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A grease trap (T.B. 4.04) should be installed in front of the soak away pit when the wastewater originates from a kitchen, showers, a sink or a washing area, in order to avoid clogging by oil and fat.


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Choose a site as close as possible to the grease trap, but at least 6 m from dwellings, 7.5 m from trees or hedges and 3 m from property boundaries. The site should preferably be downhill and at least 30 m away from (ground)water sources.


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Determine the dimensions of the trench or trenches according to the soil texture / permeability tests, the level of the water table and the quantity of wastewater to be infiltrated (T.B. 4.05).


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Prepare the site for construction: remove all debris, lay out the area with string line, install a temporary fence and bring in the needed construction material and equipment.


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Dig the trenches (about 0.3 m wide and at least 0.3 m deep) for the incoming pipe (at least 1% slope) and the union pipes to form the trident pattern for the drains (at least 1.5 m apart from each other).


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Dig the actual infiltration trenches to the required dimensions as indicated on the figure (with a slope of 0.2% to maximum 0.5%). The maximum length of a single infiltration trench is limited to 30 m, this to have a good wastewater repartition.


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Construct a distribution box at the end of the incoming pipe trench and potentially 3 manholes where the dispersal drain pipes will end (T.B. 4.03).


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Install the incoming pipe and the union pipes with elbows (min. diameter 100 mm) in the trenches, potentially on a layer of sand, and make the connections with the distribution box watertight.


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Rake the sides and bottom of the infiltration trenches. Do not walk in the trenches after this work.


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Fill the infiltration trenches with clean (uniform sized) gravel up to the level where the union pipes end, respecting the 0.2 – 0.5% slope (min. thickness of the gravel layer: 0.15 m, but preferably up to 1 m).


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Lay the drains (perforated / porous pipe, or pipe sections with loose joints, minimum diameter of 100 mm), respecting the slope of 0.2 - 0.5%. Plug the far ends with a cap and make the connection with each potential manhole watertight.


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Dispersal systems using simple or multiple trenches with infiltration pipes are a good alternative to soak away pits:


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To estimate the dimensions of the trench, evaluate the infiltration capacity of the soil (T.B. 4.05) and allow for a possible increase in the amount of wastewater to be disposed of. As the infiltration rate of the soil might differ over the length of the infiltration trench, the rate should be verified at several locations along the projected trench.


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Enough space should be available to install infiltration trenches (e.g. in high-income countries, a minimum ground surface area of 30 m² is foreseen for about 500 l of wastewater per day). Be aware that the infiltration will only take place via the vertical walls of the infiltration trench, thus the bottom should not be included as an infiltration surface (due to an “impermeable” bacterial layer forming on the bottom).


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The bottom of the infiltration trenches should be at least 1.5 m (preferably 3.0 m if connected to a septic tank) above the highest possible water table (during the rainy season). The depth of the water table can be estimated by verifying its level in nearby wells. Another option is to drive a metal bar such as a reinforcing rod or (several pieces of) ½” galvanized pipe in the ground, as deep as 1.5 m beneath the required trench depth. When pulled out, the rod or (the earth inside) the pipe should be dry. Soil saturated with water after heavy rainfall might give a false impression of the actual water table level.


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The dispersal trenches should be at least 1.5 m apart from each other. The distribution box with inspection cover (T.B. 4.03) installed at the beginning of the drains is to ensure that the effluent flow is well divided over the different pipes. The small manholes installed at the end of the infiltration pipes could facilitate the unblocking of the drains if their end caps can be removed.


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The dispersal drain pipes should have their holes starting at least 0.5 m away from the distribution box.


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The geo-textile or perforated plastic sheeting over the gravel bed prevents the entry of soil, which could block the system and/or limit the infiltration, but still allows air to go in and gasses to get out of the trenches.


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A grease trap (T.B. 4.04) should be installed in front of the infiltration trenches when the wastewater originates from a kitchen, showers, a sink or a washing area, in order to avoid clogging by oil and fat.


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Evapo-transpiration is a complex phenomenon that varies with the latitude, the season and the period of the day. An acceptable approximation can be given by:


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The “ground” dimensions of an evapo-transpiration area may be calculated on this basis, in the absence of other data.


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Excavate the evapo-transpiration area with a 0.2% slope, at least 4 m wide, maximum 30 m long and about 0.25 m deeper than the end of the union pipe trenches (but not deeper than 0.75 m overall).


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Install the dispersal drains (perforated PVC pipe with a minimum diameter of 100 mm) on a bed of clean uniform sized gravel (diameter of 20 – 50 mm), while respecting the foreseen slopes of about 0.2%. Make the connections with the union pipes watertight, and interconnect the far ends of the dispersal drains.


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Fill the evapo-transpiration area with a layer of clean uniform sized gravel, at least 0.1 m above the dispersal drains and cover it with geo-textile. If geo-textile isn’t available, it can be replaced by a thin layer of fine gravel mixed with clean coarse sand to avoid that fine soil particles will get in between the uniform gravel and cause blockages. If needed, clean sand can also be added on top of this thin layer until 0.2 m underneath the ground surface.


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Cover the evapo-transpiration area with about 0.2 m water absorbing topsoil. In case the topsoil would not be very water absorbing by itself, it can be mixed with clean sand.


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A dispensary in a hot, dry tropical zone generates 300 l of wastewater per day. The rocky soil will not allow underground dispersal. The evaporation rate is a very high 10 mm/day.


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ATTENTION: values for evapo-transpiration of only 2 mm of water per day (2 l/m²-day) have been recorded in arid areas of the northern hemisphere.


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The evapo-transpiration area is only suitable for hot, windy, arid or semi-arid climates and can only deal with very limited wastewater volumes.


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The evaporation rate (minimum, maximum and average) for a certain region might be found in specialized literature, universities or weather stations (e.g. airports).


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If the evaporation rate is not known,it may be roughly measured using an open (square) 1 m² basin filled with water that is placed outside on the ground (but not exposed to the rain). By measuring every day precisely the water height in the basin over several days, the average water evaporation can be calculated. Be aware that the longer the measuring period lasts, the more precise the avarage result will be. Know that 1 mm of water evaporated within the 1 m² basin represents 1 litre.


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Small manholes could replace the Tee and elbows at the end of the infiltration pipes, which could facilitate the potential unblocking of the drains. The distribution box and the potential manholes should have an inspection cover.


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Choose a short-rooted grass that needs a lot of water for growth. Trees absorbing a lot of water (e.g. papaya) might break the pipes with their roots, thus they shouldn’t be used for this purpose.


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A grease trap (T.B. 4.04) should be installed in front of the evapo-transpiration area when the wastewater originates from a kitchen, showers, a sink or a washing area, in order to avoid clogging by oil and fat.


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The accumulation of refuse (solid waste) creates a health risk, a nuisance as well as an environmental pollution problem. The health risks are essentially related to the proliferation of insect vectors and rodents:


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Mosquitoes of the Aedes genus (responsible for the transmission of dengue, yellow fever and other arboviruses) that lay eggs in water accumulated in empty tins, drums, tyres, etc.;


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Mosquitoes of the Culex genus (liable to transmit microfilariases) which breed in stagnant water heavily loaded with organic matter;


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Rodents attracted by the refuse, which are directly or indirectly responsible for the transmission of various diseases such as plague, leptospirosis and salmonella, and whose presence attracts snakes.


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Another health risk can be for human scavengers looking for useful material that can lead to injuries and all kinds of diseases (e.g. tetanus).


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In addition to these health risks, poor management of the collection and disposal of refuse may involve the pollution of surface water and/or groundwater. Incorrectly discarded waste also increases the risk of fire and enables a rapid spread of it when started. Smoke emissions containing pathogens and hazardous by-products (carbon monoxide, sulphur dioxide, dioxin, furans and heavy metals) can occur when waste is burned in an open fire. Lastly, the aesthetic aspects (sight and smell) are far from negligible. These risks and nuisances are all the more serious at high population densities.


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Refuse is all the solid material that is considered to be non-useful, thus people want to dispose of. Others might still find a purpose for this material and recycle it in its original or a different form, to be used for its original or a different purpose. Refuse can be domestic waste, or waste related to professional activities. Solid waste that is generated by patients and their visitors at health centres can also be considered as refuse. Medical waste however is specific and is dealt with in a separate chapter of these guidelines (Chapter 6).


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The type and quantity of refuse produced by a community are extremely variable. The main factors affecting the composition of refuse are:


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Socio-cultural: material levels and living standards may create great variations, as poor people in low-income countries have a tendency to recycle more;


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The density of refuse can be estimated to be between 100 to 200 kg/m³. The daily generated volume varies between 0.5 and 10 l/person. In general, it may be assumed that the daily volume of refuse will be small (on average more towards 0.5 l/person) when dealing with a population of rural origin and where the basic ration is under the form of dry foodstuffs (as is often the case during the initial phases of an emergency operation). But these quantities can rise quickly when aid-agencies start with the distribution of individually packaged food rations, which can’t be reused / recycled. The amount of refuse generated in urban areas is often higher as well than in rural zones. The percentage of putrescible matter may range from 20 to 70%. These figures present orders of magnitude, and in practice the quantity and volume (or density) of refuse should be determined for each situation. Its composition is only really important when disposal is by means of incineration or composting, as it has


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the quantity and volume (or density) of refuse should be determined for each situation. Its composition is only really important when disposal is by means of incineration or composting, as it has an impact on these forms of waste treatment.


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Refuse can be generated at many different places such as domestic level, workshops, warehouses, slaughter areas, markets, food distribution points, aid-agency premises or health structures. It is obvious that collection and correct disposal of refuse always have to be done to avoid health risks as well as pollution problems, certainly in high population densities where the risks and nuisances are all the more serious. The refuse disposal management in rural areas can be done on a “household” level by the population, but for camps and collective buildings / centres (e.g. after a natural disaster) a collective approach might often be more appropriate, certainly in the early stages of an emergency. The long-term refuse disposal management for urban zones, also mainly a collective approach, falls out of the scope of these guidelines. The focus in this chapter will be mainly on emergencies.


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The choice, the implementation and the maintenance of the refuse disposal method should be discussed and agreed upon with all the stakeholders (e.g. aid-agency, population, local authorities) in order to have the facilities installed, used and cleaned correctly (e.g. at public institutions such as markets, slaughterhouses and food distribution points; choice of the collective site for final disposal). Health promotion activities can help to achieve this.


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For correct planning and organisation of refuse disposal, it is necessary to follow all the different steps described in chapter 1. Some specific points directly related to domestic refuse disposal, are gathered below.


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If “household” level management is chosen, the strategy will mainly focus on promoting the system, informing the population how to make and to use a refuse pit (which can be shared by several households in camps for instance), and lending them tools and material for the construction of the pit and for the collection of the waste.


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For a collective management, focus will go more towards finding correct spots to construct collective burial places or controlled tips and setting up temporary storage, general collection and transport systems. Staff will need to be trained to do correct operation (e.g. collection, transport and final disposal of waste) and maintenance (e.g. waste containers, collective burial places).


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It will also be necessary to promote the collective refuse disposal system to the population, to inform them on the existence and the correct use of the facilities like the waste containers, and possibly to provide material for the domestic collection of the waste at their dwelling. The more users friendly the facilities are, the more they will be used. Correctly maintained facilities will also be needed to keep the population motivated to continue using them. For a more durable solution, the population themselves should perform the maintenance of the provided material, even the waste containers.


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Segregation of different kinds of waste is interesting, but will be extremely difficult to achieve during an emergency situation. Most of the “waste” that still has a value (e.g. aluminium cans) will be recycled anyway.


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Temporary Storage	Waste bin (at dwelling level)	100 l drum (max. 15 m away) Collection	Household member	 Team (2.5 pers/1000 inhabitants) Transport	Manual	 Cart / motorised vehicle “Treatment”	Generally not recommended	Only if specialised equipment


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At dwelling level, people can use a simple recipient (e.g. bucket) to temporary store their waste, but very often a family member will collect and transport the refuse directly to the final disposal place. There are no vehicles required because this place is located nearby the dwelling.


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On household level, incineration / burning of refuse is generally not recommended, as the food residues contain a lot of liquids. It means that a lot of fuel will be needed for their incineration, which is (very) costly. As wood is often used for “incineration” / burning in low-income countries (certainly in emergencies), it would lead to an even higher stress on the local environment. It may even be dangerous when it is done on a large scale, due to air pollution and the increased fire risk.


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Composting is a biological decomposition of organic matter in the presence of air, as opposed to anaerobic decomposition that takes place in septic tanks for instance (and which is very smelly). Composting can only be considered if the population has already an extensive experience in this matter or if a complete project with appropriate material, intensive training and monitoring is set up. Be aware that composting doesn’t always correspond to the habits and culture of the population. For these reasons is composting often not recommended in (acute) emergency situations.


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The easiest way of final disposal is to throw the refuse in a pit (T.B. 5.02). The bottom of the pit should be at least 1.5 m above the highest possible water table (during the rainy season), because this reduces the chance of microbiological contamination of the groundwater virtually to nil in homogeneous soils. The needed depth for fissured soils is difficult to predict however. The pit needs to be covered with a lid every day. If a lid isn’t available, the refuse should be covered with a layer of


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0.10 m of compacted soil or 0.25 m of non-compacted soil, to avoid bad odours and vectors or other animals being attracted to it. But this will fill up the pit extremely fast. Fencing is necessary to avoid people falling in the pit, certainly at night. Chopped up organic waste could also be buried in very shallow trenches of little gardens to be used as nutrition supplements for the crops. This demands a daily management, which is most probably a too heavy burden, certainly in emergencies. Another alternative is to give the organic waste to “domestic” animals as food.


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The objectives are to gather the refuse in order to facilitate the collection and to avoid its dispersion by the wind and animals. Half 200 l metal drums are generally used (T.B 5.01), but other recipients (e.g. plastic containers) can do also as long as they can’t be blown over by the wind. However these containers must be solid and have a volume of at least 60 l and maximum 100 l. The bottom of the collective dustbins should be pierced so that they do not retain decomposition liquids (bad odour) and to avoid that they would be used for other purposes. The dustbins should be provided with covers and with handles for easy lifting. In the first instance, one container per ten to fifteen families may be provided, placed at a reasonable distance from the dwellings (preferably not less than 5 m and not more than 15 m away).


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Certain structures need particular storage systems, either because of the specific nature of their refuse (e.g. specific workshops like garages), or because of the large volumes produced (e.g. market, slaughterhouse, various workshops). For public places, a team will be needed to remove the waste that has been dropped directly on the ground / floor.


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Collection should preferably be done daily to avoid the hatching of flies and odour problems. The collection of the contents of the waste containers, including incorrectly discarded waste, may be done with motorised vehicles (pickup, truck, tractor with trailer), but it may be more reliable logistically to use


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handcarts or animal carts. Moreover, it is difficult, specially in emergency situations, to commit a motorised vehicle exclusively to this task. The bottom of the carts can be perforated with small holes (about 10 mm diameter) to allow sand to fall out of the waste in order to diminish its weight. Whatever vehicle is used, they should be equipped with simple tools like brooms, shovels and disinfection equipment to clean the storage facilities on a regular basis.


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Circuits must be established and teams (e.g. 2.5 persons/1000 inhabitants) formed. A circuit must be allocated to each team. After its introduction, the collection system should be supervised and evaluated periodically if the circuit and the resources are appropriate and sufficient.


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These two steps of storage and collection require the co-operation of the population, which should also be involved regularly (once or twice per month) in a general clean up of the camp, including the market, the dwellings and their surroundings.


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Incineration can only be an appropriate treatment method when real (domestic) refuse incineration plants with qualified personnel are available and operational (e.g. Eastern countries). As the distance in between the camp / setting and the incinerator will most probably be long, trucks will be needed and thus the costs will rise significantly. The incineration itself might be rather expensive as well. So it will be only under specific circumstances that incineration can be considered as an option (e.g. lack of space in the setting, legislation). “Incineration” or burning refuse in or even outside the camp / setting itself must be avoided as it increases the health risks due to air pollution and fire hazard.


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Composting at communal level is an interesting but difficult technique to manage, certainly in (acute) emergencies, because the waste should be properly segregated before by the population. It needs special care and your technical referent must be involved because composting may cause health risks and serious odour nuisances if not implemented correctly.


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Dumping of waste (in or even outside a camp / setting) should be avoided at all times as it attracts vectors and scavengers (animals and humans), thus forming a serious direct health risk. There is also the risk of environmental pollution (e.g. pollution of surface and/or groundwater) and fire.


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An efficient and rather cheap way of final disposal is burial. Still, special attention should go to the potential risk of environmental pollution and thus indirect health hazards when refuse is buried. The construction of the pits / trenches should follow the same rules as for building latrines, as the risk of polluting the water table is similar.


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Burial can be done on a collective level in trenches, which can be constructed, operated and maintained with (only) manual means, as long as the quantities of refuse stay reasonable. For very big quantities of refuse, it might be necessary to use controlled tipping (T.B. 5.03). This procedure requires sufficient space at a distance at least 800 m away from the dwellings and an access to mechanical equipment (e.g. trucks, bulldozers). The refuse must be covered daily to avoid vectors (e.g. insects, rodents) or other animals (e.g. dogs, foxes, seagulls) to be attracted. Access to the site should be restricted by a fence. If a good drainage is not ensured, there is a great risk of the trenches


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All staff involved in the collective disposal of refuse will need the following protective clothing:


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It is recommended to foresee a washing place for the staff, where there is at least water and soap available.


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Pierce about 20 holes in the bottom to let decomposition liquids (leachates) drain out and to avoid theft (people using the drum for other purposes).


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Fix the cover on the open end of the drum with a heavy duty hinge or an alternative (e.g. metallic wire).


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Make a support. In the first stage of an emergency a metal or wooden support can do. In a later stage, the support can be made with bricks.


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Dig a hole where the dustbin will be placed, preferably 0.5 m deep, at least with the same diameter as the dustbin, and fill it with stones or gravel to drain the leachates.


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<table><tr><td>In an emergency situation, an appropriate way to dispose of household refuse (not medical waste)</td></tr><tr><td>is burial in collective or family refuse pits, certainly if there are not enough transport means and/or</td></tr><tr><td>land available for controlled tipping. The high liquid content of this type of refuse does not allow the</td></tr><tr><td>waste to be burned with simple means; apart from using a lot of fuel, its incomplete combustion</td></tr><tr><td>could even be a health risk factor. This treatment method also increases the risk of fire drastically.</td></tr></table>


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In an emergency situation, an appropriate way to dispose of household refuse (not medical waste) is burial in collective or family refuse pits, certainly if there are not enough transport means and/or land available for controlled tipping. The high liquid content of this type of refuse does not allow the waste to be burned with simple means; apart from using a lot of fuel, its incomplete combustion could even be a health risk factor. This treatment method also increases the risk of fire drastically.


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➞ The distance from water points must be > 15 m if the pit serves fewer than 10 families, > 30 m in all other cases.


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➞ The distance from dwellings must be > 10 m if the pit serves fewer than 10 families, > 30 m in all other cases.


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Make a fence around the area foreseen for the hole in order to avoid accidents and to prevent the entry of scavengers (human or animal).


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Dig a circular hole, leaving the soil to one side (to be used for the daily covering of refuse). For security reasons, the pit should not be deeper than 2 m, and the walls have to be made conical in order to reduce the risk of collapse, or reinforced with removable struts during the excavation.


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The bottom of the pit should be at least 1.5 m above the highest possible water table. The depth of the water table can be estimated by verifying its level in nearby wells. Another option is to drive a metal bar such as a reinforcing rod or (several pieces of) ½” galvanized pipe into the ground, as deep as 1.5 m beneath the required pit depth. When pulled out, the rod or (the earth inside) the pipe should be dry. Soil saturated with water after heavy rainfall might give a false impression of the actual water table level.


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Dig a drainage ditch around the pit to avoid it would flood. The ditch can be connected to the big drainage canals of the site if existing.


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Backfill the hole completely with compacted soil when the refuse level is 0.5 m underneath the ground surface. A metal grid can be put on top of the refuse before the final backfilling takes place. Coming across the grid during future excavations will indicate that a pit has already existed on the same spot. It is also possible to plant on the old refuse pits fast growing vegetation (e.g. eucalyptus), which can be used as firewood afterwards. If there is no other available solution remaining, it should be safe after at least 6 months to dig at the same spot again (if no dangerous wastes have been thrown in).


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The refuse pit can also be used for rural waste management in small villages within stabilized situations.


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The pit should be circular because it will be more resistant against collapse due to its natural arching effect. The less stable the soil, the more the walls of the pit should be conical. If the soil is too unstable, it may be useful to support the pit walls (e.g. with planks, bamboo).


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Only throw household refuse in the pit. The chance of microbiological contamination of the groundwater is very limited in homogeneous soils if the bottom of the pit is more than 1.5 m above the aquifer.


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Do not throw in hazardous waste (e.g. old engine oil or even oil filters) because this could lead to a long lasting chemical pollution of the aquifer, even if the bottom of the pit is more than 1.5 m above.


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Although (potentially contaminated) medical waste can be buried, it has to be done in a completely controlled manner with specifications beyond this simple refuse pit; e.g. specially designed pits (see chapter 6), away from the population and integrated within a fenced waste zone or controlled landfill.


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It is potentially hazardous for people’s health and the environment to burn household refuse in an open fire (e.g. smoke, risk of fire), so a collective or family waste pit should not be used for that purpose. The use of volume reducers and small incinerators (as described in T.B. 6.05 and 6.06) should be exclusively reserved for some medical wastes (mainly “soft” waste).


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It is essential that the refuse is covered, preferably with a lid, immediately after disposal to avoid attracting flies and rodents, to limit the risk of refuse been blown away and to reduce the nuisances (e.g. bad odour, visual). In case a lid isn’t available, it can also be covered with earth (and possibly wood ashes), but be aware that the pit will fill up rapidly (each layer should be 0.1 m thick if compacted or 0.25 m if non-compacted).


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In case a new pit is being dug at the same spot at least 6 months after the old one has been closed, be aware that plastics and potential glass will still be “intact” and the latter might cause injuries.


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As the population has to do its own waste management with this facility, a good health promotion campaign and some training for proper use and maintenance might have to be organized for them.


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Choose a flat area at least 800 m away from the dwellings and the living areas should not be downwind from the tip.


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Take also into account the distances from water resources, which should never be less than 50 m away and which should be uphill from the tip. The bottom of the trenches should be at least 1.5 m above the highest possible water table, this if the soil is homogeneous. This is to avoid that the leachates (liquids dripping out of the waste) would cause a microbiological contamination of the aquifer. The depth of the water table can be estimated by verifying its level in nearby wells. Another option is to drive a metal bar such as a reinforcing rod or (several pieces of) ½” galvanized pipe into the ground, as deep as 1.5 m beneath the required trench depth. When pulled out, the rod or (the earth inside) the pipe should be dry. Soil saturated with water after heavy rainfall might give a false impression of the actual water table level. In case the water table is too high, a different spot should be selected.


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Surround the tip with a fence to avoid accidents and to prevent the entry of scavengers (human or animal).


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Prepare the site for construction: remove all debris, lay out the area and bring in the needed construction material.


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Dig the trenches with conical walls, and its bottom should preferably be covered with clay, special plastic lining or even better a combination of both. But it’s very doubtful that the material and certainly the time will be available in emergencies to perform these environmental protection works.


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Dig a surface water drainage ditch around the whole area to avoid runoff water going through. The lowest corner of this ditch should lead to an infiltration facility, which is foreseen with an overflow towards the big drainage canal to evacuate water that doesn’t infiltrate during heavy rainfall.


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0.25 m of non-compacted earth. The following load should be dumped next to the first, and so on until the trench is full.


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Alley (wide enough for the passage of the	- Mechanical shovel or numerous workers refuse collection vehicle)		with digging equipment (shovels, hoes,


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Lowest corner (towards infiltration facility with overflow)	build the bridge crossing the drainage ditch


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Despite all existing hygiene precautions, nosocomial infections affect at least 5 to 15% of the patients entering health structures in high-income countries. The problem of nosocomial infections is most probably higher in low-income countries. In India, the nosocomial infection rate is estimated around 30%. The main reasons of those infections are insufficient hand washing, the use of non-sterile invasive devices, insufficient general hygiene and bad medical practices, but also to some extent incorrect medical waste management. Similarly to excreta, wastewater and refuse, improper disposal of medical waste can cause environmental pollution, together with serious smell and visual nuisance problems, and it also leads to health risks. Typical health risks related to improper medical waste management are:


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➞ Through a puncture, abrasion or cut in the skin (e.g. medical staff recapping used hypodermic needles leading to needle stick injuries; unaware and unprotected non-medical staff handling waste, including sharps; children playing with discarded used needles; patients being injected with recycled single use needles, as is the case in some low-income countries).


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➞ Hazardous smoke emissions occur when medical waste is burned at low temperatures in a poorly designed incinerator or when the incineration is not properly conducted (e.g. when the incinerator is not preheated, an open fire in a pit). These emissions contain thermo-resistant pathogens and toxic by-products like carbon monoxide, sulphur dioxide, dioxins, furans, heavy metals, or other chemical agents when for instance expired drugs are burned.


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➞ Untreated medical waste contaminating the soil and ground / surface water (used for drinking) with pathogens (e.g. faecal coliforms, hepatitis A, polio and tetanus) or chemical substances.


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The variety of health risks suggests that not only the medical and non-medical staff of health structures are at risk, but also the patients and their visitors. Other people at risk are the personnel of possible external support services (e.g. laundry, waste management), the population living in the neighbourhood where medical waste is handled incorrectly, and specially human scavengers recuperating medical waste.


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Since HIV/AIDS has appeared, more attention has been given to medical waste management with the formulation of the universal and standard precautions.


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It concerns the characteristic waste generated during medical activities (within health structures). To have a pragmatic and comprehensible medical waste management system for low-income countries, it is recommended to classify the medical waste according to “common disposal properties”:


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Sharps: objects that can be responsible for perforations or cuts of the skin (e.g. needles, scalpels, ampoules, broken glass, AD-syringes).


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“Soft” waste: includes dressings (wet or dry), packaging, paper, cardboard, plastic, syringes without needle.


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Hazardous waste: a clear distinction should be made in between recurrently generated hazardous waste and inappropriate / expired hazardous products. The former, generated on a daily, weekly or two-weekly basis, should be dealt with immediately, whereas the inappropriate / expired hazardous waste should be taken care of in special elimination campaigns (e.g. once every six months). The latter falls outside the scope of these guidelines (section 6.5. Further reading).


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➞ Biological hazardous waste: Tuberculosis sputum; urine, stool and body fluid (e.g. blood) samples from potentially infected patients; cultures of bacteria; all mostly coming from the laboratory.


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➞ Pharmaceutical waste: opened but unused drugs, cold chain damaged vaccines, expired and/or unwanted drugs.


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➞ Expired disinfectant solutions: all solutions that have been prepared since a certain period (e.g. 0.05% chlorine solution after 1 day, 1% chlorine solution after about a week).


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➞ X-ray related waste: slightly radioactive waste, expired film and mainly the chemicals to develop the photos.


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➞ Insecticides: leftovers of prepared insecticides used in vector control activities within or outside the health structure, expired or inappropriate products.


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➞ Specific hazardous waste: groups a lot of products that can be common as well as rather particular to certain medical activities within a health structure. Some examples of specific hazardous waste are:


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Waste with heavy metal content (e.g. batteries, broken appliances containing mercury such as thermometers and blood pressure gauges).


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Waste from activities related to the health structure (e.g. engine oil of the ambulances, generators, motor pump).


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Medical waste is part of health care waste, which also includes excreta, wastewater and administrative waste. Waste discarded by the patients and visitors is actually refuse (Chapter 5), but when generated in small quantities and well segregated by them, it can be integrated within the medical waste management. So can food packaging and plastic beverage bottles be considered as soft waste. Food residues, also from the kitchen, can be part of the organic waste. Food residues from patients having very infectious diseases like cholera and viral haemorrhagic fevers should not leave the health structure and should therefore always be considered and discarded as organic waste. Small amounts of vegetation waste (e.g. dead tree leaves) can be considered as organic waste, but for bigger quantities it is best to handle it as refuse (Chapter 5).


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Correct medical waste management should be implemented and promoted in all health structures, from the smallest health post to the biggest hospital, going over nutritional feeding centres, isolation centres (e.g. cholera, viral haemorrhagic fevers) and medical laboratories. Furthermore, this should be done in all situations, from the acute phase of an emergency until stabilized situations (with the management system adapted to the actual stage of the intervention).


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The hygiene committee of the health structure, consisting of key medical and non-medical staff, potentially representatives of the local and health authorities, the neighbourhood and the aid-agency should play a central role in medical waste management.


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The possible treatment and final disposal should preferably be done on the site of the health centre itself, in a well-defined area, the waste zone (T.B. 6.09). This principle has the following advantages:


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The potential treatment and final disposal of the waste can be done by clearly defined, trustworthy and trained persons.


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The medical waste remains within the health structure, thus there isn’t a risk of being misused externally.


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The segregation of the medical waste should be done by the medical staff, where the collection should be taken care of by the cleaners, or ideally by the one or two waste managers. The latter are responsible for and specialised in the collection, potential temporary storage, possible treatment and final disposal of the waste. They also take care of the waste zone in general. It is important however that all the staff (medical and non-medical) receive adequate training, and use the necessary working gear and equipment (T.B. 6.10).


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In addition, patients, attendants and visitors should also be informed where to store the waste they generate. Information campaigns towards the population living nearby a place where medical waste is handled and towards potential human scavengers should be foreseen.


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Health structures are responsible for ensuring that their medical waste is rendered harmless to all people potentially at risk. Therefore, good medical waste management should result in waste being:


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For correct planning and organisation of medical waste management, it is necessary to follow the different steps described in chapter 1. Some specific points directly related to medical waste management are gathered below.


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For acute emergencies, the essential requirements (T.B. 1.08) regarding medical waste can often be applied immediately after an initial assessment. For chronic emergencies and stabilized situations however, an additional in-depth assessment should be conducted in order to have the essential requirements integrated in a context adapted manner. Special methodologies (section 6.5 Further reading) exist to help in the in-depth assessment.


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An important issue in the planning phase during chronic emergencies and stabilized situations is that the strategy is defined in collaboration with the hygiene committee, and if possible formalized in a memory of understanding.


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Providing only technical solutions (based on the described general recommendations) is not sufficient to implement a correct medical waste management system. They must be completed by general and specific technical trainings directed towards medical and non-medical staff, and health promotion towards patients. The management system must combine safety features with easy to use measures, adapted to the needs, habits, culture and other constraints of the users. Obviously, the national legislation regarding medical waste, if existing, should be respected.


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In order to be able to implement as soon as possible the technical training of all the staff, it is often worthwhile to start with a temporary waste zone based on emergency facilities like a temporary safety box reducer (T.B. 6.04) and a temporary volume reducer (T.B. 6.05), even in a chronic emergency or stabilized situation.


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For hospitals up to 100 beds, the general recommendations are normally sufficient. It might be necessary for infrastructures with more than 100 beds to double or triple the facilities (e.g. two incinerators, double the number of organic waste pits, of which two are operational at the same moment in order not to be filled up too quickly and allow the decomposition of the waste). For 300 beds and more, other solutions for the medical waste are probably required (e.g. factory made incinerators).


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It is recommended to vaccinate the medical and non-medical staff who are potentially exposed to medical waste, at least against Hepatitis B and Tetanus.


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<table><tr><td>Medical Waste</td><td>Medical Waste</td><td>Medical Waste</td><td>Medical Waste</td></tr><tr><td>Segregation ▼</td><td>Sharps ▼</td><td>Soft waste ▼</td><td>Organic waste ▼</td></tr><tr><td>Temporary storage ▼</td><td>Yes ▼</td><td>Yes ▼</td><td>No ▼</td></tr><tr><td>Treatment (burning / incineration) ▼</td><td>No ▼</td><td>Yes ▼</td><td>No ▼</td></tr><tr><td>Final disposal</td><td>Sharps pit</td><td>Refuse pit</td><td>Organic pit</td></tr></table>


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Medical Waste Segregation ▼ Sharps ▼ Soft waste ▼ Organic waste ▼ Temporary storage ▼ Yes ▼ Yes ▼ No ▼ Treatment (burning / incineration) ▼ No ▼ Yes ▼ No ▼ Final disposal Sharps pit Refuse pit Organic pit


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The entire technical process should preferably be done on the compound of the health structure to avoid as much as possible accidents (e.g. needle stick injuries). If any waste has to leave the compound anyway, extra security measurements should be taken, which might require support from your technical referent. To achieve a correct medical waste management, different “technical” steps for sharps, “soft” and organic waste have to be accomplished, as presented in the table above. Hazardous waste demands specific attention for their entire technical process, and advice should be asked at your technical referent.


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The segregation process and corresponding management has to be as simple as possible. Therefore, no difference is made between contaminated and non-contaminated waste. The segregation of the medical waste in the different categories as described before should be done by the medical staff (e.g. doctors, nurses, laboratory technicians, pharmacists) at the place and time that the waste is generated. Attempting to segregate the medical waste at any other place or time introduces additional and non-acceptable risks.


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Sharps: modified drugs container, Reusable Sharps Container, commercial disposable sharps container.


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Soft waste: plastic buckets with a capacity of 20 to 60 l, all of the same colour, with a well fitting lid.


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Organic waste: plastic buckets with a well fitting lid, a capacity of 15 – 20 l for deliveries and 40 – 60 l for the operating theatre. All should have the same colour, but different than those for the soft waste.


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The frequency of medical waste collection depends on the type of waste category. Sharps should be collected at regular intervals or at the latest when the disposable (single use) container (T.B. 6.01) is


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¾ full, “soft” waste on a daily basis and organic waste as soon as possible after the intervention. Sharps and “soft” waste can be stored temporarily in safe containers within the waste zone (although not recommended) whilst organic waste has to be disposed of immediately.


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If possible, every health structure should have a waste zone (T.B. 6.09), where the waste can be treated and/or disposed of. This zone will be composed of several facilities:


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Different waste pits: sharps pit (T.B. 6.02), equipped or not with a safety box reducer (T.B. 6.03), residues (ash) pits (T.B. 6.07), organic waste pits (T.B. 6.08),


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The size of the waste zone depends on the amount of waste that is generated, thus on the size of the health structure itself and on the number of patients that are treated each day. The quantity of medical waste generated daily in low-income countries varies normally between 0.3 to 1.5 kg/bed (or 2 to 3 l/bed). The actual quantity of waste generated per category must be determined by each health structure itself in order to set up a correct medical waste management system. It is important to foresee sufficient space for the waste zone, as new pits will have to be dug once the old ones are nearly full. However, the different treatment / disposal facilities must be kept rather close together, to avoid spreading of the contamination over a large area and to provide an “ergonomic” and convenient working environment for the waste manager.


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Few medical waste treatment methods are appropriate, affordable or available in the field. Burning in a volume reducer or preferably incineration in a double combustion incinerator often remain the most suitable treatment methods for soft waste in low-income countries. An exception may be urban situations where the space to build an incinerator is limited or where the smoke would cause a nuisance to the neighbours. Another exception could be very small health structures (in rural areas) where the production of medical waste is limited and the available space on the compound large enough for land filling.


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Burning and incineration with limited means are too complicated (thus potentially dangerous) and too energy (fuel) consuming for sharps and most organic waste, thus the treatment is by-passed for these categories. Sharps and organic waste are disposed of directly in their respective pits.


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Food residues can be disposed off in the organic waste pit if they are produced in small quantities (less than 10 l/day), if not the pit will fill up too fast. For higher quantities, burial at an “official” landfill should strongly be considered. Composting could also be an alternative but to do it correctly, it demands motivation and specific knowledge, which falls out of the scope of these guidelines.


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Recurrently generated hazardous waste has to be managed on a case-by-case basis. Small amounts of chemical liquids (e.g. lab reagents and X-ray developing products) can be diluted with plenty of clean water before being discarded via a sink connected to a closed sewer system or a river with a substantial flow. Bio-hazardous waste like tuberculosis sputum, bacteria cultures or blood samples should be incinerated whilst adding sufficient combustibles, and preferably be autoclaved before when coming from the laboratory. Materials being used to administer cytotoxic drugs (not including sharps) should be collected separately and be incinerated in a double combustion incinerator with additional fuel to ensure a high combustion temperature. Glass bottles containing (bio-)hazardous samples or opened vials still containing vaccines have to be disposed of in a completely lined sharps pit or have to be encapsulated. Urine and stools can be disposed of in pit latrines, as long as the safety


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opened vials still containing vaccines have to be disposed of in a completely lined sharps pit or have to be encapsulated. Urine and stools can be disposed of in pit latrines, as long as the safety distances with water points are respected (Chapter 3). Disinfectant solutions can be “recycled” for cleaning the floors of non-critical areas (e.g. NOT for an operating theatre). Prepared but leftover insecticides that have been used for spraying health structures indoors can be utilised to treat the latrines. For the correct management of specific hazardous waste, ask advice to your technical referent.


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Inappropriate / expired hazardous products have to be eliminated according to the national legislation (if existing) or during specially organised (six monthly) campaigns, based on the feedback of your technical referent on the hazardous waste list that you have send (section 6.5 Further reading).


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Commercial disposable (single use) sharps containers are easily available in high-income countries, but often unaffordable for low-income countries, certainly when the aid-agency pulls out. Thus, it is often necessary to find cheaper, but as safe alternatives. To have good and safe sharps containers, they must:


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be fixed in every treatment room (e.g. on the wall nearby the place where the injections are given) or on a tray / trolley for treatment at the patients’ bed within the wards.


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Based on these specifications, glass / plastic infusion and beverage bottles are prohibited and it is strongly recommended not to use soft drinks / beer cans as sharps containers either. Correct alternatives are modified empty generic drugs containers, preferably the sturdy plastic models, although that metallic ones can also be used.


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Choose an empty drugs container that is sturdy, has enough storage capacity and a well fitting lid. It should also be well rinsed with water and dried afterwards.


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Make with a cutter knife a triangular hole in the top of the lid nearby its edge (see figure). The hole size depends on the sharps waste that has to be disposed of. Make sure that at least one corner of the triangle has a sharp angle to facilitate the one-hand removal of the needle from a Luer syringe.


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Put some glue for plastics on the circular inner edge of the lid and remount it on the container. The container can only be used once the glue has dried and the lid is securely fastened.


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Provide a holder system for the sharps container to be fixed to a wall, tray or trolley; e.g. Velcro straps or a PVC pipe (connector) with strong elastic bands. It’s important that the sharps container can be removed from the holder for final disposal, but it should stay immobile during the segregation of the sharps (e.g. needle being separated from its syringe). The holder should be strong enough for prolonged periods.


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Sharps should be segregated where and when they are generated, by the (para-)medical staff (e.g. doctors, nurses, laboratory technicians, pharmacists).


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Needles should never be recapped after use because the risk of injuries is extremely high during this action.


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The right location of the sharps containers must be decided in close collaboration with the medical staff.


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A single use sharps container should be collected and brought to the waste zone for final disposal when it is ¾ full.


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Sharps should not be burnt in volume reducers or even in good auto-combustion incinerators as they will stay sharp and thus form a risk for injuries when the residues are removed from the furnace. This could potentially lead to an infection of the waste manager during the manipulation of other medical waste. The people emptying full residues (ash) pits that contain rusty sharps (metal of sharps will corrode after they have been exposed to high temperatures) could be exposed to Tetanus. Glass sharps often explode when they are burnt or incinerated, which can lead to injuries of the waste manager.


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The waste manager should discard the single use sharps containers within a sharps pit (T.B. 6.02). The containers can never be opened, emptied nor reused.


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The triangular hole of a self-made sharps container (modified drugs container) is not adapted to remove a needle from a Luer-lock syringe, because of its screw pitch.


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When generic drugs pots aren’t available (in sufficient amount), or when people try to recycle them, the Reusable Sharps Container (RSC) can be an interesting alternative. This solid container corresponds to the specifications mentioned above and can be used for most kinds of sharps generated in health structures, including needles connected to Luer-lock syringes. However, sharps that are too long like the Auto-Disable (AD) syringes, (razor)blades with a long handle and very long needles (e.g. lumbar puncture needles) should not be introduced in the RSC because it will be very difficult to remove them afterwards. The RSC is provided with an opening mechanism that enables the safe disposal of the sharps in their designated pit. As the mechanism should be locked with a padlock, only the waste manager can open the container. To avoid sharps being stuck inside by overfilling the container, it has to be emptied regularly (daily or at least once a week if very few sharps are generated).


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waste manager can open the container. To avoid sharps being stuck inside by overfilling the container, it has to be emptied regularly (daily or at least once a week if very few sharps are generated). Before the container goes into circulation again, its outside should be rinsed with clean water, washed with water and soap (detergent), rinsed again, disinfected with a 0.1% chlorine solution (T.B. 2.20) and rinsed a last time with clean water. A small amount of chlorine solution (1 - 2 ml) can also be left within the RSC to reduce blood stained sharps sticking to its inside. Make sure that the responsible (waste manager) will not try to introduce his hand inside the RSC to remove those sharps. Check that the padlock is put back and the key is removed before the RSC goes back into circulation (section 6.5 Further reading).


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As the needle can’t be separated from Auto-Disable (AD) syringes (normally only to be used for immunisation activities), they have to be collected in their whole within cardboard safety boxes. The cardboard safety boxes must then be burned in a (temporary) safety box reducer (T.B. 6.03 and 6.04).


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Other long sharp objects like scalpels / razorblades with long handles and very long needles can also be collected in safety boxes and then burned in a safety box reducer (T.B. 6.03), or even collected in big modified drugs containers which can be discarded directly in the sharps pit.


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It is recommended to segregate (big) glass vials and ampoules in separate closable containers (big drugs pots or small buckets) in order to reduce their volume in specially designed glass crushers, placed directly on top of the sharps pit. For mass vaccination campaigns, the empty vials / ampoules should be encapsulated (section 6.5 Further reading).


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Choose an appropriate place within the waste zone (T.B. 6.09) for the construction of a sharps pit. In case there would be a lot of glass to be disposed of (e.g. empty vials, ampoules), it’s advisable to construct at least two sharps pits in order to have a reserve pit immediately available when the first one is filled up.


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Prepare the site for construction: remove all debris, flatten the surface, put up a (temporary) fence, do a soil texture test (T.B. 4.05) and bring in the needed construction material and equipment. Normally the preparation of the different waste zone facilities is done all at the same time.


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Lay out the area for the excavation of the sharps pit. The area should be larger than the actual size (lining) of the sharps pit itself. The sharp pit’s volume is not only depending on the size of the health structure and the number of patients, but also on the type of interventions (e.g. in some places, most of the treatments are done by injections). An example on volume calculation is given below.


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Dig the pit and check that its bottom is more than 1.5 m above the highest possible water table. The depth of the water table can be estimated by verifying its level in nearby wells. Another option is to drive a metal bar such as a reinforcing rod or (several pieces of) ½” galvanized pipe in the ground, as deep as 1.5 m beneath the required pit depth. When pulled out, the rod or (the earth inside) the pipe should be dry. Soil saturated with water after heavy rainfall might give a false impression of the actual water table level.


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Cast a closed foundation in reinforced concrete (300 kg/m³; T.B. 2.05) with a minimum thickness of 0.2 m on the bottom of the pit.


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Line the pit completely from the bottom till the top (at least 0.1 m above the ground surface) with plain concrete rings that are cemented and preferably also bolted together (T.B. 2.04), or with closed masonry-work, made watertight with cement plaster (T.B. 2.05). For the outer surfaces of the sharps pit, only one 10 mm layer of cement plaster is required, whereas internally it is recommended to add a second 10 mm layer once the first one has dried.


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Put a reinforced concrete slab on top of the pit’s lining. This slab can be cast in situ as it should not be removable, or it can be made like a latrine slab (T.B. 3.05) and secured on the lining with a 10 mm layer of mortar. The slab should only have a round hole in the middle, large enough to fit the drop pipe.


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Place the drop pipe, with its diameter adapted to the available sharps containers and about 1 m in length, in the slab’s hole and secure it with mortar. To ensure a better anchorage, a clamp can be connected to the drop pipe at the level where it will be mortared in the slab. Equip the drop pipe with a cover to avoid vectors and rainwater entering the pit.


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Make a drainage channel around the pit to prevent runoff water entering and to protect its walls (although the pit should be more or less watertight with the complete lining).


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Dispose immediately of the sharps (with their disposable container) into the pit when they arrive at the waste zone. Make sure that the drop pipe’s cover is always replaced after having disposed of the sharps.


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Close down the pit permanently when the level of the sharps is 0.30 m underneath the slab. The drop pipe should be cut at its base. Concrete or preferably a mixture of cement, lime and some water (weight ratio: 3, 3, 1) should be poured into the hole to encapsulate the sharps completely.


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Be aware however that single use sharps containers also take up quite some space as they can only be filled to ¾ of their volume. Other sharps like ampoules and vials require a lot of space as well, certainly when they are not crushed. So double or even triple the calculated useful volume!


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Don’t forget to add a free space above the waste (at least 0.30 m deep) to allow complete encapsulation!


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Only dispose of sharps (with disposable container) in the pit. Do not throw in soft or organic waste.


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A watertight sharps pit also permits to discard very small amounts of recurrently generated hazardous waste (e.g. broken mercury thermometer, itself encapsulated within an empty plastic drugs container and covered with plaster or a cement – lime – water mixture).


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If the soil is unstable, reinforce the vertical walls with removable struts during the excavation or make the pit conical.


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➞ If the subsoil is very rocky, the area flood prone or the water table high, the pit may have to be partially constructed aboveground in a very well compacted earth mound. A complete lining that is entirely watertight is essential (T.B. 3.12).


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➞ A sharps pit can also be made of a big round plastic / polyester reservoir that is normally used for water storage. Such a reservoir can even be put in the water table as it is completely watertight and corrosion resistant. But during the construction, a concrete layer should be poured on its bottom to weigh it down in order to avoid that the reservoir would float when standing in a high water table. A heavy concrete slab should still be installed on top of the plastic / polyester reservoir, in which the drop pipe is integrated. These kinds of reservoirs can’t be used however when a safety box reducer (T.B. 6.03) will be installed on top of the sharps pit because of the damages that the hot ashes falling in would cause.


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The volume of the sharps pit should be calculated according to the amounts of sharps that will be generated over a period of at least 5 years.


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The diameter of the drop pipe is important: it should be possible to drop the unopened disposable sharps containers (e.g. modified drugs containers) inside the pit without any obstructions, or to fit the discharge outlet of a Reusable Sharps Container. The length of the pipe is to prevent people reaching in the pit, trying to recuperate sharps..


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The drop pipe, slab and surroundings should be cleaned regularly and preferably occasionally sprayed with a 0.1% chlorine solution (T.B. 2.20).


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In acute emergencies (e.g. temporary health structure in a camp) or within the first phase of medical waste management, it is possible to make a “sharps pit” out of a single or double 125 l plastic recipient or a 200 l drum (preferably plastic but metal can do as well). As it is a “temporary sharps pit”, it is recommended to foresee some handles on the drum to be able to remove it afterwards. A hole adapted to the size of the available sharps containers should be made in the top cover of the recipient / drum and a drop pipe with a length of 1 m installed. A metallic pipe can be welded to a metallic drum with some external reinforcements. A plastic drop pipe can be glued in some kind of flange (purchased or self-made; section 6.5 Further reading) that can be connected to the recipient / drum with bolts. Another alternative is to make a concrete slab to anchor the drop pipe and to place the slab over the recipient / drum. The recipient / drum can (partly) be buried while the majority of


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with bolts. Another alternative is to make a concrete slab to anchor the drop pipe and to place the slab over the recipient / drum. The recipient / drum can (partly) be buried while the majority of the drop pipe has to stay aboveground. This temporary sharps pit is to be used as a normal model.


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In urban areas (e.g. slums) where there isn’t enough space to make a permanent sharps pit, such a temporary model can be useful as well. With a reduced drop pipe length, the “transitory sharps pit” can also be located at a safe place aboveground where there isn’t access for unauthorised personnel.


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Once the health structure is dismantled or the “transitory sharps pit” is ¾ full, the recipient / drum should be dug out and/or transported to a safer area (e.g. the waste zone of a long-term hospital or a controlled landfill) where it will need to be encapsulated with a cement, lime and water mixture (3, 3, 1 parts by weight) or concrete before final burial.


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Auto-Disable syringes and cardboard safety boxes that are used in the health structure within an immunisation program for instance, shouldn’t be disposed as such in a sharps pit as they take up too much space. A safety box reducer, preferably in heat resistant bricks, should be constructed on top of the sharps pit, next to the drop pipe (T.B. 6.03). Make sure that the concrete slab is designed to withstand the additional weight of the volume reducer.


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In case a lot of glass waste is generated (e.g. ampoules, vials), a glass crusher should be installed on top of the sharps pit (section 6.5 Further reading). Contact your technical referent for more information.


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The operator (waste manager) should receive intensive training and a complete set of protective clothing, which should always be worn during operation and maintenance (T.B. 6.10).


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Choose and prepare within the waste zone (T.B. 6.09) an appropriate place, and dig the sharps pit (as explained in T.B. 6.02). Take the dominant wind direction into consideration for its location to avoid smoke nuisances, and stay away from objects that can catch fire. Make the pit twice as large sideways or dig a separate sharps pit to accommodate the safety box reducer.


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Construct the sharps pit in concrete or “watertight” masonry-work as described above (T.B. 6.02). Its reinforced concrete slab on top should have a drop pipe next to a hole just as big as the internal surface of the safety box reducer (the standard size of the hole is two refractory bricks deep and one wide; normally 0.46 m x 0.23 m). The reinforced concrete slab should be able to resist the weight of the safety box reducer (the standard model can weigh up to 400 kg).


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Build two closed layers of refractory (heat-resistant) bricks around the hole in the concrete slab (section 6.5 Further reading). The bricks should be put together with a very fine layer of refractory cement (2 - 3 mm smeared directly on the refractory bricks). Keep the refractory bricks away from humidity and direct heat (e.g. direct sunlight) because the latter has a bad influence of the strength of the refractory cement.


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Foresee four openings in the refractory bricks when the third layer is constructed in a similar manner as described above. The four holes can be obtained simply by installing two refractory bricks ¾ in length in the middle of the long sides of the safety box reducer. The easiest way to obtain a ¾ refractory brick is to make a (small V-shaped) cut all around the brick and than break it in two with a good blow by means of a hammer and a flat chisel.


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Build another five layers in a similar way as above, but the front side should be left open. Therefore, four bricks will have to be cut in half in the same manner as described above.


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Place a prefabricated metallic cover on top of the refractory bricks, which is foreseen with a hole for the chimney and a hanging loading door (potentially with locking mechanism).


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Construct an outer metallic hull or a normal brick wall around the refractory part of the safety box reducer, leaving a free space of some centimetres, and/or construct a roof above to protect it from harsh weather conditions (refractory bricks should not get wet).


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Fit a chimney with head cap on the hole in the cover. The chimney should be at least 2 m high and be secured to the fence of the waste zone or with cables to the ground.


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Open the loading door and check if residues from the previous cycle are remaining in the safety box reducer. Push them down into the sharps pit with a long solid poking bar before starting a new cycle.


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Light the safety box at its handle and check if the fire takes well. In case the fire would die out, some extra combustibles like paper, cardboard and dry coconut shells or wood can be added to help starting the combustion.


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Monitor the combustion, but be careful for explosions when glass sharps would accidentally have been included in the waste. As the combustion progresses, the residues should fall straight in the pit.


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The design of the safety box reducer should permit that the residues with the burned needles fall directly into the sharps pit. The vertical entrance and its size should allow that only one safety box can be loaded at the time, rendering the access difficult for the recipients of other kinds of waste.


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Although the safety box reducer is similar to the principle described in T.B. 6.04 (Mass vaccination campaign waste), this device should not be used to reduce the sharp waste generated during big campaigns because the sharps pit designed for long-term use would fill up too fast.


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The volume of the sharps pit should be calculated according to the amounts of sharps that will be generated


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over a period of at least 5 years. Take into consideration that the residues of burned safety boxes do take up more space than individual needles. When a correct combustion takes place, a volume reduction of at least 90% should be obtained (the residues volume < 10% of the original safety box volume).


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Important: foresee an additional depth of 0.30 m in the calculation of the pit size for final encapsulation. It is not part of the effective pit volume.


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Refractory cement can be aggressive. It is thus recommended to wear the needed protective clothing during the construction process (at least thin gloves).


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To avoid that the safety box reducer and its waste load get wet (and hence is more difficult to burn), a roof should be constructed above, if possible. Do not use combustible building material for the roof.


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Use this reducer only for safety boxes containing Auto-Disable (AD) syringes, and potentially very long needles, scalpels and razorblades with a long non-detachable plastic handle that don’t fit in a normal sharps container. Never put organic waste (e.g. placentas, food residues), explosive objects (e.g. aerosol cans) and/or materials that give off toxic fumes (e.g. drugs) in the safety box reducer.


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As glass might explode when heated, it shouldn’t be burned in the safety box reducer. In case there would


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be a lot of glass waste (e.g. empty vials, ampoules) being generated, it’s advisable to construct at least a second regular sharps pit from the beginning in order to have a reserve one immediately available when the first one is filled up. A glass crusher directly installed above the sharps pit will allow a drastic volume reduction of the glass waste, resulting in a longer lifespan of the pit. Contact your technical referent for more information.


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If residues remain in the safety box reducer, the air draught might be hindered during the next cycle, with a bad combustion as a result. Do not empty the safety box reducer via the loading door, but push the possible remaining residues downwards with a poking bar before starting the next combustion cycle.


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The operator of the safety box reducer (waste manager) should receive intensive training and a complete set of protective clothing, which should always be worn during operation and maintenance (T.B. 6.10).


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<table><tr><td>Most of the waste generated during mass vaccination campaigns are sharps. Sharps are</td></tr><tr><td>considered to be very dangerous medical waste. The normal practice of sharps being discarded</td></tr><tr><td>directly in a sharps pit is unfeasible during mass vaccination campaigns because most often</td></tr><tr><td>Auto-Disable (AD) syringes are used. As their needle can’t be disconnected, the AD syringes</td></tr><tr><td>represent a big volume that would fill up the sharps pit too fast. These syringes are therefore</td></tr><tr><td>collected in cardboard safety boxes, transported to a centralised place and burned in a temporary</td></tr><tr><td>safety box reducer. Its design is such that when the safety boxes are burned, the residues fall</td></tr><tr><td>straight into a pit, thus nobody gets in contact with the burnt sharps. Do take in consideration that</td></tr><tr><td>glass sharps (vials, ampoules) might explode and therefore form a danger for the operator. Thus,</td></tr><tr><td>it’s strongly recommended that this kind of waste is disposed of by encapsulation without treatment.</td></tr></table>


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Most of the waste generated during mass vaccination campaigns are sharps. Sharps are considered to be very dangerous medical waste. The normal practice of sharps being discarded directly in a sharps pit is unfeasible during mass vaccination campaigns because most often Auto-Disable (AD) syringes are used. As their needle can’t be disconnected, the AD syringes represent a big volume that would fill up the sharps pit too fast. These syringes are therefore collected in cardboard safety boxes, transported to a centralised place and burned in a temporary safety box reducer. Its design is such that when the safety boxes are burned, the residues fall straight into a pit, thus nobody gets in contact with the burnt sharps. Do take in consideration that glass sharps (vials, ampoules) might explode and therefore form a danger for the operator. Thus, it’s strongly recommended that this kind of waste is disposed of by encapsulation without treatment.


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Cut the upper and bottom lids completely out of a metallic 200 l drum to obtain an open cylinder, which will become the temporary safety box reducer. Make sure that the sharp edges are worked in such a way that they can’t injure the operator.


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Make 10 holes in the circumference of the cylinder at about 1/3 of its height. As such, five metallic reinforcement bars can be slid parallel to each other in the drum.


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Cut the upper lid completely out of another metallic 200 l drum to make a container that will collect the burnt residues. Make sure that the sharp edges are worked in such a way that they can’t injure the operator.


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Choose an appropriate place for the installation of the temporary safety box reducer, preferably within an existing waste zone (T.B. 6.09). Take the dominant wind direction in consideration to avoid smoke nuisances and stay away from objects that can catch fire.


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Dig a hole according to the size of a 200 l drum and place the residues collection drum inside. Its top should just be reaching the surface.


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Put two metallic beams or a metallic grid with rather large holes (at least 0.1 m x 0.1 m) over the collection drum. The material used should be strong enough to support a metallic 200 l drum full of filled up safety boxes. Be aware that the metal of the grid might get hot, loose partly its rigidity and potentially bend.


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Make sure there is a fence around this temporary facility and allow only access to authorised personnel in order to avoid accidents.


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Make sure there is also a short term but safe storage place nearby for the safety boxes, with a roof during the rainy season because it is essential to keep the big amount of waste dry.


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Push, by means of a poking bar, the potential remaining residues of the temporary safety box reducer into the collection drum, before starting a new cycle.


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Place a closed safety box inside the temporary safety box reducer and pour some kerosene on and around its handle.


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Light the safety box at its handle with a piece of burning paper and give the fire the time to take well. In case the fire would die out, some extra combustibles like paper, cardboard and dry coconut shells or wood can be added to help starting the combustion.


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Monitor the combustion from a distance, and be careful for explosions when glass sharps would accidentally have been included in the safety boxes.


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Keep on monitoring with precaution and add batches until all safety boxes have been burnt or until the end of the working period. In case the residues don’t fall into the pit, push them down with a poking bar.


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Remove the safety box reducer and the beams / grid when the collection drum inside the pit is filled up to 4/5 of its height, or when all the safety boxes are burnt. It is recommended to strike the safety box reducer a couple of times with the poking bar or a hammer, so that some last sharps might fall into the “pit”. In case all the waste has been burnt, consider the alternative to bury also the grid and the safety box reducer.


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Encapsulate the residues by pouring concrete or preferably a mixture of cement, lime and some water (weight ratio: 3, 3, 1) inside the collection drum and once settled, cover everything with compacted earth.


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During a mass vaccination campaign, it is a common policy to bring back all the waste to a safe centralized place, where the quantity will potentially be checked by the medical staff and where it can also be eliminated. It is therefore interesting to choose as centralised place a health centre with an existing waste zone. The safety box reducer can be situated within or next to this waste zone, and its location should be where its smoke won’t bother the health services nor the population.


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If needed, place the burner underneath some kind of roof (do not use combustible building material) to avoid that the waste load gets wet (and thus is more difficult to burn).


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The amount of safety boxes to be burnt during a mass vaccination campaign is often that high that a single residues collection drum won’t be sufficient. In that case, a trench with several collection drums will need to be prepared. Attention needs to be given that nobody, including the operator can’t fall in the open drums.


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When there aren’t enough drums available, other material (e.g. concrete rings, bricks) to line the pit should be looked for to permit a correct encapsulation afterwards. In the worst case scenario, the temporary safety box reducer can also be placed directly over the pit, which bottom should preferably be more than 1.5 m above the water table. The depth of the water table can be estimated by verifying its level in nearby wells. Another option is to drive a metal bar such as a reinforcing rod or (several pieces of) ½” galvanized pipe in the ground, as deep as 1.5 m beneath the required pit depth. When pulled out, the rod or (the earth inside) the pipe should be dry. Soil saturated with water after heavy rainfall might give a false impression of the actual water table level.


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In case of an extremely big mass vaccination campaign, several temporary safety box reducers can be put together and be used simultaneously to speed up the elimination process.


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The waste should be eliminated as soon as possible once it has arrived at the centralized place, but only after clearance by the medical staff .


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Never over-fill the reducer with safety boxes as this could hinder the free air circulation (causing a lack of oxygen), resulting in a bad combustion. Thus, it is better to burn small numbers of safety boxes at the time and gradually introduce new batches.


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When a correct combustion takes place, a volume reduction of at least 90% should be obtained (the residues volume <10% of the original safety box volume). Volume reductions up to 96% have already been noticed.


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Wet cotton balls, used to clean the skin before vaccination, can be collected in a carton and burned in the temporary safety box reducer. However, it is probable that some additional combustibles will be needed.


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As glass might explode when heated, the vials or ampoules generated during the mass vaccination campaign shouldn’t be burned in the temporary safety box reducer. It is recommended to encapsulate them immediately in drums (after having been counted by the medical staff), which should be buried within the same waste zone where the safety boxes are treated, or in a controlled tip (T.B. 5.03) or a sanitary landfill.


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Never put organic waste (e.g. placentas, food residues), explosive objects (e.g. aerosol cans) and/or materials that give off toxic fumes (e.g. drugs) in the temporary safety box reducer. Always seek advice from your technical referent before, in case of doubt.


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If residues remain in the temporary safety box reducer, the air draught might be hindered, with a bad combustion as a result. Therefore, push the remaining residues downwards with a poking bar, before starting a new burning cycle.


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The temporary safety box reducer and the potential open part of the pit should be covered when not in use, in order to avoid that residues would be blown away by the wind.


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The operator of the temporary safety box reducer (waste manager) should receive appropriate training and a complete set of protective clothing and equipment, which should always be used during operation and maintenance of the facility (T.B. 6.10).


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As soft waste represents the biggest quantity of all the medical waste that is generated in a health structure, it’s important to reduce its volume drastically before it is finally disposed of into a residues (ash) pit. In an acute emergency, a temporary volume reducer can achieve this objective efficiently. A permanent incinerator should replace the temporary volume reducer if the health structure becomes permanent.T.B. 6.05 Temporary volume reducer


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Cut out its top cover over around 2/3 of its perimeter. Keep the cut out as it will be used as the loading door.


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Cut a hole in the remaining part of the top cover. Its size should be adapted to the diameter of the chimney


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Cut out a panel of about 0.4 m wide x 0.25 m high at the lower part of the drum’s cylinder. Keep the cut out panel because it will be used as the ash door.


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Prepare a metal plate with a length that is equal to the internal height of the drum and a width that is the same as the straight part of the loading door.


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Perforate the metal plate over its complete surface with 10 mm holes about 20 mm apart from each other.


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Make sure that all the sharp edges of the drum, the loading door, the ash door and the perforated plate are worked in such a way that they can’t injure the operator.


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Slide the perforated plate into the drum and fix it to divide the inside into two chambers of unequal volume.


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Connect the loading door to the top of the drum with a hinge mechanism (e.g. solid hinges with a minimal size of 50 mm) and attach a handle so that it may be opened and closed easily. The handle should be designed in such a way that the loading door cannot pivot towards the inside of the drum.


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Join the ash door with a hinge mechanism to the bottom of the drum and install a handle, designed in such a way it can be attached to the drum’s cylinder.


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Cut some rigid metal grating to the same size as the inner cross section of the large chamber (in front of the perforated metal plate), and fix it horizontally about 0.2 m from the bottom of the drum. The grating will separate the soft waste from the ash part of the volume reducer.


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Fit the chimney solidly on the hole that is made in the drum’s top cover. The chimney must be at least 2 m high, and equipped with a head cap.


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Remove the ashes of the previous cycle via the ash door and discard them in the residues pit (T.B. 6.07).


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Open the loading door and put some paper, cardboard and combustibles (e.g. dry firewood, dried coconut


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Light the paper / cardboard through the ash door. Once the fire takes off, the ash door can be closed. Give the fire the time to take well.


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Introduce via the loading door a small batch of soft waste (equivalent to the content of a waste bin) once the fire is burning well.


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Monitor the combustion. If the fire would start to die out, add via the loading door some combustibles like dry wood or coconut shells.


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Rinse the soft waste bins with clean water, wash them with water and soap (detergent), rinse again, disinfect with a 0.1% chlorine solution (T.B. 2.20) and rinse a last time with clean water, before they go into circulation again.


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Place the temporary volume reducer in the foreseen waste zone, at a location where the smoke won’t bother the health services nor the neighbouring population. The required height of the chimney depends on the surrounding obstacles (e.g. buildings and vegetation), so its outlet should normally be above them.


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Alternative: it’s possible to remove the bottom of the drum completely and to place the volume reducer immediately over the residues (ash) pit by means of metallic beams or a metallic grid with big holes (at least 0.1 m x 0.1 m). The material used should be strong enough to support a metallic 200 l drum full of waste. Be aware that the metal of the grid might get hot, loose partly its rigidity and potentially bend. This system has the advantage that all the residues fall immediately in the pit, although it might still be necessary to push them down before a new combustion cycle is started. The inconvenience is that the residues pit can’t be closed easily at the end of a cycle and ashes could be blown away by the wind.


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Place the volume reducer underneath a roof (do not use combustible building material) to avoid that the waste load gets wet during the rainy season and thus is more difficult to burn. The roof also helps to reduce a little bit the drum corrosion.


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Even under the best circumstances, a drum volume reducer that is frequently used will not last very long. This is due to corrosion, enhanced by the corrosive gasses that are generated when burning soft waste and the heat produced inside the drum.


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Clean out the ash part of the volume reducer before each new cycle is started, otherwise the air draught will be hindered, resulting in a bad combustion. Do not empty the volume reducer via the loading door.


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Do not try to over-economize on combustibles (e.g. paper, cardboard, dry firewood, dried coconut shells): always preheat the volume reducer and keep a good fire going to guarantee the best combustion possible.


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Never over-fill the temporary volume reducer with soft waste: this would block the free circulation of air (causing a lack of oxygen), resulting in a bad combustion and thus more toxic fumes. Thus, it is better to burn small batches (e.g. content of a 20 l waste bin) at the time and once they are nearly completely burned, a new batch can be introduced.


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The opening of the ash door may be adjusted to regulate the draught. However, it is preferable to burn with the ash door closed, if the draught is sufficient.


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When a correct combustion takes place, a volume reduction of at least 90% should be obtained (the residues volume < 10% of the original volume).


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Never burn sharps (e.g. needles, scalpels, ampoules, vials), organic waste (e.g. placentas, food residues), explosive objects (e.g. aerosol cans) or materials that give off toxic fumes (e.g. drugs) in a volume reducer. Other facilities should be available (see appropriate Technical Briefs) in the waste zone to dispose of them. In case of doubt, always seek advice from your technical referent.


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The operator of the temporary volume reducer (waste manager) should receive an appropriate training and a complete set of protective clothing and equipment, which should always be used during operation and maintenance of the facility (T.B. 6.10).


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The “ideal” permanent incinerator for normal sized health structures within low-income countries should respond to the following specifications:


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Composed of a primary and secondary combustion chamber to extend the retention time of the gasses in a hot environment. It allows to drastically reduce the number of thermo-resistant pathogens and to burn off more (toxic) emissions.


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Build in refractory material (heat resistant bricks and cement) to extend its lifetime and to have less temperature variations when new or wet waste is introduced.


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Consists of an auto-combustion system, which functions mainly on the burnable waste and doesn’t need additional fuel. It results in an important reduction of the amount of additional combustibles needed, except during the start up phase to preheat the incinerator, and when extremely wet or some specific (bio-)hazardous waste has to be incinerated.


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Always seek advice from your technical referent in case of doubt for the choice of an appropriate incinerator.


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For factory made incinerators, the instructions from the manufacturer should be followed precisely. Below is a general description of how to use a batch auto-combustion incinerator (e.g. the De Montfort):


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Empty the ashtray containing ashes and residues from the previous incineration cycle into the residues (ash)


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pit (T.B. 6.07). An extra sweep inside the incinerator with a long-handle broom might be necessary to remove residues that fell beside the ashtray.


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Open the loading door and put some paper, cardboard and combustibles (e.g. dry firewood, dried coconut shells) in the incinerator.


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Light the paper / cardboard through the ashtray door. Once the fire takes off, close the ashtray door.


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Give the fire the time to take well and to preheat the incinerator. The preheating should last until a roaring fire is heard or at least until good flames are visible in the secondary combustion chamber (this can be seen via the peephole at the back side of the incinerator, if available).


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Introduce via the loading door a small batch of soft waste (equivalent to the content of a waste bin), once the fire is burning well.


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Monitor the combustion in the primary and secondary combustion chambers (if possible): if the fire would start to die out in one of the chambers just after a new batch of waste went in, add via the loading door some combustibles like dry wood or coconut shells.


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Rinse the soft waste bins with clean water, wash them with water and soap (detergent), rinse again, disinfect


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with a 0.1% chlorine solution (T.B. 2.20) and rinse a last time with clean water, before they go into circulation


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Skilled people are needed for the construction of incinerators. Since refractory cement can be aggressive, it is recommended to have the builders wear the needed protective clothing during the construction process (at least thin gloves).


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If refractory bricks and cement aren’t available on the spot, look in neighbouring countries or order from high-income countries (e.g. in Europe). Correct refractory bricks for batch (auto-combustible) incinerators have a high density (weight of about 4.5 kg/brick) and are made out of kaolin enriched with alumina (Al2O3; concentration ideally around 60%). This material has a high resistance to


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Position the incinerator in the foreseen waste zone, at a location where the smoke won’t enter the health structure’s buildings nor bother the neighbouring population.


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The required height of the chimney (preferably in stainless steel or thick plated metal tubes) depends on the surrounding objects (e.g. buildings and vegetation), with its outlet always well above them. Be aware that a higher chimney creates more draught, which has an influence on the combustion temperature (can be positive or negative). The admission of air is also function of the size of the air inlets.


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Position the incinerator underneath a roof (do not use combustible building material) to avoid that the waste load gets wet and thus is more difficult to incinerate. The roof also helps to reduce the corrosion of the (hot) metallic parts of the incinerator.


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Big incinerators take longer to preheat and therefore need a lot more combustibles, thus it is advisable to construct (rather) small incinerators. For large health structures where the capacity of a small incinerator doesn’t seem to be sufficient, it is often more appropriate to build two small ones than one big incinerator. Only for very big hospitals (> 300 beds), larger models of commercially available incinerators might be needed.


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Do not scale up the size of existing designs because this might have serious consequences on the efficacy of the incinerator.


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Empty the incinerator’s ashtray each time before a new incineration cycle is started, otherwise the draught will be hindered, resulting in a bad combustion with more toxic fumes. Do not empty the incinerator via the loading door.


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Do not try to over-economize on combustibles: always preheat the incinerator and keep a good fire going to guarantee the best combustion possible.


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Never over-fill the incinerator with soft waste: this would block the free circulation of air (causing a lack of oxygen), which would result in a bad combustion and thus more toxic fumes. Thus, it is better to incinerate smaller batches at the time and once they are nearly completely incinerated, a new batch can be introduced.


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When a correct combustion takes place, a volume reduction of at least 90% should be obtained (the residues volume <10% of the original volume).


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Never incinerate sharps (e.g. needles, scalpels, ampoules, vials), organic waste (e.g. placentas, food residues), explosive objects (e.g. aerosol cans) or materials that give off toxic fumes (e.g. drugs) in a batch (auto-combustion) incinerator. Other facilities should be available (see appropriate Technical Briefs) in the waste zone to dispose of them. In case of doubt, always seek advice from your technical referent.


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Bio-hazardous waste like tuberculosis sputum and blood can be incinerated if enough fuel (e.g. dry wood or coconut shells) are added to compensate for the heat loss due to the liquid nature of the waste. Always seek advice from your technical referent in case of doubt


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Attention: when the loading door is opened, a big flame might shoot out. Some flames might be noticed as well via the air inlet when the loading door is closed again. The operator should stand away from the flames.


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The operator of the incinerator (waste manager) should receive an intensive training and a complete set of protective clothing and equipment, which should always be used during operation and maintenance (T.B. 6.10).


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Determine the amount of residues to be disposed of, based on the average volume of soft waste that is generated on a daily basis.


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Determine the required capacity of a single residues pit; after a correct combustion, the residues volume should represent less than 10% of the original volume. The suggested lifespan is two years at least.


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Choose within the waste zone (T.B. 6.09) an appropriate place to construct the residues pits, nearby the volume reducer / incinerator. It is recommended to construct at least two ash pits from the beginning in order to have a reserve readily available when the first one is full.


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Prepare the site for construction: remove all debris, flatten the surface, implement a soil texture test (T.B. 4.05), determine the depth of the water table and bring in the needed material. Usually the preparation of the different waste zone facilities is done at the same time.


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Prepare, excavate and line the pit in a similar way as described for a simple pit latrine (T.B. 3.04) or a VIP latrine (T.B. 3.07), depending on the soil type and the skills of the mason. The same excavation can be used to construct the two residues pits at the same time when a closed separation wall is built in the middle. In case the water table doesn’t permit deep excavation, each pit can be increased in size by foreseeing two or more standard size slabs next to each other. In this case, it isn’t necessary to put a closed separation wall in between each “cubicle”. The layer of lean concrete for stabilisation on the bottom of the pit (VIP construction method) is recommended however.


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Make a concrete standard size slab (T.B. 3.05 or 3.08, depending on the type of lining, but without the ventilation pipe). The drop hole’s shape and size (square of about 0.3 m x 0.3 m), hence the location of the reinforcement bars need to be modified. Provide a lid for the drop hole, preferably connected to the slab with some kind of heavy-duty “hinges”. The lid can be made in wood (emergency situations), but preferably in concrete or metal.


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Install the prefabricated slab with its lid on the residues pit’s lining / base, once it has settled for at least 3 days. To ensure a secure seating, the slab should be fixed to its lining / base (overlaps of at least 0.1 m) with a 10 mm thick mortar layer (T.B. 2.05).


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Make a drainage channel around the pit to lead runoff water away, protecting its walls against erosion.


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Remove the ashes and other residues from the incinerator / (temporary) volume reducer before a new cycle is started, and dispose of them in the residues pit. Make sure that the residues are always covered with the slab’s lid or by at least 0.1 m of compacted soil when there is no slab (emergency situations).


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Close down the pit when the residues’ level is about 0.3 m underneath the slab. For acute emergency settings, remove the temporary slab, put a metal grid on top of the residues and backfill the remaining space with compacted soil. Coming across the grid during future excavations will indicate that a pit has already existed on the same spot. In chronic emergencies and stabilised situations, the remaining space needs to be backfilled with soil without removing the concrete slab. It is possible to empty a residues pit that has been closed down for at least two years. However, special precautions should be taken to avoid injuries with sharps that have accidentally been discarded in the residues pit. The residues can be taken to a controlled tip (T.B. 5.03) or sanitary landfill.


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<table><tr><td/><td>Key</td><td>Input</td></tr><tr><td>Pit Slab Lid Base / lining</td><td/><td>String line, sticks and measuring tape Shovel, hoe, pick axe, miner’s bar Fired bricks / cement blocks and/or sand, cement, gravel and clean water</td></tr></table>


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Key Input Pit Slab Lid Base / lining String line, sticks and measuring tape Shovel, hoe, pick axe, miner’s bar Fired bricks / cement blocks and/or sand, cement, gravel and clean water


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Lining represented in the figure is similar to the method used for a simple pit latrine (T.B. 3.04), but also other methods can be used (e.g. T.B. 3.07).


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Wood ash can be used for several purposes (e.g. covering excreta for odour reduction in latrines, hand washing), but the ash from incinerated / burnt soft waste should only be discarded at a safe place.


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If the pit is dug in one time until the required depth and the soil is unstable, the vertical walls should be reinforced with removable struts during the excavation, or the hole should be made conical.


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The bottom of the pit should be at least 1.5 m above the highest possible water table. The latter can be estimated by verifying the water level in nearby wells. Another option is to drive a metal bar such as a reinforcing rod or (several pieces of) ½” galvanized pipe in the ground, as deep as 1.5 m beneath the required pit depth. When pulled out, the rod or (the earth inside) the pipe should be dry. If not, the pit depth should be adapted accordingly. Soil saturated with water after heavy rainfall might give a false impression of the actual water table level.


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Another construction method for residues pits is the individual circular-shaped pit, which is often more difficult to excavate but less due to collapse because of its natural arching effect. This can be particularly interesting for emergency residues pits that won’t be lined. When necessary, the circular pit can be reinforced with one or more concrete rings (T.B. 2.06). Other valid construction methods and materials exist for circular pits, but fall out of the scope of these guidelines. Contact your technical referent for more information.


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➞ If the subsoil is very rocky, the area flood prone or the water table high, the pit may partially be constructed in the ground and the remaining aboveground part in a very well compacted earth mound. A different technique (T.B. 3.12) will have to be used. For big health structures generating large quantities of incinerator residues, long aboveground “trenches” might be more appropriate.


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➞ A residues pit can also be made of a big round plastic / polyester reservoir that is normally used for water storage. Such a reservoir can even be put in the water table as it is completely watertight and


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corrosion resistant. But during the construction, the reservoir should be weighted down (e.g. with a concrete layer or big stones on its bottom) in order to avoid that it would float when standing in a high water table. Hot ashes should not be discarded in such a residues pit.


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If it rains a lot in the region, the lining / base can be made a little higher aboveground, for the pit to be less at risk of flooding.


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The calculated pit volume should include a free space above the residues of at least 0.30 m high. It isn’t part of the effective pit volume, but will allow the pit to be closed properly once it’s nearly full.


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For acute emergencies, a temporary wooden slab or layers of compacted earth can do. For chronic emergencies and stabilised situations, a concrete standard size slab is recommended as it still has a reasonable weight that can easily be removed.


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For a large pit with several slabs, each one should have its own covered 0.3 m x 0.3 m drop hole, allowing an equal residues repartition over the pit. All of the slabs have to be sealed to each other with mortar.


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Only discard incinerated / burnt residues of soft waste in the pit. Do not throw in any other kinds of waste, and certainly not sharps!


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It is essential that the residues are covered immediately after disposal, to avoid that the wind would blow the ashes away (causing potentially respiratory infections) and/or that unburned residues would attract vectors (e.g. flies).


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If a residues pit is emptied (at least two years after it has been closed down), all its slabs should be removed to permit easy access and safe working conditions. Once all the slabs are removed, wait some time before entering into the pit to evacuate all potential hazardous gasses.


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During works within a used residues pit, make sure that the person inside the pit has a strong rope around his waist. This rope permits colleagues standing at the side of the pit to lift the person out if something goes wrong.


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Determine over a period of at least a week, the volume of organic waste that needs to be disposed of.


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Determine the required capacity of a single organic waste pit, based on the daily average amount of organic waste. The suggested lifespan is 2 years at least.


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Choose an appropriate place within the waste zone (T.B. 6.09) to construct the organic waste pits. It is strongly recommended to construct at least two organic waste pits from the beginning in order to have a reserve immediately available when the first one is full.


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Prepare the site for construction: remove all debris, flatten the surface, implement soil texture and permeability tests (T.B. 4.05), determine the depth of the water table and bring in the needed material and equipment. Usually the preparation of the different waste zone facilities is done all at the same time.


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Prepare, excavate and line the pit in a similar way as described for a simple pit latrine (T.B. 3.04) or a VIP latrine (T.B. 3.07), depending on the soil type and the skills of the mason. The same excavation can be used to construct the two organic waste pits at the same time when a watertight separation wall is built in the middle. In case the water table doesn’t permit deep excavation, each pit can be increased in size by foreseeing two or more standard size slabs next to each other. In this case, it isn’t necessary to put a separation wall in between each “cubicle”. The layer of lean concrete for stabilisation on the bottom of the pit is highly recommended for the VIP construction method however.


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Make a concrete standard size slab with ventilation hole (T.B. 3.08), but the drop hole’s shape and size (about 0.3 m x 0.4 m), hence the location of the reinforcement bars need to be modified. Provide a lid for the drop hole, preferably connected to the slab with some kind of heavy-duty “hinges”. The lid can be made in wood (emergency situations), but preferably in concrete or metal that needs to be protected against corrosion (as the gasses within the pit are aggressive). A small piece of plastic pipe (diameter of at least 100 mm, preferably 150 mm and about 200 mm high) should be integrated in the slab’s ventilation hole.


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Install the prefabricated slab with its lid on the lining / base of the organic waste pit, once it has settled for at least 3 days. To ensure a secure seating, the slab should be fixed to its lining / base (overlaps of at least 0.1 m) with a 10 mm thick mortar layer (T.B. 2.05).


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Place the plastic ventilation pipe over the small pipe integrated within the slab. The pipe should be at least


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2.5 m long, with its outlet higher than the potential obstacles in the direct vicinity (e.g. buildings, trees). To prevent from being blown over during heavy winds, the ventilation pipe should be anchored to the fence of the waste zone or with cables to the ground. The outlet of the pipe should have a rain cap (Tee), being covered with a (preferably stainless steel) screen to avoid that vectors would enter inside the pit.


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Make a drainage channel around the organic waste pit to lead runoff water away, thus protecting its walls against erosion.


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Lining represented in the figure is similar to the method used for a simple pit latrine (T.B. 3.04), but also other methods can be used (e.g. T. B. 3.07).


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Dispose of the organic waste into the pit immediately when it arrives at the waste zone. Use only one pit at the time. Make sure that the pits are always closed with the slab’s lid.


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Rinse the organic waste bins with clean water, wash them with water and soap (detergent), rinse again, disinfect with a 0.1% chlorine solution (T.B. 2.20) and rinse a last time with clean water, before they go into circulation again.


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Close down the pit when the level of the organic waste is about 0.5 m underneath the slab. Put a thick layer of wood ash on top of the organic waste and top up with compacted soil if the pit is closed permanently. Do not use ash from burnt soft waste for this purpose. Most organic waste will decompose into harmless matter, so it is normally possible to empty a pit that has been closed down for at least two years. Be aware however that bones of amputated limbs will still be intact. The population could perceive the removal of these remainders as offensive. Take also special precautions to avoid injuries with sharps that have accidentally been discarded in the organic waste pit. A new permanent burial place should be found for the organic waste remainders, potentially a controlled tip (T.B. 5.03) or a sanitary landfill.


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For very small health centres with only an occasional delivery (e.g. max. 3 per month) and no other medical interventions that generate organic waste, an organic waste pit isn’t required. The placentas can be discarded in a simple pit or V.I.P. latrine.


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The bottom of the pit should be at least 1.5 m above the highest possible water table. The latter can be estimated by verifying the water level in nearby wells. Another option is to drive a metal bar such as a reinforcing rod or (several pieces of) ½” galvanized pipe in the ground, as deep as 1.5 m beneath the maximum pit depth. When pulled out, the rod or (the earth inside) the pipe should be dry. If not, the pit depth should be adapted accordingly. Soil saturated with water after heavy rainfall might give a false impression of the actual water table level.


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Another construction method for an organic waste pit is the individual circular-shaped pit, which is often more difficult to excavate but less due to collapse because of its natural arching effect. This can be particularly interesting for emergency organic waste pits that won’t be lined. When necessary, the circular pit can be reinforced with one or more perforated concrete rings (T.B. 2.06).


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If the subsoil is very rocky, the area flood prone or the water table high, the pit may partially be constructed


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in the ground and the remaining aboveground part in a very well compacted earth mound. A different technique (T.B. 3.12) will have to be used.


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If it rains a lot in the region, the lining / base can be made higher, for the pit to be less at risk of flooding.


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The calculated pit volume should include a free space above the waste of at least 0.50 m high. It isn’t part of the effective pit volume, but will allow the pit to be closed properly once it’s nearly full.


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In the very early stages of an emergency, layers of compacted soil or a temporary wooden slab can do to cover the organic waste, but must be replaced as soon as possible with a slab of more durable material (e.g. concrete). To be able to empty an organic waste pit safely, its slab should be completely removable, hence having a reasonable weight. It is therefore strongly recommended to use an adapted version of the standard size concrete VIP slab (adapted from T.B. 3.08).


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For a large pit with several slabs side-by-side, each one should have its own covered 0.3 m x 0.4 m drop hole, allowing an equal organic waste repartition over the pit. However, one ventilation pipe can be sufficient for the whole pit. All of the slabs have to be sealed to each other with mortar.


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The small plastic pipe in the ventilation hole should be flush to the bottom of the slab in order to avoid too many (burnable) gasses accumulating in the pit. To ensure a better anchorage, a clamp can be connected to the small pipe at the level where it will be mortared in the slab. To ensure a better evacuation of the gasses, the slab can be slightly tilted upwards towards the ventilation pipe.


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Only discard organic waste in the pit. Don’t throw in any other kinds of waste, and certainly not sharps!Do not smoke when opening an organic waste pit because flammable gasses like methane might have accumulated underneath the slab!It is essential that the organic waste is covered immediately after disposal, to avoid bad odours and vectors (e.g. flies) being attracted to them.Adding lime to the organic waste pit can reduce drastically the smell, but might slow down the decomposition process. This might eventually result in the pit filling up faster. A better option is to introduce occasionally some wood ash, which does reduce the odours as well and might increase the decomposition rate. Besides, wood ash can often be obtained for free. However, do not use ash residues from the incinerator / volume reducer (incinerated / burnt soft waste).The slab and surroundings should be cleaned and disinfected regularly. Check frequently if the ventilation pipe isn’t blocked. Remove all material


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/ volume reducer (incinerated / burnt soft waste).The slab and surroundings should be cleaned and disinfected regularly. Check frequently if the ventilation pipe isn’t blocked. Remove all material that could obstruct the ventilation of the pit by pouring some water trough the pipe. Check also if the screen is still intact and replace when necessary.The operator (waste manager) should receive intensive training and a complete set of protective clothing, which should always be worn during operation and maintenance (T.B. 6.10).If an organic waste pit is emptied (at least two years after it has been closed down), all its slabs should be removed to permit easy access and safe working conditions. Once all the slabs are removed, wait some time before entering into the pit to evacuate all hazardous gasses.During works within a used organic waste pit, make sure that the person inside has a strong rope around his waist, which permits colleagues standing at the side of the pit to lift him out if


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gasses.During works within a used organic waste pit, make sure that the person inside has a strong rope around his waist, which permits colleagues standing at the side of the pit to lift him out if something goes wrong.


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The waste zone is a special area within the compound of the health structure where all types of medical waste can be disposed of. This zone concentrates the different treatment / final disposal facilities to avoid that the contamination is spread over a large area. It also has the advantage of providing an “ergonomic” working environment for the operator being responsible of the area (waste manager).


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Away from groundwater points and preferably downhill from them to avoid direct contamination (minimum distance from groundwater points > 30 m and > 50 m when organic waste pits are present).


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Easily accessible (even by truck for big infrastructures) to bring in waste and combustibles or to evacuate waste residues when emptying the residues or organic waste pits.


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The type of facilities that are needed within the waste zone and their capacity depend on the types and amounts of wastes that are generated. The amounts of wastes are depending on the type of the health structure itself (e.g. OPD, IPD, hospital), its activities (e.g. operating theatre, maternity, laboratory) and its size, and also on the number of patients that are “passing by” every day (e.g. an organic waste pit is often not necessary in small structures or camp situations). It is important however to foresee enough space, as new pits might have to be dug once the old ones are nearly full.


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For emergencies, a simple waste zone can be made with temporary facilities (a temporary volume reducer, an emergency sharps pit made out of a drum, temporary ash and organic pits, and a washing area). Although temporary, the lay out of the waste zone must be respected to facilitate the work of the waste manager. In case the temporary health structure is closed, it is advised to remove the emergency sharps pits and to bury them in a safe area after having been encapsulated (T.B. 6.02).


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In case the construction of the complete waste zone would take long, a temporary waste zone with acute emergency facilities should be made as a first step, even for chronic emergencies and stabilised situations. This will enable to start immediately with correct medical waste management (T.B. 1.08), certainly if the staff has already been trained in segregating the waste and the use of the waste zone facilities.


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A roof has to be foreseen for the incinerator / (temporary) volume reducer(s) and for the temporary storage area for the soft waste, to avoid that it gets wet (and thus becomes more difficult to burn). It is also recommended to construct a roof over the potential safety box reducer, although that a protective hull (made with bricks or metallic sheets) can already be sufficient.


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The residues (ash) pit and the organic waste pit come preferably in pair and can potentially be reused. It’s suggested not to put a complete concrete floor around the ash and organic waste pits, to be able to construct additional ones within the same waste zone when needed. Gravel around the pits is essential however as it will avoid that the waste zone turns into a mud pool.


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A washing area is essential for disinfecting, rinsing and cleaning the empty waste containers. Water supply, chlorine solutions and soap are essential for the washing area.


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A grease trap and infiltration system (T.B. 4.04, 4.06, 4.07 and 4.08) are necessary for the washing area.


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The waste zone and all reusable containers need to be inspected regularly and replaced when necessary.


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Only the responsible of the waste zone (waste manager) should have access to this site. In situations where the cleaning staff would do the waste collection and transport towards the waste zone, it can be interesting to leave an opening in its fence where the containers can be shifted through without having to enter the area.


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The main objective of protective clothing is to reduce the physical harm risk for the staff during their potentially dangerous activities. The protective clothing will have to be adapted according to the kind of activities performed by the staff. If the cleaners have to work with dangerous goods (e.g. highly concentrated chlorine solutions), a plastic apron, rubber gloves and goggles are essential besides the standard overall. The waste manager should have the same protective clothing as the cleaners, including a respirator, a face shield, heavy duty boots and preferably armoured gloves when he operates the incinerator. A poncho / rain coat and rubber boots come in handy during the rainy season for those staff working outside.


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Besides the protective clothing, the staff should also receive correct equipment. This equipment should not only ease the work of the staff but also render it safer. Correct equipment includes amongst others:


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Finally, the staff should be trained in using the equipment, the material (specially the use of disinfectants or other chemical products) and all the facilities correctly. Safety should be an important issue in the training package.


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In low-income countries, vector-borne diseases such as malaria, dengue, leishmaniasis and sleeping sickness are common and among the important causes of morbidity and mortality.


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refugees or displaced populations may lack immunity to a disease or a particular strain of the disease in the settlement area (e.g. malaria).


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refugees or displaced populations having fled through an area infested with certain vectors (e.g. sandflies transmitting leishmaniasis).


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refugees or displaced populations live in crowded and unsanitary conditions, that result in a sharp increase of vectors - this may be compounded by a lack of sufficient water for personal and domestic hygiene (e.g. body lice transmitting typhus).


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poor housing favours an increase in vectors exposure, and the spread of the associated communicable diseases.


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being located in an area which supports significant vector populations (e.g. mosquitoes in a swampy area).


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Health structures are generally crowded with weakened people and high densities of pathogens are met. Without general vector control measures, the risk of further infection of the patients, caretakers, and visitors increases dramatically (e.g. body lice transmitting typhus). In addition, if the prevalence of vector-borne diseases is low in the area, small scale vector control measures in health structures are particularly important since the health structure is likely to be the major source of pathogens.


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A vector carries and transmits infectious pathogens directly or indirectly from a reservoir (e.g. environment, animal, human) to another host either mechanically or through its bodily functions. Infection can occur via biting (e.g. malaria transmitting mosquitoes), via (skin) penetration (e.g. typhus transmitting lice) or the gastrointestinal tract (e.g. food contaminated by flies). It is important to distinguish between a nuisance, and a mechanical and/or biological vector spreading a communicable disease.


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It is their presence in large numbers that defines a pest population as merely a nuisance (e.g. bedbugs) instead of a vector. Control methods are generally designed to reduce the pest population or reduce the pest-human contact.


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These vectors transmit pathogens by transporting them on their feet or mouthpart (e.g. housefly). In this way pathogens are spread from contaminated material (e.g. faeces) to human foodstuffs, drinks, faces or eyes. Mechanical vectors are usually only one of several transmission routes for a particular disease. Diarrhoeal diseases, for example, as well as being transmitted mechanically by vectors are also transmitted through poor hygiene and contaminated water. Control measures for mechanical vectors are designed to reduce their population, and/or the likelihood of disease transmission (e.g. covering food to prevent vector access).


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Biological vectors may be a serious threat to health, even when their numbers are relatively low. These vectors are by nature involved in the life-cycle of the pathogen, which must pass through the vector in order to mature. The pathogens are acquired from, and are transmitted to, a human or animal host when the vector takes a blood meal (e.g. plasmodium cells via mosquitoes). Control measures are


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designed to reduce the likelihood of person-vector contact, reduce the risk of the vector population becoming infectious and reduce the survival rate of the vector (e.g. Long-lasting insecticidal Net).


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Following groups of vectors are considered of main interest in precarious situations. The biology, public health significance, methods of detection and simple control measures for these groups are described in the respective technical briefs.


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<table><tr><td>- Mosquitoes (T.B. 7.01)</td><td>- Fleas (T.B. 7.04)</td><td>- Mites (T.B. 7.07)</td></tr><tr><td>- Flies (non-biting) (T.B. 7.02)</td><td>- Lice (T.B. 7.05)</td><td>- Bedbugs (T.B. 7.08)</td></tr><tr><td>- Sand flies (T.B. 7.03) 7.2.2 Vector control</td><td>- Rodents (T.B. 7.06)</td><td>- Cockroaches (T.B. 7.09)</td></tr></table>


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- Mosquitoes (T.B. 7.01) - Fleas (T.B. 7.04) - Mites (T.B. 7.07) - Flies (non-biting) (T.B. 7.02) - Lice (T.B. 7.05) - Bedbugs (T.B. 7.08) - Sand flies (T.B. 7.03) 7.2.2 Vector control - Rodents (T.B. 7.06) - Cockroaches (T.B. 7.09)


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Control of these vectors, through personal protection, environmental and/or chemical control has a documented impact on the reservoir and/or on the transmission of important disease pathogens. Knowledge of the biology of each vector is an essential condition of effective control measures. It is useless to try to combat body lice by treating head hair, or to try to control Culex larvae by treating clean standing water. It is vital to know how, where and when to act.


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Complete eradication is generally unattainable. The objective should be to keep the vector population below a level at witch it poses a too great risk of an epidemic.


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The aim should be to make the local environment unfavourable for the development and survival of the vector.


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Appropriate vector control measures must be implemented in endemic zones and/or in epidemic-prone contexts, and/or when there is a high presence of the vector. They must always be implemented in camps and all types of health structures, from small health centres to large hospitals including disease-specific programmes (e.g. kala-azar, yellow-fever, HIV) and Therapeutic Feeding Centres. This as specified in the essential water and sanitation requirements (T.B. 1.08, 1.09).


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In prevention of epidemics where it should take place immediately following identifiable alarm signals for a specific epidemic area (e.g. migration of large number of non-immune persons into high transmission areas, abnormally heavy rain, flooding, high minimum temperature).


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In epidemic control where outbreak detection takes place in the early stages and vector control activities can be achieved sufficiently early to cut off the peak in transmission.


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In areas of known intense seasonal transmission (and associated high morbidity and mortality) where vector control activities just before the peak season can reduce transmission.


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The control of a specific vector, in an open setting outside a health structure or refugee or displaced camp requires a deeper understanding of the vector biology and of its interaction with humans and the environment, as well as expertise in specific vector control measures. These guidelines do not have the scope to deal with such issues in sufficient detail.


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Timing of the vector control activities depend on the context but the desired outcome is to achieve the required coverage before the start of the transmission and to maintain a residual effect for its duration. Timing can have significant operational implications where transmission is largely confined to one season. In areas where transmission is more or less constant throughout the year, the timing is less of an issue.


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A big factor in the effectiveness of vector control activities is a clear allocation of responsibility, at both a strategic level and at implementation level. Where the aid-agency is working in health structures that are part of local or national health infrastructures, it is especially important to define ultimate


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responsibility with a view to the future running of the vector control activities. Once an agreement of responsibilities is reached amongst all the involved counterparts, it should be formalised in writing. An important body, in terms of providing direction and feedback to any vector activities, is the hygiene / health committee which should be present in all health structures.


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Implementation of the vector control measures should be managed by a suitably experienced technician. The execution of environmental vector control measures requires relatively little technical skills once the facilities are installed, and will typically be carried out by trained health structure cleaners, caretakers or grounds men. Avoid people with the following risk conditions when selecting staff to make up a chemical vector control team: pregnancy or lactating; alcoholism; history of liver or nerve disorder; heavy smoking; allergies or skin diseases. More subjective criteria are also important: like professional integrity, meticulous work and neatness and tidiness.


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Chemical control measures involving pesticides and other toxic chemicals require expertise and should only be carried out by those who have received appropriate training on safe and effective procedures (T.B. 7.13). Even for apparently straightforward application of public health pesticides, a minimum of protective clothing is required (T.B. 7.20).


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Each person is responsible for their own personal protection against disease transmitting vectors. The personal protection strategies are simple and can potentially be implemented individually. However they need to be supported by appropriate and simultaneous promotional activities. Otherwise, it may be difficult to persuade persons to protect themselves, especially when they are not greatly bothered by bites from the vectors present.


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As with all interventions, the project cycle of assessment, strategy planning, implementation, monitoring and evaluation should be followed when setting up a vector control intervention. The below comments highlight some specific key considerations related to the planning and organisation of vector control activities.


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Assessment should be based on the essential requirements, checklists and the accompanying guidelines on appropriate usage of vector control tools (T.B. 1.06, 1.08, 1.09).


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The vector control activities should be guided by national legislation and clear objectives that address the vector-related priority problems identified in the assessment and analysis. Common objectives of vector-control activities include: preventing or controlling outbreaks, stopping preventable deaths from vector-borne disease, minimising illness from vector-borne diseases or protecting the population subgroups with reduced immunity.


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The objectives of the vector control activities can only be achieved with appropriate vector control measures addressing the context specific epidemiological situation and risk factors. Vector control may have no impact if it targets the wrong vector, uses inappropriate or ineffective methods, or targets the right vector at the wrong place and/or at the wrong time. The selected vector control measures should be appropriate for controlling the specific vector species, given its breeding, flight range and resting behaviour. Also, the measures should be simple to understand and apply. Where vector-borne diseases become a problem, using chemicals should always be regarded in combination with environmental sanitation and promotional activities.


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When considering the use of chemical control measures it should be remembered that although public health pesticides are relatively safe, they can be toxic and dangerous to both living creatures and the environment if not used properly (T.B. 7.10, 7.11, 7.12 and 7.13). All vector control activities should be based on the national and international protocols. Certain vectors rapidly develop resistance to particular pesticides and


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the choice of pesticide should take this into account. The decision to carry out a chemical control program and the choice of the pesticide should always be made in consultation with your technical referent.


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Staff training is very important in vector control interventions, particularly where chemical control measures are being used. Inappropriate usage and disposal of pesticides is the most common problem and has detrimental effects on people and the environment. Comprehensive training should be given to all staff on safe and correct usage of chemical control measures. All employees, patients of the health structure, as well as the whole camp population should be given information on both personal protection methods as well as their role in the general vector control activities.


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Monitoring will ensure a vector-borne disease outbreak is detected early and will prevent any waste of resources on inappropriate control measures. Evaluation will measure the effectiveness and impact of the activities. Vector control requires close management of personnel to insure that work is carried out in accordance to pre-defined standards and strategies. Consistency of effort is very important in vector control (e.g. small lapses in sanitation activities like open disposal of food waste can result in a rodent or fly invasion within days). Therefore, the performance of staff involved in on-going sanitation / vector control activities should be continuously monitored and regularly evaluated. The details of intermittent vector control activities, such as insecticide residual spraying or impregnation of bednets, should be recorded in a specific logbook. Such records are essential to inform upon the appropriateness of future activities e.g. the timing to repeat insecticide residual


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or impregnation of bednets, should be recorded in a specific logbook. Such records are essential to inform upon the appropriateness of future activities e.g. the timing to repeat insecticide residual spraying. Recorded information should include: why, what, where, when, who and how the particular activity was carried out. As well as monitoring the vector control activities themselves, attention should be paid to environmental factors external to the health structure or camp, which may affect the prevalence of vectors, and their associated diseases in the area. For instance, seasonal changes in climate, or a substantial influx of new beneficiaries may result in increased disease transmission by vectors.


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It is essential for the vector control planners to work closely with the health care staff and those responsible for epidemiological assessment and monitoring.


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It is important that clear case definitions are adopted and whenever possible laboratory confirmation of the initial suspected cases is sought. In addition to the routine health information system, there must be a standard procedure for immediately reporting vector-borne diseases with epidemic potential indicating the location of suspected cases. From the very onset, a map of the area should have been sketched showing where population clusters, suspected cases, and potential vector breeding sites are located. Because each vector species has a characteristic breeding and biting habit , they should be monitored using different vector-specific methods and indicators (T.B. 7.01 until 7.09).


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Evaluation can be based on direct observation (e.g. proper use of LN, state of pit latrines, food preparations and refuse collection sites). It can also be more formal by re-assessing against the initial assessment and essential water and sanitation requirements (T.B. 1.06, 1.08, 1.09).


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Different vector control strategies are presented here. Generally the most effective control of any vector will utilise a range of different activities which intervene in various aspects of the reservoir and transmission routes.


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It is important to select a site that does not expose the patient, refugee or displaced population to excess risk for vector-borne diseases. Sometimes the choice of a site is limited by politics, security or other factors (T.B. 1.10).


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Environmental control methods include avoiding the creation of breeding sites like pools of standing


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water inside and outside (e.g. open water reservoirs, flower pots, bottles, old tyres, stagnant water and blocked drains) and removal of existing breeding sites (by filling or draining them). However, good local knowledge and entomological expertise are required to target the most productive breeding sites in the surrounding and to avoid wasting time and recourses on unimportant breeding sites.


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Basic sanitary engineering measures should be taken whenever possible to reduce the opportunities of insect vectors breeding. Latrine design should minimize the access of vectors to reduce the opportunity for them to breed; e.g. use of lids, VIP latrines or water seal designs (Chapter 3).


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Waste collection and disposal points should be sealed from the environment (e.g. garbage bins with lids, waste pits with a lid, or covered daily with ashes / soil in acute emergencies) (Chapters 5 and 6).


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Building design should minimize mechanically the access of vectors into the structure; e.g. insect screens, sealing of openings under doors, rodent baffles on drainpipes.


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Mowing or even burning of vegetation (control the risk of fire) in the vicinity of camp sites and buildings can be recommended to control mites and ticks. Piles of decaying grass clipping, compost heaps and other accumulations of rotting vegetable matter serve as good breeding places for flies. Nevertheless, there is no evidence that the widely advocated practice of cutting down grass and bush around houses in general reduces malaria transmission. Clearing of vegetation may however be effective in removing resting places for adult mosquitoes, promote the evaporation and drying up of small accumulations of water and make breeding sites more visible for control purposes.


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Personal protection methods may offer significant safety using simple, small and portable equipment against infection and vector nuisance. Methods include:


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Regular and complete personal hygiene (e.g. hand and face washing, washing of body and clothes with soap, food covers) will reduce the chance of disease transmission by flies or lice. Sufficient water is necessary for personal and domestic hygiene. This also requires the availability of sanitary facilities and the promotion of personal hygiene within the project team, health structures and/or camp population.


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Clothing can be an effective physical barrier against several biting insects and can therefore reduce the risk of disease transmission. Effectiveness of protection will increase with the thickness of the material and the amount of skin covered. The impregnation of clothes with a repellent offers better protection and typically lasts for a few days. The impregnation of clothes with an appropriate insecticide is also an option and typically lasts for about 5 washes.


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Repellents can be either natural or chemical products to be used as protection against insects. They can be applied on the skin or clothes. Natural products are often country specific. Chemical products such as DEET® (NN diethyl 3 methylbenzamide) are usually more effective and longer lasting than natural products. They occur in a range of applications such as lotions, sprays and creams. Applied on the skin they usually offer protection for between 6 and 8 hours, limited by the sweating of the person. They do not offer the required protection for a person asleep throughout the night. Cutaneous use of DEET® does not provoke undesirable reactions with adults. Repetitive cutaneous use of DEET® is not recommended for pregnant women and young children (below 30 months). For them, it is more appropriate to use the repellent on their clothing instead.


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Coils can be used as a quick and easy way to neutralise insects in rooms or enclosed areas where no electricity is available. Burning coils vaporise an insecticide into the air and this has, where ventilation is limited, a knockdown effect on mosquitoes. Public health pesticides present in coils are formulated at a relative low dosage.


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The quality of coils can vary greatly and some are completely ineffective. In some countries, coils are formulated with organochloride compounds which give rise to serious health concerns. Still the most commonly used active ingredient belongs to the group of quick knock-down pyrethroid. In confined area’s such as a closed tent or a non-ventilated room, the smoke may cause irritation to the eyes and lungs. Depending on the active ingredient, burning coils may also have a repellent effect on mosquitoes in open veranda’s. If the coils are used outdoors it is important that they are upwind of the people to be protected.


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The whole period of burning normally lasts between 6 and 8 hours and one coil can be used for a room of approximately 35 m³. The coils should be lit just before the mosquitoes become active. To increase efficiency, convenience and safety, coils should be burnt in special holders.


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Electric vaporizer systems are products requiring an electrical heating device to evaporate an insecticide from a base, which may be composed of any suitable material and which is referred to as “refill”. The heater and refill are a unit and must be used together. These systems have been designed mainly for the control of mosquitoes and work only with a reliable electric power supply. The heating devices should provide a sufficient duration of operation and should not be affected by tropical climates, such as heat combined with high relative humidity. The active ingredients used in these systems belong to the natural pyrethrins and quick knock-down pyrethroids.


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Aerosol sprays can be used when a room or closed area needs to be cleared of flying or crawling insects. Flying Insect Killer aerosols (FIK) use a short lasting insecticide easily dispersed in space. The active ingredients in FIK are usually from the pyrethroid family. In FIK, a combination of a killing agent and a knockdown agent is very common. The knockdown effect of the aerosols will eliminate most flying insects within 15 minutes. Their residual effect is very limited which means that a cleared room can be reinvaded by insects about 20 minutes after treatment. It also means that there is little risk of toxic residues in the treated area. After spraying, the room must be left immediately and stay close for about 20 minutes. The windows must be opened to ventilate after re-entry.


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Crawling Insect Killer (CIK) aerosols however exhibit excellent residual effect due to their adherence to surfaces. Those designed to be applied directly onto insects such as cockroaches, silverfish, bugs and ants have also very good knockdown effect. If applied as surface spray, the residual effect may last several weeks (4 to 8 or even up to 12 weeks) depending on the physical properties of the surface, the active ingredient applied and its formulation. Most aerosols contain flammable substances and they should not be directed on fires or smouldering objects (do not smoke, disconnect electric equipment while spraying), and be protected from direct sunlight and temperatures exceeding 50 °C. Follow carefully the application instructions and safety measures indicated on the spray cans. Empty pressurized spray cans should be disposed of in an enclosed sharp pit (if few in number, T.B. 6.02) or by encapsulation if more numerous.


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Insecticide-treated nets are one of the major ways to control malaria and they are accepted worldwide by communities affected by malaria. Their correct utilisation reduces the survival chance of the vector and interrupts malaria transmission.


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Apart from their killing effect, nets will also avoid mosquito feeding, hence reducing the reproductive potential of vectors that feed on human blood. Insecticide treated nets have the same disabling effect on


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other biting insect vectors like lice, fleas and sandflies. They also protect against spiders and cockroaches. Within a health structure they prevent the spread of vector borne diseases, by isolating patients and limiting thus further transmission of the pathogen; this is especially important in the context of malaria, yellow fever, dengue and leishmaniasis.


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Traditional insecticide-treated nets require re-impregnation (T.B. 7.17) every six to twelve months which is difficult to implement. The best results can be obtained with Long-lasting insecticidal Nets (LN), which retain their insecticidal properties for two to six years, the life span of the net, thus making re-treatment unnecessary (T.B. 7.16). These LN would be expected to retain chemical activity for at least 20 standard washes as defined by WHO. The use of LN is strongly recommended over the use of nets that require re-impregnation.


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A requirement for successful use of insecticide-treated nets is that the malaria transmitting vector feeds at a time and place when people are using the LN. LN’s will only have an impact on malaria transmission if they are properly used and maintained, hence the importance of appropriate and simultaneous promotional activities. The use and acceptance of LN depend on a range of social and cultural factors that should be identified and taken into consideration prior to distribution. The identification of these social and cultural factors is less relevant when implementing LN in a health structure but occasional evaluation of their actual use by sleeping patients is recommendable.


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Blankets and shelter material are often distributed as part of the emergency response and these materials may constitute the only surfaces suitable or readily available for insecticide treatment. In areas where mosquitoes bite early in the evening, before patients go to sleep under nets, use of insecticide-treated curtains over openings such as windows, doors and eave gaps may provide protection.


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IRS is widely used for vector control, especially against mosquitoes, triatomine bugs (vector of Chagas disease) and sandflies. Its objective is to ensure the safe and correct application of a residual insecticide dose to surfaces on which vectors may rest, usually ceilings, inside surfaces of tents and walls and the lower surfaces of large furniture. It is an effective manner of interrupting malaria transmission through killing adult female mosquitoes after feeding but before they can transmit the infection to another person. As such, it is not useful for the control of mosquitoes which tend to rest outdoors. However, it may be effective against outdoor biting vectors which enter houses for resting after feeding.


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IRS is only effective if adequate coverage is achieved and if the insecticide is correctly applied. The selection of the insecticide has to take into account the susceptibility of local vectors and duration of the residual effect in relation with the length of the transmission season. Prior to implement IRS, verify these issues with your technical referent.


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Insecticide zoo-prophylaxis could be used in settings where vectors bite domestic animals as well as humans. Rather than being applied to houses, the insecticide is applied to the hair and skin of domestic livestock, such as cattle, goats and sheep, using a sponge or animal dip. A specific dose can also be applied between the shoulder blades from where it spreads over the skin. Trials of this method have shown its effect on malaria and tryponosomiasis transmission reduction.


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An insecticidal dust consists of talcum powder, or another inert carrier powder, mixed with insecticides. In health structures, insecticidal dusting can be applied on rodent footpaths and habitats. When the rats groom themselves, the dust spreads on their fur, thus killing their fleas.


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Prior to dusting people against lice, verify with your technical referent the insecticide to be used.


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An important method to reduce rats and mice related health risks is poisoning them with rodenticides. Complete eradication remains very difficult as only a limited area can be targeted with rodenticides. The control campaign should be accompanied by promotional activities on proper household hygiene behaviour. Use chronic or slow acting poison instead of acute poison to limit the risk of accidental poisoning of humans and non-targeted animals.


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Larval control is most practicable where the vector breeding sites are limited in number and relatively permanent in time. It requires the ability to locate and map out a very large proportion of the breeding sites within vector flight range of the community which it is required to protect. It is complex, requires expertise, but can significantly affect vector densities. In areas where it is an acceptable option, larval control must be carried out thoroughly to have an impact.


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The most commonly used larvicide is the temephos®, an organophosphate which is effective and safe in drinking and bathing water. It is to be applied at very low concentrations. Some living organisms, such as bacteria (e.g. Bacillus Thuringiensis israeli) can also be used against vector larvae as they contain toxins against larvae.


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A space spray is a liquid insecticide, dispersed into the air in the form of millions of tiny droplets. It remains only effective while the droplets remain airborne. The aim of space spraying is usually to rapidly reduce populations of flying insects to reduce or interrupt temporarily the transmission cycle of insect borne diseases. Mosquitoes, houseflies, and other biting flies may be targeted by space spraying. Nevertheless space spraying is complex, require expertise and only have a temporary effect with little or no residual effect. As such space treatments must be considered in conjunction with other control methods where possible.


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Malaria is a most important vector-borne disease worldwide in terms of morbidity and mortality. It is considered to be one of the five top causes of child mortality in the acute phase of a majority of refugee emergencies. All malaria is transmitted by the Anopheles mosquitoes.


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Feeding time and location: most Anopheles feed at night but each species feeds at a particular time of night. Some mosquitoes prefer to feed inside houses and others outside. In Africa, it can be assumed (until proved otherwise) that malaria vectors bite at night and rest indoors. Control measures can thus be taken accordingly.


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Host preference: some mosquito species prefer to feed on humans and others on animals; several species feed partly on humans and partly on animals. Species that have a strong preference for feeding on humans tend to be the most dangerous vectors because they are the most likely to transmit malaria pathogens.


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Resting location: after feeding, a female mosquito needs somewhere to rest while digesting the blood meal and developing its eggs. Some species rest inside, while others go and find places outdoors. IRS is not useful for the control of mosquitoes which tend to rest outdoors. However, it may be effective against outdoor biting mosquitoes which enter houses for resting after feeding.


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Choice of egg laying site: Anopheles mosquitoes have different preferences for breeding sites or larval habitats, and lay their eggs in a wide variety of water bodies. Individual species tend to choose a narrow range of egg laying sites.


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Flight range: most Anopheles mosquitoes do not fly more than 3 km from where they begin their lives. Malaria risk can be reduced by installing health structures or refugee or displaced camps further than 3 km from breeding sites.


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Malaria control strategies that kill and reduce the density of the vector (e.g. larviciding, space spraying) or that reduce the intensity of the contact between vector and person (e.g. non-impregnated nets, screening houses, repellents, protective clothing) have a lower impact than strategies reducing the survival chance of the vector (e.g. IRS, LN, zoo-prophylaxis).


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Adequate coverage of human habitations with IRS and LN reduces the survival chance of mosquitoes that enter dwellings to seek a blood meal and shortens their average lifespan. This reduces the proportion of mosquitoes living long enough for the malaria cycle to be completed and thus becoming infective. A decreased proportion of old malaria infective mosquitoes in the total female mosquito population considerably reduces malaria transmission.


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As such, and where possible, the malaria control methods of choice are IRS within the inside surface of houses or tents (T.B. 7.14, 7.15) and LN distribution (T.B. 7.17). Both are about equally effective against mosquito species that bite at night and rest indoors like it is the case, unless proven otherwise, in Africa for malaria vectors (Anopheles).


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The final choice to implement IRS, and/or a distribution of LN can only be made after studying both options in detail in the given context. There is no “standard” best approach for a given situation as the final decision to implement either IRS and/or distribute LN will depend on many factors, and advantages and disadvantages will have to be weighed to each other (see hereunder).


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<table><tr><td>IRS</td><td>IRS</td><td>LN</td><td>LN</td></tr><tr><td>Advantage</td><td>Disadvantage</td><td>Advantage</td><td>Disadvantage</td></tr><tr><td>Can not be looted, stolen or sold</td><td>Can not be moved if the population is displaced</td><td>Can be transported by beneficiaries if they have to move.</td><td>Can be looted, stolen or sold</td></tr><tr><td>Protect the whole family and does not require any significant behaviour change.</td><td/><td/><td>-Might be improperly or not used at all -Space in the shelter might be insufficient to put up enough nets to protect the whole family</td></tr><tr><td>A high coverage is easy to obtain in a short time frame.</td><td>To be effective, more than 80% of the shelters need to be sprayed so it cannot be targeted specifically to vulnerable groups.</td><td>The personal protection provided allows deployment in a progressive way, starting with low population coverage. Distribution can also be targeted to vulnerable groups</td><td>-A high coverage is difficult to obtain. -Low retention rates in camps where families choose to sell the net to increase family food intake.</td></tr><tr><td/><td>Will only remain effective for 3-6 months, so it needs to be repeated</td><td>Can remain effective for 3 to 5 years</td><td/></tr><tr><td>Often quick to implement, especially in camp settings and emergencies.</td><td/><td/><td>Net distribution can be complex to organise. It will require community participation and promotional activities.</td></tr><tr><td>In areas where malaria transmission is confined (largely) to one season, one IRS is needed per year</td><td>In areas where malaria transmission is constant, IRS needs to be repeated every three to six months.</td><td>Only one distribution each 3-5 years</td><td/></tr><tr><td>Low start-up cost</td><td/><td/><td>Higher start-up cost but long impact (3-5 years)</td></tr></table>


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IRS LN Advantage Disadvantage Advantage Disadvantage Can not be looted, stolen or sold Can not be moved if the population is displaced Can be transported by beneficiaries if they have to move. Can be looted, stolen or sold Protect the whole family and does not require any significant behaviour change. -Might be improperly or not used at all -Space in the shelter might be insufficient to put up enough nets to protect the whole family A high coverage is easy to obtain in a short time frame. To be effective, more than 80% of the shelters need to be sprayed so it cannot be targeted specifically to vulnerable groups. The personal protection provided allows deployment in a progressive way, starting with low population coverage. Distribution can also be targeted to vulnerable groups -A high coverage is difficult to obtain. -Low retention rates in camps where families choose to sell the net to increase family food intake. Will only remain effective for 3-6 months, so it needs to be repeated


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is difficult to obtain. -Low retention rates in camps where families choose to sell the net to increase family food intake. Will only remain effective for 3-6 months, so it needs to be repeated Can remain effective for 3 to 5 years Often quick to implement, especially in camp settings and emergencies. Net distribution can be complex to organise. It will require community participation and promotional activities. In areas where malaria transmission is confined (largely) to one season, one IRS is needed per year In areas where malaria transmission is constant, IRS needs to be repeated every three to six months. Only  one  distribution each 3-5 years Low start-up cost Higher start-up cost but long impact (3-5 years)


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In acute emergencies, IRS is often used initially, especially when LN are not readily available on the ground. It is quick to deliver and high coverage is easy to obtain at relatively low cost. When IRS needs to be continued for many years, there may be an attrition of people’s acceptance to spraying. In contrast, LN’s are more suitable for progressive introduction and incorporation into population habits.


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Mosquitoes have four distinct stages in their life cycle: egg, larva, pupa and adult. The first three phases are aquatic. Under good conditions, the entire period from egg to adult takes about 7-13 days. Males only feed on flowers nectar. The females usually mate only once but produce eggs throughout their life. Each blood-meal is often followed by laying eggs. Their adult lifespan varies from one to several weeks. Depending on the species, female mosquitoes are able to lay between 30 to 300 eggs at a time. For their blood-meal, the female mosquitoes are attracted by odour (e.g. smelly feet), carbon dioxide and body heat.


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Most Anopheles mosquitoes breed in non-polluted water sources e.g. pools, quiet places in slow-running streams, rice fields, leaf axils of certain plants and puddles of rain water. Eggs are laid individually and float on the water’s surface. Only older females (2 weeks or more) can transmit malaria. They usually fly, noiseless, up to 3 km from their breeding site but have been found to be carried by the wind up to 30 km from their breeding site.


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Aedes (aegypti) mosquitoes mainly breed in relatively clean water in the domestic environment; e.g. small water storage tanks inside / outside houses, roof gutters, leaf axils, bamboo stumps and temporary containers (e.g. used car tyres, tin cans). Single eggs are laid close to the water surface.


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Culex mosquitoes prefer breeding in water polluted with organic material like refuse, excreta or rotting plants (e.g. in soak away pits, pit latrines, septic tanks, blocked drains, canals). Eggs are laid in rafts of over 100 and float on the water’s surface.


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In Africa, it can be assumed until proven otherwise that malaria transmitting Anopheles species bite essentially at night and rest indoors; control measures can be taken accordingly. They are often found resting inside houses in dark corners of rooms / latrines / showers. Anopheles are most easily monitored in their adult form through the following methods: morning indoor collection of mosquitoes resting on the wall using a simple tube; morning indoor pyrethrum spraying (e.g. with aerosol spray) and collection of dead mosquitoes on white sheets spread on the ground (also under the beds and furniture); night time capture on human bait or alternatively with battery powered light trap collections.


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Aedes species bite mainly outdoors, in the morning and early evening during cocktail hour (dusk). Aedes are also better monitored through larval surveys of domestic water containers. For example, in larval surveys for yellow fever and dengue control, the results are expressed in terms of standard indices of Aedes aegypti (e.g. Breteau Index) to predict the chances of disease transmission in a population.


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The most common Culex species bite during the night, indoors and outdoors. Culex are better monitored (and controlled) through larval surveys of drains loaded with organic material and pit latrines because they often produce enormous numbers of eggs that can easily be detected.


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Mosquitoes control activities should systematically be integrated, as per essential requirements (T.B. 1.08, 1.09), in endemic zones or during outbreaks of malaria, yellow fever, dengue, lymphatic filariasis and/or when there is a high presence of the vector. Personal protection methods may additionally offer significant protection against infection and mosquito nuisance.


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Contact your technical referent to obtain information about mosquito behaviour as several aspects of it are relevant when determining a vector control strategy (section 7.2.2).


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Strategies aiming to reduce the survival chances of Anopheles like the use of Long lasting insecticidal Nets (T.B. 7.16) or Insecticide Residual Spraying (T.B. 7.14, 7.15) are the most successful for reducing malaria transmission (more detailed control measures are presented in section 7.2.3).


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Aedes is often associated with human dwellings where its breeding site can be any open container of water. Control measures aim at getting rid of these types of sites, or at protecting them (e.g. a cover, mosquito netting). Large containers of water should be frequently, at least once a week, emptied.


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Control measures of Culex aim to eliminate bodies of stagnant water loaded with organic matter (e.g. latrines), or if not, then to eliminate surface vegetation in stagnant water and verify that these water bodies are at least 1.2 m deep.


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The life cycle of the fly consists of four stages: egg, maggot (larva), pupa and adult. A single female housefly can lay up to 2000 eggs a month. Eggs are deposited in various habitats, especially in garbage and human and animal wastes. Depending on the temperature, it takes from one to six weeks for the egg to develop into an adult. Adult flies have a life span of three weeks to three months, depending on the climate and the species of concern. Flies feed on all kinds of waste, sweat and excreta (human or animal).


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The housefly breeds in organic domestic waste in urban areas and tends to breed in animal excrement in rural areas. Contrary to popular belief, houseflies do not lay their eggs in latrines.


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The face fly breeds predominantly on human faeces on the soil surface, but not in covered pit latrines. They are known to feed on the secretion produced by eyes of people, especially children, and hence they are an agent in the transmission of the eye disease trachoma.


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The blowfly has a strong preference for breeding in pit latrines, decomposing meat, garbage and animal excrement. Simple pit latrines in refugee camps often provide an ideal breeding site. Blow flies rarely enter houses, but are very active in market places. They are easily recognized by their shiny green colour.


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The non-biting flies of health importance usually hover around food, carrion, garbage, and human and animal waste. When they land, they may either transfer or carry pathogens that attach on their legs and other parts of their bodies. These pathogens may then be mechanically transferred to humans and/or animals. Even though they can also be transmitted via fly faeces, pathogens do not undergo biological transformation in the flies. Pathogens that are carried by flies are known to be responsible for enteric infections (e.g. dysentery, diarrhoea, typhoid and certain helminth infections), eye infections (e.g. trachoma, epidemic conjunctivitis), poliomyelitis and some skin infections (e.g. leprosy, mycoses).


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Flies are usually not associated with cholera. A larger infectious dose of cholera bacteria is required for direct cholera transmission than the body surface of the fly allows to carry. However, once a small number of cholera bacteria is deposed on non-covered food it can incubate and multiply until the infective dose it reached.


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It is more difficult to monitor non-biting fly populations than mosquito populations. Rather than counting the number of flies collected over time per sticky trap, monitoring of fly populations is best carried out as part of larval control and sanitation inspections, especially around feeding centres, hospitals, latrines, and refuse disposal sites.


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Fly control activities should systematically be integrated, as per essential requirements (T.B. 1.08, 1.09), in endemic zones or during outbreaks of enteric and eye infections, and/or when there is a high presence of the vector.


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Larval sites (the places where eggs are laid and where the larvae develop) are very often a product of human activity. The basic principle of all control measures should be to reduce or remove these sites, or to prevent access to it by flies. Without these environmental hygiene measures, all control efforts are in vain.


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Personal protection methods (e.g. Long-lasting insecticidal Nets (LN), T.B. 7.16) may offer significant protection against infection and fly nuisance.


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Flies should preferably be controlled by improving environmental sanitation and hygienic conditions:


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Reduce or eliminate fly breeding sites (e.g. dead animals and waste from slaughter houses should correctly be disposed of as soon as possible).


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Reduce sources that attract flies from other areas (e.g. limit open defecation, cleaning of animal excreta in cattle raising area’s, make smooth floors in feeding centres (smoothed cement or plastic sheeting) to enable cleaning of spilled food).


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Prevent contact between flies and disease causing germs (e.g. isolate patients under LN, make covered refuse containers available in laboratories and health centres).


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Ensure good removal and disposal of wastewater, particularly at washing area’s for clothes and cooking utensils.


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Add ashes to latrine pits after each defecation, or at least every morning and night, to reduce the contact between flies and excreta.


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Recourse to chemical intervention should be avoided as much as possible, because of the rapidity of appearance of resistant strains which render this option costly and ineffective.


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In the case of massive infestation or when the presence of flies creates a concrete risk of increased spread of pathogen, or when an operating theatre or treatment room must be protected, the use of larvicides and adulticides should be considered, but always in tandem with environmental measures.


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An option to destruct larvae is the use of larvicides on larval sites (e.g. in case of massive infestation by larvae of a defecation trench or latrine). To destruct adults, treatment with a residual effect should


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be done on the surfaces where flies land and rest at night. These places may differ according to the species and the climate. In general, they are external surfaces of buildings (in hot countries), trees, fences, dustbins, animal shelters. Spraying of the interior walls of the latrines is also an interesting option.


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In certain places (e.g. operating theatre, dispensary, kitchen), strips of gauze or cotton impregnated with insecticide (T.B. 7.17) may be used. Use 1 m length of impregnated strip per m² of ground surface area to be protected and renew the impregnation every 2 months. This in addition to the recommended Insecticide Residual Spraying (T.B. 7.15).


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The life cycle of the sandfly consists of four stages, namely egg, larva, pupa and adult. The total life cycle, from egg to adult, last from 1 to 4 months depending on the species and temperature. Females deposit 40 to 60 elongated and shiny brown eggs after a blood meal. The sandflies deposit their eggs in humid places on damp soil rich in humus, like ventilation shafts of termite hills, cracks in mud walls, and amongst tree roots. The larvae feed on decaying organic matter. Large populations of sandflies can build up at places where cattle are kept at night. The cattle provide a source of blood while the stable or house provide suitable resting places. Only the female sandfly bites and it needs several blood meals prior to laying eggs. Blood is taken from humans and animals such as dogs, livestock, snakes, rodents and birds. Sandflies become infected with leishmaniasis by ingesting blood from an infected reservoir host (e.g. domestic animals, infected people). Sandflies are able to


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livestock, snakes, rodents and birds. Sandflies become infected with leishmaniasis by ingesting blood from an infected reservoir host (e.g. domestic animals, infected people). Sandflies are able to survive in dry environments by withdrawing to cool humid resting sites during the day and become active at night.


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Sandflies can transmit two types of leishmaniasis: cutaneous and visceral. Visesceral leishmaniasis is highly fatal. Leishmaniasis is endemic in about 90 countries in 4 continents. The saliva of sandflies can enhance the virulence of inoculated Leishmania parasites. Species present in the Mediterranean region can transmit sandfly fever, a viral disease also known as Pappataci fever or three day fever.


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The sandflies can often only be found close to breeding places. The sandflies can only cover a radius of a few hundred meters of their breeding places as they are weak fliers. As a result, biting is restricted to areas where suitable breeding sites occur. The adult sandflies are usually active at dusk and dawn and during the night, although they can bite during the day when disturbed. They usually rest in the daytime in sheltered, dark humid sites, such as those used for breeding, but also in tree holes, caves, houses and stables; other resting places near houses are crevices in walls, stacks of firewood and rubbish.


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Sandfly control activities should be systematically integrated, as per essential requirements (T.B. 1.08, 1.09), in endemic zones or during outbreaks of leishmaniasis and/or when there is a high presence of the vector.


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Personal protection methods may additionally offer significant protection against infection and sandfly nuisance. As sandflies are still very sensitive for public health pesticides the use of impregnated mosquito nets is highly recommended. Vector control measures like Insecticide Residual Spraying (T.B. 7.15) can be effective where transmission occurs in and around the home. Where transmission occurs in the wild, people can use repellents or impregnated clothing or simply keep away from areas where sandflies are known to breed or rest. Zoo-prophylaxis (e.g. pyrethroid impregnated collars) may be a ways to control transmission from the animal reservoirs (like dogs or other domestic animals). Spraying insecticide at larval stage is usually not possible as little is known about where the larvae are.


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The life cycle of fleas consists of four different stages: egg, larva, cocoon and adult. Their developmental stages all occur on land. Under optimal conditions the development from egg to adult takes 2 - 3 weeks. Both female and male fleas take blood meals. Fleas breed close to the resting and sleeping places of the host (e.g. in dust, dirt, rubbish, floor and wall cracks, carpets). Fleas may survive in their cocoon for up to a year. The vibrations of people moving into a vacant building can cause many fleas to emerge simultaneously from the cocoons, all looking for blood meals. Fleas move around by jumping; some species can jump as high as 0.25 m. Adult fleas can survive for several months without food.


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The larvae of jigger fleas develop in dusty or sandy soil. Jigger fleas maintain themselves in a domestic environment by breeding on livestock and domestic animals.


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Rat flea bites can cause irritation, serious discomfort and loss of blood. Human contamination may take place through a rat flea bite (plague) or through rat flea excreta (typhus). As such, dust containing rat flea excreta may be highly contaminating, if not neutralized by a chlorine solution. The human flea is in spite of its name less important. Cat fleas incidentally transmit tapeworms. Jigger fleas are a serious pest in tropical Africa. The female jigger flea burrows into the soft skin of the foot and ankle in order to lay her eggs, which can cause secondary infections.


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Heavy infestations of fleas are recognized by marks of undigested blood on clothing and bedding and/or by massive skin irritation. A scratching cat or dog is an indication of a flea infestation.


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Flea control activities should be systematically integrated, as per essential requirements (T.B. 1.08, 1.09), in endemic zones or during outbreaks of plague, Typhus and/or when there is a high presence of the vector.


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Personal protection methods may offer significant protection against infection and fleas nuisance. An effective repellent, such as DEET®, applied to skin and clothing prevents fleas for a few hours from attacking. Longer lasting protection is obtained by dusting clothing with insecticide powder (T.B. 7.18) or by using impregnated clothing. Wearing shoes prevents jigger flea bites.


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Fleas and their eggs, larvae and cocoons can be effectively removed by keeping houses well swept and floors washed. Due to their close relationships with rodents, long-term control of fleas is best achieved by household hygiene, elimination of food sources and through rodent control (T.B. 7.19).


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Lice are small (3 - 4 mm) bloodsucking insects that live on the skin of mammals and birds. The species that have adapted themselves to humans are the head louse, the body louse and the crab or pubic louse.


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The aforementioned species live only on humans and have a life cycle that constitutes three different stages: egg, nymph and adult. Development from egg to adult takes about two weeks and occurs only in a warm environment, close to human skin. Body lice lay eggs on clothes. Eggs or “nits” of head and pubic lice are attached to hairs. They cannot be separated for long from their human host, their sole source of blood meals, and will starve to death after two or three days of separation. The lifespan of human lice is up to 30 days under optimum conditions.


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Neither head lice nor pubic (crab) lice are vectors of disease, but they are a nuisance. Only the body louse is a vector of human diseases. It transmits Typhus fever, Trench fever and Relapsing fever. Transmission of Typhus fever and Trench fever is through louse faeces. The fine, dry faeces can infect (scratch) wounds or the mucous membranes of the nose and mouth. Humans may become infected of Relapsing fever by crushing infected body lice between the fingernails or the teeth. The disease organisms are thus released and can enter the body through abrasions, wounds or through the mucous membranes of the mouth. Bites of body lice can cause skin irritation leading to various skin infections. Lice infestations, of all species, can cause severe irritation and itching.


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All lice are spread by close human contact. Body lice live in the clothing of the host and are transmitted either by direct or indirect contact (sharing of bedding, combs, clothing, towels or by sitting on infested seats). The prevalence of body lice is closely related to the socio-economic, hygienic and environmental sanitation status of any given population. Body lice are most common in colder areas where people do not frequently wash or change clothes. Human-to-human transmission of head and pubic lice is most commonly by direct contact. Head lice are generally found on children in all levels of society. The pubic louse is probably also very common but little information is available on the frequency of its infestation other than they are transmitted (not exclusively) through sexual contact and often associated with other sexually-borne diseases.


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Lice are spread by close human contact and are, therefore, most commonly found on people living in overcrowded, unhygienic conditions, as in poorly maintained hospitals, jails and camps. They are also spread by direct contact between people in overcrowded transport vehicles and markets. Body lice and nits are most commonly found in clothes, mainly on undergarments, socks or clothing close to skin. They leave the clothing only to go to feed and when the blood meal is completed, they return to the fibres of the clothes where eggs are laid in the seams. Scratch marks (often with secondary infection) on the upper back, around the belt line and in the armpits may be seen. Head lice are most often found on children, primarily on the hair of the head, though they can sometimes be found in the eyebrows: presence of alive lice and/or living nits (eggs) attached to the base of the hair (particularly at the back of the neck and near the ears) and itchy scalp. Scratch marks, eczema and secondary


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presence of alive lice and/or living nits (eggs) attached to the base of the hair (particularly at the back of the neck and near the ears) and itchy scalp. Scratch marks, eczema and secondary infections may be seen. The influence of length of hair and frequency of infestation appears to be unresolved. The pubic or “crab” louse lives mainly in the pubic or genital region of the human body although it is frequently found on the eyelashes and other hairy area’s (armpits, abdomen, tights) in cases of heavy infestation.


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Lice control activities should be systematically integrated, as per essential requirements (T.B. 1.08, 1.09), in endemic zones or during outbreaks of Typhus fever, Relapsing fever, Trench fever and/or when there is a high presence of the vector.


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Control measures include reduction of overcrowding and improvement of individual and community hygiene. Regular body washing and use of clean clothes usually prevents body louse infestations. Soap and cold water are not sufficient to eliminate lice from clothing. Treatment of clothing by damp heat (15 to 30 minutes at 60 °C and dry in sun) and by dry heat (ironing) must be undertaken. In areas where water is scarce, washing facilities are lacking and/or people own a single piece of clothing, this may be complicated. A more practical solution is insecticidal dusting (T.B. 7.18) or impregnation of clothing (T.B. 7.17) or to seal the clothing in a closed plastic bag for 2 weeks.


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Insecticide application to the hair gives the most effective control of head lice (contact your medical referent). Head shaving is not recommend. Disinfect combs, brushes, hats and bedding of individuals infested with head lice (wash at 60°C). Examine all contacts and treat those infected.


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Shaving of the infested pubic hairs from the body has been replaced by the application of insecticidal formulations (contact your medical referent). In heavy infestations, all hairy areas of the body below the neck should be treated. Simultaneous treatment of partners is recommended.


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The life span of rats is up to two years under optimum conditions and three years for mice. The brown rat is larger than the black rat and is not well adapted to hot climates. They principally live in sewers and holes, and they feed on refuse and human excreta. Brown rats build their nests in burrows, a small snug place affording shelter or retreat. The black rat can be found under the roof of any type of building, where they also build their nests. If the rats live outside a building, their nest can be found on the ground, in vegetation or in trees. Black rats have a very varied diet. The multi-mammate rat is less domestic than others and can multiply rapidly. The house mouse nests in any place where there is soft fibrous material for making a shelter. The smallest hole a young mouse can enter is 6 mm diameter.


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Rodents and rodent-borne diseases may become serious problems in refugee and displaced population camps that have existed for some time. These problems may result from uncontrolled and accumulating solid waste, which greatly increases rat breeding. Rodents are associated with disease transmission to humans in a number of ways: through biting (e.g. rat-bite fever and rabies), through their urine or faeces (e.g. leptospirosis, salmonellosis, lassa fever), through infected rat fleas (e.g. murine typhus and plague), and through infected ticks (e.g. lyme disease, relapsing fever). People can also contract leptospirosis from handling the dead bodies of infected rats or get trichinosis from eating undercooked meat from pigs that have eaten the dead bodies of infected rats. Finally, rats can cause important damage by destroying or contaminating food or drugs stocks.


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Information about rodents can be collected in interviews with people. A person who is familiar with the signs and traces of rats can perform fairly rapidly a survey of a rather large area. The mayor signs are faecal droppings, rodent runways, rodent footprints or tail marks in dust and tracking powders, gnaw marks of rats / mice, burrows, and nests. Rodent odours, especially of house mice, and the typical noise produced by rodents are indicative of their presence. This information can be obtained during dusk or early evening surveys. These may be undertaken at random, or trough the selection of potential trouble spots. Strong flashlights can be used to search in such places as under buildings, refuse disposal areas and harbourage. Maps are essential for this type of work and if they are not available, sketch maps should be made by the workers.


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Rodent control activities should be systematically integrated, as per essential requirements (T.B. 1.08, 1.09), in endemic zones or during outbreaks of Lassa fever, Salmonelosis, Leptospirosis, Plague and Hanta fever and/or when there is a high presence of the vector (T.B. 7.19).


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Proper household hygiene may offer significant personal protection against infection and rodent nuisance.


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Mites are small ectoparasites living on mammals, birds and humans. The major mite pests that are of medical importance to humans are: the biting mite or “chigger“ and the Scabies mite.T.B. 7.07 Mites


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The biting mite or “chigger” has egg, larval, nymphal and adult stages. The immature stages are similar to the adults but smaller. Only the larvae of biting mites feed on human tissue. The nymphs and adults live in the soil and feed on other mites and small insects. After emerging from the eggs, the larvae crawl onto grasses and low-lying vegetation and wait till they can attach themselves to an animal or human host. The larvae remain attached and feed on the skin of the host for between two days and a month, depending on the species. Then they drop to the ground and enter into the soil to develop into the harmless nymhal and adult stages. The mites favour bamboo bushes, but are also found in a number of other habitats with low-lying vegetation.


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Almost the complete life of the Scabies mite is spent on and in the human skin where they feed on the epidermis of the host, procreate and lay their eggs. The total life cycle, from egg to adult, may take as little as 2 weeks. The females may live on people for 1 - 2 months. Away from the host they survive for only a few days. Fertilized female mites burrow tiny, winding tunnels in the surface of the skin progressing 2 to 3 mm per day. The tunnels can be seen as very thin twisting lines a few millimetres to several centimetres long. Larvae leave the maternal tunnel, burrow elsewhere in the epidermis or remain at the base of a hair follicle where they transform into an adult. Scabies are usually transmitted by close personal contact, for a minimum of 15 minutes, as between people sleeping together or during sexual intercourse. The scabies mites are unlikely to be acquired by someone sleeping in a bed previously used by an infested person, but may be passed on in underclothes.


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Biting mites can transmit a number of diseases, of which scrub typhus is the most important one. Many people show allergic reactions to mites or their bites. Scabies mites cause an itching condition of the skin known as scabies. Scabies results from an allergic reaction to the infection of the skin caused by the burrowing of the mites. Outbreaks of scabies are frequently reported in places where people live in overcrowded, unhygienic conditions (e.g. refugee camps) and where there is poor personal hygiene.


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The presence of winding tunnels (scabies mite) or bites (biting mite) on the skin indicate mite infestation. Scabies infection can be confirmed by applying ink to infested areas and then washing it off, thus revealing the burrows. Scabies mites are commonly found where the skin is thin and wrinkled (back of knees, inside of elbows, nipples). In young children they may also be found on the face.


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Mites control activities should be systematically integrated, as per essential requirements (T.B. 1.08, 1.09), in endemic zones or during outbreaks of scrub typhus and scabies and/or when there is a high presence of the vector.


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Personal protection methods may additionally offer significant protection against infection and mite nuisance. Avoid terrains infested by biting mites, wear shoes and apply repellents to skin or clothing. Under conditions of frequent exposure, the best protection is given by impregnated clothing and tucking the trousers inside the socks. Personal protection against scabies requires good general hygiene, so distribute soap and supply adequate water for laundry and washing.


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There are three stages in the bedbug’s life: egg, nymph and adult. Complete development from egg to adult takes from six weeks to several months, depending on temperature and availability of food. Bedbugs cannot develop in temperatures below 13 ºC. Adults can survive for years without food. Both male and female bedbugs feed on the blood of sleeping persons at night. The blood meal takes about 10 - 15 minutes and is repeated about every 3 days. After feeding, the nymph resembles an animated drop of blood. In the absence of humans they feed on mice, rats, chickens and other animals. During the day, bedbugs hide in dark dry places (e.g. beds, mattresses, cracks in walls and floors, furniture). Hiding places are also used for breeding. Because they have no wings, bedbugs travel only short distances. They spread from one house to another mainly in second-hand furniture, bedding and sometimes clothes.


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Bedbugs are not involved in the transmission of diseases but their bites cause significant discomfort, irritation and loss of sleep. In heavily infested houses where people may receive one hundred or more bites a night, it is possible that the blood loss causes mild anaemia in infants.


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Bedbugs can move rapidly when disturbed and are not easily detected while biting. A house with “bedbug” infestation may be recognized by the distinctive bed bug odour and by the blood stains of squashed bugs. Infestations can be detected by the examination of likely hiding places for the presence of alive bugs, cast-off nymphal skins, eggs and excreta (visible as small brown marks on bed sheets). Alive bugs can be detected by spraying with an aerosol spray can into cracks and crevices, thus irritating them and driving them out of their hiding places.


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Bedbug control activities should be systematically integrated, when there is a high presence of this biting nuisance. Significant protection against infection and bedbug nuisance is offered by providing a Long-lasting insecticidal Net (T.B. 7.16) and Insecticide Residual Spraying (T.B. 7.15). This in addition to regular airing of the bedding in the full sun, improvement of the general hygiene measures, use of repellents and aerosols.


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The life cycle of a cockroach consists of three stages: egg, nymph and adult. Depending on the species, temperature and humidity, the eggs hatch after one to three months. They reach full size between 2 and 12 months depending on the species. Cockroaches have a varied diet ranging from excreta to human food, from cardboard to clothes.


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Domestic pest cockroaches have been documented to affect human health in several ways. They proliferate in the most hidden places (e.g. sewers), then thread their way everywhere and can play a role as mechanical carrier of pathogens or parasites (e.g. human intestinal parasites). Cockroaches are also known to harbour a wide variety of microbial pathogens for which they serve as potential transit host. Some people may become allergic (e.g. asthma) to cockroaches after frequent exposure.


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Cockroaches are most active at night when they search for food in kitchens, food stores, rubbish bins, drains and sewers. A particular behaviour of cockroaches is their habit of regurgitating fluid from their mouth, while dropping faeces at the same site where feeding is occurring. They also produce secretions which give a persistent and characteristic odour to areas visited by them. During the day they hide in wall cracks, furniture and other secure places like bathrooms, cupboards and sewers. Cockroaches have been spotted on the face of sleeping persons feeding on their eye secretions, as well as in the mouth of snoring persons. The presence of several sizes of nymphs and egg cases is an indication of a well established colony.


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Cockroaches control activities should be systematically integrated when there is a high presence of this vector. The key to cockroach control is cleanliness. Infestations can be dealt with by chemical control measures, followed by environmental management to deprive the cockroaches of food and shelter.


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Chemical control remains the single most effective method for the control of established infestations. Several pesticide gels allows fast and drastic cockroaches eradication in health structure and warehouses by applying a few drops per m². Current practice is to use products belonging to several different classes of chemicals to delay the build-up of resistance.


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The toxicity of an insecticide is given as the dose required to kill 50% of a sample of test animals, often rats, in a specific time, and is referred to as the lethal dose 50 (LD50). It is expressed in mg/kg


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body weight. The lower the LD50 value, the greater the toxicity of the insecticide. The World Health


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<table><tr><td>Class</td><td>Hazard level</td><td>User restrictions for operators</td></tr><tr><td>Ia</td><td>Extremely hazardous</td><td>Special licence for operator</td></tr><tr><td>Ib</td><td>Highly hazardous</td><td>Educated, trained operator. Must be under strict supervision</td></tr><tr><td>II</td><td>Moderately hazardous</td><td>Trained operator. Must carefully respect safety measures</td></tr><tr><td>III</td><td>Slightly hazardous</td><td>Operator must observe normal safety measures, but with attention</td></tr><tr><td>0</td><td>Not hazardous in normal use</td><td>Operator must observe labels and follow proper hygiene measures</td></tr></table>


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Class Hazard level User restrictions for operators Ia Extremely hazardous Special licence for operator Ib Highly hazardous Educated, trained operator. Must be under strict supervision II Moderately hazardous Trained operator. Must carefully respect safety measures III Slightly hazardous Operator must observe normal safety measures, but with attention 0 Not hazardous in normal use Operator must observe labels and follow proper hygiene measures


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The main representative of this class is DDT® which use has considerably declined in recent decades, mainly due to its environmental and potential health impact. DDT® has a residual effect of six months or more. It is, depending on the formulation, moderately hazardous to mammals. DDT® is not recommended for use in Insecticide Residual Spraying (IRS) activities. The other members of this family which have been used in malaria control are Lindane® and Dieldrin®. Dieldrin® had to be abandoned because of its toxicity to humans and Lindane® because of widespread resistance problems. Organochlorines are not recommended for use in health care programs.


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This family includes some extremely toxic public health pesticides. The organophosphates used for Insecticide Residual Spraying are low to moderately hazardous to mammals. Regular medical check-ups of sprayers and other insecticide handlers, is recommended when spraying. Organophosphate poisoning should be considered as a medical emergency, requiring immediate treatment. They have a residual effect of two to three months.


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Organophosphates used for Insecticide Residual Spraying are Malathion, Fenitrothion and Pirimiphos-methyl. Temephos is an organophosphate regularly used as active ingredient in the larvicide Abate®. Temephos has a low toxicity, but some problems have occurred with resistance.


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Carbamates are more expensive than organophosphates and are exclusively used against adult insects. Carbamates have a residual effect of two to three months, and are moderately hazardous to mammals with relatively high acute oral toxicity. The wettable powders (WP) formulations should be supplied in water soluble sachets, each one sufficient for a single pump charge. This avoids handling during weighing of the formulation and the associated exposure of the operators.


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Propoxur and Bendiocarb are carbamates used as active ingredient in WP for IRS (T.B. 7.15). Bendiocarb is moderately hazardous and very toxic to fish and ducks.


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Synthetic pyrethroids are widely used in public health in a variety of formulations. Synthetic pyrethroids have a residual effect of up to a year but have a low persistence in the environment. They have a relatively low mammalian toxicity, but are highly toxic to fish. The field use of pyrethroids, in the recommended concentrations, with the normal precautions for insecticide use, poses little or no hazards to applicators.


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Permethrin is moderately hazardous. It is effective, provokes little or no irritation in direct contact with the skin and is widely used. Deltamethrin is moderately hazardous. It is effective and widely used. Other synthetic pyrethroids often used are Alpha-cypermethrin, Cyfluthrin, Cypermethrin, Etofenprox and Lambda-cyhalothrin


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Use of pesticides on a vast and increasing scale has led to the widespread development of resistance. It is considered that the most practical approach to resistance management in spraying programs is the rotation of unrelated public health pesticides according to a pre-arranged plan in response to the results of resistance tests (e.g. from synthetic pyrethroids to carbamates). WHO has developed standard test kits for determination of susceptibility to pesticides of vectors and pests of public health importance as well as guidelines on monitoring of resistance. Ask for advice of your technical referent prior to ordering public health pesticides.


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The use of public health pesticides is regulated, depending on the country. The product should be specifically intended to be used for public health and should have received an approval by WHO Pesticide Evaluation Scheme (WHOPES). Before an insecticide is used in a particular country, it must be authorised for use in the country. The Ministry of Health can provide a list of registered public health pesticides. Gain a letter of permission for importation from the relevant authorities before purchasing, shipping and importing non-registered pesticides.


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International and local markets offer a great variety of substandard pesticide and equipment products; these may fail in operational conditions and could cause unnecessary health and environmental risks. Public health pesticides are closed articles and should not be purchased locally. This to guarantee that the quality of the public health pesticides used is conform to the specifications of WHOPES. Ask for advice of your technical referent prior to ordering public health pesticides.


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Insecticide compounds may be sold under different names. Do not confuse these names with the type of active ingredient (a.i.). For example, a commonly used insecticide formulation for residual spraying is sold under the trade name K-0thrine®, its active ingredient however is deltamethrin.


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Following the trade name is a number that refers to the concentration. The concentration of the product represents the percentage of active ingredient (a.i.) in the formulation. Insecticide compounds are available in a number of different concentrations.


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If the concentrate is 25%, it contains 250 gram a.i. per kg in the case of a powder. The amount of a.i. in liquid formulations are usually expressed as weight/volume (w/v) . If the concentrate is 25%, w/v it contains 250 gram a.i. per litre in the case of a liquid.


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In case they are expressed as weight/weight (w/w) consult the label carefully, it should also give the amount of a.i. per litre. Convert this to a percentage w/v before proceeding with the application calculations. For example, if the label indicates that the formulation is 8% w/w, but also indicates that it contains 100 g a.i. per litre, convert this to a percentage w/v (calculation: 100 g / 1000 ml = 10% w/v).


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The trade name does not always represent exactly the concentration. For example “K-Othrine WP 50®“ contains 50 g a.i. per kg, thus only has a concentration of 5%.


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Public health pesticides are rarely used in their pure form, but are available in special formulations, adapted to the required application method. A formulation is a mixture of one or more active ingredients (a.i.) together with other materials (e.g. solvents, carriers) to make it appropriate to use.


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Following the trade name and concentration are the international codes for technical and formulated pesticides. They consist of 2 letters that indicate the type of formulation. Below are presented some of the codes.


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<table><tr><td>Formulation</td><td>Description of content</td><td>Application</td><td>Advantage</td><td>Disadvantage</td></tr><tr><td>Wettable</td><td>a.i. (2,5 - 80%)</td><td>IRS (T.B. 7.15),</td><td>- easy to transport, store</td><td>- deposits left on</td></tr><tr><td>powder</td><td>+ inert carrier</td><td>after water</td><td>and use</td><td>surfaces</td></tr><tr><td>(WP)</td><td>+ wetting</td><td>addition</td><td>- effective on porous</td><td>- suspension needs</td></tr><tr><td/><td>agent</td><td/><td>surfaces (mud, bricks,</td><td>continuous stirring</td></tr><tr><td/><td/><td/><td>concrete) and on water</td><td>- ineffective on</td></tr><tr><td/><td/><td/><td>based painted walls</td><td>plastic sheeting,</td></tr><tr><td/><td/><td/><td>-not expensive</td><td>canvas tents, oil</td></tr><tr><td/><td/><td/><td>-good homogeneity on</td><td>based paint</td></tr><tr><td/><td/><td/><td>the treated surface</td><td/></tr><tr><td/><td/><td/><td>-adaptable to all types of</td><td/></tr><tr><td/><td/><td/><td>a.i.</td><td/></tr><tr><td>Suspension</td><td>a.i. (10 - 50%)</td><td>Insecticide</td><td>- easy to manipulate</td><td>- ineffective on</td></tr><tr><td>concentrate</td><td>+ wetting</td><td>Residual</td><td>- good coverage of</td><td>porous surfaces</td></tr><tr><td>(SC)</td><td>agent (liquid,</td><td>Spraying (IRS)</td><td>treated surface</td><td>and on water</td></tr><tr><td/><td>not an organic</td><td>(T.B. 7.15),</td><td>- washable</td><td>based painted</td></tr><tr><td/><td>solvent)</td><td>after water</td><td>- effective on smooth</td><td>walls</td></tr><tr><td/><td/><td>addition</td><td>surfaces as plastic</td><td>- expensive</td></tr><tr><td/><td/><td/><td>sheeting, tent canvas, oil</td><td>- storage problems</td></tr><tr><td/><td/><td/><td>based paint</td><td/></tr><tr><td>Dustable</td><td>a.i. (0.5 - 10%)</td><td>Dusting</td><td>- ready to use (no need</td><td>- even application</td></tr><tr><td>powder</td><td>+ inert carrier</td><td>(T.B. 7.18)</td><td>for water)</td><td>is difficult</td></tr><tr><td>(DP)</td><td>(talcum,</td><td/><td>- not expensive</td><td>- emitted cloud is</td></tr><tr><td/><td>gypsum)</td><td/><td>- easy to treat where</td><td>uncontrollable</td></tr><tr><td/><td/><td/><td>access is difficult</td><td>- storage problems</td></tr><tr><td/><td/><td/><td/><td>in humid climates</td></tr><tr><td>Emulsifiable</td><td>a.i. (2.5 - 25%)</td><td>IRS (T.B. 7.15),</td><td>- easy to manipulate</td><td>- expensive</td></tr><tr><td>concentrate</td><td>+ petroleum-</td><td>after water</td><td>- no notable residues on</td><td>- smell</td></tr><tr><td>(EC)</td><td>based solvent</td><td>addition</td><td>surfaces</td><td>-sensitive to cold</td></tr><tr><td/><td>+ emulsifier</td><td/><td>-allows large distribution</td><td>during storage</td></tr><tr><td/><td/><td/><td>of a.i.</td><td>-danger of</td></tr><tr><td/><td/><td/><td>-good penetration in</td><td>(phyto)toxicity</td></tr><tr><td/><td/><td/><td>vegetation</td><td/></tr><tr><td>Granules</td><td>a.i. (0.5 - 5%)</td><td>Larviciding</td><td>- easy and ready to use</td><td>- expensive</td></tr><tr><td>(GR)</td><td>impregnated in</td><td/><td>- allows better</td><td>- heavy</td></tr><tr><td/><td>inert carrier</td><td/><td>penetration of dense</td><td/></tr><tr><td/><td>(kaolin, etc.)</td><td/><td>vegetation</td><td/></tr><tr><td/><td/><td/><td>-no storage problems</td><td/></tr><tr><td>Ultra low</td><td>a.i. + solvent</td><td>Space spraying</td><td>- ready to use</td><td>- experience</td></tr><tr><td>volume liquid</td><td/><td/><td>- fast action (knockdown</td><td>required for safe</td></tr><tr><td>(UL)</td><td/><td/><td>effect)</td><td>usage (operator</td></tr><tr><td/><td/><td/><td>- large surfaces treated in</td><td>and population</td></tr><tr><td/><td/><td/><td>short periods</td><td>safety)</td></tr><tr><td/><td/><td/><td>-good penetration in</td><td>-wind can cause</td></tr><tr><td/><td/><td/><td>dense vegetation</td><td>drift of the spray</td></tr><tr><td/><td/><td/><td/><td>- expensive</td></tr></table>


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Formulation Description of content Application Advantage Disadvantage Wettable a.i. (2,5 - 80%) IRS (T.B. 7.15), - easy to transport, store - deposits left on powder + inert carrier after water and use surfaces (WP) + wetting addition - effective on porous - suspension needs agent surfaces (mud, bricks, continuous stirring concrete) and on water - ineffective on based painted walls plastic sheeting, -not expensive canvas tents, oil -good homogeneity on based paint the treated surface -adaptable to all types of a.i. Suspension a.i. (10 - 50%) Insecticide - easy to manipulate - ineffective on concentrate + wetting Residual - good coverage of porous surfaces (SC) agent (liquid, Spraying (IRS) treated surface and on water not an organic (T.B. 7.15), - washable based painted solvent) after water - effective on smooth walls addition surfaces as plastic - expensive sheeting, tent canvas, oil - storage problems based paint Dustable a.i. (0.5 - 10%) Dusting - ready to use (no need - even


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water - effective on smooth walls addition surfaces as plastic - expensive sheeting, tent canvas, oil - storage problems based paint Dustable a.i. (0.5 - 10%) Dusting - ready to use (no need - even application powder + inert carrier (T.B. 7.18) for water) is difficult (DP) (talcum, - not expensive - emitted cloud is gypsum) - easy to treat where uncontrollable access is difficult - storage problems in humid climates Emulsifiable a.i. (2.5 - 25%) IRS (T.B. 7.15), - easy to manipulate - expensive concentrate + petroleum- after water - no notable residues on - smell (EC) based solvent addition surfaces -sensitive to cold + emulsifier -allows large distribution during storage of a.i. -danger of -good penetration in (phyto)toxicity vegetation Granules a.i. (0.5 - 5%) Larviciding - easy and ready to use - expensive (GR) impregnated in - allows better - heavy inert carrier penetration of dense (kaolin, etc.) vegetation -no storage problems Ultra low a.i. + solvent Space spraying - ready to


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to use - expensive (GR) impregnated in - allows better - heavy inert carrier penetration of dense (kaolin, etc.) vegetation -no storage problems Ultra low a.i. + solvent Space spraying - ready to use - experience volume liquid - fast action (knockdown required for safe (UL) effect) usage (operator - large surfaces treated in and population short periods safety) -good penetration in -wind can cause dense vegetation drift of the spray - expensive


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Solvent: as most public health pesticides are insoluble in water, the most commonly used solvents are gas oil, kerosene or even acetone or xylene.


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Assure that packaging of pesticide can withstand transport, handling and the climatic and storage conditions to which they will be exposed. Pesticide containers should be clearly labelled, rigid, leak proof, weather and rat resistant. Wettable powders must be packed in moisture-proof bags to maintain their good suspensibility.


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Re-pack pesticides where existing containers are damaged or deteriorating; they should also be relabelled. Place damaged paper or plastic bags containing solid formulations inside a transparent, heavy polyethylene plastic bag so that the contents and label are visible.


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Take special care when handling drums in which pressure has built up, particularly if the pressure is so high that it has caused the drum to balloon. The lids of such drums should never be removed in one movement, instead they should be opened little by little to allow a controlled release of pressure.


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Always repack drums with leaks or with worn corners at the base prior to further transport. Put straw (or other absorbent material) on the bottom of the vehicle. This should be incinerated where possible or otherwise burned on arrival.


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Load with care, pack the drums closely together and tie them down to avoid them jumping up and down.


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Instruct the driver to keep public health pesticides safe from children and animals, and secure from damage and theft.


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Instruct the driver on emergency procedures in case of an accident (e.g. switch off engine and disconnect battery, keep public away, contain spills with earth or sand).


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Store pesticides in a place that can be locked and is not accessible to children or other unauthorized people. Never keep pesticides in a place where they might be mistaken for food or drinks. Storage conditions are specified on the insecticide package.


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Keep pesticides in a dry, well-ventilated place, away from sunlight and heat and separated from other chemical materials (e.g. medicines, fuel and chlorine). Some public health pesticides can convert to more toxic chemicals if they are stored at high temperatures.


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➞ Wet the area with a detergent solution (e.g. 10% saturated sodium carbonate solution, or a 5% caustic soda solution).


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Unfortunately, there are limited disposal methods that are safe and generally applicable under circumstances prevailing in low-income countries. As such, avoid accumulation of unwanted pesticides. Unwanted pesticide stocks may be:


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Products that cannot be identified because their label is absent or cannot be read due to damage or language.


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Always seek advice from your technical referent prior to recycling, neutralizing, destructing or isolating expired pesticide, pesticide waste, used containers and contaminated materials.


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High temperature incineration (e.g. cement factory kilns) is the preferred method for the safe disposal of the majority of unwanted pesticides. Encapsulation is an alternative in the case incineration is not an option.


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In low-income countries, empty insecticide containers are often highly valued and sold or exchanged as storage containers for other materials such as fuel, chemicals and even food or drinks. Such practices are dangerous and should be prevented, for example by puncturing any empty insecticide containers that cannot be returned to the supplier for safe disposal or re-use. Outer cartons and packaging material, lightly contaminated with product residues, can be incinerated in an isolated area downwind of the nearest habitation. Plastic containers should be triple rinsed and incinerated in the way recommended for lightly contaminated packaging materials. The rinsate should be used to dilute the next spray solution or safely disposed of into pit latrines, if available, or into pits dug especially for this purpose far away from sources of drinking water. The ashes can be disposed of in an ash pit (T.B. 6.07). Non-combustible insecticide containers should not be burned. They should be


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for this purpose far away from sources of drinking water. The ashes can be disposed of in an ash pit (T.B. 6.07). Non-combustible insecticide containers should not be burned. They should be encapsulated after they have been triple-rinsed and crushed or shredded. Containers may be retained as spares to replace leaking or deteriorating drums with the same product. Old and deteriorated drums can also be used as raw material at a steel smelter. They should be triple rinsed, punctured and crushed before being sent to the smelter.


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Take extra precautions in choosing public health pesticides and deciding when, how, and for how long to apply them.


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Pesticides may cause local effects when they come into contact with the body, or more widespread general effects after they have actually entered the body. Pesticides can enter the body in three ways:


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➞ Skin contact: the skin does not act as a complete barrier and pesticides may be absorbed into the body if skin contact occurs.


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➞ Ingestion: This mode of entry is likely to produce more severe poisoning. It may occur accidentally.


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Avoid skin contact. Never stir liquids or scoop pesticides with bare hands. If the pesticide gets on the skin, wash off immediately with water and soap.


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Use dedicated equipment for measuring, mixing and transferring pesticides. Ensure that any mixing takes place outside or in well-ventilated places. It is strongly recommended to purchase pre-packed pesticides of an appropriate quantity, even though they are more expensive.


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Wash your overalls and other protective clothing at the end of each working day in water and soap, and keep them separate from the rest of the family’s clothes (T.B. 7.20).


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Provide two complete sets of protective clothing and individual protective equipment to personnel involved in chemical vector control. This allows them to have one set in use while the other is being washed.


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Include information on symptoms of accidental poisoning and the immediate treatment protocol in any training aimed at those involved in an pesticide operation.


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Inform personnel repeatedly to report immediately to their supervisor if they do not feel well or in case of any incident.


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If these precautions are scrupulously respected, risks are extremely limited when working with sufficiently trained personnel that is adequately supervised.


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Plan vector control activities always in consultation with the hygiene / health committees of the health structure.


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Inform patients, health structure staff or the affected community, when chemical control methods are implemented, about the type, the timeframe and associated risks of the planned activity.


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In case of poisoning with organophosphates or carbamates, nausea, headache, fatigue, and mental or muscle disorders tend to be the first symptoms, followed by vomiting, abdominal cramps, diarrhoea, heavy sweating and salivation. Critical cases may result in paralysis and breathing problems, followed by convulsions and a loss of consciousness, leading to coma, respiratory arrest and death.


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Pyrethroids have weak toxicity in mammals and only oral doses in excess of 15 g are poisonous to humans. They can cause abnormal sensations of the face, irritation symptoms of the skin and the upper respiratory tract in case of occupational poisoning (inappropriate handling). In case of poisoning due to ingestion, initial symptoms are mainly digestive (epigastric pain, nausea and vomiting).


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All the staff should be fully aware of the following simple rules to follow in case of a pesticide poisoning:


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Flush the eyes with large amounts of clean water for approximately ten minutes when pesticide has come into contact with them; eyelids should be kept open during flushing.


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Use a hand compressed sprayer consisting of a tank holding a liquid insecticide formulation, which can be pressurized by means of a hand pump fixed to it. The compressed air forces the liquid out the tank via a hose with a cut-off valve, a lance and a nozzle.


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Spray the insecticide suspension evenly at the recommended dosage. The following factors determine how much insecticide is sprayed on a surface:


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➞ The concentration of insecticide in the suspension (generally 1 pre-weighted sachet or dose per 10 litres sprayer).


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➞ Type of nozzle (the flat spray nozzle used for wall spraying produces a spray with an angle of 80°).


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Respect these factors so that the application rate will be 40 ml/m² (calculation: 760 ml/min divided by 19 m²/min = 40 ml/m²). This means that 10 litres of spray suspension can spray 250 m² (calculation: 10.000 ml divided by 40 ml/m² = 250 m²).


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Examine the sprayer to ensure that all parts are present, assembled correctly and in good condition.


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➞ The flat-fan nozzle (E8002) delivers a fan-shaped spray, and is used for residual wall spraying. This flat-fan nozzle produces a spray with an angle of 80° and 760 ml per minute at a standard tank pressure of 280kPa.


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➞ The solid stream nozzle is used to treat cracks and crevices for control of bedbugs, soft ticks, cockroaches and ants.


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➞ The hollow-cone nozzle can be used to spray breeding sites of mosquitoes but also tick and mite habitats in vegetation.


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Protect the nozzle by putting the lance in the bracket and nozzle cup of the sprayer when it is not in use.


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Use clean water to ensure that the equipment operates properly and does not leak before using an insecticide (often a cause for poisoning).


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Operate the pump using both hands and with a foot on the footrest. Pump to the full working pressure. The lower and upper limits for the working pressure are 170 kPa (25 psi) and 380 kPa (55 psi).


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Maintain pressure between these two values during spraying by occasional re-pumping. If you hear a hissing sound of escaping air, the tank is losing pressure, most probably via an accessory on the tank, and this should be repaired.


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Check to make sure there are no leaks along the lance and hose, especially where the hose joins the tank and the trigger on / off valve.


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Check the spray pattern from the nozzle by spraying a dry wall surface. Look to see that the pattern is even and without streaks. Ensure that the nozzle does not drip when the trigger on / off valve is released.


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Open the trigger on / off valve for one minute, collect the discharge and measure the amount in a measuring jug. Repeat this procedure a further two times and calculate the average discharge.


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➞ The discharge should be about 760 ml/min. If the discharge is incorrect, check the nozzle and the screen filters to ensure they are not clogged. If necessary, replace the nozzle. Repeat the discharge test until the correct volume is obtained.


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➞ The opening in a nozzle is very small and must not be damaged. Clogged nozzles should be put in clear water for several hours before the blockage is removed by a very soft toothbrush. Never clean


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a nozzle with a hard pin or a piece of wire, and never put the nozzle to your mouth to blow through it.


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Identify a suitable WHOPES approved insecticide for public health use. Most public health pesticides available for residual spraying come in pre-weighted sachets that contain the exact amount of insecticide to be diluted into a standard 10 litres sprayer. Note that different surfaces such as grass or plastic sheeting might require a different insecticide or formulation (T.B. 7.11).


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Prepare the insecticide spray according to the manufacturer’s instructions in a separate recipient, mix thoroughly and pass it through a sieve when pouring it into the sprayer. Never fill the tank more than 3/4 full.


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Time your spray speed to cover one meter every 2.2 seconds, i.e. 4.5 seconds for a 2 m high wall. Timing may be aided by mentally counting “one thousand and one – one thousand and two – one thousand and three -…“.


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Step sideways and spray upwards from floor to roof, using an upward motion. Respect an overlap of 5 cm with the previous swath.


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Keep the spray tip about 45 cm from the wall to ensure the correct swath width of 75 cm wide. Lean forwards as you spray from top of the wall and move back as you bring the nozzle downwards. Move forward again when you are approaching the floor.


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Empty the spray tank after use; never store a spraying product in the apparatus. Latrine walls can be sprayed with remaining insecticide solution in the tank (T.B. 7.02).


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De-pressurize the tank. Pour out any remaining insecticide into pit latrines or a specific infiltration pit; any insecticide needs to be diluted with more water before being put into pits.


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Turn the tank upside down with an open lid, open the on / off valve and let all the water drain out of the hose and lance.


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Ensure the lance is placed in its holder when not in use; this protects the nozzle. When storing the sprayer for a long period hang it upside down with the lid open to allow air circulation.


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When spraying smooth surfaces, such as plastic sheeting, tent canvas, oil based paint, the run-off might be too important when the spray speed to cover one meter is every 2.2 seconds. In this case double the application speed, wait until the sprayed surface is dry and spray a second time in order to obtain the recommended dosage (g a.i./m²).


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Both the insecticide and the spraying equipment must be WHO Pesticide Evaluation Scheme (WHOPES) approved. It is strongly recommended to order public health pesticides through your technical referent. Suitable public health pesticides can possibly be made available locally by the Ministry of Health or national malaria control programs.


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Spray persons must use protective clothing (T.B. 7.20) and use public health pesticides safely (T.B. 7.13). In hot and humid climates, the wearing of protective clothing may be uncomfortable. Public health pesticides should therefore be applied during the cooler hours of the day, to minimize neglect of the safety rules.


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Set up a training area for practical training so that each spray man can learn the correct spraying technique to spray at the proper rate to cover 19 m² per minute. Nine vertical strips must be sprayed. The spray men should spray at an uniform rate starting at the top left corner of the wall and moving downwards to the bottom. A distance of 45 cm must be kept between the nozzle tip and the surface area. To keep this distance during training, a wooden stick can be attached to the lance.


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Be aware of the need for spare parts when planning a spraying operation; e.g. nozzle tips need to be changed every 20 working days.


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Regular cleaning and maintenance of compression sprayers is essential to ensure optimum performance and to maximize their working lifespan.


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Respect the precautions during spraying: do not smoke, do not eat, do not drink, avoid touching other people, wash hands and remove protective equipment after spraying. Do no spray when it is windy.


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WHOPES approved hand operated compressor	- Hand operated compressor sprayer	- Nozzles (solid stream, flat fan,


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Insecticide Residual Spraying (IRS) is widely used for vector control, especially against mosquitoes, triatomine bugs and sandflies. Its objective is to ensure the safe and correct application of a residual insecticide to surfaces on which vectors may rest, usually ceilings, walls and the lower surfaces of large furniture. Spraying may need to be repeated at least every 6 months depending on the length of the transmission season and the residual life of the insecticide on the treated surface.T.B. 7.15 Insecticide Residual Spraying campaign


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The majority of the population lives in shelters with plain walls, such as huts, tents or houses. Huts made of branches with wide voids or gaps will be difficult to spray.


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The population is not nomadic; the structures should be (semi-) permanent and not changing within the next week / month.


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The capacity to organise the spraying activities on time. The ideal time to implement the IRS campaign requires a review of previous malaria data. In area’s where transmission is seasonal, the implementation should be done preferably before the increase in transmission. In areas of intense all year-round transmission, the IRS will be highly effective whenever it is implemented given that spraying is repeated at least every 6 months (depending on the residual life of the insecticide used as per box C).


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The capacity to spray a high enough proportion of houses and rooms in the target area to ensure that the majority of mosquitoes are exposed to the insecticide or that more than 80% of the shelters will be correctly sprayed to ensure mass protection effect.


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The ability to organise an information campaign for the targeted population about IRS, its purpose and benefits. The information to be disseminated will depend on the outcome of the assessment. Without the support of the hospital staff and/or the community, its leaders and the authorities, an IRS campaign will most probably not be successful.


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Estimate the total surface A (m²) to be sprayed considering the number of units to be treated and the average surface area of each unit (m²). Doors and windows must be sprayed inside and outside. Walls and ceilings must be sprayed indoors. Floors and outside walls will not require spraying.


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Determine the type of surface (mud, grass, brickwork, plastic sheeting, oil / water paint) to be sprayed.


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Identify a suitable WHOPES approved insecticide for public health use (box C). Note that different surfaces such as grass or plastic sheeting might require a different insecticide or formulation (T.B. 7.11). Before an insecticide is used in a particular country, it must be authorised for use in the country (T.B. 7.10).


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Be aware that most public health pesticides, available for residual spraying come in pre-weighted sachets that contain the exact amount of insecticide to be diluted into a standard 10 litres sprayer.


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Note that one 10 litres sprayer can spray 250 m² (T.B. 7.14). Determine the amount of pre-weighted sachets to be ordered based on the total surface A (m²) to be sprayed.


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Calculate, in case the insecticide is supplied in bulk, the exact amount of insecticide to be diluted into a standard 10 litres sprayer as per box A, B or C. Given that one 10 litre sprayer can spray 250 m², calculate the total amount of insecticide required based on total surface A (m²) to be sprayed.


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The number of people needed will depend on the context (e.g. the level of the emergency, skills and experience of the team, the climate, the terrain, the number and density of the shelters, the logistical support). The area that can be sprayed by one spray person can be estimated between 1000 and 2000 m² per day. Determine the amount of sprayers to be ordered based on the total surface A (m²) to be sprayed.


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To make the spraying efficient, employ a minimum of two people per hand compressed sprayer tank. One to do the actual spraying. One accompanier, possibly a community health worker, to make sure the shelters are empty before the actual spraying and to deliver information about disease transmission and the purpose and benefits of IRS. Potentially also to install a LN and instruct on how to use it.


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For safety reasons, a working day for spray persons will depend on the density of households. According to the duration of spray person’s exposure, a working day will vary from 4 hours (high concentration of households) to maximum 6 hours (lower density of households).


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A team may consist of a team leader and up to 5 spray persons and 5 accompaniers, according to the specific features of each location to be sprayed. One supervisor can follow-up on a maximum of 4 teams.


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A storekeeper should be assigned to the IRS campaign to follow-up on the preparation, distribution, inventory and maintenance of the material.


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A training should be organized for all the staff involved with the IRS. Often, such a training will last around two days and should include:


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➞ some basic information on the Anopheles mosquito and malaria transmission (T.B. 7.01 and section 7.2.3),


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➞ delivery of basic messages about the disease addressed, its symptoms and the importance of seeking early treatment,


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It should be verified that the sprayer persons wear their protective equipment appropriately (T.B. 7.20).


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Inform the head of the household of the spraying schedule and the purpose of spraying, giving them time to prepare and vacate the building.


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Have the walls, where possible, be cleaned prior to spraying to prevent the removal of the insecticide residue by cleaning after spraying.


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Assure that occupants leave the building before spraying. Rooms occupied by sick people who cannot be moved must not be sprayed.


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Remove all household items, including water, food, cooking utensils and toys from the building and protect them against the rain. Items that cannot be removed should be well covered. Move and cover, or take out the furniture to allow easy access for spraying the walls.


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Ceilings must be sprayed with particular attention to all beams. Spraying movement should be as for walls. Do not stand directly below the spray fallout.


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Furniture and objects against the wall should, as far as possible, be moved in order to spray behind them. Cupboards must be emptied so they can be sprayed inside. Tables must be carefully cleaned to remove spray fallout.


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Spray persons must use protective clothing (T.B. 7.20) and use public health pesticides safely (T.B. 7.13). In hot and humid climates the wearing of protective clothing may be uncomfortable. Public health pesticides should therefore be applied during the cooler hours of the day, to minimize neglect of the safety rules.


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Instruct the hospital staff or the householders to sweep or mop the floor and all flat surfaces to remove the spray fallout before patients, other persons or items are allowed to re-enter. Instruct them not to clean the sprayed surfaces.


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Assure that all empty packaging is returned to the supervisor for safe disposal. Organize appropriate disposal of remains of insecticide and empty packaging (T.B. 7.12).


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Never poor the remaining insecticide into drinking water sources or rivers and pools as fish are highly sensitive to pyrethroids.


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<table><tr><td>Insecticide compounds and formulations (1)</td><td>Class group (2)</td><td>Dosage (g a.i./m2)</td><td>Mode of action</td><td>Duration of effective action (months)</td></tr><tr><td>Malathion (WP)</td><td>OP</td><td>2</td><td>contact</td><td>2 - 3</td></tr><tr><td>Fenitrothion (WP)</td><td>OP</td><td>2</td><td>contact and airborne</td><td>3 - 6</td></tr><tr><td>Pirimiphos-mehthyl (WP and EC)</td><td>OP</td><td>1 - 2</td><td>contact and airborne</td><td>2 - 3</td></tr><tr><td>Bendiocarb (WP)</td><td>C</td><td>0.1 - 0.4</td><td>contact and airborne</td><td>2 - 6</td></tr><tr><td>Propoxur (WP)</td><td>C</td><td>1 - 2</td><td>contact and airborne</td><td>3 - 6</td></tr><tr><td>Alpha-cypermethrin (WP and SC)</td><td>P</td><td>0.02 - 0.03</td><td>contact</td><td>4 - 6</td></tr><tr><td>Bifenthrin</td><td>P</td><td>0.025 - 0.05</td><td>contact</td><td>3 - 6</td></tr><tr><td>Cyfluthrin (WP)</td><td>P</td><td>0.02 - 0.05</td><td>contact</td><td>3 - 6</td></tr><tr><td>Deltamethrin (WP, WG)</td><td>P</td><td>0.01 - 0.025</td><td>contact</td><td>2 - 3</td></tr><tr><td>Etofenprox (WP)</td><td>P</td><td>01 - 0.3</td><td>contact</td><td>3 - 6</td></tr><tr><td>Lamda-cyhalothrin (WP, CS)</td><td>P</td><td>0.02 - 0.03</td><td>contact</td><td>3 - 6</td></tr></table>


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Insecticide compounds and formulations (1) Class group (2) Dosage (g a.i./m2) Mode of action Duration of effective action (months) Malathion (WP) OP 2 contact 2 - 3 Fenitrothion (WP) OP 2 contact and airborne 3 - 6 Pirimiphos-mehthyl (WP and EC) OP 1 - 2 contact and airborne 2 - 3 Bendiocarb (WP) C 0.1 - 0.4 contact and airborne 2 - 6 Propoxur (WP) C 1 - 2 contact and airborne 3 - 6 Alpha-cypermethrin (WP and SC) P 0.02 - 0.03 contact 4 - 6 Bifenthrin P 0.025 - 0.05 contact 3 - 6 Cyfluthrin (WP) P 0.02 - 0.05 contact 3 - 6 Deltamethrin (WP, WG) P 0.01 - 0.025 contact 2 - 3 Etofenprox (WP) P 01 - 0.3 contact 3 - 6 Lamda-cyhalothrin (WP, CS) P 0.02 - 0.03 contact 3 - 6


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Both the insecticide and the spraying equipment must be WHO Pesticide Evaluation Scheme (WHOPES) approved. It is strongly recommended to order public health pesticides through your technical referent. Suitable public health pesticides can possibly be made available locally by the MoH or national malaria control programs.


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Respect the precautions during spraying: do not smoke, do not eat, do not drink, avoid touching other people, remove protective equipment after spraying and wash hands.


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Insecticides are often classed as “toxic chemicals” and are therefore subject to strict packaging and shipping certificate requirements for transportation. Packaging requirements for wettable powders are less strict than for liquid formulations and the wettable powders are normally the most simple formulations to ship by air transport.


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Some insecticides can give allergic reactions, such as skin rash. It is therefore important to ventilate the sprayed surface and try to prevent people entering the infrastructure before the insecticide has dried. The time needed for the insecticide to dry is context dependent. A piece of toilet paper applied on the sprayed surface can be used to confirm if it is dry or not.


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Before starting up and training a team, find out if suitable people are available in the region (e.g. a lice control team is not trained to manage a program to control malaria and will need additional training).


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IRS is especially recommended in area’s where malaria transmission is largely confined to one season. IRS can then be very effective when conducted once a year prior to the start of the transmission season. In area’s where malaria transmission is more or less constant throughout the year, IRS will need to be repeated every three to eight months (according to local conditions, habitation types and insecticide used), with both cost and human resource implications.


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The nature of the sprayable surface plays a major role in the duration of the residual effect of the insecticide. Surfaces of organic origin (e.g. wood, bamboo, palm leaves or thatch and mud) are adsorptive and may break down the insecticide chemical structure. They require higher application rates to achieve satisfactory residual action. Alkaline surfaces such as whitewashed walls affect insecticides. Do not spray a corrugated iron roof exposed to the sun as the heat that will build up may rapidly inactivate insecticides or cause it to flake off the sprayed surfaces.


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The personal protection effect of a Long-lasting insecticidal Net (LN) for the people sleeping under it operates in three ways. First of all, the insecticide incorporated in the net tissue kills the mosquitoes (and/or other biting insects) that come into contact with the net. Secondly, the LN repels a proportion of the mosquitoes but this ability depends on the insecticide present in the net. Thirdly, the net acts as a mechanical barrier to biting. The mechanical barrier provides less protection, which is why nets without insecticide are less effective than treated ones. A torn untreated net offers little or no protection, whereas a torn treated net still works to some extent.


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The mass effect is important but often ignored. It extends the protection beyond that of the individuals under the net and works in three ways. Firstly, mass coverage by LN’s shortens the lifespan of the mosquitoes. Secondly, mass coverage reduces the number of mosquitoes in the community. Apart from their killing effect, nets will also inhibit mosquitoes feeding, hence reducing their reproductive potential Thirdly, with some Anopheles species, mass coverage might divert mosquitoes from human to animal biting, thereby reducing human to human transmission. Taken together, these effects on the vector population can greatly reduce transmission of disease, but only if the coverage of mosquitoes nets is sufficiently high.


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The personal protection provided by LN’s allows their deployment in a progressive way starting with low population coverage. Nonetheless, rapid scale-up with a target of complete coverage is highly desirable as the mass vector control effects of LN’s become more apparent when household coverage increases. Every LN used contributes thereby not only to the safety of its user(s), but also to the safety of others.


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LN’s are ready-to-use factory pre-treated nets with the insecticide either incorporated or coated around the fibres. Long-lasting insecticidal Nets retain their insecticidal properties for two to five years, the physical lifespan of the net. A LN only needs re-treatment after 20 washes. As a consequence, and if used in a normal way, they do not require further treatment during their normal life. Polyester and polyethylene are currently the most common fabrics for nets, but cotton fibre is also used. A square shaped net has the least person-to-net contact and is often preferred. An entrance flap is not recommended. The mesh size indicates the number of openings per square inch in the net; 156 is the most common. In tropical climates a mesh size higher than 156 may result in insufficient ventilation for comfortable use. However in desert fringes where it is cold at night, the “demuria”, a non transparent net, might be the better choice. The “denier” value of a net is an indication of the


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for comfortable use. However in desert fringes where it is cold at night, the “demuria”, a non transparent net, might be the better choice. The “denier” value of a net is an indication of the weight of the fibre and consequently its strength. Nets with a denier value of less than 100 are not recommended due to the relative ease of tearing. In practice, the size of the net is a matter of user preference and it is culturally determined.


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The ability to assess whether a LN is appropriate for the target group (Chapter 1 and section 7.2.3).


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There is a potential for behaviour change so that people will use the nets correctly, knowing that the distribution of nets should be accompanied by clear LN promotion / education messages.


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Ability to organise and implement an effective community promotion campaign prior to distribution. The information to be disseminated will depend on the outcome of your assessment. Without the support of the hospital staff and/or the community, its leaders and the authorities, a LN distribution will most probably not be successful.


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An adequate delivery system including the acquired information on number and location of houses and sleeping units requiring nets.


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LN’s are available or can be made available in time. Long commercial delivery and shipping times might be experienced with LN’s and this may delay deployment and effective protection.


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Ability to manage the distribution to targeted groups in the required time frame. The ideal time to implement the distribution requires a review of previous malaria data. Implementation should be done preferably before the start of the malaria season in area’s where transmission is seasonal. In areas of intense all year-round transmission of malaria, distribution will be effective whenever it is implemented.


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Define the size, shape and colour of the nets to be distributed. LN’s are available in rectangular and circular forms, multiple colours and in transparent or opaque cotton sheet (e.g. the Dumuria). Distribute in an emergency the model available in stock to enable rapid deployment (e.g. rectangular 1.30 m wide individual LN for patients in health centres and rectangular 1.90 m wide LN for families).


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Define the beneficiaries. A targeted distribution to risk groups (e.g. like pregnant women and children under 5 in open settings through clinics with antenatal care, immunization programmes, feeding centres or vaccination campaigns) or a mass distribution, aiming at good household coverage.


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Define how and where the nets will be distributed (e.g. mass distribution during a general food distribution, through local leaders or a house to house distribution installing the LN’s during the distribution which has a positive impact on their utilisation).


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Define a well-prepared LN promotion / education campaign. Contact your technical referent to receive already existing survey forms that have nevertheless to be adapted to the data collected on the local context (T.B. 1.01).


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Define a post-distribution monitoring method to ensure that targeted beneficiaries have actually received / retained and are using their LN correctly.


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In refugee or displaced camp settings, Insecticide Residual Spaying (T.B. 7.15) is likely to be preferable to the distribution of LN’s due to the notoriously poor retention rates for LN’s in the acute emergency phase. Faced with limited food rations, families will often choose to sell their net as a means of temporarily increasing the family food intake.


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LN use can result in rashes or allergic reactions, so it is advisable to ventilate the nets 24 hours before using them. When handling a large number of new nets, protective clothing (gloves and long sleeves) should be used by the staff.


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To reduce the risk of re-selling of LN’s by the beneficiaries, the nets should be taken out of the packaging, marked with a number or name and signed for reception by the head of the household. Some LN’s are already supplied with an individual number printed on them. This can also help with monitoring of the distribution, and to assess how well predefined targets are reached.


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In places where a pre-distribution study shows that the nets distributed to pregnant women are largely used by their husband or other relatives, distribute two nets for each pregnant woman.


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Where possible, nets should be ordered well in advance of a planned distribution, to ensure timely delivery and appropriate transportation costs.


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The shape and colour are important considerations, as some colours may be refused / misused by the beneficiaries because of the significance of certain colours to that population (e.g. white nets might be misused to wrap dead bodies or make wedding dresses). White nets may also be washed more often than coloured nets.


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A valuable LN’s intervention in malaria endemic countries is allocating one net per bed in the dormitory of schools.


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Prefabricated huts or shelters can be used during promotion campaigns to clearly demonstrate how to install the LN’s (e.g. to keep the mosquitoes and other insects out, be sure to tuck the bottom of the net under the mattress or let it hang so that it touches the ground all around).


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It might be important to provide nails and rope during distribution to facilitate the installation of the LN’s.


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In malaria prone areas, make sure the net is used every night, even where mosquitoes are not heard or seen.


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It is often found that people use mosquito nets for fishing, clothing (wedding dresses) or for crop protection; be aware of this possibility when distributing nets and include this in the promotion campaign messages in order to avoid these practices.


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In case a LN was used by a patient with a highly contagious disease (e.g. ebola), the LN should be destroyed as it cannot be disinfected; insecticides and chlorine are not compatible.


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Some bednets (LN’s) need time (up to one week) to recover their insecticidal capacity after washing. This process can be accelerated with heat (e.g. put LN under a blanket in the sun for a day; the blanket is required as insecticides break down under UV radiation).


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It is recommended to use a single pre-packed dose required for the impregnation of one net and its conversion into a Long-lasting insecticidal Net (LN). It is available as a kit, containing a single insecticide dose, a binding agent sachet, gloves, a plastic measuring container (or bag) and the impregnation instructions. It is usually more efficient to treat several nets at the same time using one dose per net treated. Used nets should be washed and dried before treatment. The following impregnation procedure can be applied to curtains and clothes as well. For the impregnation of clothes, the insecticide formulation needs to be identified with support of your technical referent (e.g. a formulation with deltamethrin as active ingredient will irritate the skin and is not at all appropriate).


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Collect the necessary equipment: basin or plastic bag, gloves, soap, net and impregnation kit (insecticide, binding agent, plastic measuring container or bag).


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Choose an appropriate site to do the impregnation. It is best to treat the net outdoors in the shade. If you must treat the net indoors, do it in a room with open windows.


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Measure the correct amount of water in the measuring bag and poor it into the basin or plastic bag: 0.5 litre is required for a synthetic net (e.g. polyester or polyethylene) and 2 litre of water is required for a cotton net and this independent of the size of the net. If the net is exceptionally large or thick, some excess water might be required.


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Add the correct amount of insecticide to the water. The amount of insecticide or “dose” needed to treat one net may come as a tablet, small bottle or sachet of liquid.


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Unfold the net and put it in the basin or plastic bag with the insecticide solution you have prepared.


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Lift the net and wring gently. Do not wring too hard - as when washing clothes - or the insecticide will be lost.


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Do not hang the net on a line, otherwise the insecticide will be distributed unevenly or even drip out. Spread the net out flat in the shade to dry. Do not leave the net in the sun as insecticides break down under UV radiation. Later, it can be hung up to finish drying.


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Use any leftover mix of water and insecticide to treat curtains. Otherwise, dispose of it in the latrine or in a specific hole, but away from ponds, rivers, streams, wells, springs, boreholes, the house or animal shelters. Never store the mix of water and insecticide.


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An untreated mosquito net, if properly used and maintained, can provide a physical barrier to hungry female mosquitoes. Biting is still possible if there is a small tear in the net, if the net is not covering the entire bed or if part of the body is touching the net. If treated with insecticide, net effectiveness is greatly improved, generating a chemical halo that extends beyond the mosquito net. This tends to repel mosquitoes from biting or shorten their lifespan and reduce malaria transmission. Even a treated net with holes will have this impact as the mosquito will have to be in contact with the net to locate the hole.


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The use of LN is recommended (T.B. 7.16). LN’s are ready-to-use factory pre-treated nets. Long-lasting insecticidal Nets retain their insecticidal properties for two to five years, the physical life- span of the net. A LN only needs re-treatment after 20 washes. As a consequence, and if used in a normal way, they do not require further treatment during their normal life.


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In health structures, nets should be washed when stained (e.g. blood, excreta, vomit) or at least at regular intervals (e.g. each month). In this particular case, LN’s will be washed 20 times after almost two years period, thus before the end of their lifespan. If the LN’s are still in good condition at this moment, they need to be re-impregnated prior to being used again (T.B. 7.17).


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Re-impregnation of LN’s is also necessary when information on when they were installed in the health structures and how many times they were washed is not available (T.B. 7.17).


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Use only public health pesticides that are recommended for mosquito nets impregnation. A wettable powder formulation cannot be used for net treatment. As the net dries, the wettable powder no longer adheres to the flexible fibres and falls down. A person using the net risks inhalation and accumulation of insecticide on the exposed skin during the night.


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If a concentration exceeding the recommended dosage is used, people may experience eye or skin irritation when sleeping under the net.


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Direct skin contact with the insecticide on a net that is still wet may cause a tingling sensation of the skin and is best avoided.


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After treatment the net may slightly smell of the insecticide. The smell will go away in a few days and is not harmful to people who sleep under the net.


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Apply insecticidal dust against rat fleas a week earlier than rat poisons during the control of urban outbreaks of plague. This is to prevent fleas from moving to humans when the rats are killed.


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Apply insecticidal dust to burrows, runways and other sites where rodents are likely to pick it up. When the rodents grooms themselves, they spread the dust on their fur, thus killing the fleas. Before control is begun, it is important to know where rodent burrows and runways are. To save insecticide, the burrows should first be closed off; only those that are subsequently re-opened by the rat should be treated.


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Blow insecticidal dust into each burrow with a duster. A 1 cm thick layer of dusting powder should be left around the opening.


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Apply dust only where it will remain undisturbed by humans, wind or rain. Insecticidal dust remains effective for 2 - 4 months if used in undisturbed dry places.


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Apply dust only when the sprayed surfaces have dried, when used together with residual spraying (T.B. 7.15).


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Use a dust that does not cause irritation when in contact with the body. Dusts with a maximum of 1% of permethrin, as the active ingredient, are recommended. Ready to use preparations are the safest and recommended option.


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Pay attention to the type of talcum used in the formulation; some are only for use on animals and some are cleared specifically for human use.


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Apply about 30 - 50 g of powder over the surfaces of clothing that are in close contact with the body for individual treatment. Powder is applied to the fully clothed subject at the neck, half at the front and half at the back, then spread by rubbing to ensure complete coverage. Pay specific attention to seams of underwear, sleeves and socks if they are worn. Make sure the powder is applied in a cultural sensitive manner, especially between the skin and underwear. Leave it for 12 to 24 hours. This is the preferred method for mass treatment.


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Treat headwear, additional clothing, blankets and bedding as well (e.g. add about 30 - 50 g of powder to a plastic bag containing the additional set of clothing).


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Make hand shakers by puncturing one end of a can (approximately 2.6 holes/cm² and of 3 mm diameter). Application with a soupspoon is also simple and practical; 1 soupspoon is about 15 gram: use one at the front and one at the back.


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Apply only dusts with a maximum of 1% of permethrin as active ingredient. Ready to use preparations are the safest and recommended option.


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Pay attention to the type of talcum used in the formulation; some are cleared specifically for human use but some are only for use on animals.


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Dust patients before being admitted to a health structure as every bout of fever or large drop in temperature (e.g. death) promotes the movement of lice to a new host.


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One treatment should be sufficient but re-treatment might be needed at intervals of 8 - 10 days if infestations persist.


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Block or protect all openings greater than 6 mm with cement or metal netting (1mm wire, mesh less than 6 mm diameter).


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Paint a smooth band (oil painting) of at least 30 cm wide on walls, at 1 m from the ground, to prevent passage on rough vertical surfaces.


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Pay particular attention to warehouse management (e.g. recondition where required, clean regularly).


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The presence of food sources and shelter in areas of human habitation attracts rodents and could be associated with outbreaks of plague. General environmental sanitation and proper household hygiene can do much to reduce any type of rodent infestation, more specifically:


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Limit access of rodents to food supply (e.g. harvest fruit in a timely manner, make it possible to store all food in rat-proof containers).


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Eliminate or at least reduce the protective vegetation cover that is crucial to the rodents. Prune shrubs so that the ground below them is clearly visible. Mow, trim or remove ground cover plants. Stack firewood, lumber and other materials at least 30 cm away from walls and fences and at least half a meter above the ground.


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Avoid, where possible, access to any source of water during hot dry weather. This unless you want to attract and trap them.


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➞ Spring traps: can be efficient but not to be used in the vicinity of children or non-targeted animals.


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➞ Rat glue is available in tubes and should be put on a piece of cardboard with some bait in the middle.


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Keep in mind that rodents are very suspicious, always use the same runs and learn very quickly. This means that traps should be used in large numbers, over a short period, on carefully chosen sites, perpendicularly to rodents runs. It is also best to leave the traps not set for a few days after installation to reduce trap shyness.


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Do not place glue boards where children, or other non-targeted animals might be in contact with them. Replace glue boards often; they lose their effectiveness when covered by dust or insects. Effectiveness is also reduced by heat and moisture, therefore it is recommended that glue boards be used only indoors.


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Chronic or slow-acting rodenticides: referred to as multiple dose anti-coagulants that are the safest for the user and generally require several doses (e.g. Difenacoum Brodifacoum, Bromadiolone, Difethialone). They are normally the first choice rodenticides and exisist in different formulations


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(e.g. grains, blocks, paste, gel). Their advantages are that they don’t cause bait-shyness, and accidental poisoning of people or animals is unlikely to happen. Some formulations are weather resistant. However, rodents can become resistant to them and before selecting the rodenticide, information on local resistance should be collected.


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Acute rodenticides such as zinc phosphate, arsenic oxide and Fluoroacetamide are mainly for industrial applications (e.g. ships). They are very toxic for human beings and are not recommended for general use. They are effective in situations where anticoagulant resistance exists and where the dead bodies can easily be found and disposed off. However, it is advised to use these products only if you have no other option because of the health risks that they represent to man and non-targeted animals. Such intervention can only be envisaged after discussion with your technical referent.


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Against a flea-born disease (e.g. plague or murine typhus), the flea control must precede rodent control to prevent fleas from moving to humans when the rats are killed. If not, the spread of these flea-born diseases can be encouraged (T.B. 7.18).


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A health promotion campaign to enlist the help of the community groups and individuals is probably the most essential component of the rodents control activities.


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Rodenticides can be very effective, but their use requires supervision and follow-up by well-trained staff.


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Before placing any bait, check that rats are not a supplement to the diet of the population / refugees. If this is the case contact your technical referent. In any case, inform the population about the control campaign and the risks of the rodenticides.


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Temper resistant bait boxes are bait boxes that can be closed with a key. These boxes should be secured to the ground, so the population cannot take and use them for other purposes like storage of food. They represent a safe way to place baits, in opposition to PVC or bamboo that are commonly used but that still allows access to the bait by children.


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Prior to embarking on a rodenticide campaign, limit the rodent access to food supply and nesting places. As long as this is not taken care off, the rodent population will grow and quickly reach its former population level. The impact of a rodenticide campaign will in this case be negligible.


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Offering rewards to bring in rat tails as proof for each killed rat has previously shown to be contra productive as it resulted in people breeding rats.


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Particular attention should be paid to protecting vulnerable refugees (such as the old and the sick) from being bitten by rats. Those suffering from leprosy may be especially defenceless when sleeping due to their lack of sensations in fingers and toes.


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Rodenticides can be used in health structures and warehouses but are generally not recommended for use in refugee camps. The large number of children, having little to do and few things to play with, make it risky to place poison bait traps around the camp environment.


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Bait must not be placed haphazardly. Care must be taken to place the bait where the rodent will find it, but children and animals cannot.


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Care has to be given to correct collection and disposal of carcasses: put dead rats safely in a plastic bag and bury them in a deep pit.


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Caution to safe handling of trapped rodents (e.g. the multi-mammate rat is the natural reservoir for the Lassa fever virus; the virus is spread through the urine of the rats; if trapped, these rats urinate wildly and become covered with the virus; their corpse must be disposed of without direct contact).


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Impact of rat control can be observed after 3 weeks for the brown rat, and 4 to 5 weeks for the black rat / mouse.


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Even for apparently straightforward application of public health pesticides (e.g. placement of cockroach poison, impregnation of fabrics), a minimum of protective clothing is required.


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During spraying, dusting or packing activities, absorption of insecticide can occur through contact, inhalation and/or ingestion. Therefore specific protective clothing must be worn, covering all parts of the body.


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Wash clothing daily. Keep it in good state of repair, and inspect it regularly for tears or worn areas. Keep clothing in a closed, ventilated place, out of the reach of children.


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Take the clothes off immediately after the work is finished and do not take them home. Protective clothing should be changed if it becomes wet. As such, a spare set of protective clothing is useful on the field.


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Change the respirator every day. The respirator prevents exposure of the face (protects nose and mouth from airborne particles of the spray) and inhalation of vapour.


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Wash face shield or goggles regularly to maintain visibility. Face shield or goggles protect the eyes from drops of insecticide.


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Wear an overall, even when hot, to protect the body and wash it regularly. Wear clothing under it (e.g. underwear, T-shirt).


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Wear plastic gloves to protect the hands when handling and spraying the insecticide. The sleeves of the overall should be tugged within the gloves. After use, the gloves should be rinsed with water before they are taken off. They should be washed daily with soap, separately from other clothing. Gloves should be washed on the inside as well. Be careful when re-using gloves not to wear them inside-out.


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Provide access to good washing facilities (after the job is done) to personnel involved in chemical vector control.


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The quality of the respirator should be adapted to the public health pesticide and formulation used, and needs to be verified with your technical referent (e.g. minimum FFP2 for pyrethroids, minimum FFP3 for carbamates).


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Depending on the situation, a centralized system of storage and care may be the best option with protective clothing handed out prior to the control activity and collected and cleaned afterwards. This ensures better control and care of the equipment.


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A face shield is the preferred option for full face and eye protection. They are less hot to wear and do not mist over as easily as goggles. If no face shield is available, a pair of safety glasses is an acceptable alternative.


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Protective clothing can be a mayor source of exposure to operators if it is not either carefully washed or disposed after use.


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In hot and humid climates, wearing of protective clothing may be uncomfortable and the sweat generated increases absorption of insecticide. Public health pesticides should therefore be applied during the cooler hours of the day, to minimize neglect of the safety rules and assure use of protective clothing. It is the responsibility of supervisory staff to ensure that the appropriate protective clothing is worn, no matter what the circumstances.


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If poisoning is suspected, medical help must be sought immediately. Some indications of insecticide poisoning are: extreme weakness and fatigue, skin irritation or burning sensation, itching eyes, nausea, vomiting, diarrhoea, headache, cough, chest pain, unconsciousness (T.B. 7.13).


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Overalls should be available in two samples to allow a daily washing and drying, even in tree samples in particular circumstances like during rainy season or under humid climates where it takes more than one day to dry.


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It’s a common misbelieve that dead bodies who are not or cannot immediately be dealt with would lead to epidemics. Dead bodies related to war, famine or natural disasters do not form a direct and immediate public health risk. So this misbelieve should not be transmitted to the affected population because it will only increase their traumatic experience. Still, it’s advisable to deal with the corpses as soon as possible because of:


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The proximity of the dead bodies, often after a traumatic experience, can lead to mental health problems of the survivors. But the unceremonious disposal of the corpses, can have the same impact as well.


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However, deceased victims of cholera, plague, typhus and viral haemorrhagic fevers (e.g. Ebola, Marburg), can have an impact on the spreading of the respective disease to a wider population and thus can represent a direct health risk. Rapid and special precautions have to be taken when disposing of these kinds of dead bodies. An in-depth description of how to deal with deceased victims of these diseases can be found in the respective guidelines (section 8.5 Further reading).


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Disposing of dead bodies can include locating the deceased, collection, preparing the body for viewing (with possible disinfection of the body and the living environment of the deceased; T.B. 8.01), registration, body dressing (e.g. putting body in a coffin), transport (with potential disinfection of the means) and burial or cremation.


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In general, the culture and wishes of the relatives should be respected as much as possible, as this helps the survivors in their mourning process. But particular rules (e.g. rapid burial) have to be respected for the casualties of specific diseases as described hereunder (T.B. 8.01 and section 8.5 Further reading) as they can lead to epidemics. It is of utmost importance that correct information concerning the risk of being in contact with deceased of highly infectious diseases is well explained to the relatives and the neighbours, otherwise they might be reluctant to bring the sick people to the health centres.


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It is obvious that dead bodies should always be dealt with, as soon as possible. It should be strongly encouraged that the relatives take responsibility themselves for the dead body, in case the deceased is a victim of war, famine or a natural disaster. This can be done according to their usual cultural and religious procedures, such as the preparation for viewing of the deceased and body dressing. Those steps are often done at home. They have a positive influence on the psychological and emotional effects of the relatives, as they are essential steps in the mourning process.


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Morgue (should be available in all in-patient health structures, and sometimes there is a need for additional ones after natural or man-made disasters (e.g. war) due to the high number of casualties, or in isolation centres dealing with specific diseases (T.B. 8.02).


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These facilities have to correspond to certain specifications. The sites need to be chosen in collaboration with the local authorities and preferably as well with the affected communities.


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The aid-agencies can also help the affected population in providing shrouds and/or transport if necessary. In particular contexts (e.g. high number of dead bodies after a natural disaster), the aid-agencies might have to collect and dispose of the deceased.


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The role of the (medical) aid-agencies in disposing of dead bodies increases in importance during the control of an epidemic of highly infectious diseases. For viral haemorrhagic fevers for instance, the preparation of the dead body (e.g. disinfection of the body and leak proof body bag) has to be taken in charge by a trained team (T.B. 8.01) in order to avoid further spreading of the epidemic. In such a context, it is important to promote and supervise safe burial, and possibly to disinfect the living environment of the deceased.


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Follow up on identification of the deceased, information towards their relatives, human rights and legal issues are very important, but fall outside the scope of these guidelines (section 8.5 Further reading).


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During epidemics of highly infectious diseases, the dead bodies will have to be disposed of with specific precautions. In all other cases, it isn’t necessary and even not advised to disinfect the corpses. Dead bodies that can’t be removed immediately (e.g. corpses left on the street due to insecurity conditions) can be covered with lime. Since the high pH of the lime “disinfects” to a certain extent the dead body superficially, but doesn’t affect internal pathogens, its effectiveness is limited. However, lime can reduce the odour of the corpses that start to decompose.


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Special attention should be paid to the protective clothing of people coming in contact with dead bodies having open wounds, or deceased victims of highly infectious diseases as described in the respective guidelines. In all other cases, the relatives that deal with the dead bodies don’t require any specific protective clothing. However, it is recommended that all people that have been in contact with dead bodies do wash themselves thoroughly with water and (preferably antiseptic) soap.


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Whereas the traditional funeral rites and practices are important for the relatives (e.g. mourning process), they should be adapted for victims of highly infectious diseases as they could lead to the further spreading of an epidemic. Supervised funerals together with other safety procedures to avoid further spreading of the specific disease should also be addressed in the obligatory health promotion campaign.


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Besides cloths, coffins are often used as well to bury the dead bodies. In case of acute emergencies, those items are often not available in sufficient numbers, thus blankets or mats or preferably appropriate body bags can be used as an alternative. In epidemics of highly infectious diseases, it is strongly recommended to use leak proof body bags (in addition to a coffin).


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In most cases, the body is carried by the relatives in procession to its final resting place. However, in epidemic situations, it might be necessary for the aid-agency to do the transport of the deceased person. It is very important to disinfect properly the vehicles used for transporting the infectious corpses, according to the existing standards per specific disease (section 8.5 Further reading).


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In general, the preferred final step is burial in a cemetery as it is simple and cheap. However it does require a lot of space (foresee about 1500 m² for a population of 10.000 persons; T.B. 8.03). If possible, individual burial should be chosen over mass graves, to allow the relatives to visit the actual tomb of the deceased person. In certain cultures, the corpses are embalmed before they are transported to their final resting place.


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If not specifically demanded by the relatives, it is strongly advised not to cremate the dead bodies, and certainly to avoid mass cremation (T.B. 8.04), not even the corpses of highly infectious diseases. Cremation will require enormous amounts of fuel. Often, the cremation will succeed only partially, especially if experienced and skilled personnel is lacking to perform this task. The smoke generated during the cremation can be hazardous to health as it contains dioxins and possibly thermo-resistant pathogens.


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Médecins Sans FrontièresCholera guidelinesMédecins Sans Frontières, 2004PAHO/WHO/IFRC/ICRC, GenevaManagement of dead bodies after disasters: a field manual for first respondersICRC Publication, 2006P. Harvey, S. Baghri, B. ReedEmergency SanitationWater, Engineering & Development Centre (WEDC), 2002Médecins Sans Frontières Filovirus Haemorrhagic Fever Médecins Sans Frontières, 2007


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In most cases, no special precautions beyond normal hygiene practices are required when disposing of dead bodies. However, specific precautions are required if people died from highly infectious diseases. These precautions may include amongst others the wearing of protective equipment, the disinfection of the dead body and the restriction of traditional funeral practices. Nevertheless, in every circumstance, all efforts must be made to ensure that the body is treated with respect and in a dignified manner.


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The following table shows precautions recommended for the highly infectious diseases likely to be encountered in the field.


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<table><tr><td>Precaution</td><td>Cholera</td><td>Ebola Marburg</td><td>SARS</td><td>Typhus Plague</td><td>Tuberculosis</td><td>HIV/AIDS</td></tr><tr><td>Wearing of specific protective equipment</td><td>Yes rubber gloves overall apron (rubber boots) goggles (protection against chlorine splashes)</td><td>Yes respirator FFP2 goggles double rubber gloves gown head cover rubber boots apron</td><td>Yes respirator FFP2 goggles rubber gloves gown head cover rubber boots</td><td>Yes rubber gloves overall apron respirator FFP2 (if pneumonic plague)</td><td>Yes rubber gloves respirator FFP2</td><td>Yes rubber gloves</td></tr><tr><td>Body disinfection (with chlorine solution)</td><td>2%</td><td>0.5%</td><td>0.5%</td><td>No</td><td>No</td><td>No</td></tr><tr><td>Insecticide dusting of body and clothing</td><td>No</td><td>No</td><td>No</td><td>Yes</td><td>No</td><td>No</td></tr><tr><td>Blocking body orifices</td><td>Yes</td><td>No</td><td>No</td><td>No</td><td>No</td><td>No</td></tr><tr><td>Body bag (or similar)</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Immediate burial (within 12 hours)</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td><td>No</td><td>No</td></tr><tr><td>Limitation of funeral gatherings</td><td>Yes</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td><td>No</td></tr><tr><td>Promotion of safe funeral practices</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td></tr><tr><td>Supervised funerals</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td><td>No</td><td>No</td></tr><tr><td>Disinfection of the living environment of the deceased</td><td>Yes</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td><td>No</td></tr></table>


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Precaution Cholera Ebola Marburg SARS Typhus Plague Tuberculosis HIV/AIDS Wearing of specific protective equipment Yes rubber gloves overall apron (rubber boots) goggles (protection against chlorine splashes) Yes respirator FFP2 goggles double rubber gloves gown head cover rubber boots apron Yes respirator FFP2 goggles rubber gloves gown head cover rubber boots Yes rubber gloves overall apron respirator FFP2 (if pneumonic plague) Yes rubber gloves respirator FFP2 Yes rubber gloves Body disinfection (with chlorine solution) 2% 0.5% 0.5% No No No Insecticide dusting of body and clothing No No No Yes No No Blocking body orifices Yes No No No No No Body bag (or similar) Yes Yes Yes Yes Yes Yes Immediate burial (within 12 hours) Yes Yes No No No No Limitation of funeral gatherings Yes Yes Yes No No No Promotion of safe funeral practices Yes Yes Yes Yes No No Supervised funerals Yes Yes No No No No Disinfection of the living environment of the deceased Yes Yes Yes No No No


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Inform yourself well with the local population and medical staff on the customs and cultural aspects related to death. They will be able to give you information on how a morgue should look like, how long the deceased will stay in a morgue, how the relatives will collect the dead body.


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Look for a place within the “technical” zone of the health structure, close to the fence with a specific exit for the morgue. This enables the relatives to view and collect discretely the deceased person, without creating an uneasy feeling for other patients and visitors of the health structure.


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Fence the area well to avoid unauthorised people to enter. Foresee also some additional space for potential (temporary) extension of the morgue (e.g. during emergencies).


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➞ a space (quite and peaceful) where relatives can wait and mourn (this can be outside the morgue, but preferably shaded in hot countries).


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➞ a room where the deceased can be prepared and possibly be viewed by the relatives. For small health structures (e.g. about 20 beds), a capacity for 1 or maximum 2 dead bodies is sufficient. For bigger health structures, the capacity should be determined with the medical staff.


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Avoid windows in the actual morgue building. Ventilation holes in the upper part of the walls protected by grills to avoid rodents to enter are more appropriate.


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Cover the floor with smooth concrete in such a way that it has a slope of 1% leading towards a drain. This enables the evacuation of wastewater and body fluids via a grease trap towards an infiltration system (chapter 4). Make sure that small animals can’t enter the drain pipe that leads the wastewater outside.


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Provide masonry tables in chronic emergencies and stabilised situations to avoid having to put corpses on the ground. To keep these tables clean and hygienic, it’s recommended to cover them with ceramic tiles. The tables should present a gentle slope towards their centre and a channel allowing to drain body fluids and wastewater in a bucket.


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Foresee a plastic curtain in between the tables to permit some privacy when relatives come to view the deceased.


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Provide a water point close to the morgue (< 20 m) for body disinfection and washing, according to local customs.


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Choose an area at least 500 m away from the dwellings. Take care about the distance from water points, which should never be less than 50 m and which should be uphill from the burial site. The water table at its highest level (at the end of the rainy season) should be at least 3 m deep. The selection of the site has to be done in collaboration with the local authorities and preferably also with the host and the affected population.


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Dig a drainage ditch around the whole area to avoid runoff water eroding the soil away from the graves. This ditch should lead towards a drainage canal to evacuate runoff water that doesn’t infiltrate during heavy rainfall.


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Dig preferably individual graves for the relatives to be able to visit the tomb of the deceased person. The orientation of the grave might in certain cultures be important as well. The grave should be at least 1.5 m deep, and the bottom should be at least 1.5 m above the highest water table to avoid its biological contamination (if the soil is homogenous).


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Leave the burial ceremony up to the relatives according to the local cultural and religious rituals as this helps them in their mourning process, unless the deceased was victim of a highly infectious disease. In the latter case, the burial has to be supervised by trained and experienced personnel, complying as much as safely possible with the local cultural and religious rituals.


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Make sure that the dead body is covered with at least 1 m of soil. This depth is important to avoid bad odours and dogs or other carrion-feeders digging out the corpses.


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It might be necessary to foresee several cemeteries, or at least split up the graveyard in different zones when different religions and/or ethnic groups are living together.


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The bottom of the graves must be more than 1.5 m from the aquifer to avoid microbiological pollution of the groundwater by the corpses. The depth of the water table can be estimated by verifying its level in nearby wells. Another option is to drive a metal bar such as a reinforcing rod or (several pieces of) ½” galvanized pipe into the ground, as deep as 1.5 m beneath the required depth of the grave. When pulled out, the rod or (the earth inside) the pipe should be dry. Soil saturated with water after heavy rainfall might give a false impression of the actual water table level.


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Normally, it isn’t necessary to line the graves. However in unstable undergrounds, it is recommended to install a removable (wooden) rectangular support until the body is lowered in the pit. This support which should avoid collapse of the upper soil layer should have the size of the hole and a height of at least 0.5 m within the edge of the grave.


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It’s recommended to always have some graves dug in reserve but not too many at once because they will collapse over time. The Crude Mortality Rate indicates how many graves per day should be available.


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In acute emergencies when the Crude Mortality Rate is high, it might take too long to dig individual graves. Long trenches (possibly made with a mechanical shovel) where the dead bodies are put head to toe can be a solution, as it still permits to put an identification on each grave and thus the relatives visiting their deceased family member. However, try to avoid as much as possible mass graves with different bodies being pilled up on top of each other, because visiting a deceased person is part of the mourning process for the relatives.


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Be assured that the coffin is well closed (and the lid well fixed) so that an accidental event during transportation or burial doesn’t result in the body dropping out.


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Provide the possibility for the relatives to collect a piece of (white) cloth to cover the deceased person.


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Be aware that in some cultures the dead bodies are buried in a standing up or sitting position. Get information on the practices prior to the ceremony.


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In big catastrophes, with lots of dead people, it might be up to the aid-agency to do the burial of the dead bodies. Also in epidemics such as cholera, Ebola or Marburg, it is recommended to have a trained team who can do the (supervision of the) burial after the disinfection of the corpse and laying it in a leak proof / sealed body bag, in order to contain the disease.


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A fence and preferably guards are strongly recommended to guarantee the correct use of the cemetery. During emergencies, the guards should also act as graveyard watchers who count and report every day the new tombs.


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A maintenance team will be needed to dig new tombs and to keep the cemetery tidy. Depending on the size of the graveyard, this task can also be done by the guards.


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Washing (at least water and soap) and related wastewater facilities should always be available onsite.


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Inform yourself well with local people experienced in cremation. They will be able to give you detailed information on cremation, the site, the facilities and the equipment that are needed.


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Choose an area at least 500 m away and downwind from the dwellings. Take care about the distances from water points, which should never be less than 50 m away. The selection of the site has to be done with the local authorities, the people experienced in cremation and preferably with the host and the affected population as well.


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Fence the area well to avoid unauthorised people to enter or to install their dwelling. A guard is recommended who can also register the number of people that are cremated.


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Foresee a potential disposal area for the ashes, according the local customs (e.g. spreading the ashes on a well identified area). In case (unburned) residues need to be buried, the bottom of the residues pits or trenches must be more than 1.5 m above the water table to avoid microbiological pollution of the groundwater. The depth of the water table can be estimated by verifying its level in nearby wells. Another option is to drive a metal bar such as a reinforcing rod or (several pieces of) ½” galvanized pipe into the ground, as deep as 1.5 m beneath the required depth of the “grave”. When pulled out, the rod or (the earth inside) the pipe should be dry. Soil saturated with water after heavy rainfall might give a false impression of the actual water table level.


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Leave the cremation process, according to the local cultural rituals, completely over to experienced local people.


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Make sure that when potential unburned residues are buried, they are covered with at least 1 m of soil and respect the recommendations as described in the T.B. 8.03.


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<table><tr><td>Absorption</td><td>Incorporation of one substance by another (e.g. of gas by a liquid, of a liquid by the soil).</td></tr><tr><td>Accumulation rate</td><td>Rate at which decomposed faecal matter builds up in a pit latrine, expressed in m³ per person a year, and used for the calculation of the effective pit volume.</td></tr><tr><td>Activated carbon</td><td>Specially prepared powdered or granulated carbon, used in final treatment of drinking water by adsorption, particularly for the removal of dissolved (organic) pollutants which impart colour, taste and odours to water.</td></tr><tr><td>Adsorbent</td><td>Pollutants (being dissolved causing colour, odour or taste, or turbidity) sticking (adhering) to filter material with a (very) large specific surface (e.g. activated carbon).</td></tr><tr><td>Aerobic</td><td>A process taking place in the presence of oxygen.</td></tr><tr><td>Ampoule</td><td>Glass container containing a medicinal solution or powder.</td></tr><tr><td>Amputated limbs</td><td>Accidentally or surgically removed human body extremities (e.g. arm, leg).</td></tr><tr><td>Anaerobic</td><td>Micro-organism living in a place or a process taking place without oxygen.</td></tr><tr><td>Antiseptic</td><td>Substance that kills or inhibits pathogen development and is harmless when applied to living tissues (skin, mucous membranes).</td></tr><tr><td>Apron</td><td>Concrete surface surrounding the head of a well for protection and drainage. Protective cloth worn over (working) clothing when dirty or dangerous tasks have to be performed.</td></tr><tr><td>Aquatic</td><td>Living in water, or related to water.</td></tr><tr><td>Aquifer</td><td>Porous water-saturated layers of sand, gravel or rock that can store water and are permeable enough to allow water to flow through them in useable quantities.</td></tr><tr><td>Arbovirus</td><td>Any group of pathogenic viruses transmitted to vertebrates by arthropod blood suckers (e.g. mosquitoes, ticks), responsible of producing arboviroses.</td></tr><tr><td>Arthropod</td><td>A jointed-limbed invertebrate animal with a segmented body and external skeleton, which includes insects, crustaceans and spiders.</td></tr><tr><td>Auto-Disable (AD) syringe (auto-blocking syringe)</td><td>A specially designed disposable syringe with a fixed needle that is automatically disabled by blocking its plunger after a single use. Used very often for immunization; e.g. Enlarged Program of Immunization (EPI) or in mass vaccination campaigns.</td></tr><tr><td>Available chlorine</td><td>Pure chlorine content of a chlorine-generating product, expressed as a percentage, in chlorometric degrees, ppm or mg/l (e.g. 65 - 70% for calcium hypochlorite; 1º = about 0.3%, 1 ppm = 1 mg/l = 0.0001% active chlorine).</td></tr><tr><td/><td/></tr><tr><td>Bacteria</td><td>Microscopic unicellular organisms that usually multiply by cell division, certain of which are disease-causing agents. However, some can also be of aid in pollution control by metabolizing organic matter or other pollutants in wastewater, oil spills, etc.</td></tr><tr><td>Bacteriological analysis</td><td>Identification of bacteria of the coliform group (E-coli and Thermo Tolerant coliforms) and/or other micro-organisms indicating contamination of drinking water by faecal material of warm blooded animals, including humans. Total coliforms are not a good indicator for bacteriological pollution of drinking water.</td></tr><tr><td>Biodegrading / Biological decomposition</td><td>Natural process of destruction of organic material by microbiological activity.</td></tr><tr><td>Biological cycle</td><td>Developmental stages or phases through which an organism passes in one generation.</td></tr><tr><td>Bleach</td><td>Chlorine-generating product (NaOCl) in a liquid form containing 4 to 15% of available chlorine. Less stable than the solid formulations. See also sodium hypochlorite.</td></tr><tr><td>Breeding site or grounds</td><td>The place where insects proliferate, where they lay their eggs and where the eggs hatch.</td></tr><tr><td>Burial / Burying</td><td>Action of covering with earth (e.g. refuse, dead bodies).</td></tr><tr><td/><td/></tr><tr><td>Calcium hypochlorite (Ca(ClO)2)</td><td>Chlorine-generating product in granular form (also found as tablets) containing 65 to 70% available chlorine, made by reacting chlorine with calcium hydroxide. Also called HTH®, which is a brand name.</td></tr><tr><td>Candle filter</td><td>Candle shaped ceramic filter element (pore size: often 0,45 µm).</td></tr><tr><td>Carbon monoxide (CO)</td><td>A colourless, practically odourless and poisonous gas formed by incomplete combustion. Its toxic action is due to its strong affinity for haemoglobin, myoglobin, and cytochromes, reducing oxygen transport within the human body and blocking oxygen utilization.</td></tr><tr><td>Catchment</td><td>Part of the well below the water table which allows water to flow into the well. The emergence zone of a spring where safe water may be collected.</td></tr><tr><td>Catchment ring</td><td>Perforated or porous cylinder sunk into the water table, through which water passes.</td></tr><tr><td>Cavitation</td><td>The formation of gas bubbles (water vapour) and their implosion on the blades of a pump impeller or on the gate of a valve; the implosion of these bubbles can be with such force that it can cause pitting or even destruction of the impellor or the valve.</td></tr><tr><td>Chemical analysis</td><td>Tests for the identification of undesirable or toxic chemical substances whose maximum permissible concentrations determine the potability of water, according to scientifically pre- determined levels.</td></tr><tr><td>Chemical waste</td><td>Residuals or remains that contain substances that can react, affect or interfere chemically with the environment (e.g. laboratory reagents, film developer, expired disinfectants, solvents).</td></tr><tr><td>Chlorinated lime</td><td>Chlorine-generating product in powder form, containing 30% chlorine. Less stable than calcium hypochlorite.</td></tr><tr><td>Chlorine</td><td>Reactive element (Cl) with strong oxidizing power, used for (water) disinfection.</td></tr></table>


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Absorption Incorporation of one substance by another (e.g. of gas by a liquid, of a liquid by the soil). Accumulation rate Rate at which decomposed faecal matter builds up in a pit latrine, expressed in m³ per person a year, and used for the calculation of the effective pit volume. Activated carbon Specially prepared powdered or granulated carbon, used in final treatment of drinking water by adsorption, particularly for the removal of dissolved (organic) pollutants which impart colour, taste and odours to water. Adsorbent Pollutants (being dissolved causing colour, odour or taste, or turbidity) sticking (adhering) to filter material with a (very) large specific surface (e.g. activated carbon). Aerobic A process taking place in the presence of oxygen. Ampoule Glass container containing a medicinal solution or powder. Amputated limbs Accidentally or surgically removed human body extremities (e.g. arm, leg). Anaerobic Micro-organism living in a place or a process taking place without


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a medicinal solution or powder. Amputated limbs Accidentally or surgically removed human body extremities (e.g. arm, leg). Anaerobic Micro-organism living in a place or a process taking place without oxygen. Antiseptic Substance that kills or inhibits pathogen development and is harmless when applied to living tissues (skin, mucous membranes). Apron Concrete surface surrounding the head of a well for protection and drainage. Protective cloth worn over (working) clothing when dirty or dangerous tasks have to be performed. Aquatic Living in water, or related to water. Aquifer Porous water-saturated layers of sand, gravel or rock that can store water and are permeable enough to allow water to flow through them in useable quantities. Arbovirus Any group of pathogenic viruses transmitted to vertebrates by arthropod blood suckers (e.g. mosquitoes, ticks), responsible of producing arboviroses. Arthropod A jointed-limbed invertebrate animal with a segmented body and external skeleton, which


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by arthropod blood suckers (e.g. mosquitoes, ticks), responsible of producing arboviroses. Arthropod A jointed-limbed invertebrate animal with a segmented body and external skeleton, which includes insects, crustaceans and spiders. Auto-Disable (AD) syringe (auto-blocking syringe) A specially designed disposable syringe with a fixed needle that is automatically disabled by blocking its plunger after a single use. Used very often for immunization; e.g. Enlarged Program of Immunization (EPI) or in mass vaccination campaigns. Available chlorine Pure chlorine content of a chlorine-generating product, expressed as a percentage, in chlorometric degrees, ppm or mg/l (e.g. 65 - 70% for calcium hypochlorite; 1º = about 0.3%, 1 ppm = 1 mg/l = 0.0001% active chlorine). Bacteria Microscopic unicellular organisms that usually multiply by cell division, certain of which are disease-causing agents. However, some can also be of aid in pollution control by metabolizing organic matter or other


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organisms that usually multiply by cell division, certain of which are disease-causing agents. However, some can also be of aid in pollution control by metabolizing organic matter or other pollutants in wastewater, oil spills, etc. Bacteriological analysis Identification of bacteria of the coliform group (E-coli and Thermo Tolerant coliforms) and/or other micro-organisms indicating contamination of drinking water by faecal material of warm blooded animals, including humans. Total coliforms are not a good indicator for bacteriological pollution of drinking water. Biodegrading / Biological decomposition Natural process of destruction of organic material by microbiological activity. Biological cycle Developmental stages or phases through which an organism passes in one generation. Bleach Chlorine-generating product (NaOCl) in a liquid form containing 4 to 15% of available chlorine. Less stable than the solid formulations. See also sodium hypochlorite. Breeding site or grounds The place


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product (NaOCl) in a liquid form containing 4 to 15% of available chlorine. Less stable than the solid formulations. See also sodium hypochlorite. Breeding site or grounds The place where insects proliferate, where they lay their eggs and where the eggs hatch. Burial / Burying Action of covering with earth (e.g. refuse, dead bodies). Calcium hypochlorite (Ca(ClO)2) Chlorine-generating product in granular form (also found as tablets) containing 65 to 70% available chlorine, made by reacting chlorine with calcium hydroxide. Also called HTH®, which is a brand name. Candle filter Candle shaped ceramic filter element (pore size: often 0,45 µm). Carbon monoxide (CO) A colourless, practically odourless and poisonous gas formed by incomplete combustion. Its toxic action is due to its strong affinity for haemoglobin, myoglobin, and cytochromes, reducing oxygen transport within the human body and blocking oxygen utilization. Catchment Part of the well below the water table which allows water to


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for haemoglobin, myoglobin, and cytochromes, reducing oxygen transport within the human body and blocking oxygen utilization. Catchment Part of the well below the water table which allows water to flow into the well. The emergence zone of a spring where safe water may be collected. Catchment ring Perforated or porous cylinder sunk into the water table, through which water passes. Cavitation The formation of gas bubbles (water vapour) and their implosion on the blades of a pump impeller or on the gate of a valve; the implosion of these bubbles can be with such force that it can cause pitting or even destruction of the impellor or the valve. Chemical analysis Tests for the identification of undesirable or toxic chemical substances whose maximum permissible concentrations determine the potability of water, according to scientifically pre- determined levels. Chemical waste Residuals or remains that contain substances that can react, affect or interfere chemically with the environment


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of water, according to scientifically pre- determined levels. Chemical waste Residuals or remains that contain substances that can react, affect or interfere chemically with the environment (e.g. laboratory reagents, film developer, expired disinfectants, solvents). Chlorinated lime Chlorine-generating product in powder form, containing 30% chlorine. Less stable than calcium hypochlorite. Chlorine Reactive element (Cl) with strong oxidizing power, used for (water) disinfection.


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<table><tr><td>Chlorine demand</td><td>Difference between the amount of chlorine added to water and the total residual chlorine level after minimum 30 minutes, meaning the chlorine that is consumed during the disinfection process.</td></tr><tr><td>Cholera</td><td>Intestinal toxi-infection, strictly human, due to Vibrio cholerae infection.</td></tr><tr><td>Coagulation</td><td>Part of the treatment process where the negative electrical charge of the suspended particles in the water becomes neutral, due to the addition of a chemical or biological compound. This step will be followed by flocculation and potentially sedimentation and/or filtration.</td></tr><tr><td>Collection box</td><td>Construction for collecting liquids from different pipes to pass it in one pipe.</td></tr><tr><td>Combined Residual Chlorine (CRC)</td><td>That fraction of the chlorine that has been added to water, which is not consumed, nor is freely available in the water, but has combined with certain substances in the water.</td></tr><tr><td>Compost</td><td>Humus-like product produced by the controlled decomposition of organic matter; either night soil or sludge mixed with organic material rich in carbon (such as refuse or sawdust); and valued as fertilizer or mainly as soil conditioner.</td></tr><tr><td>Concrete ring</td><td>Short concrete cylinder for supporting and lining the sides of a well / pit to make them impermeable and/or stable.</td></tr><tr><td>Contact time</td><td>Period necessary for the reaction of chlorine with organic matter contained in water (at least 30 minutes for chlorine, depending on the pH and temperature of the water to be treated). Time that a high chlorine concentration stays within a well / borehole / reservoir for them to be disinfected (time depending on the method used).</td></tr><tr><td>Contamination</td><td>Introduction of potentially pathogenic micro-organisms or chemical substances presenting health risks into any environmental medium.</td></tr><tr><td>Controlled tipping</td><td>Method of disposal of solid wastes by burial in successive layers on a terrain that is exclusively reserved for this purpose. See Sanitary landfill.</td></tr><tr><td>Cytotoxic waste</td><td>All material that has been in contact with cytotoxic drugs, which are possessing a potential specific destructive action on cells.</td></tr><tr><td/><td/></tr><tr><td>Decontamination</td><td>Action to reduce contamination risks to harmless levels for people or the environment.</td></tr><tr><td>Defecation</td><td>Passage of waste matter from the bowels.</td></tr><tr><td>Density</td><td>Mass of matter within a certain volume.</td></tr><tr><td>Detergence</td><td>Physical-chemical action of a product combined with a mechanical brushing and rinsing action.</td></tr><tr><td>Detergent</td><td>Compound used in cleaning products (e.g. washing soap), often found in grey wastewater.</td></tr><tr><td>Dewatering pump</td><td>Pump that can be completely and partially submerged, as long as its the pumping part is under the water surface. These pumps can normally deal with (rather) dirty water.</td></tr><tr><td>Dioxin</td><td>Concern about them arises from their (potential) toxicity as contaminants in commercial products or within the exhaust gasses of volume reducers / incinerators. Tests on laboratory animals indicate that it is one of the more toxic anthropogenic products.</td></tr><tr><td>Disinfectant</td><td>Chemical agent that is able to reduce the viability of micro-organisms on surfaces, liquids (e.g. water) or objects (e.g. medical instruments, waste bins).</td></tr><tr><td>Disinfection</td><td>Treatment aimed at reducing the number of micro-organisms to safe or relatively safe levels on surfaces, liquids (e.g. water) or objects (e.g. medical instruments, waste bins).</td></tr><tr><td>Disposable syringe</td><td>An all-plastic syringe designed for single use.</td></tr><tr><td>Disposal</td><td>Intentional burial, deposit, discharge, dumping, placing or release of any waste material into or on any land sites, air medium, or water bodies as final destination.</td></tr><tr><td>Distribution box</td><td>Construction for collecting wastewater (e.g. effluent from a septic tank) and distributing it equally among several pipes (e.g. drains in a multiple trench infiltration system).</td></tr><tr><td>Domestic waste / Refuse</td><td>Putrescible (organic) or non-putrescible solid waste material from household activities. See solid waste.</td></tr><tr><td>DPD 1</td><td>Chemical used in tablet form with a colorimetric comparator (e.g. pool tester) to measure the Free Residual Chlorine concentration.</td></tr><tr><td>DPD 3</td><td>Chemical used in tablet form and added to a colorimetric comparator (e.g. pool tester) in which a DPD 1 tablet was already added to measure the Total Residual Chlorine concentration. The difference between the Total Residual Chlorine (TRC) and the Free Residual Chlorine (FRC) gives the Combined Residual Chlorine (CRC) concentration.</td></tr><tr><td>Drain</td><td>Underground pipe with pierced holes or slots to allow the passage and infiltration of water.</td></tr><tr><td>Drainage</td><td>Removal of runoff water or wastewater by ditches (&quot;open&quot; system) or pipes (&quot;closed&quot; system).</td></tr><tr><td>Drum</td><td>Any large (e.g. 200 litres) cylindrical shaped container.</td></tr><tr><td>Dumping site</td><td>A site used to dispose of (solid) waste without environmental controls. See disposal.</td></tr><tr><td>Dwelling</td><td>Utilised living space, within or nearby a settlement.</td></tr><tr><td/><td/></tr><tr><td>Effective grain size</td><td>Range and average dimension of grains of sand or other material used as filtration medium material.</td></tr></table>


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Chlorine demand Difference between the amount of chlorine added to water and the total residual chlorine level after minimum 30 minutes, meaning the chlorine that is consumed during the disinfection process. Cholera Intestinal toxi-infection, strictly human, due to Vibrio cholerae infection. Coagulation Part of the treatment process where the negative electrical charge of the suspended particles in the water becomes neutral, due to the addition of a chemical or biological compound. This step will be followed by flocculation and potentially sedimentation and/or filtration. Collection box Construction for collecting liquids from different pipes to pass it in one pipe. Combined Residual Chlorine (CRC) That fraction of the chlorine that has been added to water, which is not consumed, nor is freely available in the water, but has combined with certain substances in the water. Compost Humus-like product produced by the controlled decomposition of organic matter; either night soil or sludge


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available in the water, but has combined with certain substances in the water. Compost Humus-like product produced by the controlled decomposition of organic matter; either night soil or sludge mixed with organic material rich in carbon (such as refuse or sawdust); and valued as fertilizer or mainly as soil conditioner. Concrete ring Short concrete cylinder for supporting and lining the sides of a well / pit to make them impermeable and/or stable. Contact time Period necessary for the reaction of chlorine with organic matter contained in water (at least 30 minutes for chlorine, depending on the pH and temperature of the water to be treated). Time that a high chlorine concentration stays within a well / borehole / reservoir for them to be disinfected (time depending on the method used). Contamination Introduction of potentially pathogenic micro-organisms or chemical substances presenting health risks into any environmental medium. Controlled tipping Method of disposal of solid wastes


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Introduction of potentially pathogenic micro-organisms or chemical substances presenting health risks into any environmental medium. Controlled tipping Method of disposal of solid wastes by burial in successive layers on a terrain that is exclusively reserved for this purpose. See Sanitary landfill. Cytotoxic waste All material that has been in contact with cytotoxic drugs, which are possessing a potential specific destructive action on cells. Decontamination Action to reduce contamination risks to harmless levels for people or the environment. Defecation Passage of waste matter from the bowels. Density Mass of matter within a certain volume. Detergence Physical-chemical action of a product combined with a mechanical brushing and rinsing action. Detergent Compound used in cleaning products (e.g. washing soap), often found in grey wastewater. Dewatering pump Pump that can be completely and partially submerged, as long as its the pumping part is under the water surface. These pumps can


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(e.g. washing soap), often found in grey wastewater. Dewatering pump Pump that can be completely and partially submerged, as long as its the pumping part is under the water surface. These pumps can normally deal with (rather) dirty water. Dioxin Concern about them arises from their (potential) toxicity as contaminants in commercial products or within the exhaust gasses of volume reducers / incinerators. Tests on laboratory animals indicate that it is one of the more toxic anthropogenic products. Disinfectant Chemical agent that is able to reduce the viability of micro-organisms on surfaces, liquids (e.g. water) or objects (e.g. medical instruments, waste bins). Disinfection Treatment aimed at reducing the number of micro-organisms to safe or relatively safe levels on surfaces, liquids (e.g. water) or objects (e.g. medical instruments, waste bins). Disposable syringe An all-plastic syringe designed for single use. Disposal Intentional burial, deposit, discharge, dumping, placing or


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(e.g. water) or objects (e.g. medical instruments, waste bins). Disposable syringe An all-plastic syringe designed for single use. Disposal Intentional burial, deposit, discharge, dumping, placing or release of any waste material into or on any land sites, air medium, or water bodies as final destination. Distribution box Construction for collecting wastewater (e.g. effluent from a septic tank) and distributing it equally among several pipes (e.g. drains in a multiple trench infiltration system). Domestic waste / Refuse Putrescible (organic) or non-putrescible solid waste material from household activities. See solid waste. DPD 1 Chemical used in tablet form with a colorimetric comparator (e.g. pool tester) to measure the Free Residual Chlorine concentration. DPD 3 Chemical used in tablet form and added to a colorimetric comparator (e.g. pool tester) in which a DPD 1 tablet was already added to measure the Total Residual Chlorine concentration. The difference between the Total


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tablet form and added to a colorimetric comparator (e.g. pool tester) in which a DPD 1 tablet was already added to measure the Total Residual Chlorine concentration. The difference between the Total Residual Chlorine (TRC) and the Free Residual Chlorine (FRC) gives the Combined Residual Chlorine (CRC) concentration. Drain Underground pipe with pierced holes or slots to allow the passage and infiltration of water. Drainage Removal of runoff water or wastewater by ditches ("open" system) or pipes ("closed" system). Drum Any large (e.g. 200 litres) cylindrical shaped container. Dumping site A site used to dispose of (solid) waste without environmental controls. See disposal. Dwelling Utilised living space, within or nearby a settlement. Effective grain size Range and average dimension of grains of sand or other material used as filtration medium material.


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<table><tr><td>Effluent</td><td>Partially or totally treated wastewater coming from a treatment unit and going to secondary treatment or disposal in the environment.</td></tr><tr><td>Emergence / Eye</td><td>Place where spring water appears at the surface.</td></tr><tr><td>Encapsulation</td><td>Waste disposal method used to immobilize hazardous waste (e.g. expired or unwanted pharmaceuticals) by containment within a cement, lime and water mixture (3 / 3 / 1 parts by weight) in a sealed drum.</td></tr><tr><td>Environmental impact</td><td>The positive and negative effects of a certain action on the population, the surrounding mediums (e.g. air, soil, water) and the climate.</td></tr><tr><td>Escherichia coliform (E-coli)</td><td>A bacteria group often used as the indicator of choice in micro-biological analysis for faecal pollution (of warm blooded animals, humans included).</td></tr><tr><td>Evapo-transpiration</td><td>Natural process where water is removed / lost into the air by a combination of direct soil evaporation and transpiration by plants. This principle can be used for the disposal of wastewater, particularly in arid areas.</td></tr><tr><td>Excreta</td><td>Human wastes, particularly faeces and urine.</td></tr><tr><td/><td/></tr><tr><td>Faeco-oral transmission</td><td>Transmission of pathogens from faecal matter to the digestive system via the mouth (e.g. faecal contamination of water, food, hands).</td></tr><tr><td>Ferrocement</td><td>Technique of constructing walls by applying layers of cement mortar to a framework of wire / mesh.</td></tr><tr><td>Fertilizer</td><td>Substance (chemical or organic) used in agriculture to improve soil fertility.</td></tr><tr><td>Filtration</td><td>Passage of water through a porous medium (filter) that traps solid and sometimes dissolved particles. This principle can happen naturally or be man-made to remove elements that are unwanted and/or hazardous to health (e.g. suspended particles, pathogens).</td></tr><tr><td>Final disposal</td><td>Disposal that is undertaken without the intention of retrieval in a later stage. See disposal.</td></tr><tr><td>Flocculation</td><td>Process by which suspended solids in water are aggregated into clusters through biological or chemical action (coagulation), so that they can be separated from water by sedimentation or filtration.</td></tr><tr><td>Flock</td><td>A cluster of suspended solids formed in the water by biological or chemical action. See flocculation.</td></tr><tr><td>Flow rate</td><td>The rate at which a fluid is flowing, either naturally or man-made (e.g. pumps). Expressed as volume per time unit (e.g. litres per second, m³ per hour).</td></tr><tr><td>Free Residual Chlorine (FRC)</td><td>That fraction of the chlorine that has been added to the water, which is not consumed, nor combined with certain substances in the water, but that remains freely available in excess after a contact time of at least 30 minutes, and has as such still a rapid disinfecting capacity. (desired concentration: 0.2 to 0.5 mg/l if pH &lt; 8; 0.4 to 1.0 mg/l if pH &gt; 8)</td></tr><tr><td>Furan</td><td>Substance / contaminant found in different concentrations in combustion smoke (e.g. wood), thus also in the exhaust gasses of engines and incinerators, depending on the combustion quality. Furan is carcinogenic to humans and its primary exposure route is inhalation.</td></tr><tr><td/><td/></tr><tr><td>Germ</td><td>General term that refers to micro-organisms such as bacteria, protozoa, viruses, fungi that are harmful to health.</td></tr><tr><td>Gravel</td><td>Small (river) stones, used in construction, which can be found naturally or are produced by crushing larger stones.</td></tr><tr><td>Grease trap</td><td>Special construction for separating grease, fat or oil from grey wastewater, before secondary treatment or its disposal in infiltration facilities (e.g. soak away pit, infiltration trenches) or into the sewer.</td></tr><tr><td>Grey water</td><td>Domestic wastewater not containing excreta, also called sullage.</td></tr><tr><td>Groundwater</td><td>Infiltrated water contained in underground porous layers, forming a body of water, which can supply wells and springs.</td></tr><tr><td/><td/></tr><tr><td>Hazardous</td><td>Intrinsic potential property or ability to cause harm.</td></tr><tr><td>Hazardous waste</td><td>Waste (often medical) that is considered to be dangerous for health or the environment; includes e.g. expired or unwanted drugs, laboratory reagents, insecticides, X-ray related waste, expired disinfectants.</td></tr><tr><td>Health care waste</td><td>Waste generated by all kinds of medical activities, including medical waste (sharp, soft, organic and hazardous waste), excreta and wastewater.</td></tr><tr><td>Heavy metal</td><td>Metallic elements with high atomic weight (e.g. mercury, chromium, cadmium, arsenic, and lead) that can harm living beings at low concentrations and tend to accumulate in the food chain.</td></tr><tr><td>Helminths</td><td>Scientific name for worms.</td></tr><tr><td>Host</td><td>A living organism (e.g. human patient, animal) that maintains or harbours an infectious agent (virus, bacteria or parasite). Considered as a part of disease transmission.</td></tr><tr><td>Human waste</td><td>Faeces and urine (excreta).</td></tr></table>


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Effluent Partially or totally treated wastewater coming from a treatment unit and going to secondary treatment or disposal in the environment. Emergence / Eye Place where spring water appears at the surface. Encapsulation Waste disposal method used to immobilize hazardous waste (e.g. expired or unwanted pharmaceuticals) by containment within a cement, lime and water mixture (3 / 3 / 1 parts by weight) in a sealed drum. Environmental impact The positive and negative effects of a certain action on the population, the surrounding mediums (e.g. air, soil, water) and the climate. Escherichia coliform (E-coli) A bacteria group often used as the indicator of choice in micro-biological analysis for faecal pollution (of warm blooded animals, humans included). Evapo-transpiration Natural process where water is removed / lost into the air by a combination of direct soil evaporation and transpiration by plants. This principle can be used for the disposal of wastewater, particularly in arid areas.


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water is removed / lost into the air by a combination of direct soil evaporation and transpiration by plants. This principle can be used for the disposal of wastewater, particularly in arid areas. Excreta Human wastes, particularly faeces and urine. Faeco-oral transmission Transmission of pathogens from faecal matter to the digestive system via the mouth (e.g. faecal contamination of water, food, hands). Ferrocement Technique of constructing walls by applying layers of cement mortar to a framework of wire / mesh. Fertilizer Substance (chemical or organic) used in agriculture to improve soil fertility. Filtration Passage of water through a porous medium (filter) that traps solid and sometimes dissolved particles. This principle can happen naturally or be man-made to remove elements that are unwanted and/or hazardous to health (e.g. suspended particles, pathogens). Final disposal Disposal that is undertaken without the intention of retrieval in a later stage. See disposal. Flocculation


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unwanted and/or hazardous to health (e.g. suspended particles, pathogens). Final disposal Disposal that is undertaken without the intention of retrieval in a later stage. See disposal. Flocculation Process by which suspended solids in water are aggregated into clusters through biological or chemical action (coagulation), so that they can be separated from water by sedimentation or filtration. Flock A cluster of suspended solids formed in the water by biological or chemical action. See flocculation. Flow rate The rate at which a fluid is flowing, either naturally or man-made (e.g. pumps). Expressed as volume per time unit (e.g. litres per second, m³ per hour). Free Residual Chlorine (FRC) That fraction of the chlorine that has been added to the water, which is not consumed, nor combined with certain substances in the water, but that remains freely available in excess after a contact time of at least 30 minutes, and has as such still a rapid disinfecting capacity. (desired


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combined with certain substances in the water, but that remains freely available in excess after a contact time of at least 30 minutes, and has as such still a rapid disinfecting capacity. (desired concentration: 0.2 to 0.5 mg/l if pH < 8; 0.4 to 1.0 mg/l if pH > 8) Furan Substance / contaminant found in different concentrations in combustion smoke (e.g. wood), thus also in the exhaust gasses of engines and incinerators, depending on the combustion quality. Furan is carcinogenic to humans and its primary exposure route is inhalation. Germ General term that refers to micro-organisms such as bacteria, protozoa, viruses, fungi that are harmful to health. Gravel Small (river) stones, used in construction, which can be found naturally or are produced by crushing larger stones. Grease trap Special construction for separating grease, fat or oil from grey wastewater, before secondary treatment or its disposal in infiltration facilities (e.g. soak away pit, infiltration trenches) or into the


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construction for separating grease, fat or oil from grey wastewater, before secondary treatment or its disposal in infiltration facilities (e.g. soak away pit, infiltration trenches) or into the sewer. Grey water Domestic wastewater not containing excreta, also called sullage. Groundwater Infiltrated water contained in underground porous layers, forming a body of water, which can supply wells and springs. Hazardous Intrinsic potential property or ability to cause harm. Hazardous waste Waste (often medical) that is considered to be dangerous for health or the environment; includes e.g. expired or unwanted drugs, laboratory reagents, insecticides, X-ray related waste, expired disinfectants. Health care waste Waste generated by all kinds of medical activities, including medical waste (sharp, soft, organic and hazardous waste), excreta and wastewater. Heavy metal Metallic elements with high atomic weight (e.g. mercury, chromium, cadmium, arsenic, and lead) that can harm living beings at


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soft, organic and hazardous waste), excreta and wastewater. Heavy metal Metallic elements with high atomic weight (e.g. mercury, chromium, cadmium, arsenic, and lead) that can harm living beings at low concentrations and tend to accumulate in the food chain. Helminths Scientific name for worms. Host A living organism (e.g. human patient, animal) that maintains or harbours an infectious agent (virus, bacteria or parasite). Considered as a part of disease transmission. Human waste Faeces and urine (excreta).


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<table><tr><td>Hygiene</td><td>Practises related to cleanliness and health as it prevents the dispersion of diseases.</td></tr><tr><td/><td/></tr><tr><td>Improved trench latrines</td><td>Improved version of normal trench latrines with prefabricated (plastic) slabs and a basic plastic sheeting superstructure for more privacy, still intended for (acute) emergencies.</td></tr><tr><td>Incineration</td><td>A waste treatment process involving destruction of waste by controlled burning at high temperatures, reducing voluminous waste into ashes.</td></tr><tr><td>Incinerator</td><td>A furnace for burning (medical) waste under controlled conditions, often utilised in health facilities as a waste treatment tool. In this manual, mainly double combustion chamber furnaces are referred to as incinerators, in contradiction to volume reducers which only have a single combustion chamber.</td></tr><tr><td>Inertization</td><td>Immobilization of certain powdered / solid hazardous waste (after being crushed) by being embedded within a cement, lime and water mixture (3 / 3 / 1 parts by weight) that solidifies, in order to minimize the risk of toxic substances contained in the waste to migrate to the environment. Used for disposal of pharmaceutical waste.</td></tr><tr><td>Infiltration (rate)</td><td>The quantity of water that can enter the soil in a specified time interval, normally measured as litre per m² of infiltration surface a day (l/m²-day).</td></tr><tr><td>Infiltration trench</td><td>Structure for disposing of wastewater by underground drainage, using trenches and drains.</td></tr><tr><td>Insect</td><td>A kind of arthropod. Insects have three distinct body regions (head, thorax and abdomen), three pairs of legs, one pair of antennae, and usually one or two pairs of wings in the adult phase.</td></tr><tr><td>Irrigation furrow / Irrigated garden</td><td>Vegetable garden watered with clean spilled wastewater recovered from water points (e.g. hand pump, tapstand).</td></tr><tr><td/><td/></tr><tr><td>Lancet</td><td>Puncturing device used to collect blood drops for medical analysis.</td></tr><tr><td>Larva</td><td>The intermediary stage between the egg and the pupa, in the development of an arthropod. See arthropod.</td></tr><tr><td>Larvicide</td><td>A chemical or biological compound which specifically kills insect larva.</td></tr><tr><td>Latrine</td><td>(External) defecation place for deposition, retention and sometimes decomposition of excreta.</td></tr><tr><td>Leachates</td><td>Liquid resulting from decomposition of organic matter in a waste bin, dump sites or landfills, sometimes joined with water trickling through. It may result in hazardous substances entering surface or ground water, or the soil.</td></tr><tr><td>Lime</td><td>Ca(OH)2. Yellowish white stone or powder. Can be found in the environment and has various uses; e.g. construction, water treatment, waste disposal.</td></tr><tr><td>Lining</td><td>Construction strengthening / sleeving / supporting a mainly underground structure, like for hand dug wells, pit latrines and waste pits.</td></tr><tr><td>Luer syringe</td><td>Syringe on which a separate needle can be connected with a sliding motion, and disconnected similarly.</td></tr><tr><td>Luer-lock syringe</td><td>Syringe on which a separate needle can be connected with a screwing motion, and disconnected similarly.</td></tr><tr><td/><td/></tr><tr><td>Manure</td><td>Animal excreta, normally faecal matter from livestock.</td></tr><tr><td>Medical waste</td><td>Waste generated by all kinds of medical activities, but excluding excreta and wastewater. In this manual, medical waste is considered under four different categories: sharps, soft (burnable) waste, organic waste and hazardous waste.</td></tr><tr><td>Micro-organism</td><td>Any micro-biological entity, cellular or non-cellular, capable of replication or of transferring genetic material under certain environmental variables. It includes bacteria, virus, protozoa and microscopic fungi.</td></tr><tr><td>Motor pump</td><td>Surface pump powered by an electric motor or combustion engine.</td></tr><tr><td/><td/></tr><tr><td>NaDCC</td><td>Sodium Di-Chloro isoCyanurate. Chlorine-generating product under granular or tablet form, usually containing 55 to 60% active chlorine. By far, the most stable chlorine-generating product.</td></tr><tr><td>Needle</td><td>Hollowed and pointed steel stem used for puncturing or injecting.</td></tr><tr><td>Needle stick injury</td><td>Harm caused by unintentional needle puncture. Can cause nosocomial infections, such as hepatitis B, hepatitis C and HIV / AIDS.</td></tr><tr><td>Nitrates (NO3)</td><td>A plant nutrient and inorganic fertilizer, nitrates are found in septic systems, animal feed lots, agricultural fertilizers, manure, industrial waste waters, sanitary landfills, and garbage dumps. High levels of nitrates in drinking water should be avoided for newborn babies, small infants and pregnant women, due to the severe health effects that can be caused.</td></tr><tr><td>Non-return valve</td><td>Valve allowing water to flow in one direction only.</td></tr><tr><td>Nosocomial infection</td><td>Secondary infection contracted by the patients or the staff while being within a health structure. Often referred to as hospital infection.</td></tr></table>


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Hygiene Practises related to cleanliness and health as it prevents the dispersion of diseases. Improved trench latrines Improved version of normal trench latrines with prefabricated (plastic) slabs and a basic plastic sheeting superstructure for more privacy, still intended for (acute) emergencies. Incineration A waste treatment process involving destruction of waste by controlled burning at high temperatures, reducing voluminous waste into ashes. Incinerator A furnace for burning (medical) waste under controlled conditions, often utilised in health facilities as a waste treatment tool. In this manual, mainly double combustion chamber furnaces are referred to as incinerators, in contradiction to volume reducers which only have a single combustion chamber. Inertization Immobilization of certain powdered / solid hazardous waste (after being crushed) by being embedded within a cement, lime and water mixture (3 / 3 / 1 parts by weight) that solidifies, in order to minimize the risk of


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certain powdered / solid hazardous waste (after being crushed) by being embedded within a cement, lime and water mixture (3 / 3 / 1 parts by weight) that solidifies, in order to minimize the risk of toxic substances contained in the waste to migrate to the environment. Used for disposal of pharmaceutical waste. Infiltration (rate) The quantity of water that can enter the soil in a specified time interval, normally measured as litre per m² of infiltration surface a day (l/m²-day). Infiltration trench Structure for disposing of wastewater by underground drainage, using trenches and drains. Insect A kind of arthropod. Insects have three distinct body regions (head, thorax and abdomen), three pairs of legs, one pair of antennae, and usually one or two pairs of wings in the adult phase. Irrigation furrow / Irrigated garden Vegetable garden watered with clean spilled wastewater recovered from water points (e.g. hand pump, tapstand). Lancet Puncturing device used to collect blood drops for


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furrow / Irrigated garden Vegetable garden watered with clean spilled wastewater recovered from water points (e.g. hand pump, tapstand). Lancet Puncturing device used to collect blood drops for medical analysis. Larva The intermediary stage between the egg and the pupa, in the development of an arthropod. See arthropod. Larvicide A chemical or biological compound which specifically kills insect larva. Latrine (External) defecation place for deposition, retention and sometimes decomposition of excreta. Leachates Liquid resulting from decomposition of organic matter in a waste bin, dump sites or landfills, sometimes joined with water trickling through. It may result in hazardous substances entering surface or ground water, or the soil. Lime Ca(OH)2. Yellowish white stone or powder. Can be found in the environment and has various uses; e.g. construction, water treatment, waste disposal. Lining Construction strengthening / sleeving / supporting a mainly underground structure, like for


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found in the environment and has various uses; e.g. construction, water treatment, waste disposal. Lining Construction strengthening / sleeving / supporting a mainly underground structure, like for hand dug wells, pit latrines and waste pits. Luer syringe Syringe on which a separate needle can be connected with a sliding motion, and disconnected similarly. Luer-lock syringe Syringe on which a separate needle can be connected with a screwing motion, and disconnected similarly. Manure Animal excreta, normally faecal matter from livestock. Medical waste Waste generated by all kinds of medical activities, but excluding excreta and wastewater. In this manual, medical waste is considered under four different categories: sharps, soft (burnable) waste, organic waste and hazardous waste. Micro-organism Any micro-biological entity, cellular or non-cellular, capable of replication or of transferring genetic material under certain environmental variables. It includes bacteria, virus, protozoa and


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Any micro-biological entity, cellular or non-cellular, capable of replication or of transferring genetic material under certain environmental variables. It includes bacteria, virus, protozoa and microscopic fungi. Motor pump Surface pump powered by an electric motor or combustion engine. NaDCC Sodium Di-Chloro isoCyanurate. Chlorine-generating product under granular or tablet form, usually containing 55 to 60% active chlorine. By far, the most stable chlorine-generating product. Needle Hollowed and pointed steel stem used for puncturing or injecting. Needle stick injury Harm caused by unintentional needle puncture. Can cause nosocomial infections, such as hepatitis B, hepatitis C and HIV / AIDS. Nitrates (NO3) A plant nutrient and inorganic fertilizer, nitrates are found in septic systems, animal feed lots, agricultural fertilizers, manure, industrial waste waters, sanitary landfills, and garbage dumps. High levels of nitrates in drinking water should be avoided for newborn babies,


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animal feed lots, agricultural fertilizers, manure, industrial waste waters, sanitary landfills, and garbage dumps. High levels of nitrates in drinking water should be avoided for newborn babies, small infants and pregnant women, due to the severe health effects that can be caused. Non-return valve Valve allowing water to flow in one direction only. Nosocomial infection Secondary infection contracted by the patients or the staff while being within a health structure. Often referred to as hospital infection.


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<table><tr><td>Organic matter</td><td>Residues or extracts of living organisms.</td></tr><tr><td>Organic waste</td><td>Biodegradable waste. Waste generated in health care facilities such as amputated limbs, placentas, organs, blood and food residues.</td></tr><tr><td>Oxidize</td><td>To transform in the oxidized state. Normally signifies the chemical addition of an element (e.g. oxygen) to break down pollutants or organic wastes.</td></tr><tr><td/><td/></tr><tr><td>Parasite</td><td>An organism which, for all or part of its life, lives in or on the body of another organism (the host) and obtains nourishment from it, without causing the death of the host. Parasites include fungi, arthropods, protozoa, helminths.</td></tr><tr><td>Pathogen</td><td>Any disease causing organism or substance.</td></tr><tr><td>Percolation</td><td>The movement of water downward and radial through subsurface soil layers, usually continuing downward to ground water. Slow seepage of water through a filter.</td></tr><tr><td>Permeability</td><td>The characteristic or the measure of the ease with which water can flow through / infiltrate a solid media / soil.</td></tr><tr><td>Pest</td><td>An inconvenient insect, rodent, nematode, fungus, weed or other form of terrestrial or aquatic plant or animal life that is injurious to health or the environment.</td></tr><tr><td>Pesticide</td><td>Substances or mixtures that are intended for preventing, destroying, repelling, or mitigating any pest.</td></tr><tr><td>pH</td><td>Expression of the degree of acidity or alkalinity of a substance; may range from 0 to 14. The value of 7 is considered as neutral, values below are acidic, values above alkaline (basic).</td></tr><tr><td>Pharmaceutical waste</td><td>All medicines that cannot be used anymore such as opened but unused drugs, cold chain damaged vaccines, expired and unwanted drugs.</td></tr><tr><td>Phenol Red</td><td>Chemical compound used to measure the pH by colorimetric comparison (e.g. pool tester), often in tablet form.</td></tr><tr><td>Pond</td><td>Small body of surface water.</td></tr><tr><td>Porosity</td><td>The ratio of open space in comparison to the total volume (of soil), which is an indicator of the ability of a medium to pass fluids through it.</td></tr><tr><td>Pour flush latrine</td><td>Latrine in which the slab has a pan and water trap, and which is flushed manually.</td></tr><tr><td>ppm</td><td>Parts per million</td></tr><tr><td>Precipitation</td><td>Water in the form of rain, sleet, hail or snow that falls from the atmosphere onto the land and bodies of water.</td></tr><tr><td>Protozoa</td><td>Group of unicellular micro-organisms that are larger and more complex than bacteria, certain of which may cause disease in humans (e.g. amoeba).</td></tr><tr><td>Pupa</td><td>The intermediate stage between the larva and the adult , in the development of an insect.</td></tr><tr><td/><td/></tr><tr><td>Radioactive waste</td><td>Material that contains or is contaminated with radionuclide at concentrations or activities greater than clearance levels. See radionuclide.</td></tr><tr><td>Radionuclide</td><td>An atom (nuclide) that exhibits properties of spontaneous disintegration, liberating energy and is accompanied by the emission of different types of (very harmful) radiation.</td></tr><tr><td>Rainfall patterns</td><td>Historical records of the distribution and quantity of rainfall for a certain area.</td></tr><tr><td>Rainwater</td><td>Water from atmospheric precipitation which may be collected or form / contribute to a water body.</td></tr><tr><td>Rainwater harvesting</td><td>Controlled collection and storage of rainwater, to be used for human activities.</td></tr><tr><td>Rapid sand filter</td><td>Water treatment system at high velocity (4 - 50 m/h) by mechanical filtration (sand bed).</td></tr><tr><td>Refuse</td><td>Generally domestic solid waste.</td></tr><tr><td>Resurgence</td><td>Surface water that went underground coming back at the surface, often wrongly interpreted as a spring.</td></tr><tr><td>Retention time</td><td>Time during which wastewater is held in a tank to undergo some form of treatment (e.g.: 1 to 3 days in a septic tank). Time during which combustion gasses stay within the hot environment of an incinerator.</td></tr><tr><td>Risk</td><td>Probability that a hazard will cause harm, and the severity of that harm.</td></tr><tr><td>Rodent</td><td>Mammals including rats, mice, squirrels, muskrats, beavers and others. Concern is due to their high infestation rate causing damage to infrastructures, food stocks and potential health risks.</td></tr><tr><td>Runoff (water)</td><td>That part of the precipitation (e.g. rain, snow, hail, snow melt), or irrigation water that flows naturally on the ground towards surface water bodies (e.g. river, lake).</td></tr><tr><td/><td/></tr><tr><td>Safe injection</td><td>An injection that does not harm the patient, does not expose the health worker to any risk, and does not result in waste that puts the handlers and/or the community at risk.</td></tr><tr><td>Sand</td><td>Granular silica compound which is found naturally and is used as building material and filtration medium in water treatment plants.</td></tr></table>


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Organic matter Residues or extracts of living organisms. Organic waste Biodegradable waste. Waste generated in health care facilities such as amputated limbs, placentas, organs, blood and food residues. Oxidize To transform in the oxidized state. Normally signifies the chemical addition of an element (e.g. oxygen) to break down pollutants or organic wastes. Parasite An organism which, for all or part of its life, lives in or on the body of another organism (the host) and obtains nourishment from it, without causing the death of the host. Parasites include fungi, arthropods, protozoa, helminths. Pathogen Any disease causing organism or substance. Percolation The movement of water downward and radial through subsurface soil layers, usually continuing downward to ground water. Slow seepage of water through a filter. Permeability The characteristic or the measure of the ease with which water can flow through / infiltrate a solid media / soil. Pest An inconvenient insect, rodent, nematode,


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water through a filter. Permeability The characteristic or the measure of the ease with which water can flow through / infiltrate a solid media / soil. Pest An inconvenient insect, rodent, nematode, fungus, weed or other form of terrestrial or aquatic plant or animal life that is injurious to health or the environment. Pesticide Substances or mixtures that are intended for preventing, destroying, repelling, or mitigating any pest. pH Expression of the degree of acidity or alkalinity of a substance; may range from 0 to 14. The value of 7 is considered as neutral, values below are acidic, values above alkaline (basic). Pharmaceutical waste All medicines that cannot be used anymore such as opened but unused drugs, cold chain damaged vaccines, expired and unwanted drugs. Phenol Red Chemical compound used to measure the pH by colorimetric comparison (e.g. pool tester), often in tablet form. Pond Small body of surface water. Porosity The ratio of open space in comparison to the total volume


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used to measure the pH by colorimetric comparison (e.g. pool tester), often in tablet form. Pond Small body of surface water. Porosity The ratio of open space in comparison to the total volume (of soil), which is an indicator of the ability of a medium to pass fluids through it. Pour flush latrine Latrine in which the slab has a pan and water trap, and which is flushed manually. ppm Parts per million Precipitation Water in the form of rain, sleet, hail or snow that falls from the atmosphere onto the land and bodies of water. Protozoa Group of unicellular micro-organisms that are larger and more complex than bacteria, certain of which may cause disease in humans (e.g. amoeba). Pupa The intermediate stage between the larva and the adult , in the development of an insect. Radioactive waste Material that contains or is contaminated with radionuclide at concentrations or activities greater than clearance levels. See radionuclide. Radionuclide An atom (nuclide) that exhibits properties of


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Material that contains or is contaminated with radionuclide at concentrations or activities greater than clearance levels. See radionuclide. Radionuclide An atom (nuclide) that exhibits properties of spontaneous disintegration, liberating energy and is accompanied by the emission of different types of (very harmful) radiation. Rainfall patterns Historical records of the distribution and quantity of rainfall for a certain area. Rainwater Water from atmospheric precipitation which may be collected or form / contribute to a water body. Rainwater harvesting Controlled collection and storage of rainwater, to be used for human activities. Rapid sand filter Water treatment system at high velocity (4 - 50 m/h) by mechanical filtration (sand bed). Refuse Generally domestic solid waste. Resurgence Surface water that went underground coming back at the surface, often wrongly interpreted as a spring. Retention time Time during which wastewater is held in a tank to undergo some form of treatment


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Surface water that went underground coming back at the surface, often wrongly interpreted as a spring. Retention time Time during which wastewater is held in a tank to undergo some form of treatment (e.g.: 1 to 3 days in a septic tank). Time during which combustion gasses stay within the hot environment of an incinerator. Risk Probability that a hazard will cause harm, and the severity of that harm. Rodent Mammals including rats, mice, squirrels, muskrats, beavers and others. Concern is due to their high infestation rate causing damage to infrastructures, food stocks and potential health risks. Runoff (water) That part of the precipitation (e.g. rain, snow, hail, snow melt), or irrigation water that flows naturally on the ground towards surface water bodies (e.g. river, lake). Safe injection An injection that does not harm the patient, does not expose the health worker to any risk, and does not result in waste that puts the handlers and/or the community at risk. Sand Granular silica


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An injection that does not harm the patient, does not expose the health worker to any risk, and does not result in waste that puts the handlers and/or the community at risk. Sand Granular silica compound which is found naturally and is used as building material and filtration medium in water treatment plants.


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<table><tr><td>Sanitary inspection</td><td>Field observation, using criteria to evaluate the environmental hygiene status of a settlement (e.g. refugee camp). It should include the inspection of water points (e.g. well, river) and sanitary facilities (e.g. latrines, wastewater disposal), if existing.</td></tr><tr><td>Sanitary landfill</td><td>Disposal sites for non-hazardous solid wastes spread in layers, compacted to the smallest practical volume, and covered by soil applied at the end of each operating day. In some cases, a specific part of the site can be foreseen to dispose of hazardous waste, or more in general medical waste.</td></tr><tr><td>Scalpel</td><td>Medical instrument consists of a handle and a sharp disposable blade used in surgical dissection.</td></tr><tr><td>Scavengers</td><td>Human or animal which depends on refuse (from waste dumps) for survival.</td></tr><tr><td>Schmutzdecke</td><td>Biological layer (bio film) at the surface of a slow sand filter, playing a purifying role. See slow sand filter.</td></tr><tr><td>Sedimentation / Settling</td><td>The process of deposition of impurities in water (e.g. suspended solids) to the bottom part of a reservoir, due to gravity.</td></tr><tr><td>Segregation</td><td>Separation of waste materials (medical waste) into different categories: sharps, soft (burnable), organic and hazardous waste. It is desired to take place at the source where the waste is generated.</td></tr><tr><td>Septic tank</td><td>Reservoir for collection and partial treatment of wastewater (mainly sewage, and potentially sullage) before further treatment and/or disposal (e.g. into sub-surface drainage, closed sewer).</td></tr><tr><td>Sewage</td><td>Wastewater containing excreta. Sometimes also called black water.</td></tr><tr><td>Sharps</td><td>Medical equipment such as needles, scalpel and raiser blades, lancets, and also empty ampoules, vials and broken glass that can cause injuries. Considered after use as a separate category of medical waste.</td></tr><tr><td>Sharps container</td><td>Recipient used in health facilities for segregating, temporary storage, transportation and eventual disposal of sharp wastes.</td></tr><tr><td>Slow sand filter</td><td>Water treatment system at low velocity by combination of mechanical filtration (sand bed) and biological purification (Schmutzedcke).</td></tr><tr><td>Slurry</td><td>A watery mixture of insoluble matter resulting from some pollution control techniques and installations.</td></tr><tr><td>Soak away pit</td><td>Hole filled with (big) stones, used for infiltration of pre-treated wastewater (from septic tank / grease trap).</td></tr><tr><td>Sodium Di-Chloro isoCyanurate</td><td>Chlorine-generating product under granular or tablet form, containing 55 to 60% active chlorine, often called NaDCC. By far, the most stable chlorine-generating product.</td></tr><tr><td>Sodium hypochlorite</td><td>Chlorine-generating product (NaOCl) under liquid form, containing 4 to 15% chlorine, often called bleach. Much less stable than calcium hypochlorite and NaDCC.</td></tr><tr><td>Sodium thiosulphate</td><td>Crystalline chemical substance used for de-chlorinating drinking water (used during sampling of chlorinated water for micro-biological analysis).</td></tr><tr><td>Soil</td><td>A complex mixture of inorganic materials (clay, silt, gravel and sand), decaying organic matter, water, air and living organisms, which covers the Earth&#x27;s surface.</td></tr><tr><td>Solid waste</td><td>All non-liquid waste.</td></tr><tr><td>Spring</td><td>Groundwater seeping naturally out of the earth. A spring can be a seasonal or a permanent water source.</td></tr><tr><td>Stakeholders</td><td>Any organization, governmental entity, or individual that has an interest in or may be affected by a given approach to environmental regulation, pollution prevention, energy conservation, etc.</td></tr><tr><td>Standing water / Stagnant water</td><td>Water from rain or human activities, which remain static on the ground surface.</td></tr><tr><td>Sterile</td><td>Any object or media that does not contain germs or any other form of life.</td></tr><tr><td>Sterilisation</td><td>Elimination of all micro-organisms ( viruses, bacteria and microscopic fungi) from water, objects or from a surface.</td></tr><tr><td>Stock solution / &quot;Mother solution&quot;</td><td>Concentrated solution of 1%, used for treating (chlorination, coagulation - flocculation) a known volume of water.</td></tr><tr><td>Storm water</td><td>Rainwater running on the ground surface (collected and disposed of separately from wastewater). See runoff water.</td></tr><tr><td>Strainer</td><td>Sieve to keep back large impurities that are present in the water. It should be installed, often in combination with a non-return valve, at the bottom end of a suction pipe. It is also integrated directly on submersible and dewatering pumps.</td></tr><tr><td>Submersible pump</td><td>Pump that is completely, as well the pumping part as the electrical motor, under the water surface. Normally designed to pump clean water.</td></tr><tr><td>Subsoil</td><td>A complete mixture of inorganic materials (clay, silt, gravel, sand) under the ground level and above the bedrock.</td></tr></table>


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Sanitary inspection Field observation, using criteria to evaluate the environmental hygiene status of a settlement (e.g. refugee camp). It should include the inspection of water points (e.g. well, river) and sanitary facilities (e.g. latrines, wastewater disposal), if existing. Sanitary landfill Disposal sites for non-hazardous solid wastes spread in layers, compacted to the smallest practical volume, and covered by soil applied at the end of each operating day. In some cases, a specific part of the site can be foreseen to dispose of hazardous waste, or more in general medical waste. Scalpel Medical instrument consists of a handle and a sharp disposable blade used in surgical dissection. Scavengers Human or animal which depends on refuse (from waste dumps) for survival. Schmutzdecke Biological layer (bio film) at the surface of a slow sand filter, playing a purifying role. See slow sand filter. Sedimentation / Settling The process of deposition of impurities in water (e.g. suspended


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layer (bio film) at the surface of a slow sand filter, playing a purifying role. See slow sand filter. Sedimentation / Settling The process of deposition of impurities in water (e.g. suspended solids) to the bottom part of a reservoir, due to gravity. Segregation Separation of waste materials (medical waste) into different categories: sharps, soft (burnable), organic and hazardous waste. It is desired to take place at the source where the waste is generated. Septic tank Reservoir for collection and partial treatment of wastewater (mainly sewage, and potentially sullage) before further treatment and/or disposal (e.g. into sub-surface drainage, closed sewer). Sewage Wastewater containing excreta. Sometimes also called black water. Sharps Medical equipment such as needles, scalpel and raiser blades, lancets, and also empty ampoules, vials and broken glass that can cause injuries. Considered after use as a separate category of medical waste. Sharps container Recipient used in health


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blades, lancets, and also empty ampoules, vials and broken glass that can cause injuries. Considered after use as a separate category of medical waste. Sharps container Recipient used in health facilities for segregating, temporary storage, transportation and eventual disposal of sharp wastes. Slow sand filter Water treatment system at low velocity by combination of mechanical filtration (sand bed) and biological purification (Schmutzedcke). Slurry A watery mixture of insoluble matter resulting from some pollution control techniques and installations. Soak away pit Hole filled with (big) stones, used for infiltration of pre-treated wastewater (from septic tank / grease trap). Sodium Di-Chloro isoCyanurate Chlorine-generating product under granular or tablet form, containing 55 to 60% active chlorine, often called NaDCC. By far, the most stable chlorine-generating product. Sodium hypochlorite Chlorine-generating product (NaOCl) under liquid form, containing 4 to 15% chlorine, often


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chlorine, often called NaDCC. By far, the most stable chlorine-generating product. Sodium hypochlorite Chlorine-generating product (NaOCl) under liquid form, containing 4 to 15% chlorine, often called bleach. Much less stable than calcium hypochlorite and NaDCC. Sodium thiosulphate Crystalline chemical substance used for de-chlorinating drinking water (used during sampling of chlorinated water for micro-biological analysis). Soil A complex mixture of inorganic materials (clay, silt, gravel and sand), decaying organic matter, water, air and living organisms, which covers the Earth's surface. Solid waste All non-liquid waste. Spring Groundwater seeping naturally out of the earth. A spring can be a seasonal or a permanent water source. Stakeholders Any organization, governmental entity, or individual that has an interest in or may be affected by a given approach to environmental regulation, pollution prevention, energy conservation, etc. Standing water / Stagnant water Water from rain or


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that has an interest in or may be affected by a given approach to environmental regulation, pollution prevention, energy conservation, etc. Standing water / Stagnant water Water from rain or human activities, which remain static on the ground surface. Sterile Any object or media that does not contain germs or any other form of life. Sterilisation Elimination of all micro-organisms ( viruses, bacteria and microscopic fungi) from water, objects or from a surface. Stock solution / "Mother solution" Concentrated solution of 1%, used for treating (chlorination, coagulation - flocculation) a known volume of water. Storm water Rainwater running on the ground surface (collected and disposed of separately from wastewater). See runoff water. Strainer Sieve to keep back large impurities that are present in the water. It should be installed, often in combination with a non-return valve, at the bottom end of a suction pipe. It is also integrated directly on submersible and dewatering pumps.


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present in the water. It should be installed, often in combination with a non-return valve, at the bottom end of a suction pipe. It is also integrated directly on submersible and dewatering pumps. Submersible pump Pump that is completely, as well the pumping part as the electrical motor, under the water surface. Normally designed to pump clean water. Subsoil A complete mixture of inorganic materials (clay, silt, gravel, sand) under the ground level and above the bedrock.


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<table><tr><td>Subsurface drainage</td><td>Treatment and elimination of wastewater by infiltration into the subsoil.</td></tr><tr><td>Subsurface water</td><td>All the water which is underground, wh+B102ether in the saturated or unsaturated zone.</td></tr><tr><td>Sullage</td><td>Domestic wastewater not containing excreta, also called grey water.</td></tr><tr><td>Sulphur dioxide (SO2)</td><td>A pungent colourless gas formed primarily by the combustion of fossil fuels; becomes a pollutant when present in large amounts.</td></tr><tr><td>Surface pump</td><td>Hand pump or motor pump with the pumping part above the water level and a suction pipe under the water level (suction head limited to 7 m).</td></tr><tr><td>Surface water</td><td>Water from streams, rivers, lakes, ponds, swamps.</td></tr><tr><td>Suspended solids</td><td>Small organic and mineral particles that are suspended (hanging around) within a fluid (water).</td></tr><tr><td/><td/></tr><tr><td>Thermo-Tolerant Coliforms (TTC)</td><td>A bacteria group used as indicator in micro-biological analysis for faecal pollution (of warm blooded animals, humans included). A very large percentage (more than 80%) of the TTC are Escherichia coliforms.</td></tr><tr><td>Trench latrines</td><td>Long shallow excavations used for defecation during the early stages of certain emergency settlements (e.g. camps).</td></tr><tr><td>Turbid water</td><td>Water containing fine particles in suspension which give it a cloudy appearance; turbidity is often expressed in (N)TU.</td></tr><tr><td>Twin pit latrine</td><td>Latrine with two defecation holes and two completely separated pits used alternately.</td></tr><tr><td/><td/></tr><tr><td>Vector</td><td>An organism, often an arthropod or rodent, that carries disease.</td></tr><tr><td>Vector-borne (disease)</td><td>Disease which is transmitted by vectors.</td></tr><tr><td>Vector control</td><td>Measures used to contain the population of pests below certain levels by environmental, chemical and biological methods or techniques.</td></tr><tr><td>Ventilated Improved Pit latrine (VIP)</td><td>Pit latrine equipped with a ventilation pipe to reduce odours, and with a screen at the top of the pipe to act as a fly trap.</td></tr><tr><td>Virus</td><td>A sub-microscopic agent that can only multiply inside living cells. Usually very harmful to health.</td></tr><tr><td>Volume reducer</td><td>A single combustion chamber furnace for burning (medical) waste under controlled conditions, often utilised in small and/or emergency health facilities as a waste treatment tool.</td></tr><tr><td/><td/></tr><tr><td>Washing area</td><td>Place or structure designed for washing clothes or for personal hygiene (e.g. washing slab, wash tub)</td></tr><tr><td>Waste</td><td>All items that are considered as not useful anymore, and can therefore be discarded.</td></tr><tr><td>Waste area</td><td>Solid waste collection place, where refuse is contained and either potentially treated and finally disposed of, or transferred to a treatment and/or disposal place.</td></tr><tr><td>Waste management</td><td>All the activities, administrative and operational, involved in the potential segregation and conditioning, temporary storage, handling (including transportation), treatment and final disposal of waste.</td></tr><tr><td>Waste storage</td><td>The placement of waste in a suitable location where isolation, environmental and health protection are provided.</td></tr><tr><td>Wastewater</td><td>Sewage and sullage. The used water that contains dissolved or suspended matter, and often also pathogens.</td></tr><tr><td>Waste zone</td><td>Area where the segregated medical waste is collected, potentially treated and finally disposed of.</td></tr><tr><td>Watercourse</td><td>Stream, river or canal with the direction of water flowing from upstream to downstream.</td></tr><tr><td>Water table</td><td>Top level of ground water.</td></tr><tr><td>Weir</td><td>1. A wall or plate placed in an open channel to measure the flow of water. 2. A wall or obstruction used to control flow from settling tanks and clarifiers to ensure a uniform flow rate and avoid short-circuiting.</td></tr><tr><td>Well</td><td>A drilled, driven or manually dug hole in the ground which enters an underground body of water (aquifer) to allow its abstraction.</td></tr><tr><td/><td/></tr><tr><td>Yield</td><td>The rate at which a fluid is flowing, either naturally or man-made (e.g. pumps). Expressed as volume per time unit (e.g. litres per second, m³ per hour).</td></tr></table>


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Subsurface drainage Treatment and elimination of wastewater by infiltration into the subsoil. Subsurface water All the water which is underground, wh+B102ether in the saturated or unsaturated zone. Sullage Domestic wastewater not containing excreta, also called grey water. Sulphur dioxide (SO2) A pungent colourless gas formed primarily by the combustion of fossil fuels; becomes a pollutant when present in large amounts. Surface pump Hand pump or motor pump with the pumping part above the water level and a suction pipe under the water level (suction head limited to 7 m). Surface water Water from streams, rivers, lakes, ponds, swamps. Suspended solids Small organic and mineral particles that are suspended (hanging around) within a fluid (water). Thermo-Tolerant Coliforms (TTC) A bacteria group used as indicator in micro-biological analysis for faecal pollution (of warm blooded animals, humans included). A very large percentage (more than 80%) of the TTC are Escherichia coliforms. Trench


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used as indicator in micro-biological analysis for faecal pollution (of warm blooded animals, humans included). A very large percentage (more than 80%) of the TTC are Escherichia coliforms. Trench latrines Long shallow excavations used for defecation during the early stages of certain emergency settlements (e.g. camps). Turbid water Water containing fine particles in suspension which give it a cloudy appearance; turbidity is often expressed in (N)TU. Twin pit latrine Latrine with two defecation holes and two completely separated pits used alternately. Vector An organism, often an arthropod or rodent, that carries disease. Vector-borne (disease) Disease which is transmitted by vectors. Vector control Measures used to contain the population of pests below certain levels by environmental, chemical and biological methods or techniques. Ventilated Improved Pit latrine (VIP) Pit latrine equipped with a ventilation pipe to reduce odours, and with a screen at the top of the pipe to act as a


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and biological methods or techniques. Ventilated Improved Pit latrine (VIP) Pit latrine equipped with a ventilation pipe to reduce odours, and with a screen at the top of the pipe to act as a fly trap. Virus A sub-microscopic agent that can only multiply inside living cells. Usually very harmful to health. Volume reducer A single combustion chamber furnace for burning (medical) waste under controlled conditions, often utilised in small and/or emergency health facilities as a waste treatment tool. Washing area Place or structure designed for washing clothes or for personal hygiene (e.g. washing slab, wash tub) Waste All items that are considered as not useful anymore, and can therefore be discarded. Waste area Solid waste collection place, where refuse is contained and either potentially treated and finally disposed of, or transferred to a treatment and/or disposal place. Waste management All the activities, administrative and operational, involved in the potential segregation and


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treated and finally disposed of, or transferred to a treatment and/or disposal place. Waste management All the activities, administrative and operational, involved in the potential segregation and conditioning, temporary storage, handling (including transportation), treatment and final disposal of waste. Waste storage The placement of waste in a suitable location where isolation, environmental and health protection are provided. Wastewater Sewage and sullage. The used water that contains dissolved or suspended matter, and often also pathogens. Waste zone Area where the segregated medical waste is collected, potentially treated and finally disposed of. Watercourse Stream, river or canal with the direction of water flowing from upstream to downstream. Water table Top level of ground water. Weir 1. A wall or plate placed in an open channel to measure the flow of water.	2. A wall or obstruction used to control flow from settling tanks and clarifiers to ensure a uniform flow rate and avoid


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1. A wall or plate placed in an open channel to measure the flow of water.	2. A wall or obstruction used to control flow from settling tanks and clarifiers to ensure a uniform flow rate and avoid short-circuiting. Well A drilled, driven or manually dug hole in the ground which enters an underground body of water (aquifer) to allow its abstraction. Yield The rate at which a fluid is flowing, either naturally or man-made (e.g. pumps). Expressed as volume per time unit (e.g. litres per second, m³ per hour).


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<table><tr><td>Volume</td><td>Volume</td><td>Volume</td><td>Volume</td><td>Volume</td><td/><td>Capacity</td><td>Capacity</td><td>Capacity</td></tr><tr><td>1 m³</td><td>=</td><td>1.308 yd³</td><td>=</td><td>1000 litres</td><td/><td>1 litre</td><td>=</td><td>0.22 UK Gal</td></tr><tr><td/><td>=</td><td>35.32 ft³</td><td/><td/><td/><td/><td>=</td><td>1.76 UK Pints</td></tr><tr><td>1 cm³</td><td>=</td><td>0.061 in³</td><td>=</td><td>1 ml</td><td/><td/><td>= =</td><td>0.26 US Gal 2.11 US Pints</td></tr><tr><td>1 yard³</td><td>=</td><td>27 ft³</td><td>=</td><td>765 litre</td><td/><td>1 ml</td><td>=</td><td>0.0675 fluid</td></tr><tr><td>1 foot³</td><td>=</td><td>1728 in³</td><td>=</td><td>28.32 litre</td><td/><td>1 UK Gal</td><td>=</td><td>4.546 litres</td></tr><tr><td>1 inch³</td><td>=</td><td>16.39 cm³</td><td>=</td><td>16.39 ml</td><td/><td/><td>=</td><td>1.20 US Gal</td></tr><tr><td/><td/><td/><td/><td/><td/><td>1 US Gal</td><td>=</td><td>3.791 litres</td></tr><tr><td/><td/><td/><td/><td/><td/><td/><td>=</td><td>0.83 UK Gal</td></tr></table>


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Volume Capacity 1 m³ = 1.308 yd³ = 1000 litres 1 litre = 0.22 UK Gal = 35.32 ft³ = 1.76 UK Pints 1 cm³ = 0.061 in³ = 1 ml = = 0.26 US Gal 2.11 US Pints 1 yard³ = 27 ft³ = 765 litre 1 ml = 0.0675 fluid 1 foot³ = 1728 in³ = 28.32 litre 1 UK Gal = 4.546 litres 1 inch³ = 16.39 cm³ = 16.39 ml = 1.20 US Gal 1 US Gal = 3.791 litres = 0.83 UK Gal


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<table><tr><td>PLASTER* per m³ 1-3 mix Cement 0.003 m³ Sand 0.01 m³ Mason labour 0.14 m-d Unskilled labour 0.22 m-d * Each coat of plaster 1 cm thick</td></tr></table>


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PLASTER* per m³	1-3 mix Cement	0.003 m³ Sand	0.01 m³ Mason labour	0.14 m-d Unskilled labour	0.22 m-d * Each coat of plaster 1 cm thick


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<table><tr><td>SPECIFIC WEIGHTS kg/m³ Portland cement: 1440 Brick masonry: 2120 Stone masonry: 2450 Concrete: 2409 Seasoned wood: 650 Water: 1000 Dry-stone masonry: 2000</td></tr></table>


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SPECIFIC WEIGHTS	kg/m³ Portland cement:	1440 Brick masonry:	2120 Stone masonry:	2450 Concrete:	2409 Seasoned wood:	650 Water:	1000 Dry-stone masonry:	2000


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<table><tr><td>Square: Area = s2</td><td>Circle: Area = pi × r2</td></tr><tr><td>Rectangle: Area = a × b</td><td>Ellipse: Area = pi × r1 × r2</td></tr><tr><td>Parallelogram: Area = b × h</td><td>Equilateral Triangle: Area =</td></tr><tr><td>Triangle: Area = 1/2(b × h)</td><td>Triangle given SAS (two sides and the opposite angle): Area = 1/2 × a × b × sin C</td></tr><tr><td>Trapezoid: Area = 1/2h(b1 + b2)</td><td>Rhombus: Area = 1/2 × d1 × d2</td></tr><tr><td>Regular Polygon:</td><td/></tr></table>


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Square: Area = s2 Circle: Area = pi × r2 Rectangle: Area = a × b Ellipse: Area = pi × r1 × r2 Parallelogram: Area = b × h Equilateral Triangle: Area = Triangle: Area = 1/2(b × h) Triangle given SAS (two sides and the opposite angle): Area = 1/2 × a × b × sin C Trapezoid: Area = 1/2h(b1 + b2) Rhombus: Area = 1/2 × d1 × d2 Regular Polygon:


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<table><tr><td>Cube: Volume = a3</td><td>Sphere: Volume = (4/3) × pi × r3</td></tr><tr><td>Rectangular Prism: Volume = a × b × c</td><td>Pyramid: Volume = (1/3) × b × h</td></tr><tr><td>Cone: Volume = (1/3) × pi × r2 × h</td><td>Cylinder: Volume = pi × r2 × h</td></tr></table>


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Cube: Volume = a3 Sphere: Volume = (4/3) × pi × r3 Rectangular Prism: Volume = a × b × c Pyramid: Volume = (1/3) × b × h Cone: Volume = (1/3) × pi × r2 × h Cylinder: Volume = pi × r2 × h


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Belgium	Médecins Sans Frontières / Artsen Zonder Grenzen 46 rue de l’Arbre bénit, 1050 Bruxelles/Brussel Tel.: +32 (0)2 474 74 74


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Himachal Pradesh, a state characterized by its mountainous terrain and dispersed population, places significant emphasis on ensuring the health and wellbeing of its citizens. Recognizing the unique challenges posed by its geography and the diverse socio-economic conditions of its residents, the state government, in conjunction with national initiatives, implements a range of healthcare and social security schemes. This report aims to provide a detailed analysis of the existing healthcare and wellbeing schemes in Himachal Pradesh, categorizing them based on the primary beneficiaries: the general population, pregnant women, children and infants, and disabled individuals. By examining the eligibility criteria and benefits of each scheme, this analysis seeks to offer a comprehensive understanding of the social welfare framework in the health sector of Himachal Pradesh. The subsequent sections of this report will delve into the specifics of each beneficiary category, followed by a


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of the social welfare framework in the health sector of Himachal Pradesh. The subsequent sections of this report will delve into the specifics of each beneficiary category, followed by a comparative analysis of the schemes and evidence-based recommendations for potential enhancements.


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The healthcare landscape for the general population in Himachal Pradesh is significantly shaped by the Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) and its state-specific counterpart, HIMCARE. AB-PMJAY, a flagship national health insurance scheme, aims to provide financial protection for healthcare to a large section of the population, particularly those from economically weaker backgrounds [1, 2]. Eligibility for AB-PMJAY is primarily determined based on the Socio-Economic Caste Census (SECC) 2011 data, encompassing households meeting specific deprivation criteria in rural areas, such as those living in dwellings with only one room with kucha walls and roof, households with no adult member between the ages of 16 and 59, female-headed households with no adult male member in the same age group, households with a disabled member and no able-bodied adult, SC/ST households, and landless households deriving a major part of their income from manual casual labor [3, 4].


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in the same age group, households with a disabled member and no able-bodied adult, SC/ST households, and landless households deriving a major part of their income from manual casual labor [3, 4]. Additionally, certain occupational categories in urban areas, including ragpickers, beggars, domestic workers, street vendors, construction laborers, and transport workers, are also eligible [2, 3]. The scheme offers a health cover of ₹5 lakh per family per year for secondary and tertiary care hospitalization, providing cashless treatment at empanelled public and private hospitals across the country [1]. This substantial coverage aims to reduce out-of-pocket expenditure and prevent families from facing financial hardship due to medical emergencies [1, 5].


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Recognizing that the eligibility criteria of AB-PMJAY might leave out some vulnerable residents, the Government of Himachal Pradesh implemented the Mukhya Mantri Himachal Health Care Scheme (HIMCARE) [6]. HIMCARE serves as a supplementary scheme, providing


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similar cashless treatment coverage of up to ₹5 lakh per year per family in empanelled hospitals to those who are residents of Himachal Pradesh but not covered under AB-PMJAY [6]. HIMCARE operates on a co-payment basis, with differential premium rates based on various categories of residents [6]. Certain vulnerable groups, such as BPL families not covered under AB-PMJAY, registered street vendors, MNREGA workers who have worked a minimum number of days, and children living in orphanages, are eligible for free enrollment under HIMCARE [6]. Other categories, including single women, persons with more than 40% disability, mid-day meal workers, daily wage workers, part-time workers, contractual employees, and outsourced employees, pay a nominal annual premium of ₹365 [6]. The remaining residents of Himachal Pradesh are required to pay an annual premium of ₹1000 to avail the benefits of the scheme [6]. This two-tiered system, combining a national scheme with a state-specific initiative,


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of Himachal Pradesh are required to pay an annual premium of ₹1000 to avail the benefits of the scheme [6]. This two-tiered system, combining a national scheme with a state-specific initiative, demonstrates a proactive approach by Himachal Pradesh towards achieving broader health coverage for its population [6, 7].


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As elaborated above, the Mukhya Mantri Himachal Health Care Scheme (HIMCARE) is specifically designed for residents of Himachal Pradesh who do not qualify for AB-PMJAY [6]. The primary requirement for eligibility is being a resident of the state, coupled with a category-based premium payment for most beneficiaries [6]. The scheme provides cashless treatment up to ₹5 lakh per year per family in hospitals empanelled under HIMCARE, which also includes hospitals empanelled under Ayushman Bharat within the state, as well as PGIMER Chandigarh and GMCH Sector 32 Chandigarh [6]. The premium structure is designed to be inclusive, with exemptions for the most vulnerable and subsidized rates for other specific categories, while the remaining population contributes a higher premium [6]. Beneficiaries can enroll in HIMCARE through an online system or by visiting Lok Mitra Kendras or Common Service Centers, highlighting efforts to enhance accessibility [6]. The alignment of the benefit amount with


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can enroll in HIMCARE through an online system or by visiting Lok Mitra Kendras or Common Service Centers, highlighting efforts to enhance accessibility [6]. The alignment of the benefit amount with AB-PMJAY ensures a consistent level of financial protection for a wider range of the state's population, strengthening the overall healthcare safety net in Himachal Pradesh [6].


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The Sahara Yojana in Himachal Pradesh targets individuals suffering from specified chronic illnesses who are domiciles of the state and whose family income is less than ₹4 lakh per year [User Query]. The specified chronic illnesses include conditions such as Parkinson's disease and paralysis, indicating a focus on debilitating and potentially long-term ailments [User Query]. Eligible beneficiaries under this scheme receive financial aid of ₹3,000 per month to support their treatment expenses [User Query]. This direct financial assistance aims to alleviate the economic burden associated with managing these chronic conditions, providing a regular supplement to help cover medication costs, regular check-ups, and other necessary medical expenditures [User Query]. The income eligibility criterion suggests that the scheme is intended to support lower to middle-income families who might face significant financial strain due to the prolonged and often expensive treatment required for these


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suggests that the scheme is intended to support lower to middle-income families who might face significant financial strain due to the prolonged and often expensive treatment required for these illnesses [User Query]. By focusing on domicile and specific chronic conditions, Sahara Yojana provides targeted support to a segment of the population facing unique healthcare challenges [User Query].


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The Janani Suraksha Yojana (JSY) is a centrally sponsored scheme implemented in Himachal Pradesh to reduce maternal and infant mortality by promoting institutional deliveries [8, 9]. Eligibility for JSY in Himachal Pradesh, consistent with the national guidelines, is primarily for pregnant women belonging to Below Poverty Line (BPL) families or those who are from Scheduled Castes (SC) or Scheduled Tribes (ST) [User Query]. A key requirement is that the delivery must take place in a government health facility or a private health facility accredited under the scheme [User Query]. The primary benefit provided under JSY is cash assistance to the eligible pregnant woman to help with expenses related to the delivery and immediate post-natal period [10]. The amount of cash assistance can vary depending on whether the beneficiary resides in a rural or urban area and the specific category they belong to, as observed in the implementation of JSY in other states [10]. In Himachal Pradesh, this


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on whether the beneficiary resides in a rural or urban area and the specific category they belong to, as observed in the implementation of JSY in other states [10]. In Himachal Pradesh, this cash incentive aims to encourage women from vulnerable socio-economic backgrounds to opt for safer institutional deliveries over home births, thereby reducing the risk of complications and improving maternal and child health outcomes [11, 12]. JSY is often linked with the Janani Shishu Suraksha Karyakram (JSSK), which ensures free and cashless delivery and other related services at public health facilities [13, 14].


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The Pradhan Mantri Matru Vandana Yojana (PMMVY) is another significant scheme in Himachal Pradesh focused on the health and wellbeing of pregnant and lactating mothers [15, 16]. The scheme specifically targets women who are pregnant or lactating for their first child [User Query]. A crucial requirement for availing benefits under PMMVY is the registration of pregnancy at an early stage [User Query]. Eligible beneficiaries receive a cash benefit of ₹5,000, which is typically disbursed in three installments upon fulfilling certain conditions, such as early registration of pregnancy, completion of six months of pregnancy with at least one antenatal check-up, and registration of the child's birth and completion of the first cycle of immunization [10]. The primary objective of PMMVY is to provide partial compensation for wage loss during pregnancy and to ensure adequate nutrition and healthcare for the mother and her first child [10, 17]. Recent guidelines under 'Mission Shakti' have also


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partial compensation for wage loss during pregnancy and to ensure adequate nutrition and healthcare for the mother and her first child [10, 17]. Recent guidelines under 'Mission Shakti' have also extended the maternity benefit under PMMVY for the second child, provided the second child is a girl [9, 16]. This initiative aims to encourage positive behavioral change towards the girl child [16]. The implementation of PMMVY in Himachal Pradesh contributes to the national efforts in improving maternal and child health indicators [15].


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The Janani Shishu Suraksha Karyakram (JSSK) plays a vital role in providing comprehensive and free healthcare services to pregnant women and sick newborns in Himachal Pradesh when they utilize government health facilities [12]. The scheme ensures that pregnant women are entitled to free delivery, including Caesarean section if required, without any out-of-pocket expenditure [14]. Additionally, JSSK covers the cost of treatment for sick newborns up to 30 days after birth, which has been further expanded to include sick infants up to one year of age in some contexts [11, 13]. The benefits under JSSK are extensive, encompassing free medicines and consumables, free diagnostic tests, free provision of blood, free diet during the mother's stay in the health institution (for three days in case of normal delivery and seven days for a Caesarean section), and free transport from home to the health institution, between facilities in case of referral, and a free drop back home after 48 hours of


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of normal delivery and seven days for a Caesarean section), and free transport from home to the health institution, between facilities in case of referral, and a free drop back home after 48 hours of stay [14]. This scheme aims to eliminate financial barriers to accessing essential maternal and neonatal healthcare services at public health facilities in Himachal Pradesh, thereby contributing to the reduction of maternal and infant mortality rates [12, 18].


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The Rashtriya Bal Swasthya Karyakram (RBSK) is a significant initiative in Himachal Pradesh aimed at early identification and intervention for a wide range of health conditions in children from birth to 18 years of age [19]. The program focuses on screening children for the "4 Ds": Defects at birth, Diseases, Deficiencies, and Development delays, including disability [20]. These screenings are conducted at various points, including health facilities at the time of birth, at home by ASHAs as part of the Home Based Newborn Care (HBNC) package, at Anganwadi centers for children aged 6 weeks to 6 years, and in government and government-aided schools for children enrolled in classes 1st to 12th [20, 21]. Mobile health teams play a crucial role in conducting outreach screenings [20]. For children identified with any of the 32 prevalent health conditions covered under RBSK, the program ensures free treatment and management, which includes surgeries at the tertiary level if required [21]. This


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identified with any of the 32 prevalent health conditions covered under RBSK, the program ensures free treatment and management, which includes surgeries at the tertiary level if required [21]. This comprehensive approach aims to improve the overall quality of life for children by facilitating early detection and providing access to necessary medical interventions, thereby reducing the financial burden on families [20, 22].


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The Universal Immunisation Programme (UIP) is a cornerstone of public health in Himachal Pradesh, providing free vaccination to children of specific ages against a range of preventable diseases [3]. This program aims to protect children from potentially life-threatening infections, contributing significantly to the reduction of childhood morbidity and mortality [18]. The vaccines are administered according to a nationally recommended schedule, ensuring that children receive timely protection at critical stages of their development [23]. By making vaccines freely available, the UIP ensures equitable access for all children in Himachal Pradesh, regardless of their socio-economic background, thereby helping to achieve high immunization coverage rates and protect the community through herd immunity [3, 24]. The UIP is a vital component of the state's efforts to safeguard child health and prevent outbreaks of infectious diseases [25].


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The Integrated Child Development Services (ICDS) scheme has a widespread presence in Himachal Pradesh, catering to the holistic needs of children aged 0-6 years and pregnant and lactating mothers [26]. Delivered through a network of Anganwadi centers, ICDS provides a package of essential services aimed at improving the nutritional and health status of young children and mothers, laying the foundation for proper psychological, physical, and social development of the child, reducing the incidence of mortality, morbidity, malnutrition, and school dropouts, and enhancing the capabilities of mothers to look after the health and nutrition needs of their children [27, 28]. The benefits offered under ICDS include supplementary nutrition to address malnutrition, immunization (often provided in coordination with the UIP), regular health check-ups, referral services for children needing specialized medical attention, non-formal pre-school education to promote early learning, and nutrition and


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with the UIP), regular health check-ups, referral services for children needing specialized medical attention, non-formal pre-school education to promote early learning, and nutrition and health education for women [29]. This integrated approach recognizes the interconnectedness of various factors influencing child development and aims to provide comprehensive support at the community level [28, 30].


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The Mukhya Mantri Madhu Care Yojana is a specific healthcare scheme in Himachal Pradesh designed to support children under the age of 18 years who are diagnosed with Type 1 Diabetes and whose family income is less than ₹2.5 lakh per year [User Query]. Recognizing the lifelong and often expensive management required for Type 1 Diabetes, this scheme provides crucial support by offering free insulin, glucometers, and testing strips to eligible children [User Query]. This initiative aims to ensure that children with this chronic condition from economically weaker families have access to the essential medical supplies needed to manage their diabetes effectively, thereby improving their health outcomes and quality of life [User Query]. By directly addressing the financial burden of these necessary medical provisions, the Mukhya Mantri Madhu Care Yojana plays a vital role in supporting the wellbeing of children with Type 1 Diabetes in Himachal Pradesh.


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Himachal Pradesh implements a Social Security Pension Scheme for Persons with Disabilities to provide financial support to residents with disabilities [User Query]. Eligibility for this scheme requires the applicant to be a resident of Himachal Pradesh and have a disability of 40% or more [User Query]. Additionally, there are specific age and income criteria that need to be met to qualify for the monthly pension [User Query]. While the user query does not specify the exact pension amount, similar schemes in other states like Ladakh offer ₹1,000 per month [31], and Delhi provides ₹2,500 per month [32], indicating that the benefit amount can vary. The primary aim of this pension scheme is to provide a regular source of income to persons with disabilities who may face challenges in securing employment or have limited means of financial support, thereby enhancing their social security and overall wellbeing [33, 34].


