20110427 Argentina Mission Report Nov 2010 FINAL · 2011. 5. 10. · Title: Microsoft Word - 20110427 Argentina Mission Report Nov 2010 FINAL.doc Author: dhuaman Created Date: 5/10/2011

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Argentina Mission Report November 10 – November 19, 2010

Summary The Global Project Team (GPT) members had meetings with Dr. Ernesto de Titto, National Project Coordinator, and other project team members to discuss the progress of the project and to strategize on activities moving forward. The GPT informed the project team, UNDP, PAHO, and other project partners that the project’s end date will be June 30, 2012 and that project activities should be completed by March 2012. A meeting was also held with the MOH’s financial department, Unidad de Financiamiento Internacional de Salud (UFI), to discuss ways to avoid delays in the transfer of project funds and the purchasing of project equipment. It was agreed that the project will provide UFI with a timeline of the project’s upcoming procurement plans and UFI will work with the project to ensure an efficient procurement process. Site visits were conducted of the model facilities at Garrahan Hospital in Buenos Aires and Francisco Lima Lopez Hospital in General Roca. The GPT met with the healthcare waste management committees of both facilities. Since travel to Reconquista Central Hospital was difficult, the GPT met with their healthcare waste management committee in Buenos Aires and discussed project activities in their facility and region. The team visited the Incol Manufacturing Warehouse in San Martin as well as one of their autoclave units at a waste treatment facility in General Roca. Meetings were held with the MOH team working on mercury and Health Care Without Harm to discuss areas of collaboration. The project’s training component was reviewed with the training team at Universidad Tecnologica Nacional (UTN). The meeting with PAHO focused on regional dissemination of the results of the project and translation of the revised WHO guidelines on healthcare waste management. The GPT attended the National Project Steering Committee meeting where the committee was updated on the project’s progress and activities as well as the GPT’s mission. The GPT also attended the National Working Group meeting where project partners provided updates on completed and upcoming activities. The Global Project Team members concluded that the project in Argentina has made major advances despite the late start and is doing well. The GPT made recommendations related to the global project deadline of June 30, 2012, as well as specific recommendations for each of the model facilities, the treatment technologies, mercury and training components, and regional dissemination. All objectives of the mission were accomplished. Objectives of the Mission The objectives of the mission were:

1. To meet with the National Project Steering Committee, National Working Group, and other key partners in the project

2. To obtain updates on each component of the national project 3. To share information about technical materials developed by the Global Project Team

and about developments in the other seven project countries

Argentina Mission Report

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4. To review the work plan, timeline, and budget for the remaining duration of the national project

5. To find out how the Global Project Team can further support the national project and to provide technical assistance as needed.

Mission Team Members and Dates of Mission Dr. Jorge Emmanuel, Chief Technical Advisor: November 10 to November 19, 2010 Ashley Iwanaga, Global Project Coordinator: November 10 to November 19, 2010 Description of Meetings and Field Visits WEDNESDAY, November 10, 2010

9:00 AM: Brief Meeting with National Technical Consultant (Daniel Alfano) Dr. Emmanuel and Ms. Iwanaga held a brief meeting with Daniel Alfano, the National Technical Consultant. Mr. Alfano provided Dr. Emmanuel and Ms. Iwanaga a brief overview of the project and noted that the official start date of the project in Argentina is January 2010.

10:00 AM: Meeting with the Ministry of Health and Project Team (Dr. Jaime Lazovski, Undersecretary of the Ministry of Health & National Project Director; Dr. Ernesto de Titto, National Director of Health Determinants and Research, Ministry of Health and National Project Coordinator, Ministry of Health; Engineer Ricardo Benitez,Chief of the Department of Environmental Health; Engineer Luisa Viviana Brunstein, Project Engineer, Ministry of Health; Engineer Daniel Alfano, National Technical Consultant; Lic. Sonia Sagardoyburu, Social Work, and Francisco Chesini, Project Technical Assistant at Garrahan Hospital)

Dr. Emmanuel and Ms. Iwanaga briefly met Dr. Jaime Lazovski, Undersecretary of the Ministry of Health & National Project Director. The project team explained the staff structure of the local project team and the MOH departments working with the project. The team also discussed how Argentina’s federal structure functions in relation to the drafting, implementation, and enforcement of laws and policies. Each province has its own laws, which can lead to different legal criteria in different parts of the country. Although pathogenic waste is addressed in National Law 24051, laws referring to pathogenic and healthcare waste (HCW) differ in each part of the country. HCW classifications and definitions are an issue and lack of sanitary landfills exacerbates the problem. One obstacle could be that provinces are concerned with the intervention of the national government on local issues and laws so it is important to work on municipal and/or provincial regulations but many municipalities do not see waste as a priority. The hospital in Reconquista is similar to those in about 5,000 other small to medium cities. Many face the same problem of being far from recycling and disposal sites. Transport of waste is complicated by jurisdictional issues between national and provincial routes. Organizational culture inside hospitals is another concern. The project will develop models for other health facilities to emulate.


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The project has created internal committees for healthcare waste management (HCWM) within the model hospitals that include medical doctors, nurses, and various other departments. For most healthcare facilities the provincial government pays HCW costs and local governments are usually not in charge of the costs. Financial concern is higher in private facilities because they have their own cost management.

1:00 PM: Meeting with the Project Team (Dr. Ernesto de Titto, National Director of Health Determinants and Research and National Project Coordinator, Ministry of Health; Ricardo Benitez, Chief of the Department of Environmental Health , Ministry of Health; Luisa Brunstein, Project Engineer, Ministry of Health; Daniel Alfano, National Technical Consultant; Sonia Sagardoyburu, and Francisco Chesini, Project Technical Assistant at Garrahan Hospital)

The mission agenda was discussed including Dr. Emmanuel’s video teleconference at Universidad Tecnologica Nacional (UTN) on November 16 and simultaneously televised to multiple regionally located campuses throughout Argentina. The team discussed options for the alternative technology or other waste management ideas in Reconquista. Reconquista has selected a piece of land where the technology could be located, but they have not decided on the type of technology or HCWM system. The 140‐bed hospital generates 70% of the 110‐120 kg/day of healthcare waste in the area. The team provided updates on the model facilities: Garrahan Hospital in Buenos Aires; Francisco Lopez Lima Hospital (FLLH) in General Roca; and Reconquista Central Hospital in Reconquista. The following issues were identified in all the hospitals:

• Lack of an inter‐disciplinary waste management committee – committees have now been established with a diverse mix of members from various departments

• Procurement of supplies and lack of procurement policies – Reconquista is working to procure mercury‐free devices and has already conducted awareness‐raising; MOH will co‐finance the replacement of incubators with mercury thermometers

• Deficiencies in HCWM – including internal transport and storage; Reconquista Central Hospital and Garrahan Hospital are being provided with electronic scales to weigh their waste; Reconquista Central Hospital and FLLH need storage areas where waste is collected

• Waste management manuals – these have to be compiled and improved on • Recovery and recycling – the project will work with the hospitals to try to recover

cardboard and plastic (serum bags), and possibly glass. • Chemical waste • Mercury – all hospitals need training and a strategy

Garrahan Hospital has an internal transport system that is quite rigid and particular. The project has helped design some changes to the system carts. Transportation will be improved and storage area will be increased by 50%. The project team suggested that the outside transportation system needs to be improved but this is an outside entity.


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4:00 PM: Meeting with UNDP Country Office (Daniel Tomasini, Environmental and Sustainable Development Unit Coordinator, UNDP Argentina; Matias Mottet, Project Focal Point, UNDP Argentina; Luisa Brunstein, Ministry of Health; Daniel Alfano, National Technical Consultant)

Dr. Emmanuel provided a brief update on the global project. He informed Mr. Tomasini and Mr. Mottet that the project’s official end date is June 2012 so all project work should be completed by March 2012 in order to leave enough time to collect reporting information. Mr. Mottet noted that they should start the technology procurement in Q1 2011. The delay in receiving funds for the project from the Ministry of Health’s financial department, Unidad de Financiamiento Internacional de Salud (UFI), was discussed. A meeting is planned to try to resolve this situation. Dr. Emmanuel noted that a midterm evaluation will occur in early to mid 2011. Mr. Mottet noted that UNDP Argentina has always had both a local and international evaluator for other projects, which was extremely helpful so he suggested the project think about a similar model. It was also noted that the first half of March or later would be the best time for the evaluation in Argentina and 2011 is an election year so work may be delayed. Dr. Emmanuel noted that there would most likely be a Global Project Steering Committee meeting in April 2011. Mr. Mottet stated that the Global Project Team did not provide enough time for UNDP Argentina to complete their information for the Global PIR. He requested that there be at least a 30 day deadline to complete any future PIR reports. THURSDAY, November 11

10:00 AM: Meeting with the Project Team (Chief Ricardo Benitez, Ministry of Health; Luisa Brunstein, Ministry of Health; Daniel Alfano, National Technical Consultant; and Francisco Chesini, Project Technical Assistant at Garrahan Hospital)

The various options for the waste treatment in Reconquista (located in Santa Fe Province) were discussed. The autoclave at the central treatment facility in Rosario (500 kilometers from Reconquista) was shut down. This is one reason Reconquista is interested in installing their own autoclave. Reconquista’s municipal government and the Santa Fe provincial government have been discussing the option of installing an autoclave. The amount of waste is about 3,500 kg/month but the project team has not been able to find a locally manufactured autoclave that is small enough for Reconquista. Several scenarios for Reconquista were discussed:

1. Expand the service coverage of the autoclave (go further down and include bordering provinces) and make Reconquista a treatment center. Use a public‐private partnership model with the treatment plant owned by the state but operated by the private sector with 5 or 10 year operating agreements.


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2. Make Reconquista a transfer station at the location where the plant would have been. The transfer station would have refrigeration and the project would invest in sealed transport vehicles to take the waste to the Rosario plant periodically. The Rosario plant has a 750 kg/cycle autoclave handling 8 tonnes per day during two shifts.

Dr. Emmanuel suggested that they use a costing tool to see which method is the best and most efficient choice for Reconquista. Dr. Emmanuel suggested that given the lack of an appropriately sized autoclave and the fixed costs involved in running an autoclave, the transfer station might be a good option. Mr. Alfano noted that the equipment for a transfer station is easily available. This model can be replicated nationally. The spreadsheets of waste generation studies from General Roca and Garrahan were discussed.

12:00 NOON: Meeting with Ministry of Health Project on Mercury in Dentistry (Engineer Ricardo Benitez, Chief of the Environmental Health Department, Ministry of Health; Dr. Eduardo Rodriguez, Occupational Health and Safety, Ministry of Health; Dr. Ana Digon, Chemical Risk Program, Ministry of Health; Luisa Brunstein, Ministry of Health; Daniel Alfano, National Technical Consultant; and Francisco Chesini, Project Technical Assistant at Garrahan Hospital)

Garrahan has already started a mercury phase‐out program. General Roca finished its mercury phase‐out although it is not clear what was done to the mercury devices that were removed. Reconquista has not yet started. Drs. Rodriguez and Digon discussed the MOH’s five‐phase process on the use of mercury. A working team was created and in 2008, they conducted a national assessment. The second phase involved resolutions prohibiting use and banning imports in medical and veterinary services. The resolutions regarding thermometers and sphygmomanometers were issued in 2009 and 2010, respectively. The third phase deals with dentistry. The fourth phase will deal with sources outside the health field, and the fifth phase will be risk awareness. For dentistry, they will focus on exposure to workers and environmental impacts. Dental assistants and students receive the most exposures. They want to issue a protocol on safe handling of dental fillings and a mechanism to recover mercury from the dental chair and wastewater. In a meeting held on 21 October, the issue of mercury in oral health was discussed with stakeholders. Among the results of the consultation were the plans to improve mercury use through standardized protocols, informational campaigns, and the involvement of stakeholders in the phase‐out of mercury in dentistry. Mr. Alfano asked Dr. Emmanuel to provide any information he has on mercury in amalgam traps. He also proposed the idea of measuring mercury in dental wastewater for dental facilities with and without amalgam recovery devices and requested some suggestions. Dr. Rodriguez suggested conducting a pilot study on exposure of dental assistants and other dental workers to mercury. Drs. Rodriguez and Digon will draft a proposal for conducting a study. RECOMMENDATION: Recommendations regarding amalgam traps are provided in Appendix 1. RECOMMENDATION: Appendix 4 has recommendations on methods of sampling and chemical analysis for mercury in dental wastewater.


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ACTION ITEM: Dr. Emmanuel provided technical materials electronically to Drs. Rodriguez and Digon regarding biological monitoring of mercury in urine and blood, as well as sample preparation and analytical methods for testing tissue for mercury.

2:30 PM: Lunch Meeting with Health Care Without Harm (Dr. Maria Della Rodolfa, Health Care Without Harm; Alejandra Livschitz, Health Care Without Harm; Luisa Brunstein, Ministry of Health; and Daniel Alfano, National Technical Consultant)

Health Care Without Harm discussed some of their resources and plans, including their newsletter, a video that they would like to produce, a Latin American regional mercury workshop that they want to organize with PAHO, and HCWM workshops.

3:30 PM: Site Visit to a manufacturing plant and the Incol Manufacturing Warehouse in San Martin (Engr. Osvaldo S. Campillo, Incol; Luisa Brunstein, Ministry of Health; and Daniel Alfano, National Technical Consultant)

The team visited a large Incol autoclave at a manufacturing plant. Then the team visited the Incol manufacturing warehouse in San Martin where they manufacture autoclaves and incinerators for medical waste treatment. Mr. Campillo provided a presentation on the Incol autoclave technologies which range from 720 to 1500 kg per hour. They use vacuum pumps for the small autoclaves and steam ejectors for the large autoclaves to generate a vacuum. The air exhaust is treated with a HEPA filter or secondary steam sterilization. They can make smaller autoclaves but the breech‐lock door is expensive. The working pressure is 40 psi with temperatures from 131 to 145 °C. The autoclaves operate in four stages: (1) vacuum cycle to 0.4 bar for 4 minutes; (2) steam injection to 2.5 or 3 bar within 2 to 4 minutes; (3) exposure at 134 °C and about 2.3 bar for 30 minutes; and (4) release of steam. Microbial inactivation validation is done by the University of Buenos Aires. The door has an interlock and temperatures and pressures are recorded. The equipment has an electrical pressure valve and two mechanical relief safety valves. They reported that the cost of their incinerators (with scrubber) is five times more than autoclaves of the same capacity and have a higher operating cost than the autoclaves. Dioxin testing cost about $21,000 per study. ACTION ITEM: The UNDP GEF Project has included Incol in its international list of possible autoclave vendors. FRIDAY, November 12

10:00 AM: Site Visit with Garrahan Hospital in Buenos Aires (Dir. Dr. Josefa Rodriguez, Hospital Director; Dr. Maria Cristina Fernandez, Head of HCWM Committee; Dr. Isabel Maza, Quality Management Coordinator; Dr. Jorge Nestor Correa, safety officer; Lic. Sylvia Benavidez, hygienist; Marta Rubinstein, lab representative; Lic. Osvaldo De Caria, General Services Manager; Arch. Teresita Dalvo; Raquel Gallardo, Nursing Coordinator; Dr. Ernesto de Titto, National Project Coordinator, Ministry of Health; Luisa Brunstein, Ministry of Health; Daniel Alfano, National Technical Consultant; and Francisco Chesini, Project Technical Assistant at Garrahan Hospital)


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The team met with members of Garrahan Hospital’s HCWM Committee. Dr. Rodriguez provided an overview of the hospital. It is a large pediatric hospital with 504 beds (93% occupancy rate in 2009, average stay of 7.4 days), 388 doctors, and over 1000 nurses that serve Argentina as well as the South American region. The team conducted a site visit of the hospital and visited multiple wards as well as the mezzanine floor where they store the waste and where the existing internal chain cart system for the waste is located. The HCWM Committee is an open inter‐disciplinary committee that meets every two weeks. Members of the HCWM Committee gave presentations about the functions of the HCWM committee, the hospital’s HCWM plan, the architectural plans for the expansion of the storage area and the improvement of the bin washing station, hygiene safety, and mercury phase out plan. The hospital is committed to reducing waste, implementing a HCWM plan, and improving their recycling program. They conducted an analysis of risk and determined that only biosafety level 3 and 4 pathogens are a significant risk thereby designating soiled diapers as municipal solid waste. They recently implemented the shift to dispose of diapers in the general trash bins instead of in the infectious waste bins (with the exception of diapers from isolated patients), which could greatly reduce the amount of infectious waste that is produced since they generate 45,000 diapers per month. They currently generate between 33,000 to 34,000 kg/month of infectious waste but plan to reduce the amount by 20‐30%. The project will provide new containers, enlarge the storage area including a wash area, and convert the trolley system to a bar code system. They have an intranet system that is used to disseminate information about HCWM changes to hospital personnel. They monitor occupational injuries including sharps injuries and use EPINET. An environmental health committee was established in 2005. Their assessment showed 511 broken thermometers per month or about 6 kg mercury released per year. They began their work to phase out mercury devices in 2007 by evaluating their current mercury device usage and conducting information workshops with personnel about the dangers of mercury. They began to slowly implement digital devices in March 2009 and continue to monitor the change. About 79% of thermometers are digital and 86% of sphygmomanometers are digital or aneroid dials. Their maintenance protocol is every 6 months to a year. RECOMMENDATION: Mandatory reporting of needle‐stick injuries and other accidental exposures should be reactivated at Garrahan Hospital to monitor occupational injuries, establish root causes, find solutions, and determine possible links to waste management practices. SUNDAY, November 14 9:30 PM to MIDNIGHT: Travel from Buenos Aires to General Roca, Rio Negro Province

MONDAY, November 15 10:00 AM: Site visit to Francisco Lima Lopez Hospital: (Dr. Avriel Martinez, Hospital Director; Basaul Yonina, Infection Control Committee; Maria Emilia Bello, Project Technical Assistant at FLLH; Miguel Dionisio Barzola, Chief of Nurses; Laura del Valle Juarez, General Roca


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Municipality; Dr. Ernesto de Titto, National Project Coordinator, Ministry of Health; and Daniel Alfano, National Technical Consultant)

The team met with the HCWM Committee at Francisco Lima Lopez Hospital (FLLH). Dr. Martinez provided a brief overview of the Rio Negro provincial hospital, a 138‐bed facility that is about 50 years old seeing about 104 patients per day and serving half the provincial population (114,000 people) and half the geographic area. The hospital has been mercury‐free since 2005. In April 2010, they had a workshop on segregation. Through improved segregation, they have also reduced the amount of waste from 8,000 kg/month in 2005 to about 5,000‐6,000 kg/month in 2008, to 1,500‐2,500 kg/month today. They plan to write up the process and develop a manual. The Occupational Safety and Health, Healthcare Waste Management, and Infection Control committees are all working together. The municipality’s environmental health section is interested in the project. The team toured various departments and observed the current HCW collection and disposal process. We took a tour of the hospital. Internal collection of the waste involves two shifts and occurs two to three time a day but more if needed. Taped markings on the floor outline where bins will be placed with posters above to identify the waste. Pick‐up areas are not accessible to the public and are strategically located in areas of high waste generation. In the Neonatal Department, waste collectors do not enter and the waste is brought out by the nurses to designated areas at two set times during the day. The ICU Department uses needle cutters that break the needles into the sharps container while the plastic piece is placed in black bags unless there is visible blood or body fluids. Waste in the isolation room of the ICU is considered infectious. The central treatment facility weighs the waste during their pick‐up at 8am. With regards to disinfection, the medical instruments are sterilized using ortho‐phthalaldehyde (OPA) diluted in water. The outside waste storage unit is a concrete shed with two separate, locked storage rooms that are washed and disinfected daily. The storage unit will be modified such that the infectious waste and non‐infectious hazardous waste will be stored in the locked rooms while general waste and recyclable waste (plastic and cardboard) will be stored on either side. They are working with the municipality on the storage building plan. The municipality has recycling programs for dry and wet waste and the hospital is part of the pilot. Clean waste is separated as plastic (yellow), glass (green) and cardboard (blue). The color‐coding used by the municipality may not be consistent with that used in the hospital. RECOMMENDATION: Separate carts should be used for infectious (red) and general (black) waste at Francisco Lima Lopez Hospital. A small autoclave should be used in the lab to disinfect cultures before they leave the laboratory. RECOMMENDATION REGARDING OPA: OPA for manual processing of reusable medical instruments is used in concentrations of 0.55% or 0.6% for at least 12 minutes at 20°C with maximum reuse of no more than 14 days. Although OPA seems to pose a less toxic risk to human health than glutaraldehyde or formaldehyde, it is toxic to aquatic species. OPA solution should not be dumped in the drain. Commercial neutralizers are available. If not, OPA can be neutralized by adding 25 grams of glycine powder (CAS # 56‐40‐6) per gallon of OPA solution or


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about two tablespoons of pure glycine for every gallon of solution. The glycine should be mixed well and allowed to stand for one hour to achieve neutralization prior to disposal. 10:00 AM: Site visit of Zavecom Treatment Facility and Landfill (Dr. Ernesto de Titto, National Project Coordinator, Ministry of Health; Daniel Alfano, National Technical Consultant; and others) The team visited the Zavecom Treatment Facility and Landfill. Zavecom is a municipally owned facility that treats and disposes the waste from FLLH using an Incol autoclave. RECOMMENDATION: Microbiological testing should be conducted at Zavecom to ascertain that the autoclave operating conditions are sufficient to achieve at least a 99.99% (or Log 4) reduction of Geobacillus stearothermophilus. See Appendix 5 for the recommended test protocol. 9:45 PM to MIDNIGHT: Travel from General Roca, Rio Negro Province to Buenos Aires

TUESDAY, November 16

12 NOON: Meeting with the Ministry of Health’s Unidad de Financiamiento Internacional de Salud: (Andrea Morales, UFI; another UFI representative; Dr. Ernesto de Titto, National Project Coordinator, Ministry of Health; Matias Mottet, Project Focal Point, UNDP Argentina; Luisa Brunstein, Ministry of Health; Daniel Alfano, National Technical Consultant; and Soledad Garavelli, National Project Assistant)

Dr. Emmanuel informed Ms. Morales that the project’s official end date is June 2012 so any delays in the transfer of project funds could hinder the success of the project. Ms. Morales noted that UFI is committed to working closely with UNDP Argentina and the project to ensure that the project is not delayed. She suggested creating a short‐term strategic work plan with projected dates so that they can flag any upcoming issues or deadlines. She will be the primary UFI contact for the project and will be responsible for following the work plan closely. Mr. Mottet informed Ms. Morales that the technical equipment would need to be bought in the first quarter of 2011. Mr. Alfano asked if someone at UFI could assist them with the proper process in order to avoid additional delays. Ms. Morales suggested that they set up a fixed agenda with the deadlines and she will tell the procurement department to assign one specialist to the project. Mr. Alfano informed Ms. Morales that there are weekly project team meetings at MOH that UFI can join to hear about project updates and to make appropriate adjustments or decisions. The team will draft an acquisition plan by November 30. They all agreed to create a plan for funding training sessions. The team and UFI will meet again in two weeks to discuss details on how to move forward. The mid‐term evaluation was also mentioned. RECOMMENDATION: It is essential that a smooth process is established with UFI that avoids delays in the implementation of the national project in order to meet the global deadline of June 2012.


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3:00PM: Technical Video Teleconference at the Universidad Tecnologica Nacional by Dr. Jorge Emmanuel

The team briefly met with Dr. Walter Legnani (Secretary of Science and Technology) and Eng. Carlos Alberto Castillo (Subsecretary of University Extension) of UTN. Dr. Emmanuel gave a video teleconference presentation followed by a discussion on healthcare waste and non‐burn technologies to multiple UTN campuses throughout Argentina. Approximately 150 people participated. WEDNESDAY, November 17

9:30 AM: Meeting with the Universidad Tecnologica Nacional to discuss the National Training Program (Lic. Patricia Monica Frances, UTN; Liliana Ferranti, UTN; Luisa Brunstein, Ministry of Health; and Daniel Alfano, National Technical Consultant)

Ms. Ferranti and Ms. Frances provided an update on UTN’s work with the national training program and the existing structure of training of healthcare workers within Argentina. UTN formalized a team to work on training with tasks to perform divided into two components: (1) specifications of the program and (2) the module and teaching materials. The first part entails identifying regional characteristics, existing knowledge, regulatory gaps, beneficiaries, sustainability beyond the project, teaching methods, etc. It may be possible to link laws on occupational health and safety risks to training needs. The plan is to complete the survey of the situation in the regions, define the training objectives including target audience, develop a profile and create a roster of master trainers, complete the development of training materials and methods by June 2011, test and evaluate the material, set up a management team, implement the training‐of‐trainers (TOT) program in the second half of 2011, and implement training in academia and other areas. UTN has had much experience in individual certification of trainees related to job competencies. Teachers from UTN will be identified to conduct the TOT but it is important for the master trainers to commit to staying in their institutions for a length of time to ensure knowledge transfer. Dr. Emmanuel provided an update on the Global Project Team’s training materials and informed UTN that the University of Illinois, Chicago (UIC) can share information with the local team on training programs. ACTION ITEM: The Global Project Team linked the Argentina UTN training team with the Global Project Team’s training group at the University of Illinois‐Chicago. RECOMMENDATION: As a complement to the work of developing a national training, the Ministry of Health may wish to initiate a campaign to promote training within healthcare facilities on healthcare waste management.

11:00 AM: Meeting with the Universidad Tecnologica Nacional to discuss the Chemical Waste Treatment Technology (Dr. Ester Chamorro, Director of the Organic Chemistry and Biology Research, Regional Faculty of Resistencia, UTN; Dr. Gustavo A. Velasco, Biochemist, Regional Faculty of Resistencia, UTN; Luisa Brunstein, Ministry of Health; and Daniel Alfano, National Technical Consultant)


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Dr. Chamorro and Dr. Velasco provided an update on UTN’s work on the chemical waste treatment technology. Much of their work has been based on Dr. Emmanuel’s technical proposal from early 2010. One criterion they are working on is identifying between five to ten components that are the most used compounds and are hard to treat. Due to time and budget, only a few representative compounds will be tested. In a 10‐day survey, they found a lot of contaminated paper, textile, glass and plastic such as gloves. Some waste residue is in closed bottles so packaging may be an issue. By mid‐December, they want to develop the methodology to survey the drugs used and their volumes. There was discussion about the best way to move forward with the work given the limited amount of time and budget. Dr. Emmanuel recommended that they work with the Fenton technology first and suggested that the work focus on testing the effectiveness of the destruction and the residues. However, equipment such as high performance liquid chromatography and mass spectrometry are not readily available. They may be able to collaborate with the University of Buenos Aires and the National Institute of Industrial Technology (INTI). . They plan to design a table top‐size system. If they can show that the concept on a laboratory scale works, then they could build a small‐scale equipment prototype that could be tested by an independent body. INTI will also be involved in the project. The team decided on the following activities:

• December 2010 to February 2011: complete the survey, identify the chemicals to be tested, and begin designing the system

• March and April 2011: get the equipment ready and conduct tests • May 2011: test the residues • Mid‐year 2011: issue the first report and conclusions and continue designing the small scale Fenton with shredder‐type abilities on the inside and ecological testing

They will need a cost analysis before they move forward with the testing, so Mr. Alfano suggested they do a preliminary cost analysis and then go from there. The question of intellectual property was discussed. Dr. Emmanuel clarified that the intellectual property belongs to GEF during the duration of the project. At the end of the project, UNDP can work with GEF to transfer the intellectual property to the appropriate parties. RECOMMENDATION: A revised and simplified proposed methodology for the chemotherapeutic waste treatment study will be sent out by the Global Project Team.

2:00 PM: Meeting with Reconquista Central Hospital (Dr. Liliana Lorenzón, Head of HCWM Committee; Mario Alberto Aidit, Maintenance; Maria Ines Cosa, Head Nurse; Teme Otto, Laboratory Technician; Maria Soledad Alaba, Technical Consultant Advisor; Valerie Altamirano, Administrative Clerk; Luisa Brunstein, Ministry of Health; Daniel Alfano, National Technical Consultant; and Francisco Chesini, Project Technical Assistant at Garrahan Hospital)


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The team met with Reconquista Central Hospital’s HCWM Committee, headed by the former hospital director Dr. Lorenzon. The committee provided an overview of the current situation at the hospital. They have identified different lines of work regarding HCWM and two training sessions generated strong interest. There is still a lot of work to be done but they have limited resources. Local health authorities are interested in the project but there is a need for stronger commitment from hospital management. Santa Fe province consists of five regions and Reconquista is the largest in geographical area (200 sq km) but is the poorest in resources. The 144‐bed hospital is the highest level in the region, with a 66.32% occupancy rate, and 44,920 outpatients per semester. They provide services to a large area. They are currently building a new hospital facility but that will not be completed for three more years. The hospital’s on‐site infectious waste storage is a truck trailer that cannot close well and the general waste is held in a rundown storage unit that is sometimes entered by animals. There are no carts so the staff has to manually carry the waste without PPE or uses a supermarket cart. They are working with the municipality to place their infectious waste storage in what is now the general waste storage. Since they plan to have a new hospital facility in about three years, they will upgrade their existing storage situation instead of replacing it. They have no carts to collect waste and overall waste collection is irregular so the amount of waste often builds up and the odors are strong. Every 10‐15 days, the health centers bring their medical waste to the storage unit. They are now identifying temporary storage areas and have removed red bags from patient beds, resulting in a reduction of 40‐50% of waste from May to November. They are improving segregation and are recycling plastics and cardboard. A key challenge is getting doctors to change their practices. The mayor of Reconquista has been supportive. They are working on their mercury phase‐out plan. Their incubator mercury thermometers will be replaced with new incubators as a co‐finance by the MOH. Mr. Alfano noted that the digital devices procurement will begin in March 2011 and replacement efforts can happen before this to get buy‐in of hospital personnel. Department heads will be given the digital equipment with a letter of intent to replace mercury. They have already conducted workshops on HCWM and personnel have responded positively to the importance of HCWM. RECOMMENDATION: The economic feasibility of the proposal to make Reconquista Central Hospital a treatment center for the area and install an autoclave should be investigated as soon as possible in order to finalize the selection of an economically viable plan and begin implementation. 3:30 PM: Brief meeting with Francisco Lima Lopez Hospital (Dr. Ariel Martinez, Hospital Director; Basaul Yonina, Infection Control Committee; Maria Emilia Bello, Project Technical Assistant at FLLH; Miguel Dionisio Barzola, Chief of Nurses; Luisa Brunstein, Ministry of Health; Daniel Alfano, National Technical Consultant; and Francisco Chesini, Project Technical Assistant at Garrahan Hospital)

The team briefly met with members of the HCWM Committee. Ms. Bello reviewed the hospital’s presentation for the National Working Group meeting. Procurement has to be started as soon as possible. THURSDAY, November 18


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9:30 AM: Meeting of the National Project Steering Committee: (Dr. Ernesto de Titto, National Project Coordinator, Ministry of Health; Daniel Tomasini, Environmental and Sustainable Development Unit Coordinator, UNDP Argentina; Matias Mottet, Project Focal Point, UNDP Argentina; Pablo Issaly, National Directorate of Environmental Management, Secretariat of Environment and Sustainable Development; Dr. Luis Escoto, Project Focal Point, PAHO; Dr. Leila Devia, Director, Basel Convention Regional Centre for South America, Instituto Nacional de Tecnología Industrial (INTI); Veronica Odriozola, Health Care Without Harm; Ricardo Benitez, Ministry of Health; Luisa Brunstein, Ministry of Health; Daniel Alfano, National Technical Consultant; Sonia Sagardoyburu; Francisco Chesini, Project Technical Assistant at Garrahan Hospital; Soledad Garavelli, National Project Assistant)

The National Project Steering Committee had its formal meeting to review the status of the project and to review and approve plans. Among the issues discussed were: the new deadline for the end of the project; the new rules in relation to the UFI requirements and process; the need to accelerate the procurement process; the role of the government focal points for GEF and the various conventions as well as the role of the Ministry of Foreign Affairs; the role of PAHO especially in dissemination; the role of INTI with regards to evaluating an intermediate‐scale prototype of the chemotherapeutic waste treatment technology; and intellectual property issues. The global team shared its observations including the positive developments in all components of work, the global plans to issue another newsletter, the upcoming mid‐term evaluation and Global Project Steering Committee meeting. The global team also expressed its thanks to the national project for a very productive mission. 11:00 AM: Meeting of the National Working Group: (Dr. Ernesto de Titto, National Project Coordinator; Director Ricardo Benitez, Ministry of Health; Luisa Brunstein, Ministry of Health; Daniel Alfano, National Technical Consultant; and representatives from Hazardous Waste Management (Secretariat of Environment and Sustainable Development), Occupational Health and Safety (Ministry of Health), Garrahan Hospital, Francisco Lima Lopez Hospital in Rio Negro, Reconquista Central Hospital, Municipality of Reconquista (Municipal Mayo Engr. Jacinto Raul Speranza), Universidad Tecnologica Nacional‐Chaco, and project consultants and assistants)

Dr. de Titto opened the meeting with a brief introduction and Dr. Emmanuel gave a global overview of the project. Mr. Alfano summarized the status of each major component of the national project. Dr. Gustavo A. Velasco from UTN gave a presentation on the chemical treatment technology work. Dr. Liliana Lorenzón and technical consultant Maria Soledad Alaba gave a presentation on Reconquista Central Hospital’s project work. Dr. Ana Digon and Dr. Eduardo Rodriguez presented on the Ministry of Health’s mercury work and especially their work related to dentistry. Technical consultant Maria Emilia Bello gave a presentation on Francisco Lima Lopez Hospital’s project work. Dr. Josefa Rodriguez gave a presentation on Garrahan Hospital’s project work. Many salient issues were raised including the need for recommendations regarding dental traps (see Appendix 1); the need for solutions to deal with x‐ray processing waste; and plans to conduct a monitoring of mercury exposure among dental assistants and dental students (see Note below).


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RECOMMENDATION: Recommendations regarding recovery of silver from radiology waste are given in Appendix 2. NOTE: The Global Project Team has purchased a Jerome J405 unit, a small portable mercury vapor analyzer, which uses gold film sensor technology to measure mercury concentration in ambient air. It has a minimum detection limit of 0.5 micrograms per cubic meter (0.5 µg/m3), a detection range of 0.5 to 999 µg/m3, an accuracy of ±10% at 1 µg/m3, and a response time of 2‐12 seconds. The global team will share this equipment with the projects in Argentina, India, Philippines and other countries. FRIDAY, November 19 9:30 AM: Meeting with PAHO (Dr. Luis Escoto, Project Focal Point, PAHO; Luisa Brunstein, Ministry of Health; and Daniel Alfano, National Technical Consultant)

The project’s partnership with PAHO was discussed. PAHO could assist the project with the translation of the soon‐to‐be updated version WHO’s reference guidelines on healthcare waste management (WHO Blue Book) into Spanish. Dr. Emmanuel, Mr. Alfano, and Dr. Escoto will work with PAHO, MOH, and WHO Geneva to develop an appropriate plan to move forward with translation of the Blue Book. Mr. Alfano noted that it would be helpful to have a more secure work plan with PAHO Regional Office for the next year. Dr. Escoto noted that PAHO Argentina is committed to the project and can help the project with training activities, systemizing experiences in order to be focused on lessons learned, and disseminating good practice and focusing on project results. He stated that Engr. Diego Daza from the PAHO Regional Office could come to Argentina in early 2011 to visit the facilities and learn more about the project. Mr. Alfano will contact Mr. Daza to discuss the project and make arrangements for his visit. The national mercury conference was discussed. There may be potential to have the conference include regional partners. The possibility of covering both mercury and HCWM was also discussed. Dr. Escoto informed the team about a PAHO sub‐regional project involving MERCOSUR countries focusing on mercury and pesticides. There could be some sharing of information through the MERCOSUR Comisión Intergubernamental de Salud Ambiental y del Trabajador (CISAT). RECOMMENDATION AND UPDATE: The MOH may wish to consider formally requesting PAHO for assistance in the translation of the WHO Blue Book. The Global Project Team has informed WHO‐Geneva about this. The Blue Book is still being prepared for a last round of reviews by external experts. 11:30 AM: Debriefing with the Project Team (Luisa Brunstein, Ministry of Health; Daniel Alfano, National Technical Consultant; and Francisco Chesini, Project Technical Assistant at Garrahan Hospital)

Mr. Alfano noted that according to the Project Document, they are supposed to have four model facilities, but they are currently working with only three facilities. They proposed that the fourth health facility be a facility with less than ten beds in a small village in Northeastern Argentina. The project can use the models from General Roca and Reconquista and apply the


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project activities in a very small healthcare facility to show that it can be replicated in a small environment. They could implement this replication towards the end of the project. This fourth facility would not be a model facility, but it will be an example of how project activities were transferred. Dr. de Titto and Undersecretary Dr. Lazovski are handling this change to the project. Mr. Alfano also inquired about mercury‐free batteries for digital thermometers. Dr. Emmanuel noted that he will speak with GEF about the intellectual property question related to the chemical treatment technology. Ms. Brunstein discussed the issue of alternative packaging for medical supplies for hospitals. Taking into consideration that the quality of the supplies could be minimized due to alternative packaging versus the benefits of reducing waste generation, she asked if Dr. Emmanuel has recommendations for the best packaging for supplies or lessons learned around this issue. NOTE: The Global Project Team members agreed with the proposal to select a very small facility in Northeastern Argentina to test the replication of the best practices and techniques developed in the three model facilities. RECOMMENDATION ON MERCURY‐FREE BATTERIES: See Appendix 3. RECOMMENDATION ON PACKAGING WASTE REDUCTION: See Appendix 3 GENERAL RECOMMENDATION: The Global Project Team (GPT) requests that the national project share its projected timeline with the GPT so as to be able to track milestones and provide support during implementation. Conclusions and Recommendations The Global Project Team members concluded that the project in Argentina has made major advances despite the late start and is doing well, in large part because of the leadership of the national project coordinator and his colleagues at the Ministry of Health, the skills and expertise of the national technical consultant, the commitment of key people involved with the three model hospitals and in UTN, and the support of UNDP‐Country Office, PAHO, and HCWH. There remain major challenges, including the need to complete all the activities by the first quarter of 2012, establishing a smooth process with UFI, the decision regarding the best approach for Reconquista Central Hospital, and finalizing the work plan on the chemotherapeutic waste treatment study. The Global Project Team members felt that all objectives of the mission were accomplished. Below is a summary of recommendations: GENERAL


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• It is essential that a smooth process is established with UFI to avoids delays in the implementation of the national project in order to meet the global deadline of June 2012.

• The Global Project Team (GPT) requests that the national project share its projected timeline (schedule) with the GPT.

GARRAHAN MODEL HOSPITAL

• Mandatory reporting of needle‐stick injuries and other accidental exposures should be reactivated at Garrahan Hospital to monitor occupational injuries, establish root causes, find solutions, and determine possible links to waste management practices.

FRANCISCO LIMA LOPEZ HOSPITAL

• Separate carts should be used for infectious (red) and general (black) waste at Francisco Lima Lopez Hospital.

• A small autoclave should be used in the lab to disinfect cultures before they leave the laboratory.

• Ortho‐phthalaldehyde (OPA) disinfectant is toxic to aquatic species and should not be dumped in the drain. OPA can be neutralized by adding 25 grams of glycine powder per gallon of OPA solution, mixing well and allowing to stand for one hour prior to disposal.

RECONQUISTA CENTRAL HOSPITAL

• The economic feasibility of the proposal to make Reconquista Central Hospital a treatment center for the area and install an autoclave should be investigated as soon as possible in order to finalize the selection of an economically viable plan and begin implementation.

WASTE TREATMENT TECHNOLOGIES

• Microbiological testing should be conducted at Zavecom treatment facility to ascertain that the autoclave operating conditions are sufficient to achieve at least a 99.99% (or Log 4) reduction of Geobacillus stearothermophilus. The recommended test protocol can be found in Appendix 5.

• A revised and simplified proposed methodology for the chemotherapeutic waste treatment study will be sent out by the Global Project Team.

MERCURY

• Recommendations regarding amalgam traps are found in Appendix 1.

• Recommendations regarding methods of sampling and analysis for mercury in dental wastewater are found in Appendix 4.

• Recommendations regarding mercury‐free batteries are found in Appendix 3. OTHER WASTE ISSUES


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• Recommendations regarding recovery of silver from radiology waste are given in Appendix 2.

• Recommendations regarding minimization of packaging are found in Appendix 3. NATIONAL TRAINING

• As a complement to the work of developing a national training, the Ministry of Health may wish to initiate a campaign to promote training within healthcare facilities on healthcare waste management.

REGIONAL DISSEMINATION

• The MOH may wish to consider formally requesting PAHO for assistance in the translation of the WHO Blue Book. The Global Project Team has communicated with WHO‐Geneva about this.

Acknowledgment The Global Project Team members are grateful to the entire national project team, their colleagues, and all the project stakeholders for the warm welcome and cooperation. The GPT members commend the Argentina project participants for their commitment and support of the GEF project.

APPENDIX 1

RECOMMENDATION REGARDING DENTAL AMALGAM REMOVAL FROM DENTAL WASTEWATER GENERAL RECOMMENDATIONS:

1. To minimize occupational risks, precapsulated amalgam should be used instead of bulk elemental mercury and personal protection equipment should be worn.

2. Store different sizes of capsules to minimize amalgam waste; use only the correct amount to minimize waste.

3. Collect and recycle disposable capsules. 4. Depending on the recycler or amalgam reclamation company, it may be advantageous

to separate non‐contact scrap amalgam (excess left over from the preparation) and contact amalgam (amalgam that has been in contact with the patient such as extracted teeth with amalgam restoration or carving scrap).

5. Since chair‐side traps and vacuum pump filters only remove between 40 to 80% of amalgam from the wastewater,1 multiple levels of amalgam retention devices should be installed. That is, dental amalgam separators should be installed along with chair‐side traps and secondary vacuum pump filters.

6. Use a disposable or reusable chair‐side trap to capture the amalgam. 7. Replace vacuum filters every quarter or according to manufacturers’ specifications.

When removing the filter, hold it under a tray to catch spills; amalgam‐free liquid can be released to the drain. Amalgam‐containing liquid and the filter should be stored and labeled as “contact‐amalgam waste.”

8. Use an amalgam separator in the vacuum line to remove amalgam from the rinse water before the water is released into the sewer.

9. Do not use bleach or chlorine‐based cleaners to clean out pipes and drain lines since these cleaner help dissolve amalgam in the pipes. Use non‐chlorine, environmentally friendly cleaners.

10. Store capsules, non‐contact amalgam, contact amalgam, contents of traps, and used filters in appropriate, wide‐mouthed, air‐tight, properly labeled, unbreakable containers. Water or photographic fixative solution could be added to reduce volatilization. Bleach could be added to contact amalgam waste for disinfection. Send the waste to an approved recycler or amalgam reclamation company.

11. After installing amalgam retention devices, replace old plumbing sink traps and other low points in the plumbing where amalgam may have settled. Collect, store, and label the amalgam waste.

12. Send all amalgam waste to an approved recycler or amalgam reclamation company.

1 H. Batchu, D. Rakowski, P.L. Fan, and D. M. Meyer, “Evaluating amalgam separators using an international standard,” J Am Dent Assoc, Vol 137, No 7, 999‐1005 (2006).

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GENERAL INFORMATION REGARDING CHAIR‐SIDE TRAPS AND FILTERS: Chair‐side traps can filter particles as small as 0.7 mm. They come in filter sizes ranging from 40 to 100 mesh. Vacuum filter traps can capture particles as small as 0.4 mm. When chair‐side traps and filter traps are used together, a combined removal rate of 40% to 80% of amalgam particles could be achieved.

Illustration adapted from the Department of Ecology, State of Washington

RECOMMENDATIONS FOR CHAIR‐SIDE TRAPS:

1. There are no international standards for chair‐side traps but it is generally recommended to use smaller mesh sizes to trap amalgam particles more efficiently as long as the suction system can function properly with the finer mesh size. For example, use size 100 mesh traps instead of size 40 mesh traps if possible.

2. Change or clean chair‐side traps as often as necessary in accordance with manufacturers’ specifications.

3. For reusable traps, flush the vacuum system with an environmentally friendly non‐chlorine disinfectant and allow the trap contents to dry before opening the trap. Be careful not to spill any amalgam into the drain. Remove non‐amalgam particles using forceps and empty the amalgam into a wide‐mouthed, air‐tight, properly labeled, unbreakable container. Check that the reusable trap remains in good condition.

4. For disposable traps, remove the trap and place it directly into a large, wide‐mouthed, air‐tight, properly labeled, unbreakable container.

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5. Use personal protection equipment when removing or cleaning traps. GENERAL INFORMATION REGARDING DENTAL SEPARATORS: A dental separator is installed centrally so that the whole wastewater stream from the dental facility passes through it before being discharged into the sewer system. There are five types of dental separators: (a) centrifugal systems that use centrifugal force to separate amalgam particles from the wastewater, (b) sedimentation systems that decrease the velocity of the wastewater to allow amalgam particles to settle out, (c) filter systems that can remove amalgam of fine and colloidal sizes, (d) chemical systems that use a chelating agent or ion exchange resin, and (e) a combination of two or more of the above systems. The US EPA found that sedimentation, either alone or in conjunction with filtration and ion exchange, can achieve removal efficiencies of about 99%.2 RECOMMENDED SPECIFICATIONS FOR DENTAL SEPARATORS (key specification shown in red):

1. The dental separator should meet or exceed the 95% minimum removal efficiency required under the international standard International Organization for Standardization (ISO) 11143 “Dental Equipment‐Amalgam Separators.”

2. The dental separator should be tested under the ISO 11143 protocol and certified by an independent and accredited third party as meeting the ISO 11143 requirements.

3. The dental separator should be compatible with any existing wet ring or dry vacuum pump system in the facility.

4. The size of the dental separator must fit within the space limitations of the dental facility.

5. The flow capacity of the dental separator must be able to meet the needs of the number of dental chairs in the facility.

ADDITIONAL OPTIONAL FEATURES FOR AMALGAM SEPARATORS: In addition to the international standard and specifications, below are ideal features of a dental separator:

1. The separator should not adversely affect suction power. 2. The separator should require minimal or no manual operation. 3. The separator should have a simple design with a fail‐safe mechanism that protects the

user from spills or back‐ups in the event of a blockage. 4. The separator should operate quietly. 5. The separator should be easy to install and maintain. 6. The separator should be affordable with low operating and maintenance costs. 7. The separator company also provides a recycling or amalgam reclamation program.

2 “Health Services Industry Detailed Study: Dental Amalgam,” EPA‐821‐R‐08‐014, U.S. Environmental Protection Agency, August 2008.

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APPENDIX 2

RECOMMENDATIONS REGARDING RADIOLOGY WASTE

Radiological services generate the following waste streams: spent fixer solutions, old or scrap x‐ray films, wastewater from x‐ray processing, and expired or waste chemicals. Many of the chemicals used in developing film are acidic or caustic and some are inhalation hazards and should be handled with care. The film and fixer used in radiology and X‐ray services contain silver. Although silver is generally not a severe hazard to human health, it is hazardous to aquatic plants and animals. Best management practices for radiology services include:

• Storing processing chemicals properly to prolong shelf life;

• Recovering silver from fixer solution – this could be done on site or at an external facility;

• Recycling x‐ray film to recover the silver – this is usually done at an external facility;

• Extending the life of the fixing bath by adding ammonium thiosulfate and immersing the film in an acid stop bath prior to the fixing bath;

• Using acetic acid in the stop bath to keep the pH low;

• Using squeegees to wipe excess liquid from the film thereby minimizing chemical contamination of process baths;

• Segregating spent fixer, spent developer, acids, etc.;

• Switching to a digital imaging system in the future. This paper will focus on silver recovery on site. When X‐ray film is processed, the silver is released into the fixer solution. Spent fixer typically contains between 2,000 and 8,000 mg/L (equal to parts per million or ppm) of silver. On‐site silver recovery is typically used for spent fixer. A silver recovery unit can be installed at the end of the x‐ray processing line and the recovered silver can be sold to a metal recycler. Depending on the price of silver, a substantial savings can be obtained by recovering silver. The recovery of silver from x‐ray film and paper is more complicated and is generally done in an external reclamation plant. Recommendations for silver recovery depend on the average quantities of silver‐rich solution and wastewater that a facility generates per day. Therefore, the first step is to estimate the volume of x‐ray processing solutions generated and categorizing facilities based on the volume.

1. FACILITY CATEGORIES For a conventional medium to large process, estimate the amount of fixer by determining the replenishment rate of fixer per area of film (i.e., milliliters of fixer per cm2) and multiplying this value by the total area of film processed on average in one day. If the replenishment rate is set per film (milliliters of fixer per film), multiple this by the average number of films processed per

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day. X‐ray processors typically use between 70 to 120 mL of fixer per film.3 For a small dental facility, the estimate can be based on the average volume of fixer that is replenished in a month and dividing it by the number of days of operation per month. To estimate the amount of wastewater, one needs to determine the wash water flow rate of the x‐ray processing machine according to the manufacturer’s specifications. Multiply the flow rate by the amount of time the machine uses water, which may be continuous or intermittent. Some authorities use the following factors to estimate the total discharge: 75 liters per m2 of film or 12 liters per x‐ray procedure.4 Based on these estimates, the following are the size classifications:5

CATEGORY DEFINITION

Small Generates less than 8 liters per day of silver‐rich solution and less than 3,800 liters per day of process wash water

Medium Generates more than 8 but less than 80 liters per day of silver‐rich solution and more than 3,800 but less than 38,000 liters per day of process wash water

Large Generates more than 80 liters per day of silver‐rich solution and more than 38,000 liters per day of process wash water

Based on The Silver Council’s Code of Management Practice, 1999

2. TYPES OF TECHNOLOGIES FOR SILVER RECOVERY

Silver recovery technologies are generally effective within specified concentration ranges. Some can be used as stand‐alone units while others are supplementary technologies used in combination with a primary treatment technology. Silver recovery technologies include: metallic replacement, in‐line and terminal electrolysis, precipitation, ion exchange, and reverse osmosis. Metallic replacement using steel wool is the simplest, cheapest, and most common method. The steel wool is put in a bucket, column, or canister into which the solution is introduced by gravity or by using a metering pump. Inside the container, the steel wool fiber can also be wound around a core or cut up and packed into a filter or cartridge (also called a chemical recovery cartridge, metallic recovery cartridge, or silver recovery cartridge). Some cartridges are constructed using a layer of chopped steel wool sandwiched between two tightly packed spools of wound steel wool. Other cartridge manufacturers use a different metallic form, such as iron particles glued to fiber glass, iron‐impregnated resin beads, or wound iron screens. A good cartridge design is one that can recover 90% or more of the silver from the silver‐rich solution.

3 “Using the Code of Management Practice to Manage Silver in Photographic Processing Facilities,” pamphlet J‐217, Kodak Environmental Services, Kodak Eastman Company, 1999. 4 “Radiology Clinics – Pub 36,” Industrial Waste Information Brochure, Water Corporation, Leederville, Western Australia, April 21, 2010. 5 “Code of Management Practice: Guide for Photoprocessors,” The Silver Council, National Association of Photographic Manufacturers, Inc., 1999.

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Steel wool bucket

The metallic replacement technology can be a batch process or a continuous flow‐through system. As the silver‐rich solution is slowly metered into the cartridge, the silver thiosulfate is reduced to metallic silver which is left behind in the cartridge while the iron is solubilized and flows out of the cartridge or bucket. The technology requires good control of the flow rate and proper maintenance. Among the disadvantage of metallic replacement are: inconsistent silver reduction if there are variations in silver concentration in the input and the difficulty in determining when the cartridge should be replaced. Also, it is often necessary to have two metallic replacement cartridges in series to be able to achieve more than 95% silver removal efficiency. A typical dual‐cartridge system is shown below. When the first cartridge is exhausted it is removed and the second cartridge is moved into the first position while a fresh cartridge is placed in the secondary position.

In electrolysis—also called electrolytic silver recovery or electrolytic plating—a direct current is passed between an anode and a cathode causing metallic silver in the solution to deposit on the cathode. In photochemical solutions that contain both fixer and bleach, the recovery process is more efficient with higher pH so sodium hydroxide or sodium carbonate is added. The result is silver plating on the cathode that is about 90% pure. Terminal electrolysis is done at the end of the process and is a primary treatment method. One disadvantage of electrolysis is that it is difficult to obtain concentrations below 200 mg/L. Thus, it is often followed by a secondary treatment process such as metallic replacement (shown below).

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In in‐line electrolysis, the fixer solution is re‐circulated between the process tank and an electrolytic unit that keeps the silver concentration within a specific range without degrading other fixer ingredients. This technology substantially reduces the fixer replenishment rate as well as the silver concentration in the wash tank. In‐line electrolysis requires fairly sophisticated control systems. Precipitation involves the addition of chemical agents to remove silver. Precipitating agents include sodium or potassium sulfide (which form silver sulfide that is then filtered out), strong reducing agents such as sodium borohydride (which forms metallic silver), and tri‐mercapto‐s‐triazine (which forms an insoluble silver compound). This technology can achieve very low silver concentrations but is generally only used in a central treatment or specialized service facility. Ion exchange uses a polymer resin in the form of beads packed in a column. As the solution flows through the column, the sodium thiosulfate complex is exchanged with an ion of lower preference in the resin. This process only works for dilute silver concentrations. When the column can no longer absorb additional silver, the ion exchange resin has to be regenerated. The technology is used to treat wash water that can then be reused, or as a secondary treatment step (after the primary treatment unit has reduced the silver concentration). Reverse osmosis uses high pressure to force the solution through a semi‐permeable membrane to separate the silver and other large molecules. It can only be used for dilute silver solutions. Evaporation is another technique wherein wastewater is heated to evaporate the liquid. The resulting sludge is collected in filter bags and sent to a silver reclamation company. A disadvantage is this method is the release of organic compounds and ammonia in the air.

3. RECOMMENDATIONS BASED ON SIZE CATEGORY

There are three regulatory approaches to dealing with silver from x‐ray and photographic processing facilities. Some authorities limit the maximum concentration of silver in the effluent; a limit of 5 mg/L is commonly used although some authorities may use more stringent limits as low as 0.1 mg/L.

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A more common approach is to specify the percent removal efficiency based on the facility size:

CATEGORY DEFINITION

Small At least 90% efficiency in the recovery of silver

Medium At least 95% efficiency in the recovery of silver

Large At least 99% efficiency in the recovery of silver Based on The Silver Council’s Code of Management Practice, 1999

Because of the difficulty in testing wastewater and in monitoring and enforcing compliance with regulations based on concentration limits or removal efficiencies, many authorities simply require the implementation of best management practices and technologies according to facility category. A properly designed and maintained metallic replacement cartridge should have a silver recovery efficiency of 90% or higher. A dual‐cartridge system should recover 95% or higher of silver from the silver‐rich solution. The table below summarizes recommended technologies for each category.

CATEGORY TECHNOLOGY RECOMMENDATIONS

Small facility 1 MRC with flow control [see Note (a) below] or 2 MRCs with flow control

or 1 EU or

1 precipitation unit

Medium facility 2 or more MRCs with flow control or

1 EU plus 1 MRC or

1 precipitation unit or

1 EU plus 1 precipitation unit

Large facility 1 EU plus 2 or more MRCs or

1 EU plus 1 precipitation unit Acronyms: MRC = metallic replacement cartridge; EU = electrolytic unit Note (a): Very small facilities generating less than 2 liters/day of silver‐rich solution need only 1 MRC.

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APPENDIX 3

OTHER RECOMMENDATIONS

ON MERCURY‐FREE BATTERIES: Although miniature mercury‐free batteries are not readily available in many countries, they do exist and digital thermometer vendors should be encouraged to provide them. Latvia, one of the project countries, was able to find mercury‐free batteries that could be used to replace the regular batteries in the digital thermometers they are procuring. The following two web links (in English) provide information about miniature mercury‐free batteries: http://www.maine.gov/dep/mercury/minibattalt.pdf http://www.maine.gov/dep/rwm/publications/legislativereports/pdf/buttonbatteriesreportjan09.pdf ON PACKAGING WASTE REDUCTION: A recommended strategy is to work with vendors and manufacturers to reduce their packaging and/or to use more recycled packaging materials in a manner that the vendors determine is still protective of their products. Hospitals have been able to pressure vendors to minimize unnecessary packaging by approaching vendors individually or working through their GPOs or group purchasing organizations (GPOs are entities created to leverage the purchasing power of a group of hospitals to obtain discounts from vendors based on the collective buying power of the GPO members). Other approaches include: working with vendors to set up a take‐back program for returning delivery and shipping containers, conducting waste audits to identify excessive packaging, modifying procurement contracts to specify minimum packaging, identifying vendors that promote waste minimization, working with vendors to aggregate shipment of smaller items in larger reusable boxes if possible, and recycling packaging waste. The weblinks below (in English) give case studies of hospitals that have implemented waste minimization programs including reduction in product packaging: http://www.epa.gov/opptintr/library/pubs/archive/acct‐archive/pubs/hospitalreport.pdf http://www.touchbriefings.com/pdf/13/hosp031_p_GROGAN.PDF In addition, two articles (in English, weblinks below) from Pharmaceutical & Medical Packaging News provide the perspectives of a group purchasing organization and of the manufacturers of medical and pharmaceutical devices regarding minimal packaging: http://www.pmpnews.com/article/what‐do‐hospital‐buyers‐think‐about‐packaging‐waste http://www.pmpnews.com/article/sustainable‐packaging‐reaches‐pharmaceuticals‐and‐medical‐devices

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APPENDIX 4

ANALYSIS OF MERCURY IN DENTAL WASTEWATER Mercury discharged in dental wastewater is present in many forms, including elemental mercury bound to amalgam particulate, inorganic mercury, elemental mercury, and organic mercury (monomethyl mercury). The vast majority (>99.6 percent) of dental mercury discharges are in solid form (elemental mercury bound to amalgam particulate).6 During the mission, a proposal was made to test and compare the wastewater from (1) a dental facility that does not use amalgam, (2) a dental facility that uses amalgam but does not recover its amalgam waste, and (3) one or more dental facilities that use amalgam but recover their amalgam waste using chair‐side traps, filters, amalgam separators, or a combination of them. In the case of #3, such a test could determine the efficacy of various amalgam recovery devices. Another option for #3 is to test the wastewater before and after the filter and/or amalgam separator to determine the mercury removal efficiency of the device. To compare dental facilities, it would be important to select facilities of similar size (same number of dental chairs, similar number of patients, and similar type of dental procedures). The following are recommendations for conducting such as study. Sampling: The ideal sampling method is to collect all wastewater from the dental chairs during the operating hours of a dental clinic in a standard work week. A 20‐liter collection device will be needed. The collection device can be constructed by taking a 20 L carboy (a rigid container used to transport liquids) and fitting it with bulkhead fittings, flexible and rigid plastic pipes, unions, valves, tees, and elbows. A step‐by‐step procedure for constructing the collection device is given below using English sizes7 but the same can be done using metric size. For large dental facilities, two or more collection devices may be required. To construct the collection device, obtain and assemble the following materials:

• 20‐liter vacuum‐rated polypropylene carboys (Nalgene #16101‐142 or equivalent)

• Two schedule 80 PVC bulkhead fittings (Use a hole saw to penetrate the carboy, then ream and sandpaper the orifice to accommodate the bulkhead fittings. The main part of the bulkhead fitting goes from the inside out; the retaining nut is on the outside.)

• Two unions, two 1” PVC plugs, and approximately 2 feet of flexible 1” PVC pipe (When fastening bulkheads to carboy, take care to align the flexible PVC [curve and height] flush with the manifold unions.)

6 Stone, M.E. Journal of the California Dental Association 32(7):593-600 (2004). 7 Adapted from “Sampling for Mercury in Dental Waste,” Department of Ecology, State of Washington.

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• If the device is installed below (i.e., downstream from the water part of) the air‐water separator tank, then the bypass assembly (i.e., manifold) can be omitted and polyethylene substituted for vacuum‐rated polypropylene.

• 10 feet or so of 1” schedule 40 PVC pipe; PVC primer and cement (1 each, small can); three 1” valves; two 90° 1” elbows; two 1” tees; (optional) segment of clear PVC for bypass arm. (For ease of construction, assemble the carboy first before assembling the valves. Make sure vertical stubs are beveled.)

• Four 8” x 8” 90° steel brackets; two 2” U‐bolts with nuts; one 4’ x 4’ piece of 3/8” plywood; one 20” plastic tray (e.g., polyethylene storage tray, 32 quart or equivalent).

• An appropriate coupling and reducing union (if necessary) to attach the device to the dental facility’s vacuum discharge line.

The collection device should prewashed with detergents, acids, and reagent water prior to installation. The photo below shows the collection device in the “sample collection” mode with the bypass arm closed.

The manifold is supported by standard U‐bolts and brackets, mounted on a 3/8” plywood stand. The stand, manifold, and modified carboy are placed in a 32 quart household storage tray to protect against spills. Glued fittings are used (in preference to threaded fittings) wherever possible to minimize loss of particles. A segment of clear PVC may be used on the manifold bypass arm or outlet to show when an overflow condition exists. If more than one collection device is needed during sampling, the following steps are used to place a new collection device.

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Step 1: Switch valves to “bypass mode.” The bypass arm (on top) is opened and the sample collection arms closed to allow removal or replacement of the sample collection bottle. Vacuum service to the dental office continues uninterrupted. Break vacuum to the carboy by loosening the carboy lid.

Step 2: Detach the unions joining the sample collection arms. Step 3: Cap the open sample collection arms to prevent contamination. Tighten the carboy lid, if it has been loosened. Step 4: Set the sealed carboy aside and put an empty carboy in its place. Reattach the unions as shown.

Step 5: Reset the sample collection valves to the open position. Note that the bypass valve (on top) also remains open at this stage.

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Step 6: Close the bypass valve to resume normal sample collection.

Before closing the collection device, the sampled wastewater must be acidified to a pH <2 with HNO3. The sample should be analyzed within 28 days. Analysis: Mercury in the wastewater can be analyzed using US EPA Method 7470A (cold vapor atomic absorption). The method is reproduced below with slight modifications. 1.0 SCOPE AND APPLICATION 1.1 Method 7470 is a cold‐vapor atomic absorption procedure approved for determining the

concentration of mercury in mobility‐procedure extracts, aqueous wastes, and ground waters. All samples must be subjected to an appropriate dissolution step prior to analysis.

2.0 SUMMARY OF METHOD 2.1 Prior to analysis, the liquid samples must be prepared according to the procedure discussed

in this method. 2.2 Method 7470, a cold‐vapor atomic absorption technique, is based on the absorption of

radiation at 253.7‐nm by mercury vapor. The mercury is reduced to the elemental state and aerated from solution in a closed system. The mercury vapor passes through a cell positioned in the light path of an atomic absorption spectrophotometer. Absorbance (peak height) is measured as a function of mercury concentration.

2.3 The typical detection limit for this method is 0.0002 mg/L. 3.0 INTERFERENCES 3.1 Potassium permanganate is added to eliminate possible interference from sulfide.

Concentrations as high as 20 mg/L of sulfide as sodium sulfide do not interfere with the recovery of added inorganic mercury from reagent water.

3.2 Copper has also been reported to interfere; however, copper concentrations as high as 10 mg/L had no effect on recovery of mercury from spiked samples.

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3.3 Seawaters, brines, and industrial effluents high in chlorides require additional permanganate (as much as 25 mL) because, during the oxidation step, chlorides are converted to free chlorine, which also absorbs radiation of 253.7 nm. Care must therefore be taken to ensure that free chlorine is absent before the mercury is reduced and swept into the cell. This may be accomplished by using an excess of hydroxylamine sulfate reagent (25 mL). In addition, the dead air space in the BOD bottle must be purged before adding stannous sulfate. Both inorganic and organic mercury spikes have been quantitatively recovered from seawater by using this technique.

3.4 Certain volatile organic materials that absorb at this wavelength may also cause interference. A preliminary run without reagents should determine if this type of interference is present.

4.0 APPARATUS AND MATERIALS 4.1 Atomic absorption spectrophotometer or equivalent: Any atomic absorption unit with an

open sample presentation area in which to mount the absorption cell is suitable. Instrument settings recommended by the particular manufacturer should be followed. Instruments designed specifically for the measurement of mercury using the cold‐vapor technique are commercially available and may be substituted for the atomic absorption spectrophotometer.

4.2 Mercury hollow cathode lamp or electrodeless discharge lamp. 4.3 Recorder: Any multirange variable‐speed recorder that is compatible with the UV detection

system is suitable. 4.4 Absorption cell: Standard spectrophotometer cells 10 cm long with quartz end windows may

be used. Suitable cells may be constructed from Plexiglas tubing, 1 in. O.D. x 4.5 in. The ends are ground perpendicular to the longitudinal axis, and quartz windows (1 in. diameter x 1/16 in. thickness) are cemented in place. The cell is strapped to a burner for support and aligned in the light beam by use of two 2‐in. x 2‐in. cards. One‐in.‐diameter holes are cut in the middle of each card. The cards are then placed over each end of the cell. The cell is then positioned and adjusted vertically and horizontally to give the maximum transmittance.

4.5 Air pump: Any peristaltic pump capable of delivering 1 liter air/min may be used. A Masterflex pump with electronic speed control has been found to be satisfactory.

4.6 Flowmeter: Capable of measuring an air flow of 1 liter/min. 4.7 Aeration tubing: A straight glass frit with a coarse porosity. Tygon tubing is used for passage

of the mercury vapor from the sample bottle to the absorption cell and return. 4.8 Drying tube: 6‐in. x 3/4‐in.‐diameter tube containing 20 g of magnesium perchlorate or a

small reading lamp with 60‐W bulb which may be used to prevent condensation of moisture inside the cell. The lamp should be positioned to shine on the absorption cell so that the air temperature in the cell is about 10oC above ambient.

4.9 The cold‐vapor generator is assembled as shown in Figure 1 of reference 1 or according to the instrument manufacturers’ instructions. The apparatus shown in Figure 1 is a closed system. An open system, where the mercury vapor is passed through the absorption cell

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only once, may be used instead of the closed system. Because mercury vapor is toxic, precaution must be taken to avoid its inhalation. Therefore, a bypass has been included in the system either to vent the mercury vapor into an exhaust hood or to pass the vapor through some absorbing medium, such as:

1. Equal volumes of 0.1 M KMnO4 and 10% H2SO4; or 2. 0.25% Iodine in a 3% KI solution.

A specially treated charcoal that will adsorb mercury vapor is also available from Barnebey and Cheney, East 8th Avenue and North Cassidy Street, Columbus, Ohio 43219, Cat. #580‐13 or #580‐22.

4.10 Hot plate or equivalent ‐ Adjustable and capable of maintaining a temperature of 90‐95oC. 4.11 Graduated cylinder or equivalent. 5.0 REAGENTS 5.1 Reagent Water: Reagent water will be interference free. All references to water in this

method will refer to reagent water unless otherwise specified. 5.2 Sulfuric acid (H2SO4), concentrated: Reagent grade. 5.3 Sulfuric acid, 0.5 N: Dilute 14.0 mL of concentrated sulfuric acid to 1.0 liter. 5.4 Nitric acid (HNO3), concentrated: Reagent grade of low mercury content. If a high reagent

blank is obtained, it may be necessary to distill the nitric acid. 5.5 Stannous sulfate: Add 25 g stannous sulfate to 250 mL of 0.5 N H2SO4. This mixture is a

suspension and should be stirred continuously during use. (Stannous chloride may be used in place of stannous sulfate.)

5.6 Sodium chloride‐hydroxylamine sulfate solution: Dissolve 12 g of sodium chloride and 12 g of hydroxylamine sulfate in reagent water and dilute to 100 mL. (Hydroxylamine hydrochloride may be used in place of hydroxylamine sulfate.)

5.7 Potassium permanganate, mercury‐free, 5% solution (w/v): Dissolve 5 g of potassium permanganate in 100 mL of reagent water.

5.8 Potassium persulfate, 5% solution (w/v): Dissolve 5 g of potassium persulfate in 100 mL of reagent water.

5.9 Stock mercury solution: Dissolve 0.1354 g of mercuric chloride in 75 mL of reagent water. Add 10 mL of concentrated HNO3 and adjust the volume to 100.0 mL (1 mL = 1 mg Hg). Stock solutions may also be purchased.

5.10 Mercury working standard: Make successive dilutions of the stock mercury solution to obtain a working standard containing 0.1 ug per mL. This working standard and the dilutions of the stock mercury solution should be prepared fresh daily. Acidity of the working standard should be maintained at 0.15% nitric acid. This acid should be added to the flask, as needed, before addition of the aliquot.

6.0 SAMPLE COLLECTION, PRESERVATION, AND HANDLING 6.1 All samples must have been collected using a sampling plan that addresses the

considerations discussed in Chapter Nine of this manual.

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6.2 All sample containers must be prewashed with detergents, acids, and reagent water. Plastic and glass containers are both suitable.

6.3 Aqueous samples must be acidified to a pH <2 with HNO3. The suggested maximum holding times for mercury is 28 days.

6.4 Nonaqueous samples shall be refrigerated, when possible, and analyzed as soon as possible. 7.0 PROCEDURE 7.1 Sample preparation: Transfer 100 mL, or an aliquot diluted to 100 mL, containing <1.0 g of

mercury, to a 300‐mL BOD bottle or equivalent. Add 5 mL of H2SO4 and 2.5 mL of concentrated HNO3, mixing after each addition. Add 15 mL of potassium permanganate solution to each sample bottle. Sewage samples may require additional permanganate. Ensure that equal amounts of permanganate are added to standards and blanks. Shake and add additional portions of potassium permanganate solution, if necessary, until the purple color persists for at least 15 min. Add 8 mL of potassium persulfate to each bottle and heat for 2 hr in a water bath maintained at 95oC. Cool and add 6 mL of sodium chloride‐hydroxylamine sulfate to reduce the excess permanganate. After a delay of at least 30 sec, add 5 mL of stannous sulfate, immediately attach the bottle to the aeration apparatus, and continue as described in Paragraph 7.3.

7.2 Standard preparation: Transfer 0‐, 0.5‐, 1.0‐, 2.0‐, 5.0‐, and 10.0‐ mL aliquots of the mercury working standard, containing 0‐1.0 ug of mercury, to a series of 300‐mL BOD bottles. Add enough reagent water to each bottle to make a total volume of 100 mL. Mix thoroughly and add 5 mL of concentrated H2SO4 and 2.5 mL of concentrated HNO3 to each bottle. Add 15 mL of KMnO4 solution to each bottle and allow to stand at least 15 min. Add 8 mL of potassium persulfate to each bottle and heat for 2 hr in a water bath maintained at 95oC. Cool and add 6 mL of sodium chloride‐hydroxylamine sulfate solution to reduce the excess permanganate. When the solution has been decolorized, wait 30 sec, add 5 mL of the stannous sulfate solution, immediately attach the bottle to the aeration apparatus, and continue as described in Paragraph 7.3.

7.3 Analysis: At this point the sample is allowed to stand quietly without manual agitation. The circulating pump, which has previously been adjusted to a rate of 1 liter/min, is allowed to run continuously. The absorbance will increase and reach a maximum within 30 sec. As soon as the recorder pen levels off (approximately 1 min), open the bypass valve and continue the aeration until the absorbance returns to its minimum value. Close the bypass valve, remove the stopper and frit from the BOD bottle, and continue the aeration. Because of instrument variation refer to the manufacturers recommended operating conditions when using this method.

7.4 Construct a calibration curve by plotting the absorbances of standards versus micrograms of mercury. Determine the peak height of the unknown from the chart and read the mercury value from the standard curve. Duplicates, spiked samples, and check standards should be routinely analyzed.

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7.5 Calculate metal concentrations (1) by the method of standard additions, or (2) from a calibration curve. All dilution or concentration factors must be taken into account. Concentrations reported for multiphased or wet samples must be appropriately qualified (e.g., 5 ug/g dry weight).

8.0 QUALITY CONTROL 8.1 Refer to section 8.0 of Method 7000. 9.0 METHOD PERFORMANCE 9.1 Precision and accuracy data are available in Method 245.1 of Methods for Chemical Analysis

of Water and Wastes. 10.0 REFERENCES 1. Methods for Chemical Analysis of Water and Wastes, EPA‐600/4‐82‐055, December 1982,

Method 245.1.

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APPENDIX 5

DOCUMENTO ORIENTADOR PARA PRUEBAS DE PROVOCACIÓN MICROBIOLÓGICA EN AUTOCLAVES UTILIZADOS PARA EL TRATAMIENTO DE RESIDUOS GENERADOS POR LA ATENCIÓN DE LA

SALUD

INTRODUCCIÓN

Dos de los componentes del Proyecto Global del PNUD/FMAM sobre residuos generados por la atención de la salud consisten en la comprobación de las tecnologías alternativas a la incineración para el tratamiento de este tipo de residuos, de las cuales el autoclave es la más comúnmente utilizada. El presente documento incluye un protocolo para el desarrollo de pruebas de provocación microbiológica para los ensayos de validación de autoclaves de desplazamiento por gravedad o de vacío utilizados para el tratamiento de residuos médicos.

OBJETIVO DEL PROTOCOLO DE ENSAYO

El objetivo de este protocolo es demostrar la capacidad de los autoclaves descriptos anteriormente para tratar residuos médicos de manera eficaz de acuerdo con los estándares de tratamiento aceptados.

PRINCIPIOS BÁSICOS Y ENFOQUE GENERAL

La eficacia del tratamiento significa la capacidad del autoclave para alterar los residuos de manera tal de eliminar su potencial como vector de enfermedades por completo o disminuirlo en gran medida. Los términos desinfección y esterilización son de uso frecuente en los debates sobre eficacia del tratamiento. La desinfección puede definirse como la reducción o eliminación de microorganismos patogénicos con el objetivo de minimizar el potencial de transmisión. La esterilización es la destrucción total de todo tipo de microorganismo. Dado que es difícil establecer la destrucción total de los microorganismos, la esterilización del instrumental médico y quirúrgico suele expresarse como una reducción igual a 6 en escala logarítmica de un microorganismo determinado que equivale a una millonésima (0,000001) de probabilidad de supervivencia de la población microbiana.

El sistema de clasificación de STAATT, cuando se lo utiliza en reemplazo de los términos desinfección o esterilización, se refiere a niveles de “inactivación microbiana” para el caso específico del tratamiento de residuos generados por la atención de la salud. La organización se estableció con el fin definir variables para la evaluación del desempeño de las tecnologías para el tratamiento de este tipo de

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residuos. El estándar internacional de inactivación microbiana para el tratamiento de residuos generados por la atención de la salud según los criterios propuestos por la STAATT es de Nivel III: Nivel III - Inactivación de bacterias vegetativas, hongos, virus lipofílicos/hidrofílicos, parásitos y micobacterias a un nivel de reducción mayor o igual a 6 Log10; e inactivación de esporas de g. stearothermophilus y de esporas de b. atrophaeus a un nivel de reducción mayor o igual a 4 Log10.

Los indicadores microbiológicos representativos comúnmente utilizados para evaluar la conformidad con dicho estándar son bacterias mycobacterium phlei o mycobacterium bovis (BCG) a un nivel de reducción mayor o igual a 6 Log10; y esporas termorresistentes de geobacillus stearothermophilus o bacillus atrophaeus a un nivel de reducción mayor o igual a 4 Log10. Las esporas de geobacillus stearothermophilus, anteriormente denominadas bacillus stearothermophilus, son endosporas inactivas no patogénicas capaces de soportar las altas temperaturas del tratamiento con vapor así como también con calor seco. Las esporas de bacillus atrophaeus, anteriormente denominadas bacillus subtillis var. niger, son también resistentes a la humedad, el calor seco y la inactivación química. El cuadro 1 contiene una lista de los principales tipos de microorganismos, sin incluir priones, según su resistencia al proceso de desinfección química; se observa el mismo patrón en los procesos de desinfección térmica. Debido a la alta resistencia de las esporas bacterianas, en general, sólo se requiere realizar ensayos de validación con el método de referencia (esporas de geobacillus stearothermophilus o bacillus atrophaeus) para comprobar la eficacia de los autoclaves destinados al tratamiento de residuos. Cuadro 1. Microorganismos en orden descendiente según su resistencia a la desinfección química

MICROORGANISMOS EJEMPLOS

ESPORAS BACTERIANAS [MAYOR RESISTENCIA]

GEOBACILLUS STEAROTHERMOPHILUS, BACILLUS ATROPHAEUS,

CLOSTRIDIUM SPOROGENES PARÁSITOS EN FASE QUÍSTICA

QUISTES DE CRYPTOSPORIDIUM

MICOBACTERIAS

MYCOBACTERIUM TUBERCULOSIS VAR. BOVIS, MICOBACTERIA NO TUBERCULOSA

VIRUS NO LIPÍDICOS O PEQUEÑOS

VIRUS DE POLIO, VIRUS DE COXSACKIE, RINOVIRUS

HONGOS

TRICHOPHYTON SPP., CRYPTOCOCCUS SPP., CANDIDA SPP.

PARÁSITOS EN FASE NO QUÍSTICA

BACTERIAS VEGETATIVAS

PSEUDOMONAS AERUGINOSA, STAPHYLOCOCCUS AUREAUS, SALMONELLA CHLOERAESUIS, ENTEROCOCCI

VIRUS LIPÍDICOS O MEDIANOS [MENOR RESISTENCIA]

VIRUS DE HERPES SIMPLEX, CITOMEGALOVIRUS, VIRUS SINCICIAL RESPIRATORIO (VSR),

VIRUS DE HEPATITIS B, VIRUS DE HEPATITIS C, VIRUS DE INMUNODEFICIENCIA HUMANA (VIH)

Fuente: Sterilization, Part 1: Sterilization in Health Care Facilities, Arlington: Asociación para el Desarrollo del Instrumental Médico (2006)

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El método tradicional de prueba para los sistemas de esterilización por calor húmedo tales como los autoclaves se realiza con endosporas que se colocan sobre tiras de papel seco protegidas con sobres de papel glassine. Después del procesamiento, se retira la tira cuidadosamente del sobre y se la coloca en un recipiente con un medio estéril. Dentro de las 24 horas, se la inocula en forma aséptica en 5,0 ml de un medio de dilución de caldo digerido de caseína-soja. Este proceso debe realizarse con sumo cuidado para evitar la introducción de bacterias ambientales en el medio. Luego, se incuba la tira con el medio de cultivo durante un mínimo de 48 horas a 30ºC para bacillus atrophaeus y a 55 °C para geobacillus stearothermophilus para permitir que crezcan y se reproduzcan las esporas sobrevivientes. La turbidez del medio indica la falla del tratamiento con el autoclave.

En la actualidad se utiliza un método más sencillo, que recomendamos en este documento orientador. Se basa en el uso de un indicador biológico autocontenido (SCBI) que consiste en una tira de esporas dentro de un recipiente que a su vez contiene un medio de cultivo dentro de una cápsula interna precitada; se utiliza un tapón perforado junto con un filtro hidrófobo que actúa como barrera bacteriana. El recipiente se coloca dentro de una carga testigo y se recupera una vez finalizado el tratamiento. Luego, se presiona el recipiente hasta romper la cápsula interna y así permitir que el medio de cultivo se mezcle con la tira de esporas procesada. Finalmente, se lo incuba durante 24 ó 48 horas a una temperatura predeterminada. El indicador biológico autocontenido para los autoclaves que se utilizan en el tratamiento de residuos contiene una cantidad predeterminada de esporas (concentración 104)

de modo que una prueba que arroja un resultado negativo corresponde a una reducción igual a 4 Log10. Los indicadores biológicos autocontenidos con indicador de pH muestran la supervivencia de las esporas y por ende, el resultado positivo de la prueba (falla del proceso) mediante un cambio de color en el indicador. Otro método disponible se basa en el uso de cápsulas de vidrio herméticas que contienen en su interior medio de cultivo e indicador de pH. Cada cápsula, que contiene una población de endosporas predeterminada, debe mantenerse en un lugar refrigerado hasta ser utilizada y el período de incubación requerido es de 48 horas. La presencia de crecimiento se confirma por la turbidez del medio y/o el cambio de color del indicador. Otro sistema de indicador biológico detecta la actividad enzimática detectada en la espora bacteriana. Se ha demostrado que la respuesta enzimática es equivalente a capacidad que posee la espora de multiplicarse. Este método detecta la fluorescencia producida por un indicador positivo. Debido a su alto grado de sensibilidad, este método produce resultados en un espacio de 1 a 3 horas, lo que se correlaciona con un período de incubación de siete días. Para los ensayos de validación inicial de un autoclave nuevo, debe ajustarse el ciclo del proceso hasta que al menos tres pruebas consecutivas cumplan con los criterios de reducción logarítmica exigidos. Los parámetros operativos correspondientes a las pruebas exitosas (tiempo de exposición, temperatura o presión) deberán documentarse. Las condiciones operativas para todas las cargas futuras deberán respetar dichos parámetros y, a su vez, deberán ser registradas.

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El enfoque utilizado en el presente protocolo consiste en una prueba de provocación microbiológica mediante el empleo de indicadores biológicos autocontenidos de esporas de geobacillus stearothermophilus embebidas en portadores que a su vez se colocan dentro de una bolsa con residuos para demostrar una reducción de las esporas bacterianas > 4 en escala logarítmica.

PROTOCOLO DEL ENSAYO General A continuación se detallan los lineamientos generales correspondientes

al protocolo del ensayo:

• El autoclave debe manejarse en condiciones operativas normales.

• Las pruebas deben realizarse sobre residuos típicos de un

establecimiento de la salud en particular. Debe prestarse suma atención a la presencia de cortopunzantes y desechos de cultivos de laboratorio. Las pruebas deben realizarse utilizando los mismos contenedores o bolsas normalmente utilizados en el establecimiento y los mismos deben cerrarse en la forma habitual.

• La bolsa testigo debe colocarse y apilarse en el sistema de

tratamiento como se lo hace habitualmente. En caso de tratar múltiples bolsas, los indicadores biológicos deben colocarse en aquellas bolsas en las que el tratamiento sea más difícil.

Personal El personal responsable de realizar la prueba debe estar

específicamente capacitado para tal fin. La prueba puede estar a cargo de un operador de autoclave siempre y cuando éste haya sido debidamente capacitado y esté supervisado por un director del establecimiento.

EPP Al realizar pruebas sobre residuos infecciosos, deberán respetarse los procedimientos de seguridad en el trabajo. Debe utilizarse el siguiente equipo de protección personal (EPP) al abrir bolsas con residuos médicos, al colocar los portadores dentro de las mismas, al cerrarlas y al colocarlas dentro del autoclave: guantes de alta resistencia, barbijo, gafas protectoras (o máscara para proteger la cara), calzado con suela rígida (o botas) y delantal (o bata protectora) sobre la propia vestimenta. Por otra parte, debe utilizarse el siguiente equipo de protección personal al retirar los portadores de las bolsas: guantes de alta resistencia, calzado con suela rígida (o botas), delantal (o bata protectora) sobre la propia vestimenta y máscara para la cara para protegerse del vapor, según resulte necesario. Todo el equipo de protección personal deberá limpiarse luego de su uso.

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Materiales Los indicadores biológicos autocontenidos (SCBI) deben cumplir con las siguientes especificaciones (ver ejemplos en el Apéndice A):

• Indicador biológico: esporas de geobacillus stearothermophilus • Concentración: > 1 x 104 ufc/ml • Valor D: más de 1.5 minutos a 121°C

(Se sugiere un Valor D > 2 min si está disponible)

En caso de que las cargas sometidas a tratamiento en el autoclave contengan varias bolsas o contenedores, deberán utilizarse tres SCBI y un control para realizar la prueba de provocación. Cada SCBI deberá estar rotulado para distinguir entre los indicadores de prueba y el control. Deben colocarse cada uno de los tres SCBI en bolsas diferentes, una de las cuáles será ubicada en la parte central inferior de la pila. Si se somete a tratamiento una sola bolsa por carga, se utilizará sólo un SCBI y un control para realizar la prueba de provocación. El siguiente gráfico muestra cómo debe prepararse el portador.

Procedimiento Deberá cumplirse el siguiente procedimiento para la colocación, retiro e

incubación:

A) Seleccione aleatoriamente tres bolsas individuales cargadas, representativas del tamaño promedio de las bolsas de residuos generados por la atención de la salud. Ábralas con cuidado y coloque un portador dentro de cada una de ellas. Coloque la varilla de madera de manera tal que el SCBI quede ubicado en el medio. Si se encontraran otras bolsas en el interior de la bolsa principal, debe colocar el portador dentro una de ellas. A continuación, cierre las bolsas del mismo modo en el que las encontró al principio.

B) Coloque las tres bolsas en la parte central inferior, media y superior del lote de residuos dentro del autoclave. Separe el control y manténgalo a temperatura ambiente.

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C) Una vez que se haya cargado el autoclave en el modo habitual, inicie el proceso de tratamiento.

D) Deberán registrarse los siguientes datos: nombre de la persona

que realiza la prueba, fecha, parámetros operativos, detallando hora de comienzo y finalización, descripción general de los residuos y peso de la bolsa.

E) Al final del proceso de tratamiento, cuando retire la carga del

autoclave, separe las tres bolsas que contienen los portadores.

F) Retire los SCBI de los portadores y realice las observaciones correspondientes a fin de determinar si los SCBI han sufrido algún daño.

G) Una vez registradas las observaciones, incube los tres SCBI y el

control según las instrucciones proporcionadas por el fabricante del SCBI (usualmente 24 horas a 55-60 °C). La incubadora deberá poder mantener la temperatura dentro de los ±2 ºC durante el período de incubación.

H) Luego de la incubación, observe las cápsulas o recipientes del

SCBI para determinar si hubo crecimiento o no, siguiendo las instrucciones proporcionadas por el fabricante. Luego debe registrar los resultados de la prueba (ver planilla de muestra en el Apéndice B)

Frecuencia Con excepción del ensayo de validación inicial realizado sobre un

autoclave nuevo, la frecuencia normal para realizar la prueba de provocación microbiológica es una vez por semana. Si la totalidad de los indicadores de la prueba demuestran la ausencia de crecimiento en cuatro pruebas consecutivas (un mes), puede reducirse la frecuencia de las mismas a una vez cada quince días.

Fallas Los SCBI que presenten algún tipo de daño que pueda llegar a afectar la determinación de inactivación microbiana (recipientes con fisuras y exposición de las tiras de esporas, filtraciones de las cápsulas de vidrio que contienen el medio de cultivo, tapas con roturas) deberán mencionarse en el informe pero no serán incluidos en la determinación. Para que una prueba sea válida, los tres SCBI empleados deberán resultar totalmente indemnes. De lo contrario, deberá repetirse la prueba. Se considerará que el proceso ha sido exitoso cuando todos los SCBI demuestren ausencia de crecimiento. Si uno o más SCBI señala la presencia de crecimiento, deberá identificarse el problema para determinar el origen del mismo, el que puede ser, por ejemplo, la necesidad de realizar tareas de mantenimiento en el equipo o de ajustar los parámetros operativos (aumentar el tiempo de exposición, la temperatura, o la cantidad o profundidad de los ciclos de vacío en caso de tratarse de un autoclave por vacío). La prueba deberá repetirse en cada pasada hasta que ningún SCBI demuestre crecimiento. Se deberá continuar con las pruebas hasta que haya tres pruebas consecutivas que demuestren la ausencia de crecimiento en la totalidad de los SCBI.

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En adelante, se realizarán en forma semanal hasta que cuatro pruebas consecutivas demuestren la ausencia de crecimiento y a partir de entonces, podrá reducirse la frecuencia a una vez cada quince días.

Registros Los registros de los resultados de las pruebas de provocación

microbiológica deberán ponerse a disposición de las autoridades regulatorias cuando éstas los soliciten o presentarse ante ellas de manera periódica, de conformidad con la normativa vigente. El establecimiento deberá conservar los registros durante un mínimo de tres años.

Jorge Emmanuel, PhD y Ed Krisiunas, MT (ASCP), MPH

16 de noviembre de 2010

APÉNDICE A

Ejemplos de insumos para realizar los ensayos Aclaración 1: La mención de los productos detallados a continuación no representa ningún tipo de aval ni recomendación por parte del proyecto PNUD/FMAM. Los mismos se presentan sólo a modo de ejemplo. Existen otros productos que cumplen con los requisitos detallados en este documento orientador. Aclaración 2: Los siguientes ejemplos utilizan concentraciones de esporas bacterianas de 1,0 x 105. Para los autoclaves utilizados para el tratamiento de residuos, la STAATT sólo requiere concentraciones de esporas bacterianas de 1,0 x 104. Si bien una concentración igual a 105 es un requisito más estricto, puede resultar más fácil de conseguir a nivel comercial. Cápsulas ProSpore o Indicadores Biológicos Autocontenidos ProSpore 2 de Raven Geobacillus stearothermophilus ATCC 7953, concentración mínima 1,0 x 105 ufc/ml Incubadora de baño seco ProSpore o ProSpore 2, 12 cubas, 240 voltios, 35 ó 55 °C Raven Labs, P.O. Box 27261, Omaha, NE 68127 EEUU; TEL: +1-402-593-0781 http://www.mesalabs.com/products-services/raven-labs.html Indicadores Biológicos Autocontenidos AttestTM de 3MTM Geobacillus stearothermophilus (derivado de ATCC 7953) en un recipiente flexible de polipropileno, población mínima de 1 x105 esporas por tira, incluye un medio de cultivo de caldo de tripticasa de soja con indicador de pH (púrpura de bromocresol) Incubadora Attest, 220/240 voltios, capacidad para 14 recipientes, 56 ± 2°C 3M Center, St. Paul, MN 55144 EEUU http://solutions.3m.com/wps/portal/3M/en_US/IP/infectionprevention/solutions/sterilization-assurance/load-control/ Indicadores Biológicos Autocontenidos de SporView® Geobacillus stearothermophilus, población 2,2 x 105, resultados en 24 horas Medical Engineering Technologies Ltd., Yew Tree Studios, Stone Street, Stanford North, Ashford, Kent TN25 6DH, Reino Unido; TEL: +44 (0)8454 588924 http://www.met.uk.com/6a-medical-sterilisation-indicators.php#self-contained-biologigal Indicadores Biológicos Autocontenidos de Bionova Terragene Esporas bacterianas de geobacillus stearothermophilus sobre papel filtro envasadas dentro de un tubo de plástico, y en su interior, una cápsula de vidrio precintada con un medio de cultivo y un indicador cromático. MedNet GmbH, Borkstraße 10, 48163 Münster, Alemania; TEL: +49 (0) 251 32266-0 http://www.medneteurope.com/Sterilisation-Monitori.14.0.html?&L=2

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APÉNDICE B

Registro de ensayos realizados con indicadores biológicos

Prueba de provocación Nombre: __________________ Fecha de la prueba: Dirección: Marca del indicador biológico: Concentración: Número de producto/ Lote -_________ Fecha de vencimiento: ______ Número de modelo del autoclave: Parámetros operativos del autoclave: Hora de comienzo del ciclo: ______ Hora de finalización del ciclo: ______

Descripción de las bolsas con residuos seleccionadas para colocar los SCBI

Muestra Nº Peso (kg) Descripción de los residuos Ubicación en el autoclave Nº 1 Nº 2 Nº 3

Resultados de la prueba

Control negativo

Muestra Nº Resultados Nº 1 Nº 2 Nº 3

Control positivo

El control negativo es un indicador biológico no procesado Los resultados deben registrarse como “+” ante la presencia de crecimiento (falla) Y como “AC” en caso de ausencia de crecimiento Comentarios/ condiciones alteradas durante la prueba, en caso de que hubiera: ____________________________________________________

UNDP ARG 09/002 Project on Healthcare Waste

Global Team Mission to Argentina- Activities Schedule

DATE ACTIVITIES LOCATION REQUIREMENTS RESPONSIBLE DAY 1 11 / 10

10 to 12

Institutional Presentation Meeting Under-secretariat’s mission and function; National Office/ Project Team’s roles and functions; UFI’s roles and functions

Undersecretary’s Office

12 to 13 Working Lunch Revision of Mission’s activities schedule

Ministry, Floor 9

13 to 15 Technical Progress Report per Component

Annex Room, Floor 9

16 Meeting at UNDP

UNDP Offices

DAY 2 11 / 11

10 to 12 Technical Progress Report per Component

Annex Room, Floor 9

12 to 13 Report on the 1st Workshop on the Use of Mercury in Dentistry – Anna & Eduardo

Annex Room, Floor 9

13:30 Working Lunch with Health Care Without Harm

TBD

15.30

Visit to INcol plant in San Martin (National autoclave manufacturer)

San Martin

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10 to 11

Meeting with Garraham Hospital Medical Managers and Steering Committee

DME Garrahan Hospital

11 to 12.30 Guided Visit

Hospital

12.30 to 13.30 Working Lunch TBD 14 to 16 Waste Management Committee Meeting

Progress Reports Works plan/ Mercury strategy/ Radiology liquids/ Work accidents Activity Schedule

DME Garrahan Hospital

Dinner DAY 4 11 / 15

Trip to Regional Focus in General Roca F Lopez Lima Hospital, Gral Roca Rio Negro

10 to 12 Waste Management Committee Meeting Guided Visit

Hospital

12 to 13 Working Lunch with Environmental Dept of the Municipality

TBD Been w/ the project since beginning and have good relationship

13 to 15 Technical Visit Controlled landfill visit

Treatment Plant

2145 to 2400 Fly back to BA

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Global Team Mission to Argentina- Activities Schedule DATE ACTIVITIES LOCATION REQUIREMENTS RESPONSIBLE DAY 5 11/ 16

12 to 13

Meeting with MOH UFI (Financial Department)

15 to 17 Technical Conference on Treatment Technologies

UTN Principal’s Office

DAY 6 11 / 17

9:30 to 11

Meeting with National Technological University National training program

MoH/ Floor 9 Director’s Office

11 to 13 Meeting with National Technological University Treatment technology for chemical waste

13 to 14 Lunch (outside the Ministry)

14 to 15.30 Meeting with Reconquista Regional Focus Progress Report Technology in Reconquista Sta Fe Meeting with technical and political leaders from the province

MoH/ Floor 9 Director’s Office

15.30 to 17.00 Meeting with General Roca Regional Focus Progress Report

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9:30 to 10.30

National Steering Committee Meeting

ISALUD Room

10.30 to 11 Coffee Break 11 to 13 National Working Group Meeting

Global Team and Local Project Team Presentations

ISALUD Room Venezuala 925 or 931 Intersection with Hipolito Yrigoyen and Tacuari 5239-4000

13 to 13.30 Lunch SHORT TIME FOR LUNCH 14 to 17 National Working Group Meeting

Project team Presentations and Presentations of Participating Institutions

ISALUD Room

17 Conclusions and Closing Remarks ISALUD Room 21 Dinner DAY 8 11 / 19

10 to 12 Closing Meeting MoH / Floor 9 12 to 13 Lunch Break 13 to 17 Closing Meeting

MoH / Floor 9

20110427 Argentina Mission Report Nov 2010 FINAL · 2011. 5. 10. · Title: Microsoft Word - 20110427 Argentina Mission Report Nov 2010 FINAL.doc Author: dhuaman Created Date: 5/10/2011

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