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Medical waste management in Jordan: A study at the King Hussein Medical Center
Waste Management 25 (2005) 622–625 www.elsevier.com/locate/wasman
Medical waste management in Jordan: A study at the King Hussein Medical Center Rami Oweis a b
a,*
, Mohamad Al-Widyan
b,1
, Ohood Al-Limoon
a,1
Biomedical Engineering Department, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan Biosystems Engineering Department, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan Accepted 25 March 2005 Available online 8 June 2005
Abstract As in many other developing countries, the generation of regulated medical waste (RMW) in Jordan has increased significantly over the last few decades. Despite the serious impacts of RMW on humans and the environment, only minor attention has been directed to its proper handling and disposal. This study was conducted in the form of a case study at one of JordanÕs leading medical centers, namely, the King Hussein Medical Center (KHMC). Its purpose was to report on the current status of medical waste management at KHMC and propose possible measures to improve it. In general, it was found that the centerÕs administration was reasonably aware of the importance of medical waste management and practiced some of the measures to adequately handle waste generated at the center. However, it was also found that significant voids were present that need to be addressed in the future including efficient segregation, the use of coded and colored bags, better handling and transfer means, and better monitoring and tracking techniques, as well as the need for training and awareness programs for the personnel. Ó 2005 Elsevier Ltd. All rights reserved.
1. Introduction In the last few decades, human activities and changes associated with lifestyles and consumption patterns have resulted in the generation of huge volumes of different types of wastes. The wastes have threatened the survival of humans and other living things, as well as all natural resources that are necessary to human existence (Henry and Heinke, 1996). Consequently, waste management and the pollution problems associated with waste generation have attracted significant attention and a great deal of research has been conducted on these topics (LaGrega et al., 1994). Throughout most of the world, medicine is one of the sectors that has witnessed significant improvement. *
Corresponding author. Tel.: +96227201000; fax: +96227095018. E-mail addresses: [email protected] (R. Oweis, O. Al-Limoon), [email protected] (M. Al-Widyan). 1 Tel.: +96227201000; fax: +96227095018. 0956-053X/$ - see front matter Ó 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.wasman.2005.03.011
However, it seems that the fraction of waste generated at medical institutions, known as special or regulated medical waste (Lee et al., 2004) or otherwise known as clinical waste (WHO, 1994), has not attracted the same level of attention as other types of wastes, particularly in developing countries, despite the fact that medical waste is labeled as hazardous because it poses serious and direct threat to human health (Coad, 1992; WHO, 1999). Throughout this study, the term Ômedical wasteÕ is used to mean the special (regulated) or clinical portion of waste generated in medical institutions, unless otherwise specified. Jordan enjoys one of the most advanced and comprehensive medical care and service systems compared to the whole region of the Middle East. The Ministry of Health (MoH) estimated the number of beds in the country in 2002 at 10,000, compared to about 7400 in 1995. This number keeps on rising with the active participation of the private sector that owns some of the largest and most sophisticated medical centers in the
R. Oweis et al. / Waste Management 25 (2005) 622–625
country. Yet, in Jordan, like in many other developing countries, little emphasis has been placed on the proper handling and disposal of medical waste (Mato and Kaseva, 1999). A report published by the MoH along with the General Organization for Environmental Protection and Jordan Environment Society, indicated that medical waste in Jordan suffers from serious mismanagement practices that, generally, deviate substantially from the standard acceptable practices established by relevant international bodies (WHO, 1999). It was also reported that medical waste is mixed with the municipal waste and that medical liquid waste is disposed of in the public drainage network (Jaffal, 2003; Al-Qudah, 2000). Such practices create potential public health risks to humans and a burden on the environment. In light of all the above, this study was initiated and intended as a case study in Jordan. It was conducted in the King Hussein Medical Center in Amman, which is one of the leading medical centers in Jordan and the region. The goal was to report on current status of regulations and practices regarding medical waste management in the KHMC in order to identify the areas of good and acceptable medical waste handling procedures, indicate mismanagement practices, and propose potential remedies and solutions. Special emphasis was placed on radioactive waste, which refers to materials contaminated with radionuclides beyond a given threshold level established by the IAEA (Sztanyik, 1993).
2. Description of the KHMC The KHMC complex lies on a total area of 650 acres and includes three major centers: 1. King Hussein Hospital (KHH): this is a 56000-m2 building with a total capacity of 583 beds. Each year, about 458,000 patients visit this center with about 25,000 admissions. This hospital is equipped with 11 operating theaters and 1830 employees. The KHH consists of 12 departments in most medical specialties. 2. Farah Royal Jordanian Rehabilitation Center (FRJRC): this is a five-story building with a total capacity of 150 beds equipped with 4 operating rooms and with 404 employees. This center consists of 13 departments with 7 specialized clinics and is provided with a Mayo Clinic satellite link. 3. Queen Alia Heart Institute (QAHI): this is a 13000-m2 four-story building with a total capacity of 108 beds. It consists of four departments mainly for cardiac care and an outpatient clinic. The three centers are served by a nursing department that provides all nursing services by professional and highly trained personnel.
623
In addition, the KHMC complex includes a Joint Services Department for management and administration and other supporting general services required to run and serve the facility, including but not limited to supply, nutrition, maintenance, patient wards, staff residences, etc. In this study, special attention was given to radioactive waste produced in the Nuclear Medicine Department, which contains the so-called hot lab where radioactive material is prepared, radioactive waste is managed, and radioactivity and radioactive doses are monitored (by a dose calibrator). About 30 patients visit the department daily for diagnosis and therapy.
3. Methodology The KHMC was selected because it is one of JordanÕs oldest, largest, most advanced, sophisticated, and comprehensive medical compounds. Consequently, it is believed that in this center, the level of awareness of the significance of the proper handling of medical waste is higher than anywhere else in the country. The methodology of this particular study was a twostage strategy: 1. Becoming familiar with the rules, procedures, and regulations set forth by the centerÕs Directory to be followed by the concerned personnel regarding the management of medical waste generated at the center. The centerÕs Directory may be accessed via the website: www.jrms.gov.jo. 2. Spending enough time in the different departments of the center recording observations and writing notes in a critical manner about the practices of the medical waste management by the concerned personnel. These two steps were carried out with the help and guidance of a specialized officer and were meant to report reliable results and conclusions regarding the extent to which the medical waste is handled at the KHMC in light of written policies and established international standards in this regard (WHO, 1999). Being aware of its serious impacts on humans (AlQudah, 2000; Sztanyik, 1993), special emphasis was placed on the handling and management of the radioactive waste generated in the Nuclear Medicine Department at the KHMC.
4. Medical waste management in the KHMC The management of medical waste in the KHMC is directed by a seven-member committee appointed for the purpose of administering medical waste handling
624
R. Oweis et al. / Waste Management 25 (2005) 622–625
in the compound. The committee meets on a monthly basis and issues recommendations to all the centerÕs departments and oversees the implementation of the management rules by the concerned personnel. Observations during carrying out this study indicated that, in general, good management practices of medical waste do exist in the KHMC including: 1. Establishing procedures for the collection, separation, transfer and disposal of medical waste such as: (i) identifying waste type, (ii) separating non-medical (general) waste from medical waste, (iii) using appropriate labeled bags based on a color guideline, (iv) placing waste in transparent labeled bags in case of shortage of an appropriate bag type, (v) transferring all waste bags on wheeled containers and using utility gloves when dealing with broken bags and waste and then decontaminating them. 2. Enforcing strict rules when dealing with sharps and in case of injuries caused by sharps. 3. Applying specific procedures for the decontamination of contaminated instruments. 4. Using high-level disinfection (solution) and applying different sterilization techniques (steam, hot-air, chemical, and gas) for surgical and other instruments. 5. Establishing disposal subcommittees in different departments to monitor the disposal of medical waste. Upon separation of waste into medical and general (non-medical) fractions, the major disposal and predisposal (IAEA, 2000) practices of medical waste in the KHMC include: (i) collection of certain waste items in yellow bags and then transferring them to the incinerator. Such items include syringes, gloves, contaminated paper, and contaminated disposable medical tools, (ii) storing sharps in sharps containers, (iii) washing surgical tools and storing them in bags prior to transferring them to sterilization, (iv) placing body parts in labeled bags prior to sending them to the dead refrigerator. 6. Adopting strict measures for the management of radioactive waste including appointing a radiation protection committee that consists of specialists in nuclear medicine and nuclear physics to oversee the disposal of radioactive waste. The management of radioactive waste at the KHMC includes the following procedures: (i) Radioactivity monitoring: includes both environmental and personal monitoring. A. Environmental monitoring: instruments such as ÔMonitor 5Õ and ÔSurveyor 50Õ are used to make sure that solid radioactive waste reaches safe levels before final disposal and
to check the activity level in the department. The ÔSurveyor 50Õ is a portable detector (survey meter) for c-and X-ray exposure rate measurement or a-, b-, c-, and X-ray count rate measurements. The ÔMonitor 5Õ is a device that allows full view of the meter in a large window for good reproducibility and extra ray sensitivity. B. Personal monitoring: instruments such as a thermo luminescent dosimeter (TLD) are used mainly to monitor the radiation dose that reaches the medical staff due to their exposure to radiation. (ii) Radioactive waste management: for both solid and liquid radioactive wastes. A. Solid radioactive waste (0.5 m3/d): includes contaminated syringes (with Tcm99), gloves and capsule containers (for I131). These waste materials are stored in special lead containers lined with yellow bags and kept to decay to safe levels of radiation (less than 5 lSv/h) at which point they are sent to the incinerator. B. Liquid radioactive waste (40–50 l/d): includes contaminated hand washing water and patients liquid waste. This waste is passed to the delay region where it is stored to reach a safe level of activity (1–5 lSv/h) and then released to the public drainage system.
5. Conclusions and recommendations Based on the findings of this study, the following conclusions may be drawn: 1. The staff at the KHMC is aware of the significance of managing medical waste generated at the compound. 2. Separation of waste generated into medical and non-medical waste is practiced to a satisfactory extent. 3. Radioactive waste is managed and treated according to high international standards (WHO, 1999). 4. Shortcomings in the medical waste handling system at the KHMC do exist most notably of which are: (i) failure to quantify the waste generated in reliable records, (ii) lack of the use of colored bags by limiting the bags to only one color (yellow) for all wastes, (iii) the need for training the staff on how to deal with hazardous waste, (iv) the need for establishing national standards, particularly for medical waste packaging.
R. Oweis et al. / Waste Management 25 (2005) 622–625
5. Overall, it may be stated that, at the local level, the KHMC may be considered a good example for other medical centers as far as medical waste management is concerned.
Acknowledgements The authors are indebted to the KHMC for providing all the necessary support. Thanks are due to Dr. Ibraheem Habashneh for his invaluable assistance.
References Al-Qudah, O., 2000. Evaluation of medical waste disposal methods and their applications in Jordan. A MasterÕs Thesis, Jordan University of Science and Technology, Irbdi, Jordan. Coad, A., 1992. Managing medical waste in developing countries. Report of a Consultation on Medical Wastes Management in Developing Countries, WHO, Geneva, Switzerland.
625
Henry, G., Heinke, G., 1996. Environmental Science and Engineering. Prentice-Hall, Englewood, NJ, USA. IAEA, Predisposal management of radioactive waste, including decommissioning, Safety Standards Series No. WS-R-2 2000. Jaffal, G., 2003. Biomedical waste management problems and strategic solutions. Unpublished Report Supervised by Dr. Yaseen Hayajneh, College of Medicine, Jordan University of Science and Technology, Jordan. LaGrega, M., Buckinham, P., Evans, J., 1994. Hazardouss Waste Management. McGraw-Hill, New York, USA. Lee, B.-K., Ellenbecker, M., Moure-Ersaso, R., 2004. Alternatives for treatment and disposal cost reduction of regulated medical wastes. Waste Management 24, 143–151. Mato, R., Kaseva, M., 1999. Critical review of industrial and medical waste practices in Dar es Salaam City. Resources, Conservation and Recycling 25, 271–287. Sztanyik, L., 1993. A review of the management of radioactive wastes in medical institutions. Waste Management 11, 429–439. World Health Organization, Regional Office for the Eastern Mediterranean, 1994. Management of Medical Waste. Edited by WHO Regional Center for Environmental Health Activities (CEHA), Amman, Jordan. World Health Organization, 1999. In: Pruss, A., Giroult, E., Rushbrook, P. (Eds.), Safe Management of Wastes from Health-Care Activities, 1999. Geneva, Switzerland.
Medical waste management in Jordan: A study at the King Hussein Medical Center Rami Oweis a b
a,*
, Mohamad Al-Widyan
b,1
, Ohood Al-Limoon
a,1
Biomedical Engineering Department, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan Biosystems Engineering Department, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan Accepted 25 March 2005 Available online 8 June 2005
Abstract As in many other developing countries, the generation of regulated medical waste (RMW) in Jordan has increased significantly over the last few decades. Despite the serious impacts of RMW on humans and the environment, only minor attention has been directed to its proper handling and disposal. This study was conducted in the form of a case study at one of JordanÕs leading medical centers, namely, the King Hussein Medical Center (KHMC). Its purpose was to report on the current status of medical waste management at KHMC and propose possible measures to improve it. In general, it was found that the centerÕs administration was reasonably aware of the importance of medical waste management and practiced some of the measures to adequately handle waste generated at the center. However, it was also found that significant voids were present that need to be addressed in the future including efficient segregation, the use of coded and colored bags, better handling and transfer means, and better monitoring and tracking techniques, as well as the need for training and awareness programs for the personnel. Ó 2005 Elsevier Ltd. All rights reserved.
1. Introduction In the last few decades, human activities and changes associated with lifestyles and consumption patterns have resulted in the generation of huge volumes of different types of wastes. The wastes have threatened the survival of humans and other living things, as well as all natural resources that are necessary to human existence (Henry and Heinke, 1996). Consequently, waste management and the pollution problems associated with waste generation have attracted significant attention and a great deal of research has been conducted on these topics (LaGrega et al., 1994). Throughout most of the world, medicine is one of the sectors that has witnessed significant improvement. *
Corresponding author. Tel.: +96227201000; fax: +96227095018. E-mail addresses: [email protected] (R. Oweis, O. Al-Limoon), [email protected] (M. Al-Widyan). 1 Tel.: +96227201000; fax: +96227095018. 0956-053X/$ - see front matter Ó 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.wasman.2005.03.011
However, it seems that the fraction of waste generated at medical institutions, known as special or regulated medical waste (Lee et al., 2004) or otherwise known as clinical waste (WHO, 1994), has not attracted the same level of attention as other types of wastes, particularly in developing countries, despite the fact that medical waste is labeled as hazardous because it poses serious and direct threat to human health (Coad, 1992; WHO, 1999). Throughout this study, the term Ômedical wasteÕ is used to mean the special (regulated) or clinical portion of waste generated in medical institutions, unless otherwise specified. Jordan enjoys one of the most advanced and comprehensive medical care and service systems compared to the whole region of the Middle East. The Ministry of Health (MoH) estimated the number of beds in the country in 2002 at 10,000, compared to about 7400 in 1995. This number keeps on rising with the active participation of the private sector that owns some of the largest and most sophisticated medical centers in the
R. Oweis et al. / Waste Management 25 (2005) 622–625
country. Yet, in Jordan, like in many other developing countries, little emphasis has been placed on the proper handling and disposal of medical waste (Mato and Kaseva, 1999). A report published by the MoH along with the General Organization for Environmental Protection and Jordan Environment Society, indicated that medical waste in Jordan suffers from serious mismanagement practices that, generally, deviate substantially from the standard acceptable practices established by relevant international bodies (WHO, 1999). It was also reported that medical waste is mixed with the municipal waste and that medical liquid waste is disposed of in the public drainage network (Jaffal, 2003; Al-Qudah, 2000). Such practices create potential public health risks to humans and a burden on the environment. In light of all the above, this study was initiated and intended as a case study in Jordan. It was conducted in the King Hussein Medical Center in Amman, which is one of the leading medical centers in Jordan and the region. The goal was to report on current status of regulations and practices regarding medical waste management in the KHMC in order to identify the areas of good and acceptable medical waste handling procedures, indicate mismanagement practices, and propose potential remedies and solutions. Special emphasis was placed on radioactive waste, which refers to materials contaminated with radionuclides beyond a given threshold level established by the IAEA (Sztanyik, 1993).
2. Description of the KHMC The KHMC complex lies on a total area of 650 acres and includes three major centers: 1. King Hussein Hospital (KHH): this is a 56000-m2 building with a total capacity of 583 beds. Each year, about 458,000 patients visit this center with about 25,000 admissions. This hospital is equipped with 11 operating theaters and 1830 employees. The KHH consists of 12 departments in most medical specialties. 2. Farah Royal Jordanian Rehabilitation Center (FRJRC): this is a five-story building with a total capacity of 150 beds equipped with 4 operating rooms and with 404 employees. This center consists of 13 departments with 7 specialized clinics and is provided with a Mayo Clinic satellite link. 3. Queen Alia Heart Institute (QAHI): this is a 13000-m2 four-story building with a total capacity of 108 beds. It consists of four departments mainly for cardiac care and an outpatient clinic. The three centers are served by a nursing department that provides all nursing services by professional and highly trained personnel.
623
In addition, the KHMC complex includes a Joint Services Department for management and administration and other supporting general services required to run and serve the facility, including but not limited to supply, nutrition, maintenance, patient wards, staff residences, etc. In this study, special attention was given to radioactive waste produced in the Nuclear Medicine Department, which contains the so-called hot lab where radioactive material is prepared, radioactive waste is managed, and radioactivity and radioactive doses are monitored (by a dose calibrator). About 30 patients visit the department daily for diagnosis and therapy.
3. Methodology The KHMC was selected because it is one of JordanÕs oldest, largest, most advanced, sophisticated, and comprehensive medical compounds. Consequently, it is believed that in this center, the level of awareness of the significance of the proper handling of medical waste is higher than anywhere else in the country. The methodology of this particular study was a twostage strategy: 1. Becoming familiar with the rules, procedures, and regulations set forth by the centerÕs Directory to be followed by the concerned personnel regarding the management of medical waste generated at the center. The centerÕs Directory may be accessed via the website: www.jrms.gov.jo. 2. Spending enough time in the different departments of the center recording observations and writing notes in a critical manner about the practices of the medical waste management by the concerned personnel. These two steps were carried out with the help and guidance of a specialized officer and were meant to report reliable results and conclusions regarding the extent to which the medical waste is handled at the KHMC in light of written policies and established international standards in this regard (WHO, 1999). Being aware of its serious impacts on humans (AlQudah, 2000; Sztanyik, 1993), special emphasis was placed on the handling and management of the radioactive waste generated in the Nuclear Medicine Department at the KHMC.
4. Medical waste management in the KHMC The management of medical waste in the KHMC is directed by a seven-member committee appointed for the purpose of administering medical waste handling
624
R. Oweis et al. / Waste Management 25 (2005) 622–625
in the compound. The committee meets on a monthly basis and issues recommendations to all the centerÕs departments and oversees the implementation of the management rules by the concerned personnel. Observations during carrying out this study indicated that, in general, good management practices of medical waste do exist in the KHMC including: 1. Establishing procedures for the collection, separation, transfer and disposal of medical waste such as: (i) identifying waste type, (ii) separating non-medical (general) waste from medical waste, (iii) using appropriate labeled bags based on a color guideline, (iv) placing waste in transparent labeled bags in case of shortage of an appropriate bag type, (v) transferring all waste bags on wheeled containers and using utility gloves when dealing with broken bags and waste and then decontaminating them. 2. Enforcing strict rules when dealing with sharps and in case of injuries caused by sharps. 3. Applying specific procedures for the decontamination of contaminated instruments. 4. Using high-level disinfection (solution) and applying different sterilization techniques (steam, hot-air, chemical, and gas) for surgical and other instruments. 5. Establishing disposal subcommittees in different departments to monitor the disposal of medical waste. Upon separation of waste into medical and general (non-medical) fractions, the major disposal and predisposal (IAEA, 2000) practices of medical waste in the KHMC include: (i) collection of certain waste items in yellow bags and then transferring them to the incinerator. Such items include syringes, gloves, contaminated paper, and contaminated disposable medical tools, (ii) storing sharps in sharps containers, (iii) washing surgical tools and storing them in bags prior to transferring them to sterilization, (iv) placing body parts in labeled bags prior to sending them to the dead refrigerator. 6. Adopting strict measures for the management of radioactive waste including appointing a radiation protection committee that consists of specialists in nuclear medicine and nuclear physics to oversee the disposal of radioactive waste. The management of radioactive waste at the KHMC includes the following procedures: (i) Radioactivity monitoring: includes both environmental and personal monitoring. A. Environmental monitoring: instruments such as ÔMonitor 5Õ and ÔSurveyor 50Õ are used to make sure that solid radioactive waste reaches safe levels before final disposal and
to check the activity level in the department. The ÔSurveyor 50Õ is a portable detector (survey meter) for c-and X-ray exposure rate measurement or a-, b-, c-, and X-ray count rate measurements. The ÔMonitor 5Õ is a device that allows full view of the meter in a large window for good reproducibility and extra ray sensitivity. B. Personal monitoring: instruments such as a thermo luminescent dosimeter (TLD) are used mainly to monitor the radiation dose that reaches the medical staff due to their exposure to radiation. (ii) Radioactive waste management: for both solid and liquid radioactive wastes. A. Solid radioactive waste (0.5 m3/d): includes contaminated syringes (with Tcm99), gloves and capsule containers (for I131). These waste materials are stored in special lead containers lined with yellow bags and kept to decay to safe levels of radiation (less than 5 lSv/h) at which point they are sent to the incinerator. B. Liquid radioactive waste (40–50 l/d): includes contaminated hand washing water and patients liquid waste. This waste is passed to the delay region where it is stored to reach a safe level of activity (1–5 lSv/h) and then released to the public drainage system.
5. Conclusions and recommendations Based on the findings of this study, the following conclusions may be drawn: 1. The staff at the KHMC is aware of the significance of managing medical waste generated at the compound. 2. Separation of waste generated into medical and non-medical waste is practiced to a satisfactory extent. 3. Radioactive waste is managed and treated according to high international standards (WHO, 1999). 4. Shortcomings in the medical waste handling system at the KHMC do exist most notably of which are: (i) failure to quantify the waste generated in reliable records, (ii) lack of the use of colored bags by limiting the bags to only one color (yellow) for all wastes, (iii) the need for training the staff on how to deal with hazardous waste, (iv) the need for establishing national standards, particularly for medical waste packaging.
R. Oweis et al. / Waste Management 25 (2005) 622–625
5. Overall, it may be stated that, at the local level, the KHMC may be considered a good example for other medical centers as far as medical waste management is concerned.
Acknowledgements The authors are indebted to the KHMC for providing all the necessary support. Thanks are due to Dr. Ibraheem Habashneh for his invaluable assistance.
References Al-Qudah, O., 2000. Evaluation of medical waste disposal methods and their applications in Jordan. A MasterÕs Thesis, Jordan University of Science and Technology, Irbdi, Jordan. Coad, A., 1992. Managing medical waste in developing countries. Report of a Consultation on Medical Wastes Management in Developing Countries, WHO, Geneva, Switzerland.
625
Henry, G., Heinke, G., 1996. Environmental Science and Engineering. Prentice-Hall, Englewood, NJ, USA. IAEA, Predisposal management of radioactive waste, including decommissioning, Safety Standards Series No. WS-R-2 2000. Jaffal, G., 2003. Biomedical waste management problems and strategic solutions. Unpublished Report Supervised by Dr. Yaseen Hayajneh, College of Medicine, Jordan University of Science and Technology, Jordan. LaGrega, M., Buckinham, P., Evans, J., 1994. Hazardouss Waste Management. McGraw-Hill, New York, USA. Lee, B.-K., Ellenbecker, M., Moure-Ersaso, R., 2004. Alternatives for treatment and disposal cost reduction of regulated medical wastes. Waste Management 24, 143–151. Mato, R., Kaseva, M., 1999. Critical review of industrial and medical waste practices in Dar es Salaam City. Resources, Conservation and Recycling 25, 271–287. Sztanyik, L., 1993. A review of the management of radioactive wastes in medical institutions. Waste Management 11, 429–439. World Health Organization, Regional Office for the Eastern Mediterranean, 1994. Management of Medical Waste. Edited by WHO Regional Center for Environmental Health Activities (CEHA), Amman, Jordan. World Health Organization, 1999. In: Pruss, A., Giroult, E., Rushbrook, P. (Eds.), Safe Management of Wastes from Health-Care Activities, 1999. Geneva, Switzerland.