 4 JuaKaali Nakivubo Plot 54/56 William Street Transportation Domestic waste Shauriyako P.O. Box 30554 Kampala Association Tel: 0753895745 0782206802 5 Kikuubo Business P.O Box 511 Kampala Transportation Domestic Waste Community Ltd Tel: 0772 503765 6 Pilling Environment P.O Box 35641 Kampala Transportation Domestic waste Ltd Tel: 0782319778 0789 696781 33 | Uganda National Guidelines: Managing Healthcare Waste Generated from Safe Male Circumcision Procedures

NO. LICENSEE ADDRESS/CONTACT TYPE OF WASTE HANDLED INFORMATION LICENSE 7 Globe Clean Plot 318, Old Kira Rd, Transportation Domestic Waste services Kamwokya-Kampala

8 Koyinawo Trading P.O. Box 1341 Mbarara Transportation Domestic Waste Company Ltd Tel: 0752 422860 9 Eco Projects Ltd Plot133,Portbell Rd, Luzira Transportation Domestic waste P.O Box 4994 Kampala Tel: 0772332108 10 Bin-It Services Plot89,Kirard,Kamwokya Transportation Domestic waste P.O Box 1730 Kampala TRANSPORTATION OF INDUSTRIAL/HAZARDOUS 11 Array Services Ltd P.O Box 16125 Kampala Transportation Hazardous waste Tel: 0312517749, 0701840969 12 Specialised P. O Box 11022 Kampala Transportation Used oils Technical Tel: 0414510360 Services Ltd 13 Scrap Center (U) Mussajjallubwa Road, Off Transportation Scrap materials Ltd Rubaga Road. 0772436856 14 Epsilon (U) Ltd Plot 1413, Mbogo Road Transportation Hazardous wastes P.O. Box 12647 Kampala 0414 252 076 15 Green Label P.O Box 40303 Kampala. Transportation Hazardous waste Services Ltd Tel: 0414532235 16 BioWaste Plot 64, Kisanjufu, Transportation Hazardous Waste Management (U) Ltd Kyampisi, Mukono district. Tel: 0772482448 17 Maziba Holdings Ltd P.O.Box 5565, Kampala Transportation Scrap materials Contact person: Samuel Seguya, Tel: 0772588058 18 Eco Projects Ltd Plot 133, Portbellrd, Luzira Transportation Hazardous Waste P.O Box 4994 Kampala Tel: 0772332108 STORAGE OF HAZARDOUS WASTE 19 CNOOC Ug Ltd P.O. Box 3673 Kampala Storage Hazardous waste 20 Episilon (U) Ltd Plot 1413, Mbogo Road Storage Hazardous waste P.O. Box 12647 Kampala 0414 252 076 21 Hariss International Plot 83, Bombo Rd, Storage Hazardous waste Ltd Kawempe P.O. Box 24972 Kampala OWN/OPERATE A WASTE TREATMENT /DISPOSAL FACILITY 22 Quality Chemical P.O. Box 32871 Kampala Own/Operate a Industrial effluent Industries Ltd Tel:0776997647 Waste treatment facility (incinerator) 23 NLS Waste Services Plot 17 Martyrs Way Ntinda Own/Operate a Medical waste Ministers’ Village waste treatment Tel: 0772 400995 plant 24 Bio Waste Plot 64, Kisanjufu, Own/Operate a Medical waste

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NO. LICENSEE ADDRESS/CONTACT TYPE OF WASTE HANDLED INFORMATION LICENSE Kyampisi, Mukono district. waste treatment Tel: 0772482448 plant 25 Mukono Municipality P. O. Box 201 Mukono Katikolo Village, Compost/municipal waste Council Mukono disposal plant

26 Jinja Municipal P. O. Box 720 Jinja Masese Compost/municipal OTHER SERVICE PROVIDERS 27 Steel Rolling Mills Plot M-78 Tororo Road Own/operate a Steel and Metal Ltd P.O.Box2243 Jinja Metal scrap manufacturers Tel. 0434-120937 recycling plant (metal scrap) 0434-120978 srm@alarm-group 28 Bajo Glass Seeta off Bukerere Road Own/Operate a Glass recycling Tel 0774 794 611 Glass recycling plant Source: Adapted with permission from NEMA

Annex 5.7 Decontamination Process

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