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A feasibility study is planned for the study area of [], []. The study area is located [], covers an area of []
square kilometers and a population of [] inhabitants. The income level of the study area, expressed as
Gross Domestic Product per capita per year, is [].
Most wastes generated by hospitals and medical clinics are non-hazardous general wastes from hospital
organization activities (i.e., including kitchen wastes, office materials, workshop residuals) and patient
processing activities in wards which are not handling infectious diseases (i.e., first aid packaging, used
but emptied disposable bed liners and diapers, disposable masks, pharmaceutical packaging, etc.). After
source segregation of recyclables, disposal is typically by sanitary landfill.
Potentially hazardous wastes from hospitals and clinics which have a pathogenic, chemical, explosive, or
radioactive nature are called “medical wastes”. Medical wastes include the following:

pathological wastes (i.e., body parts, aborted fetus, tissue and body fluids from surgery; and
dead infected laboratory animals);
infectious waste (i.e., surgical dressings and bandages, infected laboratory beddings,
infectious cultures and stocks from laboratories, and all waste from patients in isolation
wards handling infectious diseases);
sharps (i.e., needles, syringes, used instruments, broken glass);
pharmaceutical wastes (i.e., soiled or out-of-date pharmaceutical products);
chemical wastes (i.e., spent solvents, disinfectants, pesticides and diagnostic chemicals);
aerosols (i.e., aerosol containers or gas canisters which may explode if incinerated or
radioactive wastes (i.e., sealed sources in instruments, and open sources used in vitro
diagnosis or nuclear medical therapy); and
sludges from any on-site wastewater treatment facilities may be potentially hazardous.

Pathological wastes should be destroyed by incineration under high heat (i.e., over 900o C with an
afterburner temperature at over 800o C), although some countries require burial of human pathological
wastes at official cemeteries for religious reasons. To reach these temperatures and have adequate
afterburning and pollution control typically requires development of a regional medical waste facility.
Smaller individual hospital or clinic incinerators may not be able to reach these temperatures and
afterburning retention periods. Volatilized metals (such as arsenic, mercury, lead) and dioxins and furans
could result from inadequate burning temperatures and retention periods.
Other procedures to consider may include chemical disinfection or sterilization (i.e., irradiation,
microwave, autoclave, or hydroclave) followed by secure landfill disposal of residuals. In some cases,

and is considered potentially hazardous: 0. or imaging range from 6 hours to several days.0 to 2. secure land disposal or return to the manufacturer for destruction through chemical or incineration methods. and “sealed sources” which involve indirect use of the substance within a sealed apparatus or equipment unit. by drug users). Storage on-site in a secured chamber is typically recommended for a period of 10 half-lives. including custodial personnel and waste collectors. some wastes may be recycled. as well as to those providing disposal or picking through the wastes for recyclables.e. There is the danger that syringes will be recovered from transfer depots and disposal sites by waste pickers for recycling (i. because the hospitals do not have the equipment and technology to generate these wastes. Hospital wastewater treatment sludges require treatment (i. Chemical wastes need to be source segregated according to their recycling potential and compatibility. but are circulated throughout TERMS OF REFERENCE FOR HOSPITAL WASTE STUDY 2 . thallium 201. and thallium 204. anaerobic digestion. Contaminated containers for collection of medical wastes are not usually dedicated to only one site. For developing countries. composting.following complete disinfection.) which raises temperatures to levels that destroy pathogenic microorganisms. neutralization. and syringes. For example. diagnosis. and  contaminated medical waste which needs special management. if not properly managed. The half-lives of commonly used medical radionuclides for therapy. the data base is limited. If generated. but it appears that the following range of quantities is likely:  general waste which is not contaminated. and can be handled with general municipal refuse: 1. iridium 192. while middleincome countries would tend to generate medical wastes on the upper end of this range.. incineration. These wastes are seldom present in low-income and middle-income developing countries. Pharmaceutical wastes require destruction. as sealed sources are returned to the manufacture for recycling when exhausted or no longer required. such as intravenous bags and tubs. and those which are non-recyclable may require stabilization.2 to 0. The overall quantity of wastes generated in hospitals varies according to the income level of the country.0 kg/bed/day. pose a risk to the personnel who are handling these wastes. cesium 137. The study area is within a [] income country. iodine 131.e. Radioactive wastes typically include isotopes such as technetium 99. Only open sources tend to result in radioactive wastes. based on ranking criteria established by the World Bank and published in its annual development report. etc. Radioactive medical therapy and diagnosis in high-income countries are divided into two categories: “open sources” which derive from direct use of the radiochemical substance. Medical wastes. iodine 125.8 kg/bed/day. recycling by specialized contractors is sometimes arranged after disinfection of thick plastics. or incineration. Low-income countries would tend to generate medical wastes on the low end of this range. encapsulation.. these wastes should be stored safely until the radioactivity has declined to acceptable levels and then disposed with general refuse to sanitary landfill. or for one to two months. gallium 67.

and Operate (DBOO) or Design. As part of the privatization agreement. Transportation and setup may add about 10% to these costs. and setup costs within the study area. Operate and Transfer (DBOT) concession agreements of 10 to 15 years duration. Build. Civil works and land costs which are local costs may add about 30% to these costs.0 million to implement.75 tonne/hour. Regional incinerators would typically be designed to operate on a continuous feed basis. Secured sanitary landfill is generally considered the preferred technology for medical wastes which do not require incineration or disinfection. customs may not need to be paid. Therefore. TERMS OF REFERENCE FOR HOSPITAL WASTE STUDY 3 . Each hospital would be required to pay tipping fees which fully cover the costs of investment. Hospital waste treatment/destruction facilities could be implemented through one or more Design. Incineration is generally considered the preferred technology for some. No waste picking should be allowed in the secured area. operating on a continuous feed. could cost another $ 0. On-site incinerators operating on a batch basis or regional incinerators operating on a continuous basis are considered appropriate technology. Or the government could implement the facilities and arrange for service contracts of 2 to 5 years for operation and maintenance. body parts. If government imports the equipment. as their capacity is limited to less than 1 tonne/day. Instead. medical wastes.0 million to implement. the waste should be dumped into a trench and a adequate layer of soil dumped over the waste. special measures to fence and control access to the area of landfilling for medical wastes are essential. infected tissue. At a minimum. However. such as packaging materials and general kitchen wastes. if the private sector is building the facility and needs to import the equipment. exclusive of salaries. Because of the cost of meeting stringent air pollution control emission standards. if they are added to meet 1995 USA standards. One hospital incinerator with a capacity of 0.cities as each skip truck brings an empty container to the hospital or clinic and removes the full one while it covers its daily collection route for general refuse. the machinery for compacting refuse should not come in direct contact with the waste. Also. customs. the company providing the treatment/destruction services could also be awarded the task of also providing collection of the wastes from each hospital and maintaining a manifest system to track the waste from source to ultimate disposal. if not all. or gas/vapor sterilize some of the medical wastes. chemically disinfect. the low quantities of medical wastes in developing countries would result in a costs which generally would be less than 1% of the most hospital's operating budget. debt service and operation. Air pollution control systems. the proper treatment/destruction facilities are likely to be affordable. While the costs/tonne of treatment/destruction are likely to be high (about $100 to $300/tonne depending on the level of pollution control required). Own. Build. Only thereafter is it recommendable that the machinery work over the soil covered waste to compact it and grade the surface so that infiltration of rainwater is minimized. These equipment costs do not include transportation. Nevertheless. could cost from $US 0. Incinerators which operate on a batch basis are typically dedicated to one hospital. many high-income countries are taking steps to steam sterilize. customs could add about to these costs. especially as it is for waste management purposes.5 to 1.5 to 1. and laboratory animal carcasses are generally recommended to be incinerated. Hospitals interviewed in various developing countries have indicated a willingness to pay to cover these costs. irradiate.

estimate the capacity requirements for existing hospital treatment/destruction facilities for the study area. from the above visual observations. based on transport distances and economies of scale. plastics. the following objectives are to be addressed:        determine the quantity and character of hazardous medical wastes generated by hospitals and clinics in the study area.STUDY OBJECTIVES The feasibility study will assess the technology options for medical waste treatment/destruction. Technologies to be considered include incineration. evaluate the progress being made in source segregation and develop recommendations for improving the source segregation systems of hospitals and clinics in the study area. on both a dry and wet weight basis. cloth. Estimate the calorific heating value of combined mix of medical wastes. Determine the quantity and character of medical wastes generated in the study area. SCOPE OF WORK Task 1: Waste Quantity and Character. including pathological. As part of the effort to make this determination. sizes. accomplish the following activities. Based on the records kept by the solid waste authorities within the study area and the hospitals. pharmaceutical. and radioactive wastes. This will involve TERMS OF REFERENCE FOR HOSPITAL WASTE STUDY 4 . and assess the environmental impact issues of implementing each the hospital waste facilities recommended and recommend appropriate mitigative measures to enable the facilities to meet [] environmental requirements. provide a preliminary design. weigh hospital waste loads for a period of at least 4 days. determine the number and size of hospital waste treatment/destruction facilities needed. such as the contaminated paper products. rubber. capital. wood. For purposes of the proposed study on hospital waste management. and estimate land. determine the volume and weight of medical wastes being collected. sharps. chemical. infectious. tissue. operating. irradiation. chemical disinfection and sterilization. body and bedding materials. based on the apparent contents of the waste. determine the optimum technology for cost-effective and environmentally safe treatment/destruction of medical wastes in the study area. as well as available sites for implementation. and types of medical waste treatment/destruction facilities. and staffing requirements for each of the hospital waste treatment/destruction facilities recommended. fabrics. If data does not exist. pharmaceutical. aerosol. The study will result in recommendations which outline proposed numbers. Visually describe the composition (on a percent wet weight basis) of medical wastes to be managed by treatment/-destruction facilities. including a typical site layout.

Sample. resins. and other permitting requirements and procedures which treatment/destruction facilities for medical wastes would need to address. Assess the costs versus the pollution control differences between dry versus wet scrubbing systems. Task 4: Regulatory Requirements. solvents. Estimate the total quantity of medical waste which would be generated in the study area if all hospitals were fully implementing adequate source segregation. For each of the hospitals visited. project the quantity and characteristics of medical wastes which are expected to be generated over the next 20 years. Visit at least [] hospitals to review their systems of medical waste segregation. Estimate the quantities of the liquid wastes which could be burned with the solid medical wastes. Conduct laboratory analyses of the calorific values and moisture contents of the samples. Assess the typical time demands for proposed facilities to obtain permits and address environmental impact assessment and public participation requirements. TERMS OF REFERENCE FOR HOSPITAL WASTE STUDY 5 . and dioxin removal. determine whether the variance is related to compliance with the source segregation system. trends in hospital waste generation and source segregation. Assess the corresponding air pollution control requirements for particulates removal. Assess whether there are liquid wastes from the hospitals which could be burned in conjunction with the solid medical wastes and might add to the heat value of the overall waste mixture. such as alcohol. estimate the volume/bed/day of refuse. Assess whether the addition of these liquid wastes would compromise the air emissions from the proposed treatment/destruction facility. Provide an estimated breakdown in terms of the quantity of medical waste requiring: (i) special storage for radiation decay. strippers. Task 3: Project Waste Quantities and Characteristics. coolants. on an accepted random sampling basis. thinners. phenols. list the lead agency to be contacted. Outline the environmental permitting. at least 4 loads of medical waste arriving at disposal sites. population growth projections. For each requirement. Particularly determine the air emission standards which are currently required by [] law and which would be likely to be required in the next 10 years. (ii) treatment/destruction in a medical waste facility. Report results in terms of wet “as received” lower heating value (in kcal/kg and BTU/pound). economic growth projections. building permitting. If there are wide variations among the hospitals visited. Also outline any public participation or public hearing requirements and procedures. and (iii) amenable to recovery and recycling. Inspect the storage facilities and estimate the pre-collection volume of medical waste being generated and segregated. out of the total being generated. and emulsions. dry higher heating value (in kcal/kg and BTU/pound). oils. Task 2: Source Segregation Systems. Determine all pollution control standards to be met by a medical waste treatment/destruction facility in []. flue gas scrubbing. storage.examining wastes at least [] large hospitals and examining medical wastes being discharged at disposal sites. and disposal. and moisture content (percent on a wet weight basis). Estimate the percentage of wastes which are being segregated. Based on the economic level of the study area. Task 5: Treatment/Destruction Options.

examine the travel times and distances to drive from the facilities to the location for residuals disposal. Include facilities for parking. Assess spatial requirements for the facilities. For the model facility designs developed above. and air pollution in the model process flow diagram. Assess building requirements. as well as pollution control residuals (such as flue gas cleaning sludge. estimate the costs of land acquisition. Task 8: Preliminary Design. On the basis of this assessment. hot water. such as steam. recommend a process flow for economic and environmentally sound management of medical wastes in the study area. Provide a conceptual floor layout for each of the buildings recommended with the site layout. Determine the electrical power supply available and the type of fuel (i. and chemical disinfection. examine the travel times and distances to drive in the study area from the various centers of medical waste generation to potential locations for treatment/destruction facilities. Outline user requirements. administration. spent filters. Include assessment of process residuals (such as incinerator ash). assess whether there are significant economies-ofscale to be considered. Determine the optimum number and location(s) of facilities. Based on the spatial requirements estimated above. Task 9: Land and Investment Requirements. demonstrated reliability. operating cost. develop budgetary estimates for implementation. and environmental impacts. and secured landfill. drainage. as a function of their recommended medical waste handling capacities. Include investment costs for site preparation. and in keeping with local building requirements. assess the quantity and characteristics of residuals. The technologies to be considered include: incineration. irradiation. Assess the potential for waste-to-energy conversion and which type of energy recovery would be preferred. and truck washing/disinfection in the model site layout. oil. Also. and mobile equipment. Outline the land acquisition issues and constraints which might exist in the study area. such as steam pressure requirements or hot water requirements.e. local availability of spare parts. construction of civil works. Economically analyze whether the study area would be best served by one or more than one treatment/destruction facility. ease of operation. particulates. cooling water. gate control. For the recommended treatment/destruction system. Task 7: Strategic Location and Sizing. TERMS OF REFERENCE FOR HOSPITAL WASTE STUDY 6 . Based on local land values and resettlement costs. determine how much land is required for each of the recommended facilities. assess alternative technologies and facility sizes for treatment and destruction. Develop a model process flow diagram and site layout for the recommended treatment/destruction facilities. worker sanitation and washing/changing.. weighing loads. stationary equipment. Also. including human resettlement issues and constraints. electricity. worker cafeteria and training. quantities and sizes of materials included in the study area’s medical wastes. The assessment shall compare the alternatives on the basis of capital cost. Include treatment processes for wastewater.For the types. odor pollution. Task 6: Residuals. durability. thermal liquid. local availability of operational skills. and spent activated carbon). including foundation requirements for the study area. For the recommended process flow which would provide treatment/destruction of study area’s medical wastes. hot air. natural gas) available for operating the facility. sterilization.

address the World Bank’s requirements under Operational Directive 4. and operate facilities. (b) the local or central government designs. (e) the local or central government licenses private firms to compete with each other to design. planners. builds. as appropriate. as well as the World’s Operational Directive 4. These reviews are to be conducted in accordance with local environmental impact assessment guidance. own. List the manpower requirements for the proposed treatment/destruction facilities. processes). outline mitigative measures which need to be included within the proposed design (including mitigative by wastewater treatment. supervisors. and attendants.01. registrations. Estimate the cost/tonne of waste processed if operating at 70% capacity initially and 90% capacity within 10 years. and operate facilities. owns and operates the facilities. and start-up of the proposed facilities. Task 13: Implementation Strategy. For any potential materials recycling and/or energy recovery. or (f) hospitals collectively organize a semi-private enterprise to design. Prepare an environmental report which reviews the environmental issues related to the proposed treatment/destruction facilities. including managers. In addition. operators. Include consideration of the following: (a) the local or central government designs. If any of the proposed sites for the facilities have inhabitants or tribal nomadic dwellers. air pollution control. odor control. Based on the cost of consumables. Include scheduled steps to advertise tenders. own.Task 10: Operating Requirements. (c) the local or central government designs. etc. and negotiate contracts. For adverse impacts identified within the reviews.30. Determine the cost of consumable supplies and utilities associated with operating the proposed treatment/destruction facilities. training. operate and maintain the proposed facilities. estimate the total annual cost to own. demonstration. salaries. build. build. land preparation. Task 12: Implementation Schedule. and debt service. “Environmental Assessment”. Task 11: Environmental Study and Mitigation. human resettlement.. for implementation of the proposed facilities. own. builds and owns the facilities and leases them to the private sector for their operation. insurances. Develop an implementation schedule for siting. including environmental permits. guards. build. builds and owns the facilities and contracts for operation by government. land acquisition. Assess the alternative ways in which the proposed facilities could be implemented and provide adequate discussion of the pros and cons of each alternative to enable decision-making. investment depreciation. Task 14: Financial Package. provide a monitoring program for monitoring throughout implementation and operation activities. and operate facilities. TERMS OF REFERENCE FOR HOSPITAL WASTE STUDY 7 . Include time for public participation. Estimate the cost of salaries required to operate the facilities. Further outline mitigative measures which should be included within the operational procedures. “Involuntary Resettlement” or any other relevant guidance provided by the agencies participating in this project. construction. estimate the revenue potential based on current market prices. Develop an anticipated schedule for securing all required permits. evaluate bids. (d) the local or central government develops design performance requirements and gives a concession to the private sector to design. administrators.

Provide a final draft report after completion of Tasks 11 to 15. The team will also need to be familiar with the assessment of technology options under the range of unique skill. the government. and enforcement practices at the local and central government level concerning the management of medical wastes. Review the existing regulations. within 6 months of the commencement date of the contract. Conduct the technical seminar required under Task 16. policies. within 4 months of the commencement date of the contract. Resumes of the qualifications and experience of the key members of the team will be the key criteria used to evaluate proposals. and waste haulers have the appropriate incentives and disincentives to provide proper waste management. The team will need to be qualified to put together a financial proposal for implementation of the study recommendations. Obtain their review comments during the seminar and address their comments in finalization of the report. Based on whether the money for implementation is to be borrowed by the hospitals. Provide an interim report after completion of Tasks 5 to 10. so that hospitals.Recommend financing arrangements for project implementation. and then issue the final report within 8 months of the commencement date of the contract. TERMS OF REFERENCE FOR HOSPITAL WASTE STUDY 8 . Task 15: Regulatory Framework. or invested by the private sector. provide a financial package which would enable final design and procurement activities to begin immediately at the conclusion of the study. and the more general topic of hazardous wastes. communities. Develop specific recommendations on areas which need to be improved within the regulatory framework. STUDY TEAM The team to conduct the feasibility study will need to have extensive experience in hospital waste management and design of treatment/destruction facilities. within 2 months of the commencement date of the contract. management and financial conditions which exist in developing countries. upon completion of the draft final report. The team will need to have practical knowledge of the pros and cons of various hospital waste treatment/destruction options. strategies. Task 16: Technical Seminar. Ten copies of each report are to be provided. Provide a seminar to government officials and hospital administrators on the findings of this feasibility study. REPORTS Provide a diagnostic report after completion of Tasks 1 to 4. Identify limitations and deficiencies in the regulatory framework.