- Low vaccination rates among HCPs, lack of taking occupational precaution measurements e.g., personal protective equipment (PPE) ;
- Examine how used needles are managed including handling, storage, transportation, treatment and disposal;
- Examine the possible factors (barriers and challenges, etc.), which led to the current used needles management situation;
- Suggest practical steps for an improved and safer system of needles’ management in Khartoum.
2. The Case Study
- Almost all types of wastes being mixed together;
- The partial separation of wastes existing only in a few hospitals;
- Most of the workers being illiterate or having very low education levels, and there being a shortage of personal protective equipment (PPE) (e.g., boots, aprons, gloves);
- At the hospital level, no policies or rules being found except in a few centers;
- Limited training and that which is provided being inefficient;
- In the majority of the hospitals (75%), the transportation of HCW to temporary storage areas being done manually;
- A colour-coding system often not being implemented.
3. Materials and Methods
3.1. Content Analyses
3.2. Direct Observations
3.3. Interviews about Used Needles Management Issues with the HCP
3.4. Data Collection and Analysis
- The published data were categorised according to the geographical area, i.e., state;
- The HCW production (kg/bed/day) was estimated;
- The main existing practices of managing used needles;
- Reporting of training, PPE, vaccination status and NSI issues;
- The key mentioned barriers and recommendations from the published research regarding used needles management in Sudan.
4.1. Content Analyses
4.1.1. NSIs Reported by SFMOH
4.1.2. Current Used Needles Management in Sudan
- Waste minimisation and segregation: there was no plan; irrational use of injections is common; lack of waste segregation.
- Waste handling: manual handling of HCW from the wards to the storage area, this increases the possibility of NSIs, especially as misuse of safety boxes is common; no or partial availability of PPE; partial segregation of waste; auto-retracted syringes are used in few of the observed hospitals.
- Storage: the storage area was not secure; there was a delay in disposing needles.
- Transportation: the vehicles (compactor, lorries, tipper, trailer) were not fulfilling the WHO standards ; lack of commitment to scheduling times.
- Treatment: no technologies such as autoclave or disinfection were used to treat used needles; no needle cutters; there is a possibility of the reuse of needles.
- Disposal: based on the review findings, many options are employed in Sudan to dispose of the used needles generated either in HCFs or in the home, as follows: (i) placed in a safety box or locally made sharps container (plastic bottle) and disposed of through burning in an incinerator, or buried; (ii) mixed with other HCW and disposed through a landfill site, or by burning; (iii) mixed with healthcare domestic waste and disposed of through an open dumpsite, burnt in the open environment, or a landfill site; (iv) disposed on the ground.
4.1.3. HCWM in the Rural HCFs
- Lack of water and sanitation;
- No electricity for operations such as autoclave, steam sterilisation and incineration;
- Lack of transportation, especially in the rainy season;
- Lack of the awareness among doctors and nurses, etc.
4.2.1. Safety Box Usage
4.2.2. Observation of HCWM Practices
- Lack of awareness regarding the danger and the long-term consequences (hepatitis and HIV) of such practices among HCP, especially those who are in direct contact with waste, such as waste workers
- No enforced policy in place, such as colour coding and labelling for waste disposal
- Lack of resources, i.e., shortage of safety boxes and insufficient budget for HCWM
- No dedicated department to deal with HCWM, i.e., that can monitor, evaluate and take appropriate actions accordingly
- Lack of training, especially among waste workers.
- Limited budgets for training purposes, in addition to the inefficient management of the allocated budget
- The decisions makers are perhaps not aware of the cost effectiveness of training i.e., through training, the segregation and recycling of waste will increase
- Lack of HCWM experts.
- Short-term recommendations:
- Workshops for the involved parties such as the Ministry of Health, hospital administrations, public health personnel, HCW disposal companies, physicians, nurses, researchers, pharmacists, diabetes organisations and societies, diabetes educators, etc. The materials for the workshop should be organised with the involvement of all parties
- Patients’ educational sessions about the safe disposal of sharps, especially at home
- Provision to patients of safe disposal tools, such as a safety box and a community drop safety box, this can be organised with pharmaceutical companies and non-governmental organisation (NGOs)
- Community involvement through the launching of campaigns for safe sharps disposal (posters, brochures, media sessions, etc.). Public awareness about the hazards and risks of HCW is a key of success 
- Knowing the main stakeholders and their influence regarding waste management
- Rapid assessment of HCW among the HCFs, including the availability of an incinerator for each HCF. For this purpose, the WHO Individualised Rapid Assessment Tool (I-RAT) can be used .
- Medium-term recommendations:
- Encourage the use of the available HCWM technologies
- Training and periodic updating of the staff on different aspects related to safe HCWM, such as OSH, rational usage of medicines and operation of sharps pits and incinerators. Meanwhile, the ten proposed recommendations by Laing et al.  to improve rational medicine usage in developing countries can be adopted in the Sudan context. Provision of training was found to be effective in reducing the rate and underreporting of NSIs 
- Allocation of enough resources such as budget, safety boxes, personnel, and vehicles for HCWM and PPE. However, PPE should be used as the last option of protection in the hierarchy of hazard controls . The strategy for HCW should focus on the most effective control measures e.g., minimisation of needle usage, use of engineering (e.g., auto-retracting syringes, safety boxes, etc.), and administrative (e.g., setting of policies, training, etc.) 
- Conducting audits for HCWM
- Documentation should be encouraged to identify the amount of waste and to trace the waste from the generating facility to the end of disposal. In addition, record keeping should be introduced at all HCF levels
- Establishment of sharps pits or incinerators according to the needs based on the results of the initial survey.
- Long-term recommendations:
- Development and effective implementation of HCWM legislation
- An environmental impact assessment should be implemented for all HCFs and should be mandatory before establishing any new facility
- Alternative technologies can be used. However, before selecting any technology, basic information should be available: (a) the size of the target facility, whether it is small, medium, large, or at the national level; (b) the estimated amount of waste generated; and (c) the cost of the needed technology.
- Policies regarding the safe handling and disposal of sharps, vaccination, OSH, reporting of NSIs, PEP, and colour coding and labelling for waste disposal;
- Initiatives to raise awareness of safe sharps disposal among HCP and the public through education, training and the launching of campaigns, i.e., posters, brochures, media sessions, etc.
Conflicts of Interest
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|Training||PPE 1||NSIs 2||Vaccination|
|||Only 45% were trained on HCWM 3||46.5% of did not have PPE||42.9% injured while working||69% vaccinated against hepatitis|
|||No hospital personnel were trained about HCWM and, infection control||Manual handling of waste without using PPE||27% had NSIs||4% of the HCP 4 were vaccinated|
|||Training was available only in 40% of the investigated HCFs 5||PPE only 30% in the investigated hospitals||-||-|
|||Called for HCP training and education||Deficiency in protective measures||-||Recommended vaccination for workers, especially those at risk|
|||-||-||Unacceptable injection disposal practices led to 26.1% NSIs||26.3% of the injections given in the community were used for vaccination|
|||After the intervention, an improvement in the knowledge, attitudes and practices regarding HCWM were reported||-||Decrease in the rate of NSIs and, HBV 6 infection||After the awareness intervention programme, the utilisation of HBV vaccination increased from 11% to 48%|
|53]||The training programmes for HCP with respect to HCW 7 handling were not efficient||-||-||There was no recurrent medical follow-up and vaccination for HCPs|
|||Recommended periodic training for HCPs||Only 62% were wearing PPE while handling HCW||Only 8% had NSIs||The study was carried on already-vaccinated HCPs|
|||61.7% do not receive any training in handling hazardous wastes||95.8% of them used PPE||91.3% checked with physicians after NSIs||91.6% did not receive HBV vaccination|
|||Improvement of the HCPs knowledge after educational intervention programme||More PPE were used by the staff after the programme||NSIs were more often reported by the staff||69% of the study participants in the intervention group were not vaccinated|
|||42% of HCP were not trained. The training period was not enough for those who received training, and the provision of an education and training programme were recommended||PPE were not used properly i.e., either lack of PPE or they were not aware of its importance||Only 7.5% of HCP knew that HCW is a source of HBV||-|
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