Sustainable Capacity Development of Authorities responsible for waste management and relevant private companies in Morocco Nachhaltige Schulung und Fortbildung der Abfallverwaltungen und der Privatwirtschaft in Marokko

Assessment Phase

Dr. Ute Pieper Mr. Peder Bisbjerg ETLog Health Consulting GmbH Am Kanal 15 16766 Kremmen [email protected] [email protected]

Content 1.

Background............................................................................................................................ 1

2.

Structures of the Ministry of Health .................................................................................... 2

3.

Evaluation of private waste treatment company .............................................................. 3

4.

Evaluation of healthcare facilities ....................................................................................... 5

4.1.

General Hospital in Kemitra ............................................................................................ 5

4.2.

CHU Marrakesh ................................................................................................................ 7

4.2.1. 5.

Rapid OnSite Assessment (ROSA) questionnaires results ................................. 11

Capacity development ....................................................................................................... 15 Development of capacity building modules ................................................................ 15

5.1. 5.1.1.

Healthcare Facilities ................................................................................................... 15

5.1.2.

Private Transport and Treatment companies ......................................................... 17

6.

Workshop on healthcare Waste ....................................................................................... 18

7.

Way forward......................................................................................................................... 19

7.1.

Providing immediate capacity building measures ...................................................... 19

7.2.

Development of a “Centre of Excellence” at CHU in Marrakesh ............................. 19

7.3.

Further recommendations ............................................................................................. 21

8.

Annex.................................................................................................................................... 22

8.1.

Mission Schedule ............................................................................................................ 22

8.2.

ROSA Questionnaire ...................................................................................................... 24

8.3.

Workshop Schedule ....................................................................................................... 27

8.3.1.

Participation List .......................................................................................................... 28

8.3.2.

Presentation Peder Bisbjerg ..................................................................................... 29

8.3.3.

Presentation Dr. Ute Pieper ...................................................................................... 30

1. Background This project component aims for the reduction of nosocomial infection and infectious diseases among the healthcare staff and to improve the safety regarding healthcare waste management. Actual regulations on healthcare waste management will be the basis of the trainings focused on a “Centre of Excellence” at the University Hospital of Marrakesh. The objective of the contract are the accompanying training activities in order to develop, adopt and implement a transparent and efficient system for disposing of medical and pharmaceutical waste.

The following objectives were the focus during the first part of the project, the “Assessment phase”:  Preparation of assessment material  Evaluation of the relevant authority: o Ministry of Health (Min Santé, Rabat; Centre Anti Poisson, Rabat)  Evaluation of the following hospitals: o Kemitra General Hospital o CHU Marrakesh  Evaluation of a treatment and medical waste collection company: o T-Ozone (microwaving technology)  Participation at the inter-ministerial Working Group („Groupe de Pilotage“) and presentation of the main findings of the assessment.  Preparation of an evaluation report Based on the assessment phase, the training materials for the hospitals, authorities and treatment / transport companies will be developed. Next phase: In October 2013, the “Capacity Development Phase” of the project is planned, at which the developed training materials will be used to provide training for the hospitals, relevant authorities and external medical waste treatment and transport companies. The activity is envisaged in the week of 21st – 26th of October 2013.

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2. Structures of the Ministry of Health On the 10th of September, the representative Dr. Fauzi Rabii from the Ministry of Health was interviewed. The handling of medical waste at public healthcare facilities falls under the responsibility of the Directorate of Medical Facilities and Treatment Equipment. They are directly under the General Secretary. On regional level there are 16 regional Directorates and on provincial level 75 Directorates. Private facilities are NOT part of the responsibility of this Directorate. There are about 300 to 340 private facilities with about 7000 beds. The occupancy rate in these facilities is about 90 %. The MoH is supervising the healthcare facilities – irregularly and on request. Private facilities are also monitored but without a legal basis. The Strategy of the MoH 2009-2016 highlights the improvement of service quality and safety of patients. Beside the environment, norms, safety and hygiene – waste is an essential part of the strategy. The treatment of waste is intended to be outsourced as far as possible. The hospitals should contract external companies to treat their hazardous waste if feasible. Non-burn technologies are preferred. The healthcare facilities are receiving a booklet of general requirements which is beside relevant norms also the certified waste treatment companies are listed. Currently there are 4 companies listed: 1. T-Ozone 2. Athiza 3. Saiss 4. A new one which could not be named during the interview Hospitals have to hand in waste management reports covering quantities, classes and treatment methods.1 Nevertheless, the ministry is currently conducting a questionnaire survey to all healthcare facilities asking for amounts, treatment systems, capacities and training needs. The results are expected at the end of September 2013. A department of the directorate is also responsible for training measures. Once a year the hygienists of the hospitals receive a 3-day training on hygiene and infection control. Healthcare waste management is part of this training. The Ministry itself did not receive training on medical waste management. A commission of MoH and MoE are approving the treatment plants. A certification system is not established. Recommendations:  Insertion of private facilities into the scope of responsibilities of the MoH  Approval of the draft medical waste directive (arrêté)  Identification of clear responsibilities of MoH and MoE regarding the approval of healthcare waste treatment facilities and the transport of hazardous waste on public roads  Systematic approach on the training of medical waste management: o Waste management training of MoH o Review of waste management modules within the yearly hygienic training o Review of academic and university education modules  Regular onsite healthcare waste management inspections and monitoring 1

During the Workshop on 16 Seotember 2013 it was stated that the MoH only received data on healthcare waste when it was needed. The MoH will send a request to the hospitals when they want the information.

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3. Evaluation of private waste treatment company On the 11th of September the company T-Ozone was visited. The owner of the company Mrs. Lamiae Taymi-Lopez presented the onsite waste management. The company collects infectious waste and sharps, as well as pathological and pharmaceutical waste. In some hospitals, the internal collection and treatment of infectious and sharp waste is offered. Bins and bags are supplied as well. The infectious and sharp waste is treated at T-Ozone with microwaving technology (Ecosteril 125 manufactured in 2010), which was not operational during the visit as one shredder blade had to be renewed. The collected infectious waste bags are emptied into a loading bin and sharp waste containers are placed in the loading bin as well. The bin is automatically emptied into a hopper leading to a shredder. Below the shredder, the waste is stirred in a vessel before dropping into a screw conveyor. The screw transports the waste through a microwaving system where it is heated up to 90 – 105 °C before dropping into a vessel where the waste is heated up by an electrical heater to 120 – 140 °C for one hour. If the waste is not wet enough, water has to be added at the microwaving system in order to have sufficient humidity. After treatment, the waste is disposed of as normal household waste. 4 to 5 tons of waste are treated every day. Every 3 month the waste is tested by the Institute of Hygiene for Coliforms, Staphylococcus aureus, yeast and salmonella. T-Ozone charges the hospitals between 9 and 15 Dirham per kg including internal collection, bins, bags, transport, treatment and disposal. The company would prefer to solely collect and treat waste, avoiding the internal collection in hospitals, as the supervision of staff in the hospitals is difficult and problematic. The pharmaceutical waste is mainly collected from the pharmaceutical industry – only minor amounts come from the hospitals. The generator is providing documentation with the pharmaceutical classification, amounts and risk. In accordance with the risks, they are disposed at a normal landfill or are sent for incineration in the cement industry. All pharmaceuticals are opened sorted manually and shredded at the microwaving plant, in order to prevent re-usage. Plastic and Paper goes for recycling. T-Ozone has one 3,5 tons and one 14 tons truck to collect the waste. In accordance with the ADR, which has been signed by Morocco, infectious waste is classified as hazardous waste class 6.2 and certain requirements have to be fulfilled. T-Ozone received a certificate by a governmental committee established by MoH, MoE, Ministry of Interior and Ministry of Transport and Equipment. The certificate is signed by the Ministry of Health in 2011. As there is no ADR training institute available to train the driver on transporting hazardous waste, the ministry agreed on internal training conducted by T-Ozone. The transport document is divided into 3 parts: one for the generator, one for the transporter and one for the treatment facility. Only T-Ozone is signing. The document is not forwarded to an authority and it has not been requested to date.

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Flow chart of the microwaving system

Photo of the microwaving system (under repair)

Storage site for infectious waste

Pharmaceutical waste segregation

Recommendations:  Hygiene and Occupation safety: o Clear flow from dirty to clean (hazardous to non-hazardous) o Separate entrance for staff o Clear physical separation between the pharmaceutical treatment area and the workshop area o Improved working conditions in the pharmaceutical waste handling area  Transport approval by the ADR authority  ADR training for the drivers  Improve of waste disinfection tests in collaboration with the MoH and the hygiene institute  Improved fire safety

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4. Evaluation of healthcare facilities Part of the assessment has been site visits at two hospitals: the general hospital in Kemitra and the University Hospital in Marrakesh (CHU). Besides the gathering of general information, onsite visits at different wards and the waste storage and treatment has been undertaken. In the CHU Marrakesh also a short questionnaire “Rapid On-Site Assessment (ROSA)” was distributed, in order to receive information how the staff of the hospital is rating the healthcare waste management situation inside the hospital. From Kemitra Hospital, only 1 filled questionnaire could be collected, and has therefore not been analyzed. For each hospital recommendations are provided.

4.1. General Hospital in Kemitra Kemitra General Hospital has 418 beds with an occupancy rate of 82 % (343 beds). About 700 people are working in the hospital, of which 122 medical doctors, 229 nurses, 76 Administration and 200 medical students. The catchment area of the hospital is about 2 million people. The hospital is offering every standard service – but no cancer treatment. A responsible person for healthcare waste management has been appointed, it is the Hygiene representative. He is working closely with the infection control nurse and they are documenting the hazardous waste amounts for each department, preparing and activity plan and are conducting training sessions for the head nurses. Healthcare waste management is an integrative part of the hygiene and infection control program. The training sessions are conducted every Wednesday for 1 to 3 hours depending on a topic that is presented and discussed. It rarely happens that also medical doctors participate. Cleaners are not trained, as they are from an external company. The head nurses are responsible for the healthcare waste management in their wards. They are supposed to transfer the knowledge to the lower level nurses. The hospital has implemented a 3 bin system: 1. Household waste – grey color 2. Sharp waste – yellow color 3. Infectious waste and pharmaceutical waste – red color 4. Pathological waste The maternity ward is generating additionally pathological waste in form of placenta waste. About 30 children are born per day. It was reported that the hospital is generating between 100 and 120 kg of hazardous healthcare waste per day. Which results in about 0,32 kg per occupied bed. The hospital budget is about 2,7 billion Dirham from which 450.000 Dirham is designated for hygiene measures, including waste management. The household waste is transported by the hospital cleaning staff, stored at an interim storage place and collected by the municipality. Pathological waste is in general stored in a fridge – which was broken during the visit – and then collected by an external company (T-Ozone). Sharp waste, infectious waste and pharmaceutical waste is collected once a day by staff from an external waste treatment company and are shredded and disinfected onsite by an autoclaving system (ECODAS). During the visit, the waste was not treated since several days as the operator has quit the job and new operator was not sent yet.

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The system treats on 30 kg bag of waste at once. 3-4 charges are done every day, which results maximum 120 kg. Each cycle is 45 minutes. The maximum capacity of the plant has not been reached yet. The autoclaving system has been delivered by the government in 2005 – it was one of 21 plants within the country. The system needs about 60 kg of special grease every year – 1 kg is 310 Dirham (28 Euro/kg). The grinding knifes of the shredder and seals have to be replaced regularly. The opening mechanism of the system is a weak point. The following photos provide an impression of the waste management situation on-site:

Collection system in the wards

Segregation poster

Interim storage in the wards

Central storage of non-hazardous waste

Final storage before treatment

Autoclave & Shredder (Ecodas) at the hospital

Figure 1

Photo documentation for Kemitra General Hospital

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The following recommendations have been given:  Improvement of segregation quality: o By better segregation of non-hazardous waste like paper and plastics from the syringes etc. o by segregation of pharmaceutical waste including the packaging  Capacity Building o Additional training for doctors and other nurses than the head nurses o Training for cleaners and waste workers  Improvement of safety of treatment of waste by autoclaving o Usage of stronger bags for the treated waste, as the bags are punctured easily by the needles and glass. o Improvement of hygienic situation of the storage and treatment plant  Documentation and hardware o Development of training manuals and instruction posters o Elaborate an accident response and reporting system o Use of instruction posters and clear signage where healthcare waste is handled or stored o Functioning bag holders on trolleys  General Waste Storage o Fencing of the area in order to prevent the access of animals and strangers. o Provision of sufficient waste skips to store the waste safely o Provision of adequate gloves for the waste workers on the site.

4.2. CHU Marrakesh The Marrakech University Hospital Center (“CHU”) consists of four main units:    

Hôpital Ibn Tofail with 409 beds Hôpital Ibn Nafis, a psychiatric hospital with 220 beds Hôpital Mère-Enfant with 247 beds A cancer center with 82 beds

The CHU is expanding and will have a total of 1,200 beds by 2014. The occupancy rate is 110 to 120%. There are 1.800 employees, consisting of approximately 20% doctors, 60% nurses and 20% administrative staff. Two to three hygiene technicians are responsible for hygiene in each unit covering cleanliness, management of medical and pharmaceutical waste, general waste, contagious diseases and pests. These hygiene technicians work under their hospital director and the head nurse responsible for coordinating hygiene in all four hospitals. There are coordination meetings every four days. There is an internal reporting system for healthcare waste management covering characteristics and quantities, but no data is forwarded to the Ministry of Health, unless there is a request. The hospitals have clear instructions in case of accidents with healthcare waste (e.g. an accident wit sharps), covering accident reporting and sending the injured staff member to the occupational health doctor. The hygiene technicians provide training to all new arrivals, as well as on the job training for wards. They also train subcontractors’ staff. There is no set continuous training program, it is an on-demand systems. The hospital is interested in an elearning system where staff could be trained and take annual tests to ensure that their skill are up-to-date. The hospital is aspiring to some form of Green label, ISO 14001 or similar.

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The hospital segregated waste as follows:       

Non-hazardous waste o Household waste – clear bags o Paper and plastic waste only in the oncologic hospital Sharp waste – 5 liter yellow bins Infectious waste and pharmaceutical waste – red bags that are subsequently placed in 60 liter yellow bins Pathological waste like placenta are placed into a specific bin and collected by an external company Clothing from surgery is placed in blue bags and transported to landfill Cytotoxic waste - brown bags Radioactive waste o Low level waste is decayed, documented and then o High level waste (sources) is stored and collected by the supplier

The general flow of the waste of the hospital is shown in the following diagram: Healthcare Waste Non-haz. Waste

Hazardous Waste

Only Oncology

Household

Recycling

Infectious & Pharmaceutical

Sharps

Pathological

Radioactive

Cytotoxic

Low level

Disposal by municipality Figure 2

Recycling Company

Collection by external company

High level

Collection by Supplier

Current waste stream diagram at CHU Marrakesh

The maternity ward had 16.000 births in 2012; we were unable to visit and did not see how placenta waste was handled. It was reported that the hospital is generating between 600 kg of hazardous healthcare waste per day, this will soon be 800 kg per day. This is approximately 0,58 kg per occupied bed per day. The household waste is transported by the hospital cleaning staff, stored at an interim storage place and collected by the municipality. Parts of the hospital have a source separation system for plastic and cardboard, recovering about 700 kg in 2012.

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Cytotoxic waste is collected in brown bags and collected by an external company. Lowlevel radioactive waste is stored for decay, documented and then collected by an external company. The decay room is coated with lead, but not labeled and insufficiently equipped (waste is stored on the floor). Toilet waste from the cancer wards is stored in two underground tanks and left so that all radioactive materials can decay. Radioactive source Cobalt 60 which is categorized as high level waste (half-life time of 5,23 years), is stored separately and collected by a specified company (supplier). Cobalt 60 is used as radiation source for medical radiotherapy. The whole process is overseen by a physicist. The healthcare waste is collected from the hospital’s internal storage areas by an external contractor, transported by trolley to the central storage area. Here the waste is weighed and labeled with bar-code labels. From the storage, the healthcare waste is transported for final treatment in Casablanca and Tetouan.

Collection system in the wards

Segregation poster

Interim storage in the wards

Central storage of non-hazardous waste

Preparation of radioactive medication

Decay storage room

Figure 3

Photo documentation CHU Marrakesh

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The hospital center has purchased two Sterilwave 440 microwave treatment units from Bertin in France. These should both be operational within a few months. These can treat 30 kg per cycle and altogether about 1,2 tons per day. In the longer term, the hospital is considering accepting outside waste to help recover costs. There are enclosed healthcare waste and municipal waste storages adjacent to one of the microwave treatment units; the second unit is located at a distance of 500 meters. The operation of these units will be subcontracted to give the hospital more control over the workers. For practical reasons, the hospital has no system of clean and dirty areas. Instead, the separation is managed through time: After waste is collected from wards (e.g. before 7:00 am), cleaning is undertaken before “clean” activities take place (e.g. food is served after 8:00 am).

New microwaving system at the hospital

Test treatment product (microwaved and shredded)

The following improvements are recommended:  Improvement of segregation quality: o By better segregation of non-hazardous waste like paper and plastics from the syringes etc. o by separation of pharmaceutical waste including the packaging  Capacity Building o Development of training manuals and instruction posters o Initial basic training of all staff starting to work in the hospital. o Regular training for doctors and nurses in healthcare waste management o Establish training for cleaners o The hospital management is interested in an e-learning system  Hardware o Use of instruction posters and clear signage where HCW is handled or stored o Functioning bag holders on all trolleys o An autoclave is needed to disinfect micro cultures  Radioactive waste o The decay storage of low-level waste needs to be labeled and proper bins and shelves should be provided in order to improve the hygiene in the room.

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The following diagram outlines the recommended future waste streams of CHU Marrakesh: Healthcare Waste Non-haz. Waste

Recycling

Hazardous Waste

Radioactive

Household

Low level

Infectious

Sharps

High level

Pathological

Pharmaceutical

Expired medicine

Cytotoxic

Decay storage

Collection by Supplier

Recycling Company

Inhouse treatment (microwave)

External treatment (incinerator)

Disposal by municipality

Figure 4

Draft future waste stream diagram

4.2.1. Rapid On-Site Assessment (ROSA) questionnaires results The objective of ROSA is to ascertain the opinion of the waste generators on the existing waste management, to identify weak points and possible fields for action and change. ROSA is based on an easily answerable questionnaire (using multiple-choice questions) which includes positive as well as negative questions. There are three possible answers: Yes, No, Maybe/Sometimes. 17 completed questionnaires from CHU Marrakesh could be collected – therefore it is highlighted that the results are not representative nor statistic founded, but can provide an idea at which areas of the management of waste a closer look would be recommended. 11 questionnaires have been filled by the nursing staff, which is the biggest number of employees in the hospital. One head of department, 2 technicians and one cleaner handed in the questionnaire.

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The questionnaire itself was split into two parts: Part A: Anonymous questions about the interviewed person: Position in the hospital, gender, age, years of service spent in the institution Part B: Questions about the interviewees’ opinion on the waste management situation in the hospital main sectors, 6 questions per sector. Total of 24 questions are randomly spread. A point-based ranking system has been used for the evaluation of the questionnaire and the results are displayed for each participating merged together with the average (overall) rating obtained from three hospitals. 1, 3 or 5 points can be scored for each answer (5 being the maximum). A “traffic light” system (red, yellow, and green) is used for the evaluation of the questionnaires whereas “red” indicates an urgent need for change. A sample of the used questionnaire can be found in the annex. The overall results are shown in the figure below:

Figure 5

Overview of the results of the ROSA assessment

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The answers are sorted into the areas “General Healthcare Waste Management”, “Knowhow and awareness”, “Logistic and Maintenance” and “Supply, Equipment and Treatment.” It is shown that the participants are rating the first two areas mostly in the yellow category and the other two in the greenish one. The red area questions and green area questions are highlighted in the table below. A very good waste management situation is rated in the usage of color code system, separation of waste, collection interval of waste and the reliable supply with waste bins and bags. On the other side weak points are identified by the missing waste policy, providing of information, sufficient training and the safety of internal waste transport. 1. General Healthcare Waste Management 1) Monitoring of the waste management 2) Responsible person exist and is encouraging to segregate and recycle waste 3) A waste policy is existent 4) Standard operating Procedures (SOP) are existent 5) Accident report system is set up 6) Record keeping of waste streams 2. Know how / awareness 7) Information supply on waste management 8.) Continuous training (at least every 2 years) 9) Know-how in case of accident situation 10) Awareness on risk by the staff 11) Awareness on HCW risk by the management 12) General know-how of the staff

13) 14) 15) 16) 17) 18)

3. Logistic / maintenance Usage of color code system Separation of the waste Separate rooms for dirty and clean materials Collection interval of waste (>= daily) Maintenance of waste bins Safety of internal waste transportation

4. Supply / Equipment / Treatment 19) Sufficient supply of color coded bas 20) Sufficient supply of sharp containers 21) Sufficient supply of waste bins and bags 22) Existent of central waste interim storage places 23) Correct disposal of liquid chemicals 24) Environmental friendly treatment of infectious waste

Note: The results do not display the consultant findings, but they show how the users of the healthcare waste system evaluate the situation. High or low ratings of certain issues do not necessarily reflect the real situation, but they show the opinion of the user of a certain aspect.

Sharp Accidents The healthcare workers in the target hospitals of CHU Marrakesh are exposed to blood and other bodily fluids in the course of their work. Consequently, they are at risk of infection with blood-borne viruses including human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV). Occupational exposure to blood can be the result of a cutaneous injury. The most common form of occupational exposure to blood is needle-stick injuries that can most likely result in infections. According to the WHO 2, every year about 3 million (8.5%) healthcare workers out of 35 million healthcare workers worldwide are exposed to cutaneous injuries supported by bloodborne pathogens. The risk of infection caused by a needle-stick injury while treating an infected source patient is ~ 0.3% for HIV, 3% for hepatitis C and 6-30% for hepatitis B. A research in the domain of rapid assessment of the actual healthcare waste management situation was carried out to identify whether staff is at high risk from cutaneous injuries and to identify roughly the number of accidents with sharp items among the healthcare workers.

2

WORLD HEALTH ORGANISATION, AIDE-MEMOIRE for a strategy to protect healthcare workers against infections caused by bloodborne viruses

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Question of the ROSA questionnaire: In the last 12 months, I had accidents with sharp items (e.g. a needle – stick accident) ❒0

❒1

❒2

❒3

❒4

❒5

❒ >5 (Please tick the appropriate box)

As the participation of the survey is low, no reliable data on the needle stick risk in the hospital can be provided. Out of the 17 questionnaires, 2 persons reported needle stick injures during the previous year. One reported one needle stick and one 2 needle sticks. Although this is not a representative figure it is recommended to enhance the accident reporting in the hospital in order to receive realistic data and to improve the system where needed.

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5. Capacity development

The overall goal of the capacity development activities of the project is to have a set of materials ready to train healthcare staff, external service providers and relevant ministries in the core principles of proper healthcare waste management and to introduce advanced management processes. Therefore, the training is split into 2 parts: Based on the findings of the assessment and the first on-site training; a 2-day training will be organized for responsible persons on healthcare waste management, where the fundaments of safe and environmental friendly healthcare waste management are explained. This training targets the healthcare staff that is responsible for the management of waste in the facility. Additionally the service provider, such as the external transport companies and the treatment facilities which are handling hazardous waste from healthcare facilities will be trained for 1 day.

5.1. Development of capacity building modules The main objective of the training is to educate selected target groups on safe handling of healthcare waste and the implementation of existing legal framework into a standardized processes. The participants will learn how to plan, set up and independently run the waste management system of a health institution. After the training, the employees will know how to minimize nosocomial infections and occupational accidents related to healthcare waste. They will know how to react in case of emergencies and injuries and how to use basic waste management tools. Furthermore, the relevant staff from the ministries will receive more detailed information about the legal background, transport of hazardous waste on public roads, treatment of hazardous waste and monitoring of waste systems. The training package consists out of the tutorial, a compendium on healthcare waste with background information and aid materials and the power-point presentations (per training module about 25 to 35 slides). The modules will be presented by an experience Healthcare Waste trainer. The provided training shall include simulations, questions, exercises, and practical demonstrations to make the learning enjoyable and to encourage a high level of knowledge retention. The number of participants of each training should not exceed 25. The following training plans are draft working documents which have to be adapted and revised based on the gained information and experiences of the assessment.

5.1.1. Healthcare Facilities The training is targeting employees of the middle or higher management level of a healthcare institution (hospitals, but also larger clinics and laboratories) who are or will be directly or indirectly responsible for the monitoring and management of the safe handling of healthcare waste. In order to capture the complete logistic chain, the external service providers transporting and treating the hazardous healthcare waste should also be part of the training.

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Furthermore, representatives from relevant Ministries which are responsible for the supervision and monitoring of healthcare facilities are essential participants in the training. The tutorials are practical orientated and covers a wide range of topics, including:         

General information about healthcare waste management Definition, classification and generation rates of healthcare waste Relevant international laws and regulations Logistic aspects such as segregation, collection and storage of waste Management methods for different types of waste Responsibilities for healthcare waste management Treatment methods for different kind of waste as e.g. infectious waste Occupational safety aspects and first aid measures Transport of hazardous waste on public roads

Draft Training Schedule for Healthcare Facilities and Authorities: Schedule 08:30-09:00 09:00-09:15 09:15-10:00 10:00-10:30 10:30-10:45 10:45-11:30 11:30-11:45 11:45-12:15 12:15-13:15 13:15-14:00 14:00-14:45 15:00-15:45 15:45-16:00

Day 1 Welcome of Participants Introduction Legal Regulations & Classification Risks of Infectious Waste & Occupational Safety Break Healthcare Waste Segregation Workshop: Segregation Quiz Recycling of General Waste Lunch Transport and Storage of Healthcare Waste Sharps: Handling & Mitigation Measures Workshop “Sharp Incident” Summary

Schedule 09:00-09:15 09:15-10:00

Day 2 Review of Day 1 National regulations, guidelines and policies for Healthcare Waste The Healthcare Waste Officer (HWO) Break Convince the Director (HWO / Senior Doctor) On-site treatment and disposal of infectious waste Lunch Workshop “Snap Shot Audit in a local healthcare facility” Evaluation of the training & Handing over of certificates

10:00-10:30 10:30-10:45 10:45-11:30 11:30-12:15 12:15-13:15 13:15-15:30 15:30-16:00

Responsible ETLog ETLog ETLog ETLog All ETLog ETLog ETLog All

Responsible ETLog Ministry of Health & Ministry of Environment? ETLog Break All ETLog Lunch All All TBA

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5.1.2. Private Transport and Treatment companies This training incorporates material how to pack and transport infectious waste generated in healthcare facilities on public streets and treatment examples for the treatment of medical waste. The training bases on the national and international regulations on the treatment and transport of hazardous goods of Serbia and the European Agreement concerning the International Carriage of Dangerous Goods by Road (ADR) which governs transnational transport of hazardous materials. The participants will receive in-service training on these protections and will understand the need to use universal precautions to protect individuals, public and the environment. The tutorials are practical orientated and covers a wide range of topics, including:      

Classification and risks of healthcare waste Relevant international laws and regulations Logistic aspects such as segregation, collection and storage of waste Transport of hazardous waste on public roads Treatment methods for different kind of waste as e.g. infectious waste Occupational safety aspects and first aid measures

Draft Training Schedule for private treatment / transport companies and authorities: Schedule 08:30-09:00 09:00-09:45

Day 1 Welcome of Participants

09:45-10:30

Risks of medical and pharmaceutical waste & Occupational Safety Break Transport Requirements & Documentation Workshop: Transport, Documentation, Spillages Lunch On-Site treatment of infectious waste and testing procedures Existing treatment and transport solutions in Morocco

10:30 -10:45 10:45-11:30 11:30-12:15 12:15 - 13:15 13:15-14:00 14:00-16:00

16:00-16:30 16:30-17:00

Legal Regulations & Classification

Responsible ETLog & Ministries (MoH / MoE?) ETLog

ETLog ETLog / GIZ

ETLog External treatment & transport companies (TOzone, Athisa etc.)

Test Training Evaluation & Handing over of Certificates

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6. Workshop on healthcare Waste At the inter-ministerial working group meeting at the CHU Marrakesh on the 16th of September 46 representatives from the Ministry of Health, Ministry of Environment, the CHU Marrakesh and other healthcare facilities, Universities and staff from GIZ and ETLog participated. The detailed content and presentations of the Working Group meeting can be found in the annex:  Introduction and summary (GIZ - Mr. Mountassir)  Presentation “Green Hospital” – an example from Germany (IFAG - Mrs. Arnold)  Presentation about the assessment result of the mission (ETLog – Mr. Bisbjerg)  Video presentation about the SIDID program (GIZ – Mr. Mountassir)  Presentation about the National Environmental Plan on Medical waste (MoE – Mr. Ajir)  Capacity Development on medical and pharmaceutical waste for Morocco (ETLog – Dr. Pieper)  Planned activities – the “Center of Excellence” and implementation of activities from different stakeholder (ETLog – Dr. Pieper) After each session discussions of the participants took part.

Comments from the participants:  The CHU Marrakech still has major problems with its HCWM system. Waste is frequently poorly sorted, posing a risk to all within the hospital. This is the weakest performing area within the hospital and urgently needs to be improved.  Some waste leaving hospitals is poorly segregated at source and contains objects that should not be part of the waste stream (e.g. body parts) or that is in incorrect packaging (e.g. sharps that are not in containers).  What are the advantages and disadvantages of subcontracting the HCW treatment versus treating it on-site?  Hospitals outside the big cities lack skills and funds to correctly handle HCW.  It financially benefits a hospital to recycle cardboard and plastics; it is also good for the environment!  The CHU Marrakech is willing to perform HCWM training for healthcare facilities within the region. The CHU would work local authorities, as well as other hospitals, veterinarians, private clinics and dentists.  The CHU Marrakech wishes for an e-learning training program for its staff.  There are uncertainties about the risk of wastewater from hospitals. The sources, amounts and kind of risks needs to be identified in order to find suitable treatment solutions if necessary.

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7. Way forward

7.1. Providing immediate capacity building measures Like outlined in chapter 5 initial trainings for healthcare facilities, authorities and external medical treatment and transport companies will be conducted: A) 2 days basic training for responsible person for waste management in healthcare facilities and relevant authorities. It is envisaged conducting one training in Marrakesh and one in Rabat. B) 1 day training for manager and relevant logistic staff from medical waste treatment and transport companies and relevant authorities. It is envisaged to conduct the training in the week 21-26 of October. The international trainer will be Mr. Peder Bisbjerg.

7.2. Development of a “Centre of Excellence” at CHU in Marrakesh It is planned to establish a “center of excellence” at the University Hospital of Marrakesh, at which the already existing legal background on healthcare waste management in Morocco will be implemented and will therewith become a showcase for other facilities in this country. Beside the conduction of the already outlined training activities additional support for the hospital is foreseen, in order to upgrade and revise the existing capacity building system regarding healthcare waste management. Based on the idea of a center of excellence, a set of Standard Operating procedures (SOP) and a draft waste management plan will be developed in close cooperation with the hospital and the Ministries. These documents can be taken as model documents to be used by other facilities, supporting them to implement the existing legal framework of Morocco. Furthermore marketing and information material will be developed in order to improve the visibility of the improved healthcare waste management for the generators, cleaners and logistic staff as well as the public. Beside posters and labels, also the setup of an information movie will be supported, which can be shown on the TV screens all over the hospital. The activities should include the following: 1) Support of the hospital to establish the waste flow in accordance to the legal regulations and international infection prevention rules 2) Support of Capacity Development a. Upgrading and revise of the training plans and contents b. Inclusion of trainings for nurses, logistic staff and cleaners into the existing training system c. Set up of a brief “welcome” training on healthcare waste management for ALL staff starting to work in the hospital – this training could be part of a general infection control and hygiene information session 3) Documentation a. Support of the development of a praxis related waste handling guide and safety operation procedures b. Revision of the waste stream documentation system 4) Support on the development of marketing and visible Information tools a. Development of poster on segregation

19

b. Development of poster on awareness raising for medical staff c. Development of poster on awareness raising for the public d. Development of an information movie about the risks, waste classes and correct handling of medical waste and municipal waste including recycling opportunities The Healthcare Waste Guideline will be a set of information and process instructions in order to provide a standardized and practical guideline how to manage and handle this waste in healthcare facilities. For every different waste stream, particular risk and safety instructions for safe and environmental sound processing will be outlined. The complete logistic chain from segregation, collecting, transporting and storage - up to the treatment and disposal - is considered. The operational staff must be aware on the risks arising from the handling of different waste streams and should gain the knowledge how to handle the waste properly. The Healthcare Waste Guideline will summarize the general principles for the management of risk and non-hazardous Healthcare Waste and provides only basic information on the treatment of the different kind of waste. The Healthcare Waste Guideline will outline the different types of waste categories and provides process instructions for the specific waste classes. Furthermore, it includes information about the setup of a Healthcare Waste Management Plan, the role of a responsible person in a hospital and emergency procedures for incidents and accidents. The process instructions will follow strictly the logical logistic chain. Environmental health and occupational safety measures are included. The process instructions can be used as an addendum to the internal policy for Healthcare Waste Management. In the last chapter of the Guideline, coaching and training contents for capacity building among healthcare staff and waste handling personnel can be found. The Healthcare Waste Guideline is intended as a tool to help to implement management systems to fulfill these laws and by-laws. It will be based on national and international regulations. Poster and other information material will support the improvement measures of the hospital and is further more providing valuable information for the public. Sample posters and warning signs are shown below:

20

Figure 6

7.3.

Sample warning signs and posters

Further recommendations

Following the assessment of the current situation regarding healthcare waste management, the consultant recommends the following further activities in order to improve the quality and sustainability of the healthcare waste management system in the county: 1) Regulation and Documentation a. To approve the draft regulation on healthcare waste management b. To start the implementation of SIDID c. To develop a standardized Standard Operating Procedure for the handling of healthcare waste d. To develop a national strategy after a reliable assessment of the healthcare system in Morocco has been conducted. 2) Capacity Development a. Set up of a certification system for the responsible persons on healthcare waste management, which includes regular updates of the certificates. Only certified persons should be allowed to be appointed as responsible person. b. To update and revise the existing hygiene education materials in universities, institutes and medical schools in regard of safe and environmental friendly healthcare waste management. c. To update and revise the existing hygiene education materials at the Ministry of Health in regard of safe and environmental friendly healthcare waste management. d. To provide national standardized training and information materials for the responsible person for healthcare waste management in the healthcare facilities, which are regularly revised and updated. e. Study tour for relevant members of the ministries to Europe in order to learn about existing healthcare waste systems.

21

8. Annex

8.1. Mission Schedule

Mission Sur la gestion des déchets médicaux et pharmaceutiques Du 10 au 16.09.2013 Rabat Kenitra Témara Marrakech Mission

Partenaire

Date/Heur e

Lieu

Participant

Audit Gestion Interne

CHR Kénitra

10.09.2013 13h0017h00

Kénitra

Assessement Direction

Ministère de la santé Direction des Hôpitaux et Soins Ambulatoires,

11.09.2013 / 9h3012h30

Rabat

Mme Dr Bouhamidi Min Santé M Dr Rabii Min Santé Mme Dr Pieper ETLog M Bisbjerg ETLog M Mountassir GIZ-PGPE

Assessement TOZONE Traitement des déchets médicaux et Pharmaceutique s

TOZONE

11.09.2013 / 14h0017h00

Temara/AinAti q

Mme Dr Pieper ETLog M Bisbjerg ETLog Mme Taymi-Lopez TOZONE M Mountassir GIZ-PGPE

Audit Gestion Interne

CHU Marrakech

12.09.2013 Toute la journée

Marrakech

M Dr Belkadi CHU Marrakech Mme Dr Pieper ETLog M Bisbjerg ETLog M Mountassir PGPE M Dr Rabii Santé

CHR Kénitra M Dr Rabii Min Santé Mme Dr Pieper ETLog M Bisbjerg ETLog M Mountassir GIZ-PGPE

22

GIZMin

Mission

Partenaire

Date/Heur e

Lieu

Participant

Audit Gestion Interne

CHU Marrakech

13.09.2013 Toute la journée

Marrakech

M Dr Belkadi CHU Marrakech Mme Dr Pieper ETLog M Bisbjerg ETLog M Mountassir PGPE M Dr Rabii Santé

Résumé Audit

Atelier de travail et présentation des résultats

CHU Marrakech

      

CHU Marrakech Ministère de la Santé Département de l’environnement ETLog GIZ-PGPE MEDWEM TOZONE

1415.09.2013

16.09.2013

Marrakech

Marrakech

Mme Dr Pieper ETLog M Bisbjerg ETLog M Mountassir PGPE

GIZMin

GIZ-

Groupe de travail  Min Santé  Département de l’Environnement  CHU Marrakech  MEDWEM  ETLog  Mme Arnold  GIZ-PGPE  T-OZONE  ATHISA

23

8.2. ROSA Questionnaire

Questionnaire standardisé pour l'évaluation de la situation environnementale dans le secteur de la santé Ce questionnaire est donne en relation avec le projet "Programme de Gestion et de Protection de l'Environnement - PGPE" qui est mis en œuvre par le “Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). S'il vous plaît, remplissez ce questionnaire en répondant à toutes les questions. Vos réponses sont confidentielles et ne seront utilisées que pour comprendre les modes de penser et d'agir dans votre organisation. Je vous remercie!

A. Questions générales: 1. Nom de votre établissement de santé:

2. Date à laquelle le questionnaire a été rempli:

3. Votre position dans l'hôpital (veuillez cocher s'il vous plaît ) ❒ Assistant Médical ❒ Adjoint de Clinique ❒ Docteur ❒ Infirmière Junior ❒ Nettoyeur

❒ Infirmière

❒ Matrone

❒ Sagefemme

❒ Technicien ❒ Technicien Supérieur

❒

Administration

4. Votre sexe (veuillez cocher s'il vous plaît ) ❒ Femme ♀

❒ Homme ♂

5. Votre âge (veuillez cocher s'il vous plaît )

24

❒ 50

6. Le nombre d'années que vous avez travaillé ici (veuillez cocher s'il vous plaît ) ❒ 10 ans

B. Questions spécifiques sur les déchets hospitaliers:

Cochez une caisse pour montrer votre opinion sur la façon dont les déchets hospitaliers sont gères pour la plupart du temps

Peut-être ou parfois

Oui

Non

1

Je n'ai pas reçu suffisamment d'informations sur la façon de gérer les différents déchets à l'hôpital







2

Un système de code de couleurs pour le tri des déchets est appliqué régulièrement







3

Les poubelles sont toujours sales et ne sont pas nettoyés régulièrement







4

Je pense que les déchets de soins de santé pourraient être dangereux pour moi







5

La direction est consciente des problèmes de déchets de soins de santé et tente d'améliorer la situation







6

Quand un accident se produit, je dois remplir un formulaire de rapport d'accident







7

Personne ne recense les types et les quantités de déchets que sont générés







8

Je ne sais pas comment réagir correctement en cas d'accident par piqûre d'aiguille













9

Je pense qu'il y a suffisamment de poubelles disponibles

10

Les déchets infectieux sont traités d'une manière respectueuse de l'environnement







11

Il y a des procédures opératoires normalisées pour la gestion des déchets







12

Personne ne se sent responsable de la gestion des déchets et personne ne nous encourage à séparer ou recycler les déchets







13

Une procédure a été mis en place par la direction pour la de gestion des déchets de soins de santé et je sais où obtenir une copie







14

Ma dernière formation sur la gestion des déchets de soins de santé date de il y a plus que 2 ans







15

Les zones de stockage intermédiaires existent pour différents types de déchets (ordures ménagères, déchets infectieux, etc.)







16

Il n'y a jamais assez de sacs pour déchets disponibles dans la bonne couleur







17

Les produits chimiques liquides sont normalement éliminés par l’égout







25

18

Des boîtes ou récipients anti-crevaison pour la collecte des objets pointues ou tranchants (aiguilles, scalpels) ne sont pas souvent disponibles







19

Nous séparons les déchets en différents groupes de déchets (déchets ménagers, déchets infectieux, déchets pathologiques, objets tranchants.)







20

Les poubelles sont vidées de manière régulière, au moins une fois par jour







21

Au niveau des salles d’hôpital, nous utilisons des pièces séparées pour les matériaux sales et propres







22

Le personnel de l'hôpital ne sait pas comment gérer correctement les déchets







23

La façon dont les nettoyeurs collecte et transportent les déchets est sure et fiable







24

Le suivi de la gestion des déchets dans notre hôpital est effectué régulièrement







Dans les derniers 12 mois, j'ai eu ❒0

❒1

❒2

❒3

❒4

❒5

❒ >5

(veuillez cocher )

accidents avec des objets pointus (par exemple, un accident par piqûre d'aiguille)

26

8.3. Workshop Schedule

Atelier de Travail sur la Gestion des DMP 16 septembre 2013 CHU Marrakech Ordre du jour

09h00

Introduction et récapitulation M Mountassir

09h15 Présentation du projet IFAG Mainz / Groupe de travail « Pole scientifique » / Présentation « Green Hospital » Mme Arnold 09h45

Présentation des résultats de l’Assessment de Kénitra et Marrakech M Bisbjerg

10h15

Aperçu général sur le programme SIDID

10h35

Pause café

11h00

Présentation des TdR plan national de la gestion des DMP M Ajir

M Mountassir

11h30 Capacity Building et programme de formation : Contenu / groupe cible / la durée Les activités pour le projet pilot « CHU Marrakech » Mme Dr Pieper

12h00

Planification et implémentation des différentes lignes : projet pilote

CHU Marrakech / Niveau National / plan National Mme Dr Pieper 12h30

Discussion et recommandation

14h00

Déjeuner à Hotel Riad Mogador Agdal

27

8.3.1. Participation List

28

8.3.2. Presentation Peder Bisbjerg

29

8.3.3. Presentation Dr. Ute Pieper

30