Overview of the Management of Health Care Waste in the Who's Western Pacific Region WHO/WPRO Philippines Background The management of solid wastes in the Philippines, and in particular in Metro Manila, currently is undergoing several important changes. Two of the most important changes can be attributed to: 1) the signing of Republic Act No. 8749, also known as the Clean Air Act; and 2) the signing of Republic Act No. 9003 (Solid Waste Management Act). The Philippines has a large body of laws and regulations at the national and local levels that are pertinent to the management of health care wastes. As previously indicated, two of the most pertinent laws are: • Republic Act No. 8749 - An act providing for a comprehensive air pollution control policy and for other purposes (Clean Air Act) and which effectively bans the incineration of solid wastes (including health care wastes); and • Republic Act No. 9003 – An act providing for an ecological solid waste management program for other purposes (Solid Waste Management Act). This act, among other items, requires the promotion of recycling and composting. In Metropolitan Manila, the management of hospital waste used to be regulated by the Metro Manila Council' s Ordinance No. 16, S. 1991, amended by MMDA Regulation No. 98-008. However, in 2003 the MMDA requested that the Department of Health's Regional Office (National Capital Region or NCR) assume responsibility for the oversight of the waste management process in Metro Manila. Waste Characteristics and Current Waste Management Practices Based on the results of surveys conducted in 2002, in the year 2001 there were 2,068 hospitals in the country with a total number of 93,976 beds. Using an average waste generation, the authors of the report estimated that all of the hospitals in the country produced about 28 tons per day of biomedical waste. Using population projections, the authors then projected that in 2050, the country would have a total of 231,843 hospital beds, and the production of biomedical waste would increase to about 69.5 tons per day. According to the MMDA, there are approximately 3,730 health care facilities in the Metro Manila area (of which 1,509 are hospitals and clinics). Furthermore, the MMDA estimates that these facilities generate a total of 60 tons of waste each day. Approximately nine tons of wastes are considered infectious. These estimates have not been verified in the field. Thirteen facilities have their own incineration facilities. The MMDA's regulation required that hospitals provide four types of waste bags, which used to be identified individually as follows: • black trash bag: for collection of non-infectious dry waste, or non-biodegradable/non- compostable waste; December 2003 19 Overview of the Management of Health Care Waste in the Who's Western Pacific Region WHO/WPRO • green trash bag: for collection of non-infectious wet waste or biodegradable/compostable waste; • yellow trash bag: with 0.004 gauge for collection of dry and wet infectious and puncture- proof container covered with thick solution of lime; and • orange trash bags with trefoil sign: for collection of radioactive waste, which will be stored in the hospital until rendered inactive or disposed of in accordance with prescribed rules and regulation of the Philippine Nuclear Research Institute (PNRI). Furthermore, hospitals within Metro Manila were required to match the color of the plastic bag to the color of the storage receptacle to facilitate efficient collection. The MMDA's regulation also required that hospitals provide their own means of disposal: hospital incineration system, hospital enclosed burning pit, ground pits, and a sewage disposal system for body fluids from patients with infectious diseases. The regulation also allowed for the possibility of hospitals establishing a joint disposal system. A study conducted in 2003 and which included limited waste characterization analyses estimated that the Metro Manila area generates on the order of 47 tons of health care waste (hospitals and other health care facilities) each day, of which about 27 tons are infectious. Most institutions have established a waste management committee, but the committees do not seem to be active and do not meet on a regular basis. Food waste from kitchens (food preparation and residues) and in some cases residues from patients' diets are sold or given to private individuals for use as animal feed. A large percentage of health care institutions in the Metro Manila area practice segregation of waste at the point of generation and use the different bags as prescribed by the MMDA. However, according to those responsible for waste management, some members of the staff are not conscientious about proper segregation. Some of the health care establishments have adequate facilities for the storage of waste within their compound. The storage facilities are located away from critical areas such as patients' rooms and laboratories. Hospitals use various types of containers or receptacles for the temporary storage of waste (painted grease cans, plastic containers, and others). Collection of non-infectious waste is conducted on a room-to-room basis, either manually or by relying on a pushcart. The waste is transported to an isolated storage area for eventual treatment or disposal. Collection of pathological and infectious waste is carried out using separate receptacles equipped with a plastic liner. Some hospitals use puncture-proof containers. December 2003 20 Overview of the Management of Health Care Waste in the Who's Western Pacific Region WHO/WPRO Infectious waste is transported to onsite treatment facilities or to offsite treatment plants. Private entities provide collection and transport of infectious waste to some health care facilities in Metro Manila and the waste is transported to the private entities' facilities for treatment. Internal frequency of collection varies from once a day to once per shift. Removal of waste from the hospital premises typically is carried out on a daily basis. Some hospitals pre-treat liquid and solid waste prior to disposal using chemical disinfectants and utilize the "delay to decay" principle for the management of radioactive waste. Some hospitals use onsite incineration for the management of their infectious wastes and others in the Metro Manila area contract the services to private entities. As of July 2003, there were two types of privately owned plants providing disposal services to hospitals in Metropolitan Manila: one incinerator and one microwave. The facilities charged approximately 40 Pesos per kg of infectious waste collected and treated. In the case where onsite incinerators were used, the ashes were typically disposed of in pits dug in the facility premises (in July 2003, 1 US dollar was about equal to 50 Philippine pesos). About 5 years ago, the Department of Health acquired 25 incinerators and 36 disinfection units (microwave) for its hospitals. The capacity of the incinerators varies from 300 to 500 kg per day. The total cost of the project was about US$ 20 million and is being financed through a soft loan by the Austrian government. Some of the incineration units have not been operating due to pressure from the surrounding community or because of key components are broken. At the time of this writing, all of these incinerators should not be operational so that the institutions can be in compliance with the provisions of the Clean Air Act.
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