Handbook of Good Practices PDF

To all staff members, patients and visitors:

Don’t ask someone else to keep your health facility clean and hygienic

– always ask yourself what you can do to keep it clean, hygienic, and in a good functioning condition.

Imprint Handbook on Good Practices in Health Facilities prepared by GOPA-EPOS Consultants, Kolkata, within the Basic Health Project West Bengal – Planned Preventive Maintenance

The Basic Health Project West Bengal, which was jointly funded by the German Government, through the German Development Bank (KfW-Entwicklungsbank) and the Department of Health and Family Welfare, Govt. of West Bengal, was conducted by GOPA-EPOS Consultants of Bad Homburg, Germany, from 2001 to 2011, through its local team of experts, based in Kolkata, West Bengal.

Concept and text: Kiran Mukerji (email: [email protected]) Art work: Monaj Haque Kiran Mukerji

Printed by: Sarat Impressions Press, Kolkata

First Edition: 2011 (1,000 copies)

Note: Any part of this book can be reproduced and distributed for non-commercial use with proper acknowledgement.

Handbook on Good Practices in Health Facilities iii

Introduction In olden ages, people suffered from severe diseases and died, but the causes were not known. Today we know that most transmitted diseases can be prevented by taking relatively simple precautions and, above all, by maintaining clean and hygienic conditions. Statistics of the World Health Organisation (WHO) show that about 10% of the patients admitted to health facilities acquire infections during their stay there. These are caused by viral, bacterial and fungal pathogens, which exist in higher concentrations in health facilities than anywhere else. The hi gh rate of infection is because patients tend to have weaker immune systems or have open wounds, which are highly susceptible to infection. But not only patients are at risk – the medical and supporting staff as well as visitors are equally in danger of contracting infections. The principal methods of transmission of infections are through

• Direct person-to-person contacts, that is transmission from infected patients to non-infected patients, hospital staff, and visitors;

• Indirect transmission through unclean equipment and supplies, and improper procedures;

• Transmission through the air;

• Transmission through insects and animals. All these risks can be greatly minimised with very little extra effort and expense, and that is what this booklet attempts to show. It also attempts to show that attitudes a nd procedures will have to change in order to achieve clean and hygienic conditions in health facilities.

This handbook has been prepared for distribution within the State of West Bengal, but is of use anywhere in India, and is meant to address:

• Health officials at State and District levels

• Medical and auxiliary staff of the health facilities

• Patients and visitors

• The general public

• Educational institutions, beginning at primary school level The contents of this handbook are mainly based on personal observations by the author during frequent visits to rural health facilities in West Bengal and Gujarat over the past eight years, on discussions with national and international experts in the field of health care, and on the evaluation of hundreds of information sources from India and many other parts of the world. It is hoped that the handbook w ill generate a new awareness about how rural health facilities need to be managed and maintained, and how everyone can contribute to improving the conditions in these heath facilities, as well as mainta in a healthy lifes tyle. Changes will not happen overnight, but hopefully in the course of a few years, depending on how rapidly the information is disseminated. In order to make it available to as many pe ople as possible, it is being made available online, and users are encouraged to pass on the information to anyone interested.

Kiran Mukerji, GOPA-EPOS Consultants, Kolkata

September 2011

Handbook on Good Practices in Health Facilities v

Contents Page PART 1 The Health Facility 1

1.1 What kind of health facility do you want? 2

1.2 The Compound 10

1.3 Entrance, Registration / Waiting Area, Passages / Staircases 17

1.4 Consultation and Treatment rooms 21

1.5 Wards 23

1.6 Bathrooms and toilets, water supply and sewage disposal 27

1.7 Handling garbage and bio-medical waste 30

1.8 Improving interiors, exteriors and functioning of health facilities

41

1.9 Planned Preventive Maintenance (PPM) 53

Contents Page PART 2 Guidelines for the staff and users of health facilities 63

2.1 Guidelines for the medical and laboratory staff 64

2.2 Guidelines for cleaners of health facilities 69

2.3 Guidelines for the patients, their relatives and visitors 76

PART 3 General health guidelines 79

3.1 Guidelines for general health precautions 80

3.2 Avoiding diseases transmitted by insects and animals 87

3.3 Passing on the knowledge 94

Handbook on Good Practices in Health Facilities iv

vii

PART 1The Health Facility

PART 1The health facility

1

2 PART 1 – The Health Facility

PART 1 – The Health Facility 1.1 What kind of health facility do you want? Dear Reader, if you are ill and need to be treated in a health centre, or just need some medical advice or some medicine, where would you prefer to go to? Is this the environment you prefer? .....

1.1.1 Poorly maintained

health facilities

PART 1 – The Health Facility 3

..... or this environment?.

1.1.2 Well maintained

health facility (ref.

Fig. 1.8.13 for bird’s eye view)


Should the treatment room look like this? .....


treatment room


..... or like this?


treatment room


Should the wards look like this? .....


wards


..... or like this?


ward


Should the toilets look like this?

The above situations shown on the left pages are available …….

..... without cost ..... without effort

..... without thinking


toilets


..... or like this?

The above situations shown on the right pages are available …….

..... with little cost ..... with little effort

..... with a little common sense

So let us take a look at the various areas of health facilities and see what needs to be done to make them clean and hygienic, tidy and attractive.


toilet


1.2 The Compound Reaching the health facility A clearly identifiable signboard should be placed at the entrance to guide the patient or visitor to the health facility. If the compound is only reachable from a side road and difficult to find, a large signboard on the main road should show the way (Fig. 1.2.1).

1.2.1 Showing the way to a health facility

The entrance area

1.2.2 PHC entrance The compound wall or fence should be clean and without major damage; if there is an entrance gate, it should be in working condition. There should be a light at the entrance to guide the way at night. There should be a paved pathway from the gate to the building(s), to ensure accessibility even during rains (Fig. 1.2.2).


Garbage disposal In many health facilities, drainage gutters and many parts of the compound are misused for disposal of waste, therefore garbage bins (ref. Fig. 1.7.1 and 1.8.7) must be placed at easily accessible points and all staff members and visitors/patients must be urged to use them. They should be made easily identifiable and large enough, so that they do not overflow easily (1.2.3). Regular emptying is essential to avoid littering.

1.2.3 Use of garbage bin

Vegetation around buildings

1.2.4 Cutting away vegetation close to the building

Plants growing closer than 1 metre from the buildings should be cut (Fig. 1.2.4), as the roots can damage the building when the plants are big. Overhanging branches of trees should be cut 1 metre away from the building. There must also be at least a 1 metre (preferably 2 metres or 6 feet) space around the building to permit regular inspection of cracks and other damages, moisture development, termite attacks, etc. The space around the building must also be kept absolutely clean, so that no harmful insects and animals are attracted.


Appropriate vegetation Flowering plants and shady trees should be planted where appropriate to make the place attractive and inviting (Fig. 1.2.5), but they have to be taken care of from time to time. Benches made of wood, brick or concrete should be provided for waiting patients and visitors.

1.2.5 Shady tree and garden for waiting patients

Avoiding stagnant water

1.2.6 Water channelled to a garden

Ponds and open water tanks should be avoided, as they give rise to mosquito breeding. If there is an outdoor water supply, such as a hand pump (tube well), care must be taken to avoid excessive spillage and development of puddles, where mosquitoes can breed. The water should be channelled to a garden or soak pit (Fig. 1.2.6).


Water tanks

1.2.7 Tank cleaning

Water tanks raised on high platforms or placed on roofs should be visited regularly, at least once a month, to ensure that the lid is closed and there is no leakage or damage of any kind. The tanks should be emptied and cleaned at least twice a year to ensure clean water supplies (Fig. 1.2.7). When filling the tanks every day, wastage by overflowing water must be avoided at all costs – that is, if the float valve is defective, it must be repaired or replaced immediately to stop the inflow of excessive water.

Septic tanks and soak pits must be inspected regularly (Fig. 1.2.8). If necessary, the sludge must be removed to ensure proper functioning.

1.2.8 Inspecting a septic tank


Stray animals (cows, dogs, cats, pigs, goats, etc.) should not be allowed to enter the compound (Fig. 1.2.9 and 1.2.10).

1.2.9 Dog sitting in a treatment room

1.2.10 Doctor shooing away dogs

Drainage channels Channels for surface water drainage must be kept absolutely clean, so that the water can run off easily (Fig. 1.2.11). Any plants growing inside must be ripped out immediately and any garbage must be removed without delay to avoid standing water in which mosquitoes can breed. If the site has depressions in which water can accumulate, drainage channels leading to lower areas should be made to allow the water to run off.

1.2.11 Cleaning a drainage channel


Bio-medical waste disposal The disposal of bio-medical waste must be monitored very strictly (refer to Section 1.7). No bio-medical waste disposal areas should be visible from the entrance area, and no animals, children or unauthorised persons should be able to go there easily. Burning of bio-medical waste must be strictly prohibited (Fig. 1.2.12), because they produce toxic emissions, which contaminate the surroundings and cause severe health problems. Particularly the burning of plastic materials releases dioxins and furans into the air, causing cancer, immune system damage, reproductive and developmental problems. The residues of burnt bio-medical waste generally contain mercury and other heavy metal pollutants, such as lead, cadmium, arsenic, and chromium, which ultimately contaminate the soil, groundwater, plants, livestock, fish, etc. and are transmitted to humans through food and drinking water. This can cause reduced growth and development, cancer, irreversible organ and brain damage, nervous system damage, and in extreme cases, death. Outside toilets must be kept as clean as toilets inside the building. Generator rooms and pump rooms should be accessible from a motorable road or pathway. The keys to these rooms must always be easily available to the doctor or nurse on duty.

1.2.12 No burning of bio-medical waste Post mortem rooms should be placed away from the main building and easily accessible by a paved pathway. If necessary, some trees and bushes can shield the building from sight.


Undesirable plants Any plants growing on built structures, such as medical buildings, staff quarters, post mortem, generator or pump houses, water tanks, septic tanks, boundary walls, paved gutters and the like, must be ripped out as long as they are small (few inches or centimetres) in order to avoid damage by their roots. Ripping out small plants is done in a matter of seconds, without any effort and at no cost (Fig. 1.2.13).

1.2.13 Removing a small plant

1.2.14 Removing a large plant

Removing larger plants (Fig. 1.2.14), the roots of which have penetrated the roof or walls or floor of a building, can be very difficult and take a long time. Furthermore, repairing the damage caused by the plants may cost thousands of Rupees.


1.3 Entrance, Registration, Waiting Area, Passages, Staircases

Entrance The entrance to a health facility must always be clean and with sufficient natural lighting, but also with sufficient electric lights for the night. The floors should be cleaned with a moist mop and disinfectant at least twice a day (Fig. 1.3.1).

1.3.1 Mop

Walls

1.3.2 Wall cleaning The walls must be painted with oil paint up to a height of 6 ft (180 cm), so that any dirt can easily be washed off (Fig. 1.3.2).


Garbage bins

1.3.3 Proper use of garbage bin There must be garbage bins at all places where many people assemble or pass through (Fig. 1.3.3). Each bin (made of metal or plastic) must be open at the top and preferably lined with a plastic bag. A signboard next to it must explain what the bin is meant for. The bins must be emptied at least once a day, or whenever full. The bins must be washed and scrubbed regularly with a strong detergent.

Animals and birds Dogs and other animals should not be allowed to enter the building. Birds can cause a lot of dirt by their droppings and feathers, which can be very unhygienic. Openings through which birds can enter the building, or in which birds can build nests, should be covered by wire mesh. Horizontal surfaces should have spikes or pins standing upright, preventing birds from nesting there (Fig. 1.3.4).

1.3.4 Anti-bird spikes


Spitting

1.3.5 Spittoons Wherever people chew paan, spitting is inevitable. Everywhere where people tend to spit paan (at entrances, in staircases, in dark corners) there should be bins with removable plastic or paper bags, or large pans with sand – to be used as spittoons (Fig. 1.3.5). Signboards next to each one must explain their use, also explaining that a fine will be charged for spitting anywhere other than in the spittoons.

Posters should be displayed on the walls showing patients and visitors the basics of cleanliness and hygiene (Fig. 1.3.6).

1.3.6 Wall poster


Fire extinguishers should be placed at a central place (Fig. 1.3.8) that can be easily reached in case a fire breaks out. A signboard giving a simple illustrated explanation (Fig. 1.3.7) should be fixed next to the extinguisher. A light must be installed above it and kept switched on at night.

1.3.7 How to use a fire extinguisher

1.3.8 Fire extinguisher located in a corridor


1.4 Consultation and Treatment Rooms Since these rooms are visited by sick people, the risk of transmitting infections is especially great. Therefore, the furniture used by the patients (chairs, benches, examination tables) should be cleaned and disinfected as often as possible, especially after patients with infectious diseases have been treated there. Different coloured bins (ref. Section 1.7) for the disposal of different kinds of bio-medical waste (cotton swabs, bandages, syringes, needles, etc.) should be placed in each room. The floors should be cleaned with a moist mop and disinfectant solution at least twice a day (Fig. 1.4.1).

1.4.1 Treatment room

The walls must be painted with oil paint up to a height of 6 ft (1.8 m), so that any dirt can easily be washed off. Good lighting is essential for effective examination and treatment of patients. Since natural light is the best, all window shutters must be kept open during daytime. Any defective light bulbs or tube lights must be replaced immediately. Only energy saving bulbs should be used, in order to reduce power consumption.

1.4.2 Disinfection of an examination table Examination tables must be disinfected several times a day, particularly after every patient with an infectious disease (Fig. 1.4.2).


1.4.3 Doctor washing hands

Doctors and nurses must wash and disinfect their hands before and after treating a patient (Fig. 1.4.3). Even if soap and/or disinfectant solution are not available, thorough hand washing with plain water is extremely effective in reducing the risk of disease transmission. Medical instruments must be cleaned regularly and checked for proper functioning. Bio-medical waste should not be allowed to accumulate within the rooms, but must be disposed of appropriately, according to the guidelines for bio-medical waste disposal (ref. Section 1.7).


1.5 Wards Used bed sheets and pillow covers should be replaced by clean ones every 2-3 days and after a patient is discharged (Fig. 1.5.1), otherwise the next patient may be infected by the germs left in the material. If the mattresses cannot be dried in the sun, they should at least be turned upside down, as the underside was not in direct contact with the previous patient.

1.5.1 Changing bed sheets

1.5.2 Linen in cupboard The used bed sheets must be washed, ironed, disinfected and stored in a clean place (Fig. 1.5.2).


Mosquito nets Many diseases, such as malaria, dengue fever, chikungunya, filariasis, Japanese encephalitis, are not transmitted from person to person, but through mosquito bites. In a health facility, in which there may be many patients suffering from such diseases, the risk of disease transmission through mosquitoes is extremely high. Therefore, the provision of mosquito nets (preferably impregnated with a quick-acting pyrethroid insecticide) is essential for every bed used by patients and staff members (Fig. 1.5.3). Bed nets also help to protect against other creatures, such as spiders, cockroaches, flies, etc.

1.5.3 Mosquito nets

Mattresses should be exposed to direct sunlight periodically to avoid infections (Fig. 1.5.4).

1.5.4 Drying mattresses The floors should be cleaned with a moist mop and disinfectant solution at least twice a day.


Beds and other furniture should be periodically washed, de-rusted and re-painted (Fig. 1.5.5).

1.5.5 Painting a patient’s bed

Dogs and other animals should not be allowed to enter the wards (Fig. 1.5.6 and Fig. 1.5.7).

1.5.6 Animals must not be allowed to enter a ward

1.5.7 Chasing a dog out of a ward


Coloured waste bins must be placed within the wards (Fig. 1.5.8). Posters should be placed at appropriate places info rming patients and visitors about their use. Posters must also be placed in various places, explaining that spitting inside wards and outside windows is prohibited (see Fig. 3.1.5). The same applies to throwing garbage and left over food out of the window (see Fig. 2.1.7).

1.5.8 Waste bins (black, green, white, cardboard)

1.5.8 Waste bins (black, green, white, cardboard) – also refer to Fig. 1.7.1


1.6 Bathrooms, toilets, water supply, sewage disposal The bathrooms and toilets of the health centre should be cleaned at least twice a day: Cleaning means using a short bristled brush and water to clean the floor, then wiping the floors with a mop and disinfectant solution, brushing the toilets with a toilet brush (Fig. 1.6.1) and a detergent, if necessary, and removing stains from the walls with a scrubber or moistened paper, then rinsing with clean water and drying the surface with a cloth.

1.6.1 Toilet cleaning

Appropriate cleaning kits (buckets, clean wiping cloth, toilet brushes) should be provided to the cleaning staff (see Section 2.2). The cleaning kits must be stored in clean places (Fig. 1.6.2) – wet cloth must be hung up to dry.

1.6.2 Storage place


Proper cleaning procedures The cleaners must be instructed and trained in the correct methods of cleaning and how to use cleaning utensils (see Section 2.2). Their work must be checked regularly by the health staff. After cleaning a bathroom or toilet, the cleaners must rub their hands in a disinfectant solution (Fig. 1.6.3).

1.6.3 Disinfecting hands

Water tanks must be inspected regularly and cleaned at least every 6 months (Fig. 1.6.4) to remove dirt, algae, dead creatures, insect larvae, etc. Damaged and missing lids have to be replaced immediately.

1.6.4 Water tank cleaning


Preventing water wastage Fresh clean water is not available to all people. Many people have no access to clean water and many have to walk long distances to get it. Therefore, every drop of clean water must be saved for drinking, cooking or washing. So a leaking tap or water pipe means an unacceptable wastage and should be repaired immediately (Fig. 1.6.5). Defective wastewater pipes must also be repaired immediately to avoid spreading of dirty or infectious water, which can cause diseases, bad smell and unhygienic conditions.

1.6.5 Repairing a water pipe

Puddles of water must be dried up or filled up with sand, earth, etc. immediately to avoid insect breeding. If the puddles are big and cannot be dried up easily, a few drops of oil should be added to the water (Fig. 1.6.6) – this will spread a thin oil film across the surface and thus prevent mosquito larvae from developing there.

1.6.6 Oil film Septic tanks must be checked regularly for proper functioning. Broken or missing covers to septic tanks, soak pits and inspection chambers must be replaced quickly to avoid accidents. (ref. Section 1.2)


1.7 Handling garbage and bio-medical waste Each health facility, whether small or big, produces bio-medical waste (BMW). The Central and State Pollution Control Boards have developed clear guidelines for the handling and disposal of BMW. According to the Bio-Medical Waste (management and handling) Rules 1998 (amended 2002), no untreated BMW shall be kept stored beyond a period of 48 hours. Private contractors, which run Common Treatment Facilities (CTFs), have been appointed by the State Government to take care of the collection and disposal of BMW everyday from bedded hospitals and bedded primary health centres (PHCs). However, small primary health centres (without indoor wards) and sub-centres have to handle their bio-medical waste by themselves. The most important methods are explained below. Incineration is no longer an option in health facilities While incineration of waste has been common practice in health facilities for many years, it is now widely accepted that the emissions and residues from incinerators are highly toxic, containing heavy metals, unburned toxic chemicals and new pollutants (dioxins and furans). All these eventually pollute the air, soil, groundwater, plants, livestock, fish, etc. So if the toxic substances do not reach humans directly, they can be consumed indirectly through contaminated drinking water and food. Incineration is only acceptable in CTFs, under strictly controlled conditions. Incineration of waste on the premises of health facilities is therefore now forbidden (ref. Fig. 1.2.12), but there are sufficient non-burn disinfection technologies to handle all bio-medical waste.

Types of waste The kind and amount of waste generated in a health facility depends on its size, function and number of staff and patients. The table below gives an overview of the types of general waste and how they should be treated, if they are not collected and handled by CTFs. General waste Treatment and DisposalClean packaging materials (paper, cardboard boxes, plastic packets, etc.).

Each type of material collected separately, and then sold to scrap vendors for recycling.

Dirty paper and cardboard materials.

Disposal in a compost pile (Fig. 1.7.13).

Dirty plastic packaging. Disposal in a campus pit (Fig. 1.7.11); if it is contaminated with infectious substances, chemical disinfection is required before disposal in the pit.

Gardening waste and vegetarian food waste – in other words, only fruits and vegetables (without meats, bones, dairy products, or fats)

Disposal in a compost pile (Fig. 1.7.13)

Food waste (particularly boiled and fried food), including meat, bones, dairy products, and fats

Deep burial in a trench (Fig. 1.7.12)

Dirty or broken eating utensils, plastic and earthen tea cups, metal scrap, etc.

Deep burial in a trench (Fig. 1.7.12), or if properly cleaned, sold to scrap vendors for recycling


General waste makes up about 80% of the total waste generated in a health facility. The remaining 20% is bio-medical waste (below), which is categorized by the BMW Regulations of the Ministry of Environment and Forests, Government of India, as follows: Bio-medical waste categories Treatment and DisposalCategory 1: Human Anatomical Waste (placenta, human tissues, organs, body parts).

Disposal in a campus pit (Fig. 1.7.11), or deep burial in a trench (Fig. 1.7.12).

Category 2: Animal Waste (animal tissues, organs, body parts, carcasses, etc.).

Disposal in a campus pit (Fig. 1.7.11), or deep burial in a trench (Fig. 1.7.12).

Category 3: Microbiology & Biotechnology Waste (wastes from laboratory cultures, etc.).

Disinfection by autoclaving (Fig. 1.7.9), then disposal in a campus pit (Fig. 1.7.11), or deep burial in a trench (Fig. 1.7.12).

Category 4: Waste Sharps (needles, syringes, scalpels, blades, glass, etc. that may cause puncture and unused sharps).

Mutilation of syringes, collection in a safety box (Fig. 1.7.4), chemical disinfection (Fig. 1.7.8) or autoclaving (Fig. 1.7.9), then final disposal in a sharps pit (Fig. 1.7.10) or campus pit (Fig. 1.7.11).

Category 5: Discarded Medicines (wastes comprising outdated, contaminated and discarded medicines).

Disposal in a campus pit (Fig. 1.7.11), if disposal in a secured landfill is not possible.

Category 6: Soiled Waste (items contaminated with blood and body fluids including cotton, dressings, soiled plaster casts, lines, beddings, other material contaminated with blood).

Disinfection by autoclaving (Fig. 1.7.9), then disposal in a campus pit (Fig. 1.7.11), or deep burial in a trench (Fig. 1.7.12).

Bio-medical waste categories Treatment and DisposalCategory 7: Solid Waste (generated from disposable items other than waste sharps, such as tubing, catheters, intravenous sets, etc).

Disinfection by chemical treatment or autoclaving (Fig. 1.7.9), then shredding, and final disposal in a campus pit (Fig. 1.7.11).

Category 8: Liquid Waste (generated from laboratory as well as washing, cleaning, and disinfecting activities).

Disinfection by chemical treatment (Fig. 1.7.8) and discharge into drains.

Category 9: Incineration Ash (ash from incineration of any bio-medical waste).

Deep burial in a trench (Fig. 1.7.12), if disposal in a municipal landfill is not possible.

Category 10: Chemical Waste(chemicals used in production of biological products, chemicals used in disinfection, as insecticides, etc).

Chemical treatment and discharge into drains for liquids; deep burial of solids in a trench (Fig. 1.7.12), if a secured landfill is not available.


What needs to be done? Principles of handling waste Why / how Reduce the amount of waste to a minimum.

Less waste means less need for treatment and disposal, and less sources of infection. The purchase of reusable items made of glass and metal should be encouraged. Plastics should be non-PVC, as PVC cannot be disposed of without polluting the environment.

Separate the waste at the place where it is generated.

Non-hazardous waste mixed with hazardous waste makes the whole waste hazardous, unnecessarily increasing the volume of waste to be treated and increasing the source of infection. Separation can easily be done by disposing of each type of waste in different coloured containers (Fig. 1.7.1).

Do not store untreated BMW longer than 48 hours.

Infectious organisms from BMW can increase in numbers in warm conditions; they can be distributed by careless handling, by air movement and by creatures (flies, cockroaches, rats, etc.) that are attracted to the waste. The BMW containers must be firmly closed and emptied daily, or at least within 48 hours.

In case of doubt about the type of waste, treat it as hazardous.

If the source of waste is unknown, it may be infectious. Therefore, recycling should not be considered.

Avoid incineration. Incineration of BMW produces very dangerous emissions and residues, particularly when the BMW contains plastic materials, mercury and certain drugs.


How is waste separated in different coloured containers?

In order to make sure that different types of waste do not get mixed, they should be collected in different containers at the place where the waste is generated . They should be easy to identify by different colours, as defined by the BMW Rules (1998).

All containers and transporting equipment used for infectious bio-medical waste must carry the international BIOHAZARD symbol.

Yellow container Infectious bio-medical waste, e.g.:

• Human and animal anatomical waste

• Items contaminated with body fluids

• Disposable gloves, masks, etc.

• Microbiological waste

Blue container (puncture proof) Sharps, e.g.:

• Used syringes • Blades • Broken glass items

• Scalpels

Black container General non-bio-degradable waste, e.g.:

• Old medicines • Meat, dairy products,

• Soiled packaging

• Waste cooked food

Green container Bio-degradable waste (for composting), e.g.:

• Raw vegetable and fruit waste

• Dead plants

• Egg shells

• Hair

White container Clean packaging materials, e.g.:

• Clean plastic bags • Aluminium foil

• Plastic containers

• Thermocole padding material

Cardboard box Clean paper-based items, e.g.:

• Newspapers, magazines

• Cardboard boxes

• Medicine packaging

1.7.1 Six different coloured bins and what they should contain


Container colour and type

Recommended location of container

Category and type of waste Treatment and disposal

Yellow plastic bag / bin

Operation theatres (OTs), delivery rooms, dressing/ treatment rooms, labs, nurse’s station

Cat 1: human anatomical waste Cat 2: animal waste Cat 3: microbiological waste Cat 6: soiled waste Cat 7: solid waste

Autoclaving (Cat 3, 6); Chemical disinfection; deep burial; campus pit

Blue punctureproof box made of metal, plastic,or thick cardboard

OTs, dressing/ treatment rooms, labs, nurse’s station

Cat 4: waste sharps Cat 7: plastic disposable tubing, etc.

Destruction/ shredding; chemical disinfection; autoclaving; encapsulation;sharps pit

Black plastic bag / bin

Labs, nurse’s station, wards, outside locations

Cat 5: discarded medicines Cat 9: incineration ash Cat 7: chemical waste (solid) General waste (non-biodegradable, including meat, dairy products, fats)

Disinfection; campus pit (Cat 5) or deep burial; municipal landfill

Green plastic bin

Wards, waiting areas, outside locations

General biodegradable waste (food waste without meat, dairy products, fats), dirty paper, cardboard, etc.

Compost pit

White bin or plastic bag

Entrance areas, wards, nurse’s station

Clean packaging materials made of plastic materials

Sold to scrap vendor for recycling

Large cardboard box

Entrance areas, wards, nurse’s station

Clean packaging materials of paper or cardboard

Sold to scrap vendor for recycling

Advantages of separating waste Putting different types of waste in different containers at the point of generation, then treating and disposing of them according to the guidelines • avoids contaminating non-infectious waste by infectious waste; • reduces the amount of dangerous waste that needs to be

disposed of; • reduces littering and makes the place look clean and tidy; • causes the least possible pollution of soil and water; • produces a valuable fertilizer for gardening by composting bio-

degradable food waste; • generates income by selling clean paper, cardboard, plastic

materials, scrap metal and glass bottles to scrap vendors, thus also contributing to environmental protection by recycling, as recycling reduces the need for production of new materials.


How must sharps be handled? Sharps are items that can cut or puncture a person’s skin, causing injury and infection. Sharps include needles, scalpels, blades, knives, broken ampoules/glass, nails and the like, all of which are considered hazardous (whether they are infected or not), and have to be handled with great care, that is: • Used sharps should never be handed from person to person – if at

all, they should be placed in a kidney tray and passed on (Fig. 1.7.2);

• Recapping or bending of needles is strictly prohibited, as this can cause severe injuries. Needles should be destroyed with a needle cutter (Fig. 1.7.3) and the remaining syringe should be put in a puncture proof container or safety box (Fig. 1.7.4). If a needle cutter is not available, the whole syringe and needle must be put into the safety box. This ensures that the sharps cannot be reused and the safety box ensures that the people handling the sharps cannot be injured;

• When it is three-quarters full (Fig. 1.7.5), the safety box should be used to disinfect the sharps by adding a 1% bleach solution (= one tablespoon bleaching powder mixed with 10 litres of water) (Fig. 1.7.6);

• After emptying the bleach solution, final disposal of the safety box should be in a campus pit (Fig. 1.7.11) or the contents should be emptied into a sharps pit (Fig. 1.7.10);

• Alternatively, the safety box should be filled up completely with cement mortar or plaster of Paris, allowed to harden, sealed and disposed of in a trench. This is called encapsulation (Fig. 1.7.7).

1.7.2 Passing on sharps in

a kidney tray

1.7.3 Manually operated needle cutter

1.7.4 Examples of puncture proof safety boxes for sharps


1.7.5 Safety boxes should only be filled ¾ full

1.7.6 Disinfecting sharps in a safety box

1.7.7 Encapsulation

What is chemical treatment? Infected sharps, solid and liquid waste have to be disinfected before final disposal in a campus or sharps pit, in a deep burial trench or in the drains. A quick and effective method of disinfection is by chemical treatment using chlorine based disinfectants, the most common being household bleach (sodium hypochlorite) or bleaching power (calcium hypochlorite or chlorinated lime). It is important that all parts of the waste come into contact with the disinfectant for about 30 minutes, therefore shredded waste is better to treat than objects with inaccessible parts. Since the chlorine becomes inactive quite soon, a fresh hypochlorite solution must be prepared each time it is required. If blood, saliva or other body fluids are spilt, a 10% hypochlorite solution should be poured over it (Fig. 1.7.8). Using protective gloves, this should be wiped away with gauze sponges or absorbant scrap paper (newspaper), which is disposed of in the yellow bin (for infectious waste). The surface must then be washed with soap and water.

1.7.8 Disinfecting liquid waste


What is autoclaving? Autoclaving is one of the most effective methods of disinfecting (sterilising) medical and laboratory instruments, laundry and bio-medical waste. It is a low thermal process, which takes place in a container, called an autoclave. It uses steam and pressure to kill all harmful organisms (bacteria, viruses, fungi, spores, etc.). There are several types of autoclaves (gravity, pre-vacuum and retort systems), the simplest resembling a pressure cooker with a gauge on top and bolts to fasten the lid to the pot (Fig. 1.7.9). The autoclave has an inner chamber into which the contaminated items are loaded in special metal containers. It is very important that all the contents of the autoclave come into contact with the steam, and that a minimum temperature of 121°C and minimum pressure of 15 psi is maintained for 30 to 60 minutes, depending on the type of autoclave. Higher temperatures and pressures require shorter duration. An autoclave must be maintained regularly and requires a trained operator. Each autoclaving operation must be recorded (Date, Material loaded, Detail of pressure, and Holding time). Special care must be taken when opening and unloading the autoclave, which must be allowed to cool down, or else the escaping steam can cause severe injuries.

What is a sharps pit? When the waste sharps have been sterilised, they must be disposed of safely, in order to ensure that they cannot cause injury to any person or animal. An appropriate place for disposal is a pit in a remote part of the compound. It must have a concrete base and cover, while the walls can be of masonry or concrete, with an inner diameter of 600-1,000 mm and a depth of 1,000-2,000 mm. The waste sharps enter the pit through small openings of 80-100 mm diameter, which are closed by inserting 300 mm long pipes (Fig. 1.7.10). The figure shows a glass crusher (right), developed by MSF (Médecins Sans Frontières = Doctors Without Borders) for destroying vials, ampoules, and other small glass items. When the pit is full (usually after several years), a new one should be constructed. If a sharps pit is not available, the sharps can be disposed of in a campus pit.

Fig. 1.7.9Simple table-top

autoclave

Fig. 1.7.10 Sharps pit


What is a campus pit? A campus pit is required for the final disposal of the contents of the yellow and blue waste containers (anatomical and infectious waste), as well as discarded medicines. The campus pit is a much larger version of the sharps pit, with a diameter of at least 3 m and depth of 3.3 m. The top 300 mm should be above ground level to avoid entry of surface water, in case the site is flooded (Fig. 1.7.11). The waste is dropped into the pit through three circular openings of 300 mm diameter. These must have strong lockable lids. A ramp leading up to the campus pit cover is provided for waste transports by trolleys.

What is deep burial in a trench? If a campus pit is not available, deep burial is the best alternative for final disposal of hazardous and non-biodegradable waste, and encapsulated sharps. The trench (located in a remote corner of the site) is usually rectangular, 1-2 m wide and about 5 m long. The depth can be 2-5 m, depending on the soil conditions. The base and walls should be made of concrete and masonry. There should be a security fence around it to keep animals and children away, and preferably a shed roof to protect the trench from rain (Fig. 1.7.12). The excavated earth should be kept around the trench to protect it from surface water. After unloading waste into the trench (ref. Fig. 2.2.5), about 100 mm earth should be added to cover the waste. When the trench is filled up to 500 mm below the ground level, it should be covered with lime and finally filled up with earth. A new trench will then be required.

Fig. 1.7.12 Deep burial

trench

Fig. 1.7.11 Campus pit


What is a compost pile? A compost pile is a heap of biodegradable organic matter (mainly plant materials and manure), which is decomposed by bacteria, earthworms and other small creatures to form rich compost, which can be used to enrich the soil in agriculture and gardening (Fig. 1.7.13). It is important that the organic matter is free from cooked food, meat, dairy products, fats, chemicals, etc., as these cannot be processed by the bacteria and earthworms, and tend to rot or attract flies, maggots and other unwanted creatures. The rate of decomposition depends on the size of the organic matter (the smaller the better), and on the outside temperature. The compost pile should not be exposed to the direct sun, as it would dry up the pile quickly, but must have ventilation openings on all sides. An ideal place for a compost pile is under a large shady tree, which gives protection against the hot sun and heavy rains, but allows enough rain to reach the pile to keep it moist. The pile must be placed on natural ground, that is, without a brick or concrete base, and it must be ensured that no flooding can occur, as the compost would be destroyed if it is submerged in water. The best organic matter is raw vegetable waste, gardening waste (grass cuttings, leaves, twigs, etc.), cardboard, paper, egg shells, cow dung and similar items. Large pieces must be cut to a few centi-metres in size for quicker decomposition.

Fig. 1.7.13 Compost pileThe first compartment (left) is still being filled, while the middle compartment is left to mature

(at least six months). In the last compartment the compost is ready for use in gardening.


What is recycling? Recycling is the processing of used materials (glass, plastic, metals, paper, cardboard, textiles) to make new products. A number of these materials are among the waste produced in health facilities. If they are carefully separated and kept clean, or are sterilised, as in the case of glass, plastics, metals and textiles, they can be sold to local vendors, thus generating an income from waste, and reducing the amount of waste that needs to be disposed of in some way or other. It is an important contribution to reducing environmental damage, as it reduces the need for new raw materials required for making new products. Recycling of disposables e.g. syringes, needles, gloves, transfusion bags, etc. should be prevented at all costs. Safety measures While all staff members of a health facility are at risk of contracting a disease, those who handle waste are especially endangered. Therefore, the following safety guidelines have to be followed very carefully. • Handling waste in health facilities requires special knowledge and

training, therefore unskilled and untrained persons should not be entrusted with handling waste.

• Cleaning staff must be provided with the correct equipment and safety gear (gloves, boots, masks, aprons) (Fig. 1.7.14), and instructed how and when to use them.

• They must be immunised against Hepatitis B virus. Tetanus immunisation is also recommended.

• Clean running water and soap must be available to all personnel handling waste. This is especially important in case of injury. As wounds must be washed before treatment. The same applies in case of eye injuries due to chemicals and foreign bodies.

• All accidents and even seemingly minor injuries must be reported to the medical staff immediately, so that quick action can be taken.

• All cleaning staff must be trained in the basics of first aid treatment.

1.7.14 Safety gear


1.8 Improving interiors, exteriors and functioning of health facilities Painting walls with oil paint up to 6 ft height (1.8 m) In corridors and rooms used by many people daily, the walls quickly gather dirt, much of which can be potentially infectious. If the wall surface is rough and not water resistant, it cannot be cleaned. If the wall is painted with oil paint at least up to a height of a tall person, it can easily and effectively be cleaned with water and disinfectant (ref. Fig. 1.3.2). Most other paints need to be renewed two or three times before oil paint needs renewal, making oil paint economical despite its higher cost.

Window curtains Providing window curtains makes a room more homely and pleasant (Fig. 1.8.1). Curtains also provide protection against glaring sunlight and heating up of rooms during hot sunny days. Furthermore, curtains can be used to shield patients from curious onlookers. Another important advantage is that curtains absorb sound, so that noise levels are much lower than in rooms without curtains.

1.8.1 Hanging up a curtain


Insect screens Some harmless insects may just be a nuisance, but many insects are dangerous transmitters of diseases (see Section 3.2). Therefore it is important to prevent all insects from entering buildings. This is best done by providing insect screens at all windows (Fig. 1.8.2). These allow for ventilation when the window shutters are open, but keep out insects and other undesirable creatures, such as mice, rats, birds, snakes, lizards, etc. The mesh size should be 18 threads per inch or 7 threads per centimetre to keep out most insects. A smaller mesh size would keep out smaller insects, but ventilation would be greatly reduced.

1.8.2 Flexible insect screen

1.8.3 Covered shed for waiting patients Waiting spaces for patients Most health facilities have waiting areas, but these are often too small for the large numbers of outpatients that come at peak hours. In such cases they have to wait outside the buildings exposed to the hot sun or rain (ref. Fig. 1.1.1). Providing a simple shed near the entrance to the health facility will solve the problem. The covered space should have a paved floor and sufficient benches (Fig. 1.8.3), at least for weak and old patients. If there are large shady trees, fixed benches can be installed underneath for waiting patients.


Central kitchens Bedded health facilities often have a central kitchen to provide meals for the patients. However, these kitchens are often poorly equipped, without proper working space (platform or table) or storage space (shelves or cupboards) for foodstuffs and utensils, so that everything is done on the floor, which is not always clean enough (Fig. 1.8.4). The cooking is usually done on primitive stoves using firewood, dung or charcoal, which develops dense smoke inside the kitchen. This is severe indoor air pollution, which causes many health risks, particularly for the lungs and eyes of the people working there, and lays thick layers of oily soot on the floor, walls and ceiling of the kitchen.

1.8.4 Typical kitchen of a rural hospital

Fig. 1.8.5 shows how the kitchen can be improved to make it clean, healthy and practical, by providing a smokeless stove with a chimney pipe carrying the smoke out of the kitchen. The platform and shelves offer sufficient clean space for food preparation and storage.

1.8.5 Improved hospital kitchen


Emergency lamps Since power cuts and power failures occur frequently, emergency lamps should be placed in nurses’ duty rooms, wards, toilets, labour rooms and corridors. They can be fixed in lockable boxes of strong wire mesh to prevent damage or theft. Boundary fences The compounds of many health facilities are not enclosed by a wall or fence, so that unauthorised persons and stray animals can enter the site at any time. This presents a serious security problem for the staff and patients, particularly during the night. Therefore, wherever funds are available, boundary walls made of concrete and bricks should be constructed all around the site, including a strong entrance gate, which can be locked. An alternative to boundary walls, which are usually very expensive, could be a chain link or barbed wire fence. A cactus hedge may be grown alongside the fence for additional protection, and to deter vandals who may want to damage the fence (Fig. 1.8.6).

1.8.6 Boundary fence with a cactus hedge


Fixed waste bins A clean and tidy environment is a beautiful sight to see and should not be spoilt by littering and spitting. To avoid littering, it is necessary to set up waste bins at various places around the compound and within the buildings. They have to be easily accessible, easy to use and easy to empty and clean.

Fig. 1.8.7 shows two types. The round bin is a commercially available type, made of two parts: the main container, into which a plastic bag is placed, and a cover with an opening to throw in the waste. It is light and easy to transport, but it can also be damaged and stolen easily. The other type (designed by the author) is made of concrete and permanently fixed at its position. It is easily emptied by placing a wheelbarrow below it and opening the shutter, which closes again on its own.

1.8.7a Commercially available waste bin 1.8.7b Fixed concrete waste bin


Rainwater harvesting For the proper functioning of a health facility, the availability of sufficient clean water is vital. However, adequate supplies of clean water are not always available, so that it is advisable to collect as much rainwater as possible, before it seeps into the ground, flows into a river or evaporates. There are various methods of rainwater collection, and it may be advisable to implement different methods on a site (Fig. 1.8.8). The important requirement is to collect the water in closed tanks to prevent evaporation and contamination.

Rainwater may not be suitable for drinking, as it does not contain the minerals present in groundwater, but it can be used for many other purposes, such as hand washing, bathing, cleaning utensils, and also gardening, if supplies are sufficient. Since the dry seasons may be long, it is necessary to ration the use of water and avoid wastage at all costs.

A

BC

1.8.8 Rainwater harvesting methods A. Collection from a sloping

roof, storage above ground B. Collection from a flat roof,

storage underground C. Sari-type rainwater

harvesting method: rainwater is collected by a large piece of cloth and directed into a tank


Water treatment Drinking water may not always be clear, colourless and of acceptable quality, especially when the source is unknown. Groundwater extracted by hand pumps is generally of good quality, provided that no garbage heaps, toilet soak pits, workshops, factories or the like are situated close by. In order to take no risks, it is always advisable to treat the water to destroy any harmful microorganisms. There are several ways of treating water, such as filtration, boiling, chemical and UV treatment. Filtration basically removes impurities in the water, but the effectiveness depends on the type of filtration system and the pore size of the filter medium – the denser the medium, the smaller the particles that are removed, including protozoa, bacteria and viruses. But the main purpose is to remove turbidity (cloudiness). The more turbid the water, the quicker the filter will clog. Therefore, only the cleanest available water should be filtered. If the water is very dirty, it should be allowed to stand overnight, so that the particles can settle at the bottom of the container. There are many types of filters in the market (e.g. Fig. 3.1.10), but simple filters can be made with easily available materials (Fig. 1.8.9). It is important to change filters frequently, as they become clogged and do not function effectively.

1.8.9 See-through view of simple water filtration system


Boiling is the most reliable way of killing microorganisms. This must be done after filtration. Experts claim that water temperatures above 70°C will kill all harmful organisms within 30 minutes, but since a thermometer is rarely available, it is safest to heat the water until it boils. Boiling for 10-15 minutes, as claimed by some people, is not required, as it only wastes valuable energy and reduces the water quantity by evaporation. It is perfectly safe to bring the water to a rolling boil and then turn off the heat source. To be extra safe, the water can be kept boiling for one minute, but not longer. Chemical treatment is an option where boiling is not possible. There are different types of chemical treatment, but the most common are iodine and chlorine treatment. However, iodine treatment should not be used for persons with iodine allergies or restrictions. Chlorine treatment can be done by adding bleaching powder to the water (1 table spoon per 100 litre water, or 3 drops of 1% hypochlorite solution per litre water), or by adding chlorine-based water purification tablets. Ultra-violet (UV) treatment (exposure to the sun) can destroy 99% of all microorganisms. A simple way of doing this is by placing clear plastic or glass bottles filled with water in the direct sun (e.g. on the roof) for at least six hours (Fig. 1.8.10). Note: the clearer the water, the better the result.

1.8.10 Ultra-violet treatment of water


Septic tanks and soak pits Most toilets in health facilities are connected to a septic tank and/or soak pit, but these are not always constructed or used correctly. The purpose of a septic tank is to retain the toilet effluent for about 48 hours, during which the solids get separated from the liquids and most of the pathogens (harmful organisms) die. A septic tank can only function if it is full and there is a regular passage of effluent from the toilet into the tank and onwards to the soak pit. In areas of water scarcity, septic tanks cannot function. In such cases, pit latrines (toilets placed over a hole in the ground) or direct discharge of effluent from WCs to a soak pit are the only options (Fig. 1.8.11).

1.8.11 Sanitation without septic tank


1.8.12 Design of a septic tank and soak pit The most important requirements for a septic tank (Fig. 1.8.12) are: • There must be at least two, but preferably three chambers,

because the amount of solid particles and harmful organisms decreases from the first to the second chamber and from there to the third chamber.

• There must be an opening above each chamber for inspection and removal of sludge from the tank chambers. Regular inspection of the septic tank is necessary to check its functioning. Depending on the size of the tank and intensity of use, the sludge must be removed from the tank at intervals of 2-3 years.

• Each opening must have a heavy lid to prevent people from throwing garbage or falling into the tank, and to prevent bad smells from emerging. For the discharge of gases there must be a long vertical ventilation pipe.

• The walls dividing the chambers should not reach the top of the tank, and for the liquid to pass from one chamber to the next there must be holes at half the wall height.


Gardening and landscaping A clean and pleasant external space is as important for the well-being of the patients and staff of a health facility as the interior space of the buildings. Well arranged bushes and trees not only make the place attractive, but also help to provide demarcations of pathways and boundaries, or provide shady spaces, as well as protection against wind and rain (Fig. 1.8.13). Grass cover on either side of pathways and around buildings helps to reduce dust and glare in dry sunny conditions. However, it is not enough to just arrange plants appropriately; they have to be watered and cut to size regularly, or else the plants will dry up, or in wet conditions develop into a jungle.

Fig. 1.8.13 Gardening and landscaping of a health facility


Pathways Ideally, pathways (Fig. 1.8.14) leading from the compound entrance to the main buildings, as well as between buildings, should be several inches higher than the surrounding surface, so that they can be used even during heavy rains. They should have a hard surface (made of concrete, asphalt, brick or stone paving), slightly sloping towards a drainage channel running alongside the path, and there should be no potholes, in which water can collect.

1.8.14 Paved pathway in the rain

Condemned items Technical equipment and furniture that are severely damaged and out of use are often left to rust, gather dust and occupy valuable space, which is needed for more important use than storage of useless items. It is therefore necessary to make a list of such items and report them to higher authorities to initiate the removal of these items.

1.8.15 Condemned items


1.9 Planned Preventive Maintenance What is Planned Preventive Maintenance (PPM)? Every building and every piece of equipment deteriorates gradually, whether it is in use or not. This happens by wear and tear, by sun, wind and rain, by accumulation of dirt and moisture (which cause rust and decay), by nesting creatures (which can destroy parts of building and equipment) and by misuse (generally due to lack of knowledge) and negligence. Therefore, to prolong the useful life of equipments, buildings and their surroundings, it is necessary to inspect, clean and repair them, or replace damaged or used up parts. If this is done in a planned way at regular intervals, major deterioration and damage, requiring “corrective maintenance” (which means expensive repairs and replacements), can be prevented. In other words, PPM saves considerable costs in the long run, but also ensures the proper functioning of a health facility, in which the staff is happy and motivated and the patients can recover quickly.

More than 50 % of PPM is cleaning Dirt accumulates within and outside buildings very fast. This can be • due to dirt and garbage being carried by wind, rain and animals; • due to fungal growth caused by water leakage and lack of

ventilation inside buildings; • due to the bad habits of people throwing garbage and spitting

wherever they please, causing indiscriminate littering, blockage of drains, attraction of disease carrying insects and rodents, and producing very unhygienic conditions;

• due to the lack of garbage bins placed inside and outside buildings;

• due to damaged or missing covers of water tanks, which gather dirt and birds’ droppings, attract small creatures, and develop algae by exposure to sunlight;

• due to the general opinion that toilets and bathrooms are dirty places and users are not responsible for cleaning them after use;

• due to the lack of cleaning staff, lack of training of such staff and lack of tools available to them.

All this can be avoided by regular cleaning, which is the largest single PPM activity. The other activities are removal of unwanted plant growth and gardening, masonry and painting works, carpentry and metal works, plumbing and electrical works, repairing of bio-medical equipment, and a few other works.


How must PPM be organised? Every health facility has different maintenance requirements, therefore the PPM activities will differ from place to place. It is necessary to make lists of the maintenance work to be done, as well as a time schedule. Some works must be done every day, some once a month or every 2-3 months, and some every 2-3 years. The important thing in each health facility is to appoint at least one person, who is in charge of making these lists, who organises the work, and who checks that it has been done correctly. Since a number of skills are required to carry out the various maintenance jobs, they can only be done by a team of 5-7 specially trained multi-skilled technicians and cleaners. As no single health facility is able to employ such teams on a full-time basis, the best solution is to create teams for clusters of 10-20 facilities each, which are not more than an hour’s drive away from one another. A PPM team would then visit a health facility of one cluster for a specified number of days to carry out the PPM work and then move on to the next facility. When the PPM work is completed in all the facilities of that cluster, the cycle is repeated. By this way, each facility can be visited at intervals of 2-3 months. The daily maintenance work must be done by in-house staff. In the same way as bio-medical waste disposal is being outsourced to private contractors, outsourcing PPM to private companies may be a suitable option. The maintenance funds allocated to each health facility can be utilised for this purpose.

What are the most common PPM activities? The following is a list of standard PPM activities that need to be carried out in most health facilities:

A. Garbage removal and cleaning of gutters: (Fig. 1.9.1)

• removal of garbage from all parts of the compound; • cleaning of drainage gutters (around buildings and on roofs); • removing garbage from open wells; • digging holes in appropriate places on the site to bury the

garbage (by filling the holes up to 18-20 inches (450-500 mm) below ground level, adding lime for disinfection, and filling up with earth).


B. Removal of undesirable plant growth, (Fig. 1.9.2)

• which includes ripping out small plants with two fingers, as well as chopping trees growing out of walls or roofs;

• also cutting away plants growing close to buildings and chopping overhanging branches.

C. Cleaning and repairing water tanks: (Fig. 1.9.3)

• thorough cleaning of tanks inside and outside; • repairing damaged pipes; • replacing broken or missing lids.


D. Cleaning of building interiors: (Fig. 1.9.4)

• removal of cobwebs and dust in building interiors; • cleaning fans, lights, furniture, etc.; • identifying termite tunnels and appointing a pest control

agency to destroy the termites effectively.

E. Cleaning of toilets and bathrooms: (Fig. 1.9.5)

• thorough cleaning of toilets, washbasins, floors, walls, etc.; • cleaning choked drains.


F. Plumbing works: (Fig. 1.9.6)

• repairing damaged or leaking sanitary installations (water taps and drainpipes, WC cisterns, etc.);

• making unusable toilets function again.

G. Electrical works: (Fig. 1.9.7)

• repairing damaged or malfunctioning electrical wiring, switchboards, fuse boxes, fans, lights (inside and outside buildings), etc.;

• replacing tube lights, starters, bulbs, etc.; • test-running power generators to ensure that they work when

required; • filling water in the funnels of earthing pits for proper

functioning.


H. Masonry and painting works: (Fig. 1.9.8)

• repairing damaged walls, ceilings, floors, and roof surfaces with plaster and/or tiles;

• sandpapering and painting walls and ceilings; • repainting old signboards.

I. Carpentry and metal works: (Fig. 1.9.9)

• repairing damaged doors and windows, entrance gates, etc., replacing missing or broken parts;

• welding metal parts; • repairing and repainting wooden and metal furniture.


J. Repairing simple bio-medical equipment. (Fig. 1.9.10)

• repairing electrical items (refrigerators, suction apparatus, operation theatre lamps, etc.);

• repairing mechanical items (microscope, BP apparatus, autoclave, weighing machine, wheelchair, needle cutter, etc.).

K. Removing condemned items: (Fig. 1.9.11)

• preparing lists of damaged and condemned equipment and furniture, in order to remove them and thus regain useful space.


L. Gardening and landscaping: (Fig. 1.9.12)

• filling up holes or repairing paving in pathways and cutting away plants growing on or close to them;

• planting flowery plants and trees to make the site attractive; • painting masonry or wooden enclosures of gardens and

borders along paths, etc.

In all PPM work, safety measures must be followed in the same way as described in Section 1.7 (safety measures in handling bio-medical waste). All the completed PPM work (dates, activities, materials used, costs involved, etc.) must be recorded in a PPM Report, which must be certified by the person in charge of maintenance. All the reports must be kept in files for future reference.


What tools are needed for maintenance?

Apart from the cleaning tools shown in Section 2.2, a number of

other tools and equipment are needed for regular maintenance work. The main tools and equipment are illustrated here: (Fig. 1.9.13 and 1.9.14)

General Tools Safety Gear

Electrican’s Tools


Mason’s and Painter’s Tools

Mechanic’s, Fitter’s and Plumber’s Tools

Carpenter’s Tools


PART 2Guidelines for the staff and

users of health facilities

63

64 PART 2 – Guidelines for the staff and users of health facilities

PART 2 – Guidelines for the staff and users of health facilities 2.1 Guidelines for medical, laboratory and administrative staff Attitude towards patients and visitors For a health facility to function well, it is important that there is a pleasant atmosphere and friendly relationship between all occupants. Patients may be in a serious condition, suffering pain and anxiety, they may be in the hospital for the first time and fearful about the medical treatment. Also the relatives and friends of the patients may be in great distress about the patient’s condition. It is therefore most important that all the staff members treat the patients and visitors with respect and try to make their stay in the hospital as pleasant as possible. Attitude between staff members The same applies to the way the staff members deal with each other. Friendly words, praise, encouragement will make it easier for all staff members to work effectively and enjoy their work. Offering to help a fellow staff member, or do his/her work occasionally, or just pick up garbage and dispose of it correctly, will all help to make the hospital function efficiently and ensure clean and hygienic conditions.

New patients When new patients are admitted to a ward, fresh bed sheets, pillow cases, blankets with fresh covers should be provided for every bed newly occupied.

2.1.1 Freshly prepared beds awaiting new patients

PART 2 – Guidelines for the staff and users of health facilities 65

Protection against mosquitoes Mosquito nets must be provided for each bed, even for infants (Fig. 2.1.2), and it must be ensured that there are no holes in the mosquito nets. Similarly, insect screens on windows (ref. Fig. 1.8.2) must be checked regularly to ensure that there are no holes or gaps between window frame and insect screen through which mosquitoes and other insects can enter the building.

2.1.2 Commercially available mosquito nets for infants

Cleaning beds after patients leave When a patient is released from a ward, the bed sheets, pillow and blanket covers must be removed for washing. The bed must be cleaned (Fig. 2.1.3) and inspected for any damage. The mattress must be allowed to dry out thoroughly, therefore wherever possible, the mattresses should be dried outside in the sun (ref. Fig. 1.5.4), which acts as a disinfectant.

2.1.3 Cleaning a bed after a patient leaves


Treating patients Before and after treating patients, it is important to wash hands and instruments in fresh running water, and then rubbing them with an antiseptic disinfectant liquid, such as Dettol. If disposable gloves are available, these should be used when coming into contact with blood, saliva or other body liquids, and should be changed before treating the next patient. A clean lab coat or apron should always be worn. (Fig. 2.1.4)

2.1.4 Doctor and nurse in lab coats Destroying syringes and needles after use As far as possible, only disposable plastic syringes should be used. After administering an injection, the syringe should immediately be destroyed in a syringe/needle cutter. A safety box should be attached below the needle cutter to collect the cut needles (see Section 1.7). Needle cutters (Fig. 2.1.5) should be available in all examination and treatment rooms as well as nurses’ stations.

Handling infectious items Reusable instruments, linen, trays, furniture, etc. that have come in contact with blood and other body fluids should only be handled with gloves. Contaminated items must quickly be cleaned with cool water (as blood cannot be removed with hot water, and dried blood stains cannot be effectively cleaned). Thereafter, they must be soaked in a disinfectant solution for about 30 minutes, before cleaning with a detergent. Sterilization of instruments and linen must be done in an autoclave (Fig. 2.1.6) for at least 20 minutes at 121°-132°C (or 30 minutes, if the items are in wrapped packs). Boiling instruments is regarded as an unreliable means of sterilization and is not recommended.

2.1.6 Electrically operated vertical autoclave

2.1.5 Electrically operated needle cutter


Waste disposal Hospital staff must always set a good example when handling waste. Different colour waste bins must be set at all places where waste is generated (see Section 1.7), so that the different types of waste can be collected in separate containers. Staff members should keep an eye on how patients and visitors dispose of their waste and, if necessary, instruct them about the correct use of the bins (Fig. 2.1.7).

Maintenance In each health facility, one staff member must be appointed to make sure that the building, the fittings, equipment and furniture, as well as the compound are kept in a good condition (see Section 1.9) and he/she should be assisted by all other staff members, by reporting defects that need attention. Simple works, such as changing a light bulb, or ripping out a small plant growing in a crack in a wall, or clearing a blocked drain, can be done by anyone, while major defects must be reported to higher authorities for quick rectification.

2.1.7 Nurse instructing patient to use a waste bin


Unusable equipment and furniture Old or broken items that cannot be used any more should not be allowed to occupy valuable space within a health facility, where they gather dirt, start to rust or rot, attract unwanted creatures and present very unpleasant sights. If they cannot be repaired and used again, these items must be reported as condemned and removed from the site as soon as possible.

2.1.8 Old or broken items

No animals allowed in the hospital building or compound Animals are carriers of diseases and should not be allowed to enter the hospital premises, let alone the buildings. Any stray animals found there should be chased away immediately, and patients and visitors should not be allowed to bring any animals with them to the health facility. Also any birds that may have found their way into the buildings should be chased out immediately.

2.1.9 Nurse chasing away birds from inside a ward


2.2 Guidelines for the cleaners of health facilities

Important job

The job of a cleaner in a health facility is as important as that of the doctors and nurses, because clean conditions in and around the health facility are essential to av oid the spread of diseases and to promote the well-being and quick recovery of the patients. But these clean conditions can only be achieved if the cleaners take the job seriously and follow the guidelines described below.

Attitude towards patients, visitors and hospital staff

Maintaining clean conditions in a heal th facility is not only the job of a cleaner, but that of all the occupants, that is, hospital staff, patients and visitors. Therefore, it is a jo int responsibility, which can only work if all parties cooperate. This can only happen when each person is treated with respect, and instructions about how to keep the place clean are given in a friendly manner.

2.2.1 General tools for cleaners

Cleaning tools

In order to maintain clean and tidy conditions, cleaners must be equipped with the right tools. Merely a set of grass and coconut brooms, a bucket and some rags are not enough. The following items are also essential (Fig. 2.2.1):


The outside area should be swept, and water should be sprayed, if the space is very dry and dusty. All waste bins should be emptied and the waste disposed of in special pits, which are excavated as far away from the buildings as possible.

In the later part of the morning.

Inside the buildings, all waste bins must be replaced by a fresh set of bins, while the full bins have to be taken away for appropriate disposal of the contents, after which the bins must be cleaned with bleach solution.

At least once a day, or whenever the bins are full.

All furniture, doors and windows must be wiped to remove dust.

Every alternate day.

Cobwebs must be removed from ceilings and walls, lights and fans must be wiped with a moist cloth, and dust removed from high level furniture, such as cupboards, shelves, etc., also behind and under furniture.

Once a month.

Rooftops must be swept clean and drainage gutters and outlets must be cleared of any debris.

Once a month.

Water tanks on roofs must be emptied completely and thoroughly cleaned inside and outside. It must also be ensured that the lids are not damaged and that they close the tank opening very firmly.

Every 6 months, or more often, if necessary.

Protective measures

Cleaners in a health facility must protect themselves against possible disease transmission or other dangers, for which they require the following items (Fig. 2.2.2):

2.2.2 Safety gear Cleaning routine The following routine will help to en sure a high degree of cleanliness and hygiene, which is absolutely essential for providing effective health care (also refer to the guidelines given in Sections 1.7 and 1.9).

What and where? When and how often?

Sweep the entrance area, patients' waiting space and corridors, and disinfect the same area with a mop and disinfectant solution (1% bleach solution, or diluted phenyl, Dettol, etc.).

At least twice a day (in the morning, before the out-patients queue up in the entrance area, and after the outpatients have gone).

Repeat the same procedure in all the other rooms, including the wards (inpatient department).

At least twice a day.

All bathrooms and toilets must be cleaned and disinfected.

At least twice daily, or whenever there is a need.


Cleaning procedures Special care is necessary when cleaning a health facility, in order to reduce the risk of disease transmission to an absolute minimum. Therefore, the following guidelines should be followed: • Sweeping floors with grass or coconut brooms should be done

very slowly, so that no dust is thrown up. It is better to use long handled brooms with short bristles, which do not throw up dust (Fig. 2.2.3). The dirt should finally be collected with a hand brush and dust pan, and disposed of outside the building in a suitable container, before final disposal in an earth trench.

2.2.3 Sweeping with traditional coconut broom and long handled broom

• Mopping floors must be done with clean water and a disinfectant

(1% bleach solution, or diluted phenyl, Dettol, etc.) in a bucket. Modern microfiber mops (Fig. 2.2.4) allow for quick and thorough cleaning, without leaving ugly stains at the skirting around the room or at the bottom edges of furniture. Fresh water and disinfectant should be used for every room. When furniture is moved aside for cleaning, it must be put back in the same position after the cleaning is over.

2.2.4 Mopping a floor with a microfiber mop


The waste bins inside the buildings must be emptied regularly (once a day, or whenever full). This should be done with gloves, in order to avoid coming in contact with harmful substances (Fig. 2.2.5). The bins are taken away for emptying, so fresh bins must be put in their place. After emptying the contents of the bins as described in Section 1.7, the bins must be sprayed clean with a hose pipe, or with a bucket of water and scrubber. Before putting them to dry they should be wiped out with a disinfectant solution.

2.2.5 Emptying a waste bin into a deep burial trench (ref. Fig. 1.7.12)

• The cleaning of bathrooms and toilets is absolutely critical, as the danger of disease transmission is highest in those areas. It is not sufficient to use a bucket of water and a coconut broom. It is better to use brooms with short plastic bristles and clear water (with a disinfectant added) to clean the floors. Patches on floors, walls, doors, etc. should be scrubbed with a hand-held scrubber and a strong detergent (Fig. 2.2.6), and later treated with a disinfectant solution. All corners and crevices of the WC pans must be scrubbed with special toilet brushes and special WC detergent or baking soda (sodium bicarbonate). Washbasins, water taps and other fittings must also be cleaned thoroughly with a separate brush and detergent, before rinsing with clear water and then applying a disinfectant solution.

2.2.6 Cleaning a bathroom


• Dusting furniture, doors, windows, etc. should also be done without distributing the dust into the air. Dusting should be done by wiping with a soft clean cloth, without forgetting the corners, crevices, holes, etc. (Fig. 2.2.7a + 2.2.7b). As frequently as possible, the duster must be taken out into the open and vigorously shaken to remove the dust. It should also be washed as often as possible, as only a clean duster is effective.

2.2.7a Dusting this way only distributes dust

2.2.7b Careful wiping with a soft clean cloth removes dust effectively

• Cobwebs develop on all walls and ceilings, and particularly in corners that are not easily accessible, as well as behind cupboards, underneath tables, etc. These should be removed with a special cobweb duster (feather duster) with a long handle to reach the ceiling and upper walls (Fig. 2.2.8). After removing some cobwebs, the duster must be vigorously shaken outside the building, or rubbed against the outer side of the building or over a clean patch of grass to remove the cobwebs and dust.

2.2.8 Cobweb removal


• In the labour rooms, the delivery tables must be thoroughly cleaned after every delivery (Fig. 2.2.9). The metal tables with a hole in the middle must be scrubbed with a brush, water and detergent to remove all blood stains, and subsequently disinfected.

2.2.9 Cleaning a delivery table

• In operation theatres (OTs), the operating tables should be covered by a freshly sterilized rubb er or plastic sheet, which must be replaced after every operation (Fig. 2.2.10). The soiled sheet must be thoroughly cleaned and disinfected in an appropriate place outside the OT and stored in a clean place for its next use.

2.2.10 Operating table with rubber sheet


• Monthly cleaning of rooftops (Fig. 2.2.11) is very important, because dirt is carried up by wind or leaves fall from surrounding trees, causing drainage outlets to be choked. When water is not drained from the roof, it finds its way down through cracks in the ceiling, damaging the building, furniture, equipment, etc. Therefore, every month all the debris must be removed and the gutters thoroughly cleaned. Any plants that begin to grow on or around the roof must be removed immediately. The water tanks should be inspected to see whether they need to be cleaned.

2.2.11 Cleaning rooftops

• When walking around the buildings and compound, cleaners – as well as all other staff members – should make sure that no garbage is lying on the ground or in drainage gutters (Fig. 2.2.12), that no plants are growing anywhere on the building walls, or roof, and that there are no water puddles, in which mosquitoes can bread. If garbage is found, it should be collected and disposed of correctly, plants should be ripped out immediately, and puddles should be filled up with sand or earth, or if that is not possible, a few drops of oil should be put in the puddle to prevent mosquito breeding (ref. Fig. 1.6.6).

2.2.12 Cleaning the compound


2.3 Guidelines for the patients, their relatives and visitors Attitude towards hospital staff and other patients and visitors Patients may suffer from pain, fever, respiratory problems and many other ailments, requiring much attention and help. While some patients are passive and quiet, others tend to demand attention every few minutes. It is important for patients to remember that the hospital staff is usually under great pressure to attend to all patients and manage all the daily work. Therefore, patients should try not to overburden the hospital staff with petty requests. Addressing the staff and other patients and visitors in a friendly way will help to avoid tension. Patients, their relatives and visitors must always avoid making noises and speaking loudly, as it can be very disturbing to other patients in the room (Fig. 2.3.1).

2.3.1 Loud patients and visitors

Maintaining cleanliness In a place where there are many sick people, the risk of diseases being transmitted to other people is very high, and can only be prevented by maintaining absolutely clean conditions. While the cleaners are doing their best to keep the health facility clean, it is essential for the patients, their relatives and visitors to avoid any activity that creates dirty or unhygienic conditions – and this is in their own interest. This means that garbage should not be thrown away thoughtlessly somewhere in the room, instead of in the garbage bin. Very often leftovers of meals are just thrown out of the window (see Fig. 2.1.7). This is very unhygienic and adds to the work load of the cleaners. Similarly, spitting inside the rooms (Fig. 2.3.2) or out of the windows is unacceptable (ref. Fig. 3.1.5).

2.3.2 Spitting marks inside a room


After using a bathroom or toilet, patients must always leave the place in a clean condition for the next user. This means that the bath place must be cleaned with a bucket of water, and the toilet pan must be flushed with enough water to remove all stains (Fig. 2.3.3). If necessary, some paper or a toilet brush should be used to remove stains.

2.3.3 Patient pouring a bucket of water into a toilet

The toilet pan is not a place to dispose of garbage Under no circumstances should any garbage, food leftovers, waste paper, cloth, cups, or any other items be thrown into the toilet pan, as all these items will choke the drains, making the toilets unusable. Also no liquids other than water should be poured into toilets, especially if they are connected to septic tanks, because oils, grease, paints, medicines, detergents and other chemicals can interfere with the natural biological processes that take place within the septic tank (Fig. 2.3.4).

2.3.4 No garbage in the toilet pan

food waste

oil

packaging

cups

paint

old medicine


Never bring healthy children to a hospital In a health facility, all staff members, patients and visitors are at risk of contracting a disease. Therefore, unnecessary visits to health facilities should be avoided. This applies particularly to small children, whose immune system is generally weak. But even young, middle-aged and elderly people may be at risk and should stay away from health facilities. However, if taking children to a hospital cannot be avoided, it must be ensured that they do not touch infected items (patients’ beds, garbage bins, toilets), or play on the floor. Healthy people should never share food or drink with a sick person, as the risk of disease transmission is very great. Diseases can be transmitted via clothes and body contact A healthy person returning from a visit to a health facility may be the transmitter of a disease to someone, who has not been to the health facility. This transmission can take place through the clothing, footwear, hands, hair, etc., which has come into contact with infectious material, bacteria and viruses. So although it is not possible for visitors to avoid touching patients’ beds, walls, doors, etc., they should always wash their hands before leaving the hospital – however, they should never use the same towels as the patients, as these are a direct source of infection. At home, it is advisable for visitors returning from a hospital to immediately change their clothing and take a bath, as germs can attach themselves to any part of the body, in the hair, under finger nails, and so on.


PART 3General health guidelines

79

80 PART 3 – General health guidelines

PART 3 – General health guidelines 3.1 Guidelines for general health precautions How are diseases transmitted? Diseases can be transmitted in many ways, such as: • by droplet contact – caused by coughing or sneezing on another

person; • by direct physical contact – that is by touching an infected person,

and by sexual contact; • by indirect contact – that is by touching contaminated items of

infected persons (towels, beds, telephone, money, etc.) or contaminated surfaces (floors, walls, door handles, stair rails, etc.)

• by airborne transmission – through dust particles, which can carry infectious microorganisms through the air;

• by faecal-oral transmission – through dirty hands, contaminated water sources and food;

• by vector borne transmission – carried by insects or other animals; • by transmission through blood transfusions – if the blood or

needles are contaminated. The diseases are caused by pathogens, which are microorganisms, such as bacteria, viruses, algae, fungi, protozoa (Fig. 3.1.1), which enter the body through body openings, such as nose, mouth, rectum, or open wounds.

Name of Microorganism Type Disease caused A Mycobacterium tuberculosis Bacteria TB B Streptococcus pyogenes Bacteria Sore throat, Impetigo C Yersinia pestis Bacteria Plague D Borrelia burgdorferi Bacteria (corkscrew

shaped) Lyme disease

E Rhinovirus Virus Common cold F Measles virus Virus Measles G Aspergillus flavus Fungus Aspergillus (lung

infection) H Giardia lamblia Protozoa Severe dysentery

A

B

C

D

E

F

G

H

3.1.1 Some harmful microorganisms

PART 3 – General health guidelines 81

How can disease transmission be prevented? Understanding how diseases are transmitted is the first step towards prevention. Maintaining clean conditions is the most vital requirement, but also considerate and respectful behaviour towards other people and correct procedures in daily activities are important for protecting oneself and others from getting infected by diseases. Some of the main preventive measures are: • avoiding transmission through sneezing, coughing and spitting; • avoiding direct contact with sick people, animals, garbage, etc.; • maintaining personal cleanliness regularly; • keeping all parts of the house, furniture, and equipment clean; • ensuring cleanliness in food preparation and eating; • avoiding water from questionable sources; • protecting oneself by immunisations; • protecting oneself from harmful creatures (see Section 3.2).

3.1.2 Sneezing without covering mouth and nose

Avoiding transmission through sneezing, coughing, spitting and nose picking The amount of droplets discharged during sneezing can be seen by sneezing into one’s own hands, which usually become very wet. Coughing and sneezing without covering mouth and nose (Fig. 3.1.2) can discharge germs and infected droplets over several metres, and may cause infection to other people within that distance. A way to avoid transmission of germs is by covering mouth and nose with a handkerchief when coughing or sneezing (Fig. 3.1.3), however the handkerchief may itself transmit diseases, if it comes into contact with another person. A better way to avoid affecting other people is to sneeze into one’s elbow (Fig. 3.1.4). This way, people close by, as well as food, drink, furniture, etc., and even one’s own hands cannot get contaminated by droplets resulting from sneezing or coughing.

3.1.3 Sneezing into a handkerchief

3.1.4 Sneezing into an elbow

82

Spitting in public places (just like littering public places) is a public nuisance. But at least for health reasons, spitting in the presence of other people and spitting inside rooms (on walls, floors, furniture, out of the window, etc.) should be forbidden (Fig. 3 .1.5), as saliva can contain infectious germs, which can attach themselves to other people’s skin or clothing and thus cause infections. If spitting cannot be avoided, it should be done in a spittoon or garbage bin, or in a toilet, where it must be washed down with sufficient water.

3.1.5 Spitting out of windows must be forbidden

PART 3 – General health guidelines

3.1.6 Nose picker

Picking one’s nose in other people’s company is not only an ugly sight (Fig. 3.1.6), but also a source of disease transmission, if the hand is used for preparing or serving food, or for a handshake. Disease transmission can also occur by scratching a wound, squeezing out a pimple, rubbing the eyes or cleaning the ears or other body parts.

Avoiding direct contact with sick people, animals, garbage, etc. It is not always possible to avoid coming into contact with sick people, stray animals and pets, and even with garbage, often unknowingly through footwear and clothing. In all these cases, one can pick up dangerous germs. Whenever this happens, it is vital to wash hands and other possibly contaminated body parts, as well as change into clean clothing. Regular personal cleanliness Personal hygiene is the best protection against disease. Washing hands many times a day (Fig. 3 .1.7), especially after touching dirty items (garbage, animals, dirty furniture, brooms, brushes, etc) is of vital importance. A bath should be taken at least once a day, using clean water and soap. Complete drying with a clean towel is essential, also between fingers and toes, or else painful and itchy fungal infections can develop there. Towels should be hung up to dry thoroughly before the next use. Underwear, socks and sweaty shirts should be changed at least once a day.


3.1.7 Hand washing


Brushing teeth (Fig. 3.1.8) for about two minutes at least twice a day (morning and evening) and whenever food gets stuck between teeth, especially fibres and sticky sweets, is essential to avoid health problems. Neglecting regular and thorough mouth hygiene is the cause of tooth decay, paradontosis and bad breath, but can also lead to severe diseases, such as heart problems, stroke, diabetes and a few others.

Keeping all parts of the house, furniture, and equipment clean Keeping a house clean does not only mean sweeping and mopping the floors, but also dusting furniture, equipment and fittings without distributing the dust. Cobwebs should be removed at least once a month. Dark spaces behind or under furniture and equipment tend to gather dust, and can be moist if not properly ventilated. This can attract undesirable creatures (cockroaches, rats, etc.) or develop fungus, and must be avoided at all costs.

Ensuring cleanliness in food preparation and eating Clean hands are the most essential requirement in food preparation and eating. This is unfortunately rarely ensured when eating food from roadside vendors. All vegetables, fruit, meat, fish, as well as all utensils must be thoroughly washed before cooking and serving. When drying utensils, the cloth must be clean and dry. Foodstuffs must be well protected in sealed containers against flies, cockroaches, lizards, birds, etc., which can contaminate the food. When serving food and drinks, care must be taken not to contaminate surfaces with dirty hands (Fig. 3.1.9). When cleaning a table, a moist cloth should be used to remove remains of food and liquids, and then dried with a clean dry cloth.

Fig. 3.1.9 Avoiding contamination by dirty hands

3.1.8 Brushing teeth

The wrong way to hold a spoon or glasses

The right way to hold a spoon or glass


Avoiding water from questionable sources

Clean water is essential for maintaining healthy conditions, but is unfortunately not always readily available. Even water that comes out of piped water supply may be contaminated, if the water tank, where it was stored, has not been cleaned for a long time. Water from a tube well is usually cleaner, but may also be polluted, if a garbage dump, defective sewage pipe or polluting workshop or factory is close by. Therefore, if a commercial water filter (Fig. 3 .1.10) is available, it should always be used, but it must be ensured that the filter cartridge (candle) in the upper chamber is clean, otherwise the water will not be purified. In all cases, the safest solution is to boil the water, but not more than a minute (to save energy and wastage of water through evapo-ration). If the water is clo udy, it should be filtered through a clean cotton cloth or clean filter paper before boiling. If a clear, clean transparent plastic or glass bottle (not coloured) is available, it can be used to purify water: the bottle filled with water should be placed in a sunny place on a roof or other suitable surface for at least 6 hours (ref. Fig. 1 .8.10). The sun’s ultra-violet rays kill 99% of the harmful micro-organisms that cause cholera, diarrhoea, and other diseases. This may not work with cloudy water, therefore only filtered, clear water should be used.

Protecting oneself by immunisations Not all, but many diseases can be prevented by immunisation. Every country has an immunisation programme, which differs from country to country, as the types of diseases differ, due to different climatic conditions, traditions and lifestyles. Immunisation programmes also change periodically , when new vaccines are available, when new diseases emerge, or old diseases are eliminated (e.g. smallpox). In India, it is therefore necessary to follow the recommendations of the Ministry of Health and Family Welfare.

Some of the main diseases, for which vaccines are available, are shown in the table on the next page.

3.1.10 Cut-out view of commercial water filter


Overview of the main vaccinations available It must however be noted that these are merely guidelines, taken from different sources of information, many of which differ slightly from one another. For details about the most appropriate type and time of vaccination, it is essential to follow the advice of an experienced doctor or the local medical authorities. Disease Transmission Vaccination Tuberculosis (TB) Sneezing, coughing,

speaking and spitting (sputum).

BCG (Bacillus Calmette-Guérin) vaccine given at birth, or along with DTP-1.

Diphtheria Sneezing, coughing, and unhygienic conditions.

(DTP = Diphtheria, Tetanus, Pertussis) DTP-1,2,3 vaccine providing combined immunisation of all three diseases; 3 shots given to infants between 6 and 14 weeks, and boosters at 15-18 months and 5 years, also every 10 years afterwards. Alternative vaccines are DTaP and Tdap, which have fewer side effects.

Tetanus Wounds caused by animal bites, or by contact with soil, animal excreta, etc.

Pertussis (Whooping cough)

Sneezing, coughing, and unhygienic conditions.

Measles Sneezing and coughing. MMR (Measles, Mumps, Rubella) vaccine, 2 doses (first at 12-15 months and second at 4-6 years ).

Mumps Sneezing, coughing or touching infected surfaces.

Rubella (German measles)

Sneezing and coughing.

Disease Transmission Vaccination Poliomyelitis (Polio)

Contact with stool from infected person, close contact / sharing food with infected person.

OPV (Oral polio vaccine) given together with DTP vaccines to children (at 6, 10 and 14 weeks) orally on lump of sugar (cheaper, easy to administer), or as IPV (Inactivated polio vaccine, which is safer, but more expensive); boosters at 18 months and 5 years, then every 10 years.

Hepatitis A Faecal-oral transmission through contaminated food and water, and poor hygienic conditions.

Hepatitis A vaccine (HAV), given in 2 doses at 6-12 months interval (not for children under 18 months).

Hepatitis B Exchange of bodily fluids, unsterilized needles, unprotected sexual contact, etc.

Hepatitis B vaccine (HBV), given in 3 doses, starting at birth.

Haemophilus influenzae type b (Hib), causing , childhood pneumonia and meningitis.

Sneezing and coughing. Hib vaccine, given in 3 doses in the first year of age, and last dose at 12-18 months.

Typhoid Faecal-oral transmission through contaminated food and water, and poor hygienic conditions.

First vaccine at 2 years, then every 3-4 years.


3.2 Avoiding diseases transmitted by insects and animals Which creatures are harmful, what diseases do they transmit, and how are the diseases transmitted? The creatures referred to here are only those found in and around health facilities and people’s homes. The most common insects as well as some wild and domestic animals, and only the most common types of diseases transmitted are: A. Mosquitoes, (Fig. 3.2.1) the deadliest of all creatures, which can

transmit malaria, dengue fever, chikungunya, filariasis, yellow fever, Japanese encephalitis.

Each disease is transmitted by a different species of mosquito, but it is always the female mosquito that bites and sucks blood, which it requires for the development of its eggs. In the process it injects the disease generating pathogens (viruses, protozoa, parasites), which it had earlier taken up from a sick person. Anopheles, Culex and Mansonia mosquitoes that transmit malaria, filariasis, and Japanese encephalitis usually bite in the evenings, night and early mornings, while Aedes mosquitoes (that transmit dengue fever, yellow fever and chikungunya) bite during daytime.

B. House flies, (Fig. 3.2.2) which can transmit diarrhoea, typhoid fever, cholera, tuberculosis, anthrax, ophthalmia, and parasitic worms.

The germs that cause these diseases are ingested by the fly or stick to its legs and mouth parts, when it feeds on garbage, faeces, blood, open wounds, dead animals, and other infected material. The fly does not bite, but contaminates food and water by its saliva, which it secretes while feeding, or through germs attached to its body.

3.2.2 House fly3.2.1 Mosquito


C. Cockroaches, (Fig. 3.2.3) which can transmit gastroenteritis, typhoid fever, cholera, salmonella, anthrax, hepatitis A, and parasitic worms.

Transmission of diseases occurs when the cockroach comes into contact with food and water, or any objects that come into contact with a person’s hands or face (bed sheet, pillow cover, towel, etc.), from where the germs can enter the mouth, open wounds, etc.

D. Fleas, (Fig. 3.2.4) which can transmit plague, murine (rat)

typhus, rabbit fever. These diseases are transmitted through the bite or the faeces

of the infected flea. Fleas that attack humans live mainly in the fur of cats, dogs, rats and mice.

E. Rats and mice, (Fig. 3.2.5) which can transmit rat bite fever,

leptospirosis, and a few other diseases. The diseases can be acquired through the bite or scratch of a

rodent or through ingestion of food or water contaminated with rat faeces.

F. Bats, (Fig. 3.2.6) which can transmit rabies and histoplasmosis. Rabies can be acquired through the bite of a bat, while

histoplasmosis is caused by a fungus which grows on bat faeces, which can come into human contact.

3.2.3 Cockroach 3.2.4 Flea

3.2.5 Rat and mouse

3.2.6 Bat


G. Birds, (Fig. 3.2.7) which can transmit salmonellosis (food

poisoning), psittacosis (parrot fever), histoplasmosis, avian influenza (bird flu), and some other diseases.

Salmonellosis can be acquired by eating contaminated poultry and eggs. Contact with live or dead infected birds and birds’ droppings can lead to psittacosis, histoplasmosis and other diseases.

H. Dogs and cats, (Fig. 3.2.8) which can transmit rabies, tetanus,

roundworm, ringworm, tape worm. All these diseases can be transmitted through bites, scratches

or just by contact with infected animals or their faeces. I. Sheeps, goats and cattle, (Fig. 3.2.9) which can transmit

brucellosis and Q fever. The diseases are transmitted through contact with infected

animals or their faeces.

3.2.7 Birds

3.2.8 Dog and cat

3.2.3 Sheep, goat, cow


Protective measures against diseases transmitted by insects and animals Almost all diseases mentioned above can be avoided by following a few simple rules. Personal cleanliness and hygiene By washing hands and other body parts that may have come in contact with live, wounded or dead animals and birds, or their faeces, the danger of infection is considerably reduced. Subsequently rubbing the hands and body parts with a disinfectant solution, such as Dettol, will ensure the best possible protection against infection. Even if the animals or birds appear healthy, hand washing should never be forgotten after touching them. Under no circumstances should people touch their mouth, nose and eyes, if the hands are not washed after touching animals or birds. This also means that hands must be washed after food preparation, especially after handling raw chicken, fish, meat, etc. Clean and tidy conditions Garbage heaps, dirty corners, piles of discarded and condemned items, all provide nesting and feeding places for harmful insects and rodents. This can be avoided by maintaining clean and tidy conditions in all areas inside and outside the buildings.

3.2.10 Foodstuffs kept under cover

Protecting food and drinks If food and drinks are left uncovered, they will attract flies, cockroaches, rats and other creatures, which may be carrying germs on their bodies, or in their saliva. People who consume such contaminated food and drinks are very likely to get seriously ill. Therefore, all foodstuffs must be kept under cover (Fig. 3.2.10), drinks must be kept in closed containers, and fruits and vegetables that are eaten raw must be washed thoroughly in fresh clean water before eating.

Dome shaped hood of fine insect-proof netting

A plate laid over a cooking pot

Cardboard or plastic box

A piece of mosquito netting, weighed down by beads


Preventing mosquito breeding Mosquitoes can breed in any stagnant water, whether clean or badly polluted. It is therefore vitally important to prevent accumulation of stagnant water and to prevent mosquitoes from entering water tanks and any other items containing water. The following measures must be followed: (Fig. 3.2.11) • the lids of water tanks and septic tanks have to be

tight fitting and locked; • all rainwater drainage gutters and outlets must be

absolutely free of garbage and debris, so that all water is drained, and no puddles are left in which mosquitoes can breed;

• no empty pots, cans, bottles, etc. should be left lying around, or they should be turned upside down, or the openings should be covered to prevent accumulation of water;

• in bathrooms and kitchens, no buckets or mugs containing water should be left uncovered;

• all potholes and ditches, in which rainwater can accumulate, must be filled up, but if that is not possible, a few drops of oil spread on the water surface will prevent mosquito breeding;

• water that collects in cavities in certain plants, such as bromeliads (e.g. pineapples) and axils of banana plants, has to be removed to avoid mosquito breeding;

• garbage containing broken glass, ceramic, rubber and plastic items, empty coconut shells, old car or bicycle tyres, etc. must be removed quickly.

3.2.11 Some typical mosquito breeding places


Preventing nesting possibilities for birds People can get infected by inhaling germs distributed in the air through the fluttering wings of birds, or by eating food on which germs may have settled. Touching birds’ droppings or dead birds can also be dangerous. Therefore, birds should not be allowed to find a nesting place anywhere inside or around buildings. There should be no holes or recesses, or these should be closed by wire mesh (Fig. 3.2.12). Anti bird spikes should be fixed on all horizontal beams or projections, to prevent birds from landing on them (ref. Fig. 1.3.4).

3.2.12 Wire mesh protection against birds

Protection against insect bites There are several measures to protect oneself against insect bites, for example: • loose clothing that covers the whole body, as mosquitoes can bite

through tight-fitting clothes; • insect screens fitted to all windows and ventilation openings

(which must be inspected regularly for holes or gaps between frame and screen), in order to prevent mosquitoes from entering a building – the same applies to gaps between the roof and walls, which could also be avoided by means of a false (suspended) ceiling (Fig. 3.2.13);

3.2.13 False ceiling


• mosquito nets, without any holes, hung over each bed and tucked under the mattress at all sides, to prevent mosquitoes, as well as other harmful creatures (fleas, flies, cockroaches, spiders, lizards, rodents, etc.), from entering – bed nets that are impregnated with a pyrethroid insecticide (Fig. 3.2.14), can kill or incapacitate insects that come in contact;

• insect repellent lotions, creams or sprays applied on unprotected body parts can be very effective, but may cause allergic reactions on some people;

• insecticide vaporisers, in the form of mosquito coils and electric liquid vaporisers (e.g. AllOut, Good Knight), can be effective in paralysing or killing mosquitoes, or preventing them from entering the room;

• spraying rooms with insecticide may also be effective, but can also be harmful to people, if it is sprayed on the bed, clothing or food.

Fig. 3.2.14 Spraying mosquito nets with insecticide


3.3 Passing on the knowledge All the information presented in this booklet is focussed on improving the health situation amongst the less privileged population. While special emphasis is laid on improving the condition of health facilities, the intention is to sensitise the people about the many dangers to their health and the precautions they can take to avoid such dangers. However, this information can only serve its purpose if it reaches all the people, even in the remotest village. Therefore, every opportunity should be taken to pass on this knowledge to all people, young and old. Here are some suggestions. Teaching children how to maintain a healthy lifestyle It is never too early to learn how to maintain a healthy lifestyle, both personally and in relation to other people. Most people who have not been taught good practices at a young age are less inclined or find it difficult to change bad habits, such as littering, spitting, touching foodstuffs with dirty hands, etc. If maintaining clean and hygienic conditions, as well as behaving considerately and responsibly in public is taught to children, for instance in schools or when visiting a doctor (Fig. 3.3.1), these practices will become habits. And there are many instances where children have passed on their knowledge to grownups, sensitising them about things the grownups never learnt when they were young. Therefore, any effort to improve the health situation in a country can only be successful if children are taught good practices from day one at school.

3.3.1 Teaching young children about health


Making good health practices a central issue in religious gatherings Most people follow a religion and regularly visit religious festivals and gatherings. For them certain rituals and religious practices have become integral parts of their lives and are followed without giving thought to changing these practices, as these are considered divine rules. If religious leaders would include good health practices and environmentally appropriate behaviour as an important part of their teachings (Fig. 3.3.2), most people will accept them and be willing to change their behaviour.

3.3.2 Teaching good health practices at religious gatherings


Providing health information at health fairs and in the media Most of the underprivileged population have no access to information on healthy living and environmentally appropriate behaviour. If any change is to be brought about in their lives, this knowledge must be made available to them on a large scale. A very effective means to do this is through health fairs, which are taking place around the country. But the number and frequency of these events need to be increased manifold. Also the nature of the presentations should be designed to attract maximum attention, e.g. by staging humorous shows or involving local celebrities and role models (Fig. 3.3.3). The same applies to radio and television shows, which can reach even the remotest village. Regular spots, jingles, quiz shows and prime time feature films starring popular actors, are the best means to initiate sensitisation and change of attitude amongst the people, without exerting pressure.

3.3.3 Providing health information at health fairs


Passing on the knowledge by word of mouth and by setting good examples Most of the information in this booklet is well known to a large section of the population, such that good health practices and good environmental behaviour prevail at all levels of society. It is therefore up to “those who know” to pass on the knowledge to “those who do not know” (Fig. 3.3.4). Setting good examples is another important form of passing on the knowledge. All these measures will help to achieve a significant improvement in the health situation and enable the people to live long and healthy lives.

3.3.4 Passing on the knowledge

Handbook of Good Practices PDF

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