University of Groningen
Potential for improving routine immunisation waste management using measles vaccination
campaign 2017 in Kebbi State, Nigeria
Oteri, Joseph; Bawa, Samuel; Christopher, Ezenwanne; Nsubuga, Peter; Dieng, Boubacar;
Braka, Fiona; Shuaib, Faisal
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Vaccine
DOI:
10.1016/j.vaccine.2020.12.060
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Oteri, J., Bawa, S., Christopher, E., Nsubuga, P., Dieng, B., Braka, F., & Shuaib, F. (2021). Potential for
improving routine immunisation waste management using measles vaccination campaign 2017 in Kebbi
State, Nigeria. Vaccine. https://doi.org/10.1016/j.vaccine.2020.12.060
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Potential for improving routine immunisation waste management using
measles vaccination campaign 2017 in Kebbi State, Nigeria
Joseph Oteri
a, Samuel Bawa
b,⇑, Ezenwanne Christopher
c, Peter Nsubuga
d, Boubacar Dieng
e, Fiona Braka
b,
Faisal Shuaib
a aNational Primary Health Care Development Agency, Abuja, Nigeria
bWorld Health Organization, Country Office, Abuja, Nigeria c
World Health Organization, Consultant, Kebbi State, Nigeria
d
Global Public Health Solutions, Atlanta, United States
e
Technical Assistance Consultant, Global Alliance for Vaccines and Immunisations, United States
a r t i c l e i n f o
Article history: Available online xxxx Keywords: Routine Immunisation Waste managementMeasles Supplemental activities
a b s t r a c t
Background: Immunisation activities generate sharps and infectious non-sharp waste that have harmful impact on the community and health care workers if disposed of improperly, leading to carbon mono oxide (CO) emissions which contribute to global warming. Health care waste is not effectively managed, especially in some developing countries. However, measles supplemental immunisation activities (SIAs) are used to strengthen routine immunisation system, including waste management. The waste manage-ment planning provides an opportunity to build capacity, mobilize resources and strengthen structures to ensure continual disposal of routine immunisation waste.
Methods: We reviewed the Kebbi State and LGA routine immunisation waste management situation and identified existing gaps; developed and implemented the plan for waste management, including strengthening routine immunisation waste management. The process included, reactivation of measles technical coordination committee, mobilizing resources for funding, and sustenance of immunisation waste management. The health care workforce was trained in safe immunisation waste disposal prac-tices.
Results: Immunisation waste management committee and the structure was established and strength-ened at the state and LGA levels and a total cost of 11,710.70 USD was expended on injection waste man-agement, with an average cost per injection of 0.01 USD. A total of 11,829 safety boxes were incinerated in the state, including those generated from routine immunisation sessions. Twenty-one Local Immunisation Officers, 1097 and 2192 team supervisors and healthcare worker vaccinators respectively were trained on immunisation waste disposal.
Conclusion: Immunisation waste management strategies protect healthcare workers and reduce the adverse impact on the environment. Improving key areas such as human and financial resources ensures accountability towards sustainable healthcare waste management.
Ó 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Immunisation activities generate sharps and infectious non-sharp waste that have harmful impact on the community and health care workers if disposed of improperly[1]. Safe waste man-agement involves the collection, storage, transportation and appro-priate disposal, with no harm to the provider, client and the
community or environment [2]. The World Health Organisation
(WHO), estimates that a person with one needle stick injury from a needle used on an infected patient has risks of 30%, 1.8%, and 0.3% of becoming infected with Hepatitis B Virus, Hepatitis C Virus, and HIV respectively[3].
Improper management of discarded needles and other sharps poses risks to healthcare workers, patients, waste handlers, waste pickers, and the general public. Additionally, uncontrolled and improper burning which leads to carbon mono oxide (CO) emis-sions can cause indirect health effects on the environment and contribute to global warming[4].
https://doi.org/10.1016/j.vaccine.2020.12.060
0264-410X/Ó 2021 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
⇑Corresponding author at: World Health Organization, Country Office, Abuja, Nigeria.
E-mail address:bawasa@who.int(S. Bawa).
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Please cite this article as: J. Oteri, S. Bawa, E. Christopher et al., Potential for improving routine immunisation waste management using measles vaccina-tion campaign 2017 in Kebbi State, Nigeria, Vaccine,https://doi.org/10.1016/j.vaccine.2020.12.060
Incineration of used needles and syringes is the recommended means for waste disposal for both routine immunisation services and mass supplemental immunisation campaigns and it has pro-ven to be practical and effective, especially in developing countries
[5]. General medical waste which includes administrative, packag-ing, and maintenance waste, usually represents the bulk of the medical waste, 75–90%; while hazardous waste constitutes
between 10 and 25%[6].
Despite the introduction of health care waste policies, some developing countries are still unable to effectively manage their medical waste due to poor management of available resources, and a lack of transparency in administration. For instance, in Nige-ria, neither the government nor hospital authorities pay proper attention to waste management as < 18% of the health institutions incinerate their waste in compliance with standard healthcare
waste management[7–9].
Nigeria has conducted several injectable Supplemental Immu-nisation Activities (SIAs) for measles, maternal neonatal tetanus, meningitis, and yellow fever) since 2011, and these opportunities are used to also strengthen routine immunisation systems,
includ-ing waste management practices[10]. Also, the planning process
for the conduct of the SIAs involves coordination with national and state governments and conducting advocacy for improving good practices, enhance sustainability and funding of immunisa-tion at all levels.
From the 2013/2014 Service Delivery Indicator (SDI) data col-lected from 2480 healthcare facilities in Nigeria, 21.0% of the health facilities burnt sharp HCW without any protection, and the computed risk indices for disposal of sharps by HCWs was high (0.2172) in Kebbi state[11]. All the incinerators installed in the state during the 2011 Men Afrivac campaigns remain non-functional. As a result, all injection waste generated in subsequent campaigns had to be centrally collected and transported to inciner-ation facilities in neighbouring Sokoto state for disposal. Due to the previous experience, the Measles Vaccination Campaign (MVC) 2017 recommended that immunisation wastes are to be disposed of only through incineration and preferably in the state. The waste management planning provided opportunity to build capacity, mobilized resources and strengthen structures to ensure continual disposal of routine immunisation waste according to standard guidelines.
This paper describes the engagement process, resources mobi-lized, and the capacities built to ensure sustainable health care waste management in Kebbi state.
2. Methods
2.1. Study area and population
Kebbi state has 21 local government areas (LGAs) with an esti-mated total population of 4,531,129 based on the projection from the 2006 census. As part of the 2017 MVC, Kebbi State had a target population of 848,174 children aged 9 – 59 months derived from the reviewed microplanning process applying the GIS technology. The periodic measles SIAs implementation is usually done according to guidelines and proposals approved by the interagency coordinating committee (ICC) through the National primary health care development agency (NPHCDA). According to the strategy, each State developed a detailed plan covering the thematic areas of the MVC 2017, including microplanning for targeted population, vaccine, personnel, logistics, and waste management requirement. The plan also included the identification of gaps in each aspect with mitigation measures recommended to alleviate the situation. The planning process also involved high-level advocacy to the State
Executive, through the Governors forum, which specifically advo-cated for the approval and release of counterpart funding to
sup-port the MVC, strengthen routine immunisation waste
management, adverse event following immunisation and commu-nity mobilization among others.
We reviewed the Kebbi State and LGA routine immunisation waste management situation and identified existing gaps based on the national guidelines for conducting planning and microplan-ning for measles supplemental campaigns. The state strategic immunisation plans, logistics and cold chain inventory repair plan for 2017, and the LGAs waste management documents, including the supervisory documents, were also reviewed. There was no ade-quate waste disposal plan and structure at the health facility and LGAs, with three –non-functional incinerators in the state.
We developed and implemented the plan for strengthening rou-tine immunisation waste management through the following processes:
-2.2. Reactivation of the Kebbi state measles technical coordinating committee (SMTCC)
The Kebbi State Measles Technical Coordinating Committee (KSMTCC), inaugurated to oversee the planning and implementa-tion of MVC 2017, was drawn from the State’s technical committee for immunisation. The membership of the committee includes the Director Primary Health Care (DPHC), State Immunisation Officer (SIO), State Cold Chain Officer (SCCO), the Disease Surveillance and Notification Officer (DSNO), and State Health Educator (SHE). The Executive Secretary, Kebbi State Primary Health Care Develop-ment Agency (ESPHCDA), serves as the chairman of the Committee. The National Measles Technical Coordinating Committee (NMTCC) maintained oversight to ensure accountability and timeliness in the conduct of planned activities. The SMTTC paid advocacy to the state governor on the reactivation, funding, and sustenance of immunization waste management.
The committee briefed the Kebbi State Commissioner of Health every week on the status of implementation of planned activities using the readiness assessment dashboard. The committee was replicated at the LGA level with the Directors of primary health care chairing the committee in each of the 21 LGAs of the State. 2.3. Establishment of Logistic/Waste management committee
The logistics and waste management committee conducted a situation analysis of the immunisation waste management of the state. Based on the findings, developed a waste management plan with a budget. The plan included repair and reinstallation of incin-erators, training of health workers, and waste managers that will support transportation and incineration of waste. Also, logistics for the movement of filled safety boxes from the vaccination posts to the holding point at the LGA, then to the incineration site was determined. Furthermore, the committee assessed the functional-ity of the incinerators in the state and requested the State Govern-ment to provide funds for the repairs and relocation of some of the incinerators in the State. The incinerator formerly installed in the Maternal Child Health Centre in Birnin Kebbi LGA was moved to the Kebbi State Medical Centre in Kalgo LGA.
The committee proposed to the State and LGA authorities for the institutionalization of the immunization waste disposal system in the state, which was accepted by the state and LGAs with bud-getary provision for routine immunization waste disposal. The logistic and transport of the immunisation waste was all provided by the state government. Safety boxes were provided centrally as part of the national MVC support to states.
J. Oteri, S. Bawa, E. Christopher et al. Vaccine xxx (xxxx) xxx
2.4. Training
The MVC training guideline has a comprehensive section for immunisation waste management. The entire health care work-force was trained on safe immunisation waste disposal practices. Twenty-one LGA waste managers were engaged to handle waste management issues at the LGA level and ensured that a secured dry room was dedicated to the storage of filled and marked safety boxes before transportation to incineration sites.
2.5. Supervision and handling of waste
Filled safety boxes from the vaccination posts were collected daily by the vaccinators and transported to the ward headquarters under the care of the ward focal person. The ward focal person col-lected for the entire ward and transports to the holding point at the LGA level, daily.
At the LGA level, the LGA Waste Manager is responsible for the storage of filled safety boxes and using a notebook, kept a record of the number of safety boxes collected, and a checklist to ensure that the staff adheres to the standard operating procedures. The filled safety boxes stored in the LGA holding points were moved to the incineration sites 1 week after completion of the MVC.
The filled safety boxes were transported using covered vehicles (i.e. vans, trucks, pick-up vehicles with tarpaulin) and were escorted by trained waste handlers and LGA waste managers with necessary personal protective equipment (i.e., safety boots, hand
gloves, and aprons).Fig. 1shows the flow of immunisation waste
from the vaccination posts (health facilities) to the incineration sites.
2.6. Data collection and analysis
Information was collected from advocacy and meeting reports of the waste management committee, waste management facility assessment, training conducted, and fund disbursed on repairs and reinstallation of incinerators, transportation, and incineration of immunisation waste in Kebbi state. They are presented in tables, figures, and maps.
3. Results
The SMTCC Kebbi state coordinated the planning of the MVC 2017. The series of meetings and advocacy to stakeholders pro-vided for the reactivation and strengthening of the routine immu-nisation waste management including capacity building and
budgetary provision. Previously there was no provision for strengthening waste management as waste generated during cam-paigns was centrally collected and transported to incineration site outside the state.
As shown inTable 1, the High-level advocacy on counterpart
funding of campaign activities to the Nigerian Governors Forum (NGF) was instrumental to securing the approval and release of counterpart fund to support the MVC, but also strengthened waste management, adverse event following immunisation, and commu-nity mobilization practices. Three incinerators were fully repaired, and one relocated to a new facility, 11 persons drawn from the State Environmental Health Office were trained on the use of the incinerators. Additionally, twenty-one Local Immunisation Offi-cers, 1097 team supervisors and 2192 healthcare worker vaccina-tors were trained on health care waste management.
Table 2 shows the result of the assessment of the functional state of the incinerators and types of repair carried out; ranging from roof replacement to the extension of the smoke chimney and fixing power supply sources.
Regarding expenditure on the waste management activities for MVC 2017, the State Government funded the activities, with a plan to continue the support for routine immunisation waste. The fund covered repairs of the incinerators, transport to designated inciner-ation site, personal protective equipment for waste handlers, and provision of diesel to power the incinerators. The total cost of 11710.70 USD was expended on injection waste management, with an average cost per injection of 0.01 USD, though the Federal Government supplied the safety box through the central budget for waste management.
Fig. 1. Flowchart showing the movement of Safety boxes from vaccination post to incineration sites (intra and post MVC implementation), Kebbi State, 2017.
Table 1
Immunization Health care waste system strengthening activities conducted, MVC 2017 Kebbi state.
Strategy Activity Outcome
Reactivation of the Kebbi state measles technical coordination committee (SMTCC) Inauguration of SMTCC. Weekly meeting to review campaign planned activities and dashboard
Coordination support and provision of oversight function for the MVC 2017. Counterpart fund for MVC 2017 activities fully released Logistic/Waste
management committee
Situation analysis of the immunisation waste management; assessment of the functionality of the incinerators in the state. Development of budgeted waste management plan; repairs of three and relocation of one incinerator in the state Training Training at the LGA,
Ward and vaccination team levels Twenty-one Local Immunisation Officers, 225 Waste managers, 1097, team supervisors and 2192 healthcare worker vaccinators were trained on health care waste
management Supervision and
Handling of Waste
Storage of filled safety boxes, record of number of safety boxes collected, checklist administered to ensure adherence to the standard operating procedures and transportation to the incineration sites A total number of 11,829 safety boxes were collected, transported and incinerated in the state
Note: The outcome of the activities in the thematic areas was extracted from observations, minutes of meetings, field visit, training and consultation of the coordination teams and stakeholders.
A total number of 10,973 safety boxes were sent to the state from the central level for MVC 2017, but a total number of 11,829 safety boxes was incinerated in the state, with the addition from routine immunisation sessions (Table 3).
Fig. 2shows the location of the incinerators in the state and the LGAs that send generated waste to respective sites for incineration. The holding points from the incineration site varied significantly among LGAs. A total of 1,423 safety boxes was incinerated in Argungu, 5,761 safety boxes were incinerated in Kalgo while 4,645 safety boxes were incinerated in Zuru.
4. Discussion
This study found that engaging policymakers through advocacy during the planning period to strengthen immunisation and waste management committees in the planning period not only helped to facilitate safe disposal of the immunisation wastes but the enhanced capacity building of key actors at the health facility level. Engagement with policymakers and health facility managers is a unique platform to share experiences and bring additional per-spective to immunization systems strengthening including sys-tems and structures for medical waste disposal. This underscores the values in the common assumptions that quality of [health] care is as much a policy and management endeavour, as it is a technical one. Experiences from [another context] appear to reinforce this understanding. For instance, an article by Bashir Abba et al, 2018,
found that political engagement was instrumental to successful disposal of all vials during tOPV to bOPV switch[12]. Oli et al., 2016 and Dicko M. et, al in 2000 emphasized the need for waste management committees to be formed wherever medical waste is generated, to facilitate coordination and oversight of infectious waste disposal. In a similar vein, Dicko M. et, al in 2000 also showed that crucial strategies involve planning at lower levels
with specific roles and effective monitoring tools [13,14]. The
resources mobilized was inputted to strengthen and reactivate the waste incineration system, which continued to function and handled the routine immunisation and other waste, even after completion of the SIAs, converse to previous rounds whereby the waste generated was transported to incineration site outside the state.
One major limitation was the community concerns and appre-hension about the existence of an incinerator in the municipal area. There was resistance from the community as they perceived, the emission from the incinerator would have a serious effect on the health of the inhabitants and the environment. To address this, the MVC 2017 resource provided the opportunity to relocate the incinerator, formerly in Birnin Kebbi LGA to the Kebbi State Medi-cal Centre in Kalgo LGA. The decision to site an incinerator in a municipal area should be cognizant born of public health consider-ations, as the emissions from the incinerators, present serious
health risks to the community [8,15]. Also, Ogbonna et al., in
2012, stated that the health impact of direct and indirect exposure to hazardous waste includes carcinogenic, mutagenic and terato-genic effects, reproductive and respiratory systems damage[16]. While effort is made at ensuring safe disposal of immunization waste, there should be conscious consideration for not exposing the environment and the communities around by conducting an environmental impact assessment of siting incinerators.
Also, we could not ascertain the number of safety boxes found and collected in different sites from other immunization activities (routine and previous SIAs). However, the waste management committees at the LGA level ensured that all waste brought and stored in LGA holding points were transported and appropriately incinerated.
Though some studies demonstrated exploiting the resources and visibility of SIAs to strengthen routine immunization, the con-cept has been put into practice only to a limited extent, and missed opportunities persist[17]. Bielik RJ et al, 2018, reported the oppor-tunity afforded by measles/rubella SIAs to strengthen the system, but unable to obtain information regarding the cost, impact, or
sus-Table 2
Kebbi State Incinerators’ Assessment and Repairs for MVC 2017 in Kebbi State. Location of Incinerator Number of LGAs clustered around
the Incinerator
Functionality Identified Faults Repairs Made
Zonal Health Office, Argungu 3 Not
functional
Excessive smoke Extend chimney up to 5 feet, filters and gasket
Troubleshoot Diesel for test running Not connected to the National
grid
Connect to National Grid
MCH, Birnin Kebbi 10 Not
functional
Leaking of the diesel tank, Welding of Diesel tank Not connected to National grid Connect to National Grid, service
wire
Troubleshoot Diesel for test running Excessive smoke Extend chimney up to 5 feet,
filters and gasket National Programme on Immunisation
(NPI) office, Zuru
8 Not
functional
Excessive smoke Extend chimney up to 5 feet, filters and gasket
Leaking roof Replacement of roofing sheet Faulty Generator attached to
the incinerator
Repair of Generators attached to the incinerator
Crack wall Fire cement
Table 3
Expenditure on Waste Management Activities for MVC 2017 in Kebbi State. Waste Management Activities Total
(USD) Cost of incinerator repairs 1371.00 Cost of transport of waste from ward to LGA holding sites 1875.00 Cost of transportation of waste from LGA to incineration site
including the cost of waste escorts
988.00 Cost of Personal Protective Equipment for waste handlers 139.00 Operational cost (cost of diesel) 1073.00 Cost of Safety boxes (Including Freight and handling charges) 6264.70
Total cost (USD) 11710.70
Average cost per Syringe (USD) 0.01 Total number of Safety boxes received in the state 10,983 Total number of Safety boxes Incinerated in the state 11,829 Nb: 2017 exchange rate of #308.05 to a US dollar.
J. Oteri, S. Bawa, E. Christopher et al. Vaccine xxx (xxxx) xxx
tainability of these activities[18]. But, we found that the MVC 2017 provided opportunity for organizing and strengthening routine immunization waste management, similar to report on waste man-agement disposal after a measles follow-up campaign in the
Philip-pines, 2004, where planning for the measles campaign
strengthened the need for centralized treatment of sharp waste among health-workers, for sustainable waste management prac-tices[19]. Programmatically, the conduct of the SIAs contributed to the establishment and strengthening of immunization waste, though there was no cost-effectiveness or quantifiable statistically significant outcomes.
5. Conclusion
The waste management strategies for immunization programs should protect healthcare workers and reduce the adverse impact on the environment. As the country implements the Nigerian Strat-egy for Immunisation and Primary Healthcare System Strengthen-ing, 2018 – 2028, government at all levels to cooperate in developing and instituting policies and procedures for the safe dis-posal of medical waste, especially for immunization activities[20]. Improving key areas such as personnel training, allocation of human and financial resources, and implementation of best prac-tices regarding handling, storage, and disposal of waste, will facil-itate accountability towards ensuring that proper healthcare waste management becomes sustainable. Furthermore, this study didn’t have an alternative outcome to compare with, we could not con-duct an economic evaluation for cost-effectiveness, hence the need to measure the impact and cost-effectiveness of using measles SIAs to strengthen routine immunization system.
Data statement
Data obtained for the write up was generated from the Measles vaccination campaign activities and not primarily for research. The data is accessed with the permission of the National primary Health care development agency and can be accessed through per-mission granted by them.
Funding
This research was part of the documentation of the best prac-tices from the 2017/18 Measles vaccination campaign and did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Joseph Oteri: Writing - review & editing, Validation. Samuel Bawa: Conceptualization, Methodology, Formal analysis, Writing - original draft, Writing - review & editing, Visualization. Ezenwanne Christopher: Conceptualization, Methodology, Writing -review & editing. Peter Nsubuga: Conceptualization, Methodology, Formal analysis, Writing - review & editing, Visualization. Bouba-car Dieng: Writing - review & editing, Validation. Fiona Braka: Conceptualization, Methodology, Formal analysis, Writing - origi-nal draft, Writing - review & editing, Visualization. Faisal Shuaib: Writing - review & editing, Validation.
Declaration of Competing Interest
The authors declare that they have no known competing finan-cial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
We wish to acknowledge the support of the Ministry of Health and the Primary Health Care Management Board, Kebbi state for their support to the success of the MVC 2017/18 and strengthening the routine waste management system in the state. Healthcare workers also supported the successful implementation of the Measles vaccination campaign 2017/18.
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