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Lao PDR_ Avian and Human Influenza Control and Preparedn

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Lao PDR_ Avian and Human Influenza Control and Preparedn

    E1557

    Lao PDR: Avian and Human Influenza Control and Preparedness Project

    ENVIRONMENTAL MANAGEMENT PLAN (EMP)

    January 31, 2007

1. PROJECT DESCRIPTION

    The objective of this project is to contribute to the Lao PDR Government’s integrated plan, which aims to minimize the threat posed to humans and the poultry sector by avian and human influenza infection and other zoonosis in Lao PDR, and to prepare for control and to respond to influenza pandemics and other infectious diseases in humans. The design of the subject project follows exactly the Government Strategy for avian influenza (AI). As such, the project consists of the following components: Each of the five components will include the measures (M) (i.e. subcomponents) and activities (A) specified in the Government’s strategy for AI.

    1. Component 1: Animal Health (S1). This component supports prevention, control, and eradication

    of HPAI among the animal population. It involves activities to: (i) reduce risks of AI infection in

    backyard, commercial poultry, fighting cock and production (S1M1, S1M2, S1M3); (ii) enhance

    capacity for early detection and early warning of AI outbreaks at field levels (S1M4); (iii)

    strengthen capacity for laboratory diagnosis (S1M5); (iv) conduct research and development in

    the areas of monitoring of the infected areas, risks for introduction and spread of HPAI, and wild

    bird habitats (S1M6); (v) improve the national information system (S1M7); (vi) enhance capacity

    for rapid and effective response to HPAI outbreak (S1M8); and (vii) enhance national, regional,

    and international networking (S1M9).

    2. Component 2: Human Health Surveillance and Response (S2). This component at improving

    disease surveillance and response in humans during AI outbreaks. It involves activities to: (i)

    strengthen staff capacity in surveillance and response through overseas training (S2M1), (ii)

    strengthen the routine (weekly) surveillance system through inclusion of ILI/ARI (S2M3), (iii)

    integrate the surveillance systems and data through integration/linkage (S2M4), (iv) strengthen

    the capacity to investigate and respond to EID (including AI) at central level (S2M5), (v)

    decentralize the AI investigation with linkages to animal health (S2M6), (vi) operationalize

    outbreak investigation (S2M7), (vii) develop public health emergency response measures for

    rapid intervention during outbreak (S2M8), (viii) develop public health emergency response

    measures for the pandemic (S2M9), (ix) operationalize public health activities for rapid

    intervention during outbreak (S2M10), (x) operationalize public health activities during pandemic.

    3. Component 3: Human Health Laboratory and Curative Services (S3). This component

    supports preparation of the health system to respond to AI outbreaks. It involves activities to: (i)

    strengthen healthcare human capacity and infrastructure (S3M1), and (ii) strengthen laboratory

    resources (S3M2).

    4. Component 4: Information, Education and Communication (S4). This component supports the

    activities to plan and carry out a public awareness campaign. It involves activities for networking,

    capacity building, and increasing knowledge on AI and prevention before a pandemic occurs

    (S4M1)

    5. Component 5: Program Coordination and Regulatory Framework (S5). This component is

    focused primarily on a number of cross-cutting issues, including support to the National Avian

    and Human Influenza Coordination Office (NAHICO), which will be responsible for the overall

    coordination of this project. It involves activities to: (i) strengthen the function of the National

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    CDC Committee (S5M1), (ii) develop national stockpile of essential supplies (S5M2), and

    develop financial and legal frameworks (S5M3).

2. INSTITUTIONAL FRAMEWORK IN LAO PDR

    Environmental Management. At the national level, environmental management is under the Science,

    Technology and Environment Agency (STEA), which reports to the Prime Minister’s office. STEA has

    an office in each province (PSTEO), which reports to the provincial government. In addition, in various line ministries there are units that deal with environmental issues.

    Recognizing the cross-sectoral character of environmental conservation and protection, the Lao Government has created multiple coordination bodies to facilitate inter-agency and provincial coordination. These include the National Environment Committee (NEC), the Water Resources Coordination Committee (WRCC), and the Lao National Mekong Committee (LNMC).

    Animal Health Services. At the national level, the Ministry of Agriculture and Forestry (MoAF) is responsible for animal health services. To extend these services, MoAF has a network of personnel at the national, professional, and district levels. MoAF has also veterinary laboratories, including one at the National Animal Health Center (NAHC) in Vientiane and provincial veterinary laboratories (e.g. in Champassak, Luang Prabang).

    Of the 69 qualified veterinarians in Lao PDR, 16 of them are employed at MoAF in Vientiane. As half of this staff is to retire within the next three years and there are no universities in Lao PDR offering a degree in veterinary sciences, the currently limited professional human capacity in animal health services is expected to reach critical levels if some measures are not taken promptly.

    Currently, there are 893 Government personnel who are involved in animal production and animal disease control programs and responsible for administrating animal health services for poultry at the national, provincial, and district levels. There are 785 livestock officers located at 12 provincial livestock offices. At the community level, there are 5,177 veterinary workers in 11,180 villages who are administering animal health services for poultry (20%); cattle, buffalo, pigs (50%); and dogs, and cats (30%).

    Public Health Services. The Ministry of Health (MoH) is in charge of human health services in Lao PDR. MoH has 5 central hospitals (all in Vientiane), 4 regional hospitals, 16 provincial hospitals, 141 district hospitals, and 741 health care centers. Many health facilities have insufficient professional and medical staff, limited drugs and basic equipment, including insufficient isolation rooms and inadequate equipment (e.g. ventilators) for patients with severe respiratory diseases. At the community level 14,000 village health volunteers have been working on malaria. At the hospitals, the current healthcare waste management practices need strengthening.

The public health surveillance is carried out by the National Center for Laboratory and Epidemiology

    (NCLE) in Vientiane. NCLE carries out surveillance, case and outbreak investigation, response, and research; and serves as the public health laboratory and the national reference laboratory. Although AI has not been a reportable disease in Lao PDR, NCLE has been receiving support from the U.S. Naval Medical Research Unit to implement a computerized Early Warning Outbreak Recognition System 1(EWORS) in four hospitals in Vientiane and three hospitals in three regional hospitals.

    NCLE is supported by 17 provincial surveillance units (PSU) and 141 district health offices (DHO). On the average, each PSU has two to four staff with variable level of training. Staff at DHO are typically not

     1 EWORS is a symptom-based hospital surveillance system that collects and sends data to NCLE on a daily basis from the outpatient and emergency rooms.

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    qualified in epidemiology. Some DHOs lack communication devices (e.g. telephones, faxes), making it difficult to report health events to the next level in a timely manner.

The public health laboratory structure is similar to the surveillance system. NCLE acts as the public

    health and national reference laboratory. It has not achieved bio-safety level (BSL) 2 status and currently does not have the capacity to perform AI diagnosis. Suspected AI specimens have to be shipped abroad (e.g. Japan) for testing.

3. LEGAL FRAMEWORK IN LAO PDR

    Environmental Aspects. The Environmental Protection Law of 1999 and its implementing regulation of 2002 are the principal environmental legislation in the country. This legislation includes measures for the protection, mitigation and restoration of the environment as well as guidelines for environmental management and monitoring. Other key environmental legislative measures in Lao PDR include promulgation of the regulation on Environmental Assessment (2000); creation of an Environment Protection Fund to channel earmarked revenues to environmental activities, and decentralizing environmental functions to provinces.

    Animal Aspects. In 2000, the regulation on Management of Livestock Productivity (No. 0313), sponsored by the MoAF, was promulgated. Other key regulatory actions by MoAF in the area of avian influenza (AI) include:

    ; Decree of the Prime Minister regarding animal control in Lao PDR (No. 85/PM of May 31, 2005)

    ; Order of the Prime Minister regarding AI control (No. 02/PM dated January 27, 2004)

    ; Decision of the Prime Minister regarding the policy and measures to help agriculturalists affected

    by AI (No. 06/PM of March 1, 2004)

    ; Order of MoAF regarding increasing control and prevention against AI (No. 0075/MoAF.2005 of

    February 2, 2005)

    ; Recommendation of the Director of the Department of Livestock and Fisheries regarding

    implementation of the Ministerial Order on increasing control and prevention against AI (No.

    0024/DLF.2005 of February 14, 2005).

Human Hygiene/Environmental Aspects. In 2001, the Law of the Hygiene, Disease Prevention, and

    Health Promotion (No. 01/NA, April 10/25, 2001) sponsored by the MoH was enacted. The implementing regulation (No. 1371 of October 4, 2005) for this law establishes drinking and domestic water quality standards. Other hygiene-related regulations sponsored by MoH are:

    ; Regulation on healthcare waste management (No. 1706 of July 20, 2004)

    ; Regulation on hygiene in public areas (No. 1705 of July 20, 2004) (examples of topics covered

    include public sanitary facilities, drainage, garbage control, animal control).

    ; Decree on National Policy for Health Impact Assessment (No.54/PM, March 23, 2006).

Currently, there are no national safety guidelines for laboratories.

4. EXPERIENCE IN RESPONDING TO AVIAN INFLUENZA OUTBREAKS IN LAO PDR

    In early 2004, avian influenza (AI) outbreaks occurred in three provinces of Lao PDR (38 cases in Vientiane Capital, 5 cases in Champasak, and 2 cases in Savannakhet). Of these 45 cases, 42 cases were reported from commercial enterprises and 3 cases were reported from villages). As a result, 155,000 animals died, about 1/3 of which from the disease and 2/3 from culling. It is suspected that more outbreaks might have occurred in rural areas, but these have not been reported. No human cases of AI were reported in Lao PDR. The procedures used to respond to these outbreaks were as follows:

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; Use of personal protection equipment (PPE). PPE was used at farms where AI outbreaks

    occurred and were suspected to occur (i.e. those farms where poultry was culled). Each worker

    wore one tyvex suit/day. There was no tyvex suit change in a day as the workers did not leave

    the work area or took any breaks (e.g. lunch break) until they finished their daily work. Other

    PPE used included gloves, masks, and booths.

    ; Culling of poultry. At all reported locations, except for one, neck dislocation or placement of live

    birds in plastic bags was used as the method for culling of poultry in Lao PDR. The exception

    took place at a large commercial farm where culling of about 10,000 poultry was done using

    carbon dioxide (CO) gas. 2

; Disinfection of farm surfaces, equipment, materials and wastes. After culling of poultry, the

    surfaces and equipment in a farm, poultry manure, bedding material, etc. were sprayed with

    sodium hypochlorite (NaOCl) as the least expensive disinfectant available in Lao PDR.

    ; Transportation of carcasses. Transportation of animal carcasses or farm waste was not an issue

    because AI outbreaks occurred at commercial farms. Carcasses were transported by carts only

    within the farm site to the burial pit.

    ; Disposal of used PPE. Used PPE was put in a plastic bag and then destroyed it in an incinerator

    at the city. However, incineration of PPE potentially containing chlorine-based disinfectant spills

    would likely generate hazardous dioxins and furans (which would be emitted to the atmosphere).

; Disposal of carcasses and farm wastes (e.g. bedding material, manure). Burial was used as the

    method for disposing of culled poultry. This was done as follows: (i) a burial pit of about 2

    meters was dug, (ii) the bottom of the pit was covered with lime [Ca(OH)], (iii) the carcasses 2

    were placed on top of lime for about 1 meter depth, (iv) a lime layer was spread on top of

    carcasses, and (v) the remainder of the burial pit (less than about 1 meter) was closed to ground

    level with soil.

    ; Capabilities of veterinary laboratories. Until recently, none of the veterinary laboratories in Lao

    PDR had the capacity to detect H5N1, although NAHC were able to detect Type A or B. For this

    reason, specimens had to be sent abroad (to Thailand and Vietnam) for detection of the H5N1

    virus.

; Capabilities of the national virology laboratory. As the virology laboratory at NCLE did not

    have the capability to detect the H5N1 virus, the suspected AI samples had to be sent abroad to

    Japan for testing.

    ; Measures at hospitals. At selected hospitals, isolation rooms were established to receive AI-

    infected patient or patients suspected to be AI-infected. However, no such patient was received.

    There are no respirators in any of the isolation rooms.

With FAO’s technical support and the French Government’s financial support, in March 2005, the

    Department of Livestock and Fisheries (DLF) of MoAF published a manual entitled “Basic Knowledge

    about Avian Influenza and How to Prevent It.” This manual aims at disseminating basic knowledge on

    AI and prevention methods for agriculturalists, village veterinarians, livestock technical officers, and veterinarians as well as other people interested in AI. The manual, which contains useful information would benefit from updating, with some reorganization based on specific targeted audiences.

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    The Government of Lao PDR has established a committee for the communicable diseases from 14 lines ministries, with MoH and MoAF forming the core of this committee. Within MoH, the Department of Hygiene Prevention worked with the Surveillance Unit for daily reporting of AI cases. Some hospitals have designated isolation rooms (e.g. Mittaphab Hospital and Setthathirath Hospital in Vientiane) to receive SARS patients, which can now be used potentially AI-infected patients. Guidelines have been established for personal hygiene and healthcare waste management in Lao PDR. However, although the basis of the solid healthcare waste management system is in place (with the three-bin system of infectious, sharps, and ordinary wastes; posters on waste segregation; and some staff training), implementation is 2less than perfect regarding waste segregation and treatment. In addition, sewage from hospitals

    (particularly from the isolation rooms) is not generally treated.

    In 2005, the Government of Lao PDR set up a national strategic plan that consisted of five strategies:

    1. STRATEGY 1 (S1) Development of a disease-free avian management system (animal aspect)

    2. STRATEGY 2 (S2) Disease surveillance and response in humans during AI outbreaks

    3. STRATEGY 3 (S3) Laboratory and curative care

    4. STRATEGY 4 (S4) Health education and community action

    5. STRATEGY 5 (S5) Strengthening institutional and regulatory frameworks

    In 2005, the national committee was upgraded to a higher level chaired by the Prime Minister. In January 2006, under the National CDC Secretariat, a national coordination office (NAHICO) was established whose responsibility includes coordination of the response by various sectors as well as external financiers including UN agencies.

    MoAF has identified the National Animal Health Center (NAHC) in Vientiane capital as the veterinary laboratory for AI detection. In addition, one veterinary laboratory in the south (in Champassak and/or Savannakhet) and another veterinary laboratory in the north (in Luang Prabhang and/or Oudomxay) have been designated to collect and ship the AI specimens to NAHC. NAHC has an exiting animal laboratory in Vientiane with limited space and capability. Currently MoAF is constructing a new building for NAHC, which is incomplete. FAO and OIE have supported purchase of essential equipment required to detect HPAI for NAHC (which were partially received), and the laboratory staff has been trained on test methods, personal hygiene, and quality assurance (Q/A).

    To treat patients potentially infected with AI, MoH has identified three central and four regional hospitals for upgrading. These hospitals are:

Name of Hospital Category Location Bed Capacity

    Mahosot Hospital Central Vientiane capital 450

    Mittaphab Hospital Central Vientiane capital 150

    Setthathirath Hospital Central Vientiane capital 175

    Oudomkay Prov. Hospital Regional/Provincial Oudomkay 82

    Luang Probang Prov. Hospital Regional/Provincial Luang Prabhang 100

    Savannakhet Prov. Hospital Regional/Provincial Savannakhet 200

    Champasak Prov. Hospital Regional/Provincial Champasak 250

    Each hospital is envisioned to have five (5) isolation rooms for the AI patients.

5. ENVIRONMENTAL AND HUMAN HEALTH IMPACTS AND MITIGATORY

    MEASURES TO BE ADDRESSED UNDER THE PROJECT

     2 For example, the design of the incinerator at the Settathirath Hospital does not meet the international standards (e.g. does not have a gas washing system). The incinerator is not operated as planned due to the high fuel cost.

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    The project is not expected to have any large-scale, significant and/or irreversible impacts as it is focused largely on public sector capacity building and strengthening readiness for dealing with outbreaks of avian influenza (AI) in domestic poultry as well as preventing or reducing possible human infections by strengthening emergency preparedness and response. In addition, the project design incorporates other beneficial measures such as improved biosecurity in farms and live markets, and control of poultry movement within and across countries. The project’s preventive activities (funding of facilities, equipment, laboratories, procedures, and training programs), aimed at improving the effectiveness and safety over the existing the AI practices, will have positive human health and environmental impacts. As such the project is assigned an Environmental Category B.

    The potential environmental impacts and mitigation measures to be addressed under this project are described below and summarized in Table 1. All of these mitigation measures have been incorporated into the design of the project.

Component 1: Animal Health. The main environmental and personal hygiene issues under Component

    1 of the project are associated with the:

    1. Completion of the construction of the National Animal Health Center building

    2. Personal hygiene at the animal laboratory of the National Animal Health Center

    3. Management of wastes generated at the animal laboratory of National Animal Health Center

    4. Response to AI outbreaks by veterinarians and livestock officers.

1. Completion of the construction of the National Animal Health Center Building. Construction of

    the NAHC building will be completed under funds provided through the subject project. The new building will provide additional space for NAHC. The adverse impacts during construction would include dust and noise emissions, generation of construction waste, disturbance of traffic, and discharge of untreated sewage. These adverse impacts will be mitigated by including in the construction contract a clause regarding observation of standards for good construction practices.

2. Personal hygiene at the animal laboratory of the National Animal Health Center. The project will

    not address this issue as the staff at the animal laboratory of NAHC staff has been trained by FAO on test methods, personal hygiene, and quality assurance (Q/A); and staff straining will continue under another project implemented by FAO.

3. Management of wastes generated at the animal laboratory of the National Animal Health Center.

    The project will not provide any funds in this area as the infectious wastes-sharps generated at the animal laboratory of NAHC are properly managed. This involves collection of the infectious wastes-sharps separately from common wastes, on-site treatment of these wastes by autoclaving, and collection of the treated wastes along with garbage by the municipality for disposal. Procurement of another autoclave may become necessary if the existing treatment capacity is exceeded from infectious wastes generated as a result of the analysis of potential AI samples. In this case, OIE has committed funds to procure such an autoclave.

4. Response to AI outbreaks by the veterinarians and livestock officers. The information contained

    in the Department of Livestock and Fisheries (DLF) manual will be updated for different audiences, including: (i) veterinarians and livestock officers, (ii) the commercial farm owners, (iii) backyard farm owners, and (iv) the general public. The manual for the veterinarians and livestock officers will be presented in the form of Standard Operating Procedures (SOPs). This manual will address, at a minimum, the following issues:

    (i) Packaging and shipment of animal specimens. It is important that the animal specimens be

    packaged and shipped in such a manner to avoid spread of AI. Animal specimens will be

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    shipped for analysis at the National Animal Health Center (NAHC) in Vientiane. The IATA Regulations for packaging of biological specimen will be adopted and included in the SOPs.

    (ii) Culling of poultry. It is important that culling of poultry be conducted in a humane, safe, and efficient manner. The following methods for culling poultry were identified from the OIE/FAO guidelines: (i) neck breaking (manual), (ii) neck cutting (using mechanical devices), (iii) gassing with inhalation agents (e.g. carbon dioxide), and (iv) culling following electrocution or poisoning. Based on consideration for humane, safe and efficient culling and experience from the previous AI outbreaks in Lao PDR, the following methods were selected for this project: neck breaking for backhouse farming, and use of carbon dioxide inhalation for commercial farms with large numbers of poultry. The SOPs will specify the criteria for using one versus the other method; and will provide the design and operating requirements on of the gassing systems (e.g. specific locations and quantities of stocked carbon dioxide).

    (iii) Selection of disinfectants. It is important that the disinfectants to be selected for the

    disinfection of farm surfaces, equipment, materials, and wastes do not have adverse impact on human health and the environment. The selection of disinfectants in this project will be based on such criteria as impacts of disinfectants on human health and the environment, and availability and cost of disinfectant in Lao PDR, and compatibility of the disinfectants with the disposal methods of the wastes. The selected disinfectant, which will comply with the World Bank’s Pest Management Policy (OP4.09), will be specified in the SOPs.

    (iv) Disinfection of farm surfaces, equipment, materials, and wastes. Based on selected

    disinfectant, the type of equipment and procedures for preparing (e.g. dilution with water) and applying the disinfectant will be specified in the SOPs.

    (v) Disposal of carcasses and farm wastes. It is important that the selected disposal method does

    not have adverse impacts on human and the environment. For example, improper burial practices may cause contamination of ground or surface water, and poorly designed and/or operated cremation or incineration systems may create particulate emissions and objectionable odors to neighbors. The following options for the disposal of poultry carcasses and farm wastes were considered: (i) burial in a pit, (ii) open air burning (cremation), (iii) composting, (iv) incineration at a fixed location, and (v) mobile incineration. Incineration (mobile or at a fixed location) was eliminated based on cost considerations. Among the remaining options, based on experience from the previous AI outbreaks in Lao PDR, burial was selected as the disposal method. However, criteria will be developed and included in the SOPs for the applicability of this disposal option for specific sites. This criteria will include: (i) height of the water table (the base of the burial pit must be at least 1 meter above the water table), (ii) dry weather conditions (dry season), (iii) distance to watercourses, bores, and wells, (iv) slope of the land at the burial site to the nearest watercourse (drainage to and from the pit), (v) type of soil (or soil permeability), (vi) distance to human settlements and public lands (including roads), (vii) prevailing wind direction (for odor emissions), (viii) availability of space for temporary storage of excavated soil, and (viii) accessibility of burial site by digging equipment (e.g. excavator). For those situations where the burial criteria are not met (wet weather conditions, high water table), the SOPs will specify the most appropriate, environmentally-safe, and cost-effective disposal option for Lao PDR. The SOPs will provide detailed design (depth of the pit), construction, and operating requirements (how the pit will be filled).

    (vi) Disposal of Used PPE. It is important that the selected PPE and disinfectant be compatible with the disposal method of the PPE to avoid generation of hazardous wastes. Based on experience in Lao PDR, used PPE will be incinerated. As incineration of chlorine-bearing

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    material with organics might generate emissions of dioxins and furans, care will be exercised

    in selecting PPE and disinfectants. First of all, all PPE procured under this project will be

    chlorine-free. In addition, best effort will be made to select a chlorine-free disinfectant.

    However, if this is not possible, then before incineration, used PPEs will be washed before

    incineration and the washed water needs to be disinfected and waited before discharge. The

    SOPs will describe these procedures in detail.

    (vii) Transportation of animal carcasses and farm wastes (if necessary). If proper measures are

    not taken, transportation of AI infected animal carcasses and farm wastes would likely spread

    the virus outside of the infected farm areas. Under this project, transportation of carcasses

    and farm wastes to another site for disposal will be avoided to the maximum extent possible.

    However, if transportation is required, then the SOPs will specify the specific requirements

    for vehicle design and operation as well as containment of carcasses and farm wastes for

    transportation. These SOPs will also include decontamination of vehicle surfaces (e.g. tires)

    prior to exiting the farm.

    (viii) Personal hygiene. If proper hygiene measures are not taken, AI may spread to human. For

    this reason, for each of the above-mentioned activities to be conducted during AI outbreaks,

    the SOPs will specify the level of protection (e.g. gloves, masks, overalls, boots) to be used.

Component 2: Human Health Surveillance and Response. No environmental or personal hygiene

    issues are anticipated.

Component 3: Human Health Laboratory and Curative Services. The main environmental and

    personal hygiene issues under Component 3 of the project are:

    1. Personal hygiene at hospitals

    2. Healthcare waste management at hospitals to be receiving potentially AI-infected patients

    3. Immediate measures for healthcare waste management at central and provincial hospitals

    4. Upgrading of the existing laboratory at NCLE (if funded)

    5. Health laboratory-related personal hygiene measures

    6. Waste management at the NCLE laboratory.

1. Personal hygiene at hospitals. If proper hygiene measures are not taken, AI may spread to

    humans. For this reason, guidelines regarding personal hygiene procedures will be developed at central, provincial, and district hospitals as well as community health centers. In addition, 3,150 PPE to health staff will be provided to the healthcare staff at all levels. Staff from 3 central hospitals in Vientiane capital, 4 regional hospitals, 13 provincial hospitals, 141 district hospitals as well as health care centers will be trained on these guidelines.

2. Healthcare waste management at hospitals to be receiving potentially AI-infected patients. AI

    virus may spread to humans if proper waste management measures are not taken at hospitals treating potentially AI-infected patients. Under this project, three hospitals at the central and four hospitals at the regional/provincial level have been designated to receive AI infected (or potentially AI infected) patients. This subcomponent aims at instituting proper waste management procedures at each of these hospitals. The main activities will include:

    (i) Consulting services for determining waste quantities by type (especially infectious wastes and

    sharps), selecting the optimum technology for infectious waste treatment through evaluation

    of alternatives (autoclave, microwave, incineration) and providing the specifications of the

    selected technology, identifying and providing a conceptual design for the sewage treatment

    system for the isolation rooms, and preparing detailed healthcare waste management plan for

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    each of the 7 hospitals. A waste treatment system will be installed at each of the four

    regional/provincial hospitals. However for the three hospitals in Vientiane capital, the

    consultant will evaluate the optimum arrangement for waste treatment (the treatment

    equipment located at each hospital versus at one hospital receiving also the infectious wastes

    from the two other hospitals transported by means of a van). In addition, the consultant

    services will include the design of the sewage treatment (disinfection) system for the isolation

    rooms at each of the 7 hospitals.

    (ii) Healthcare waste management investment. This will include procurement and installation of

    the solid waste treatment technology at each of the regional/provincial hospital and the

    recommended system in Vientiane [one, two or three treatment equipment, based on the

    findings from (i)]. Training of the operating staff at each hospital will be provided by the

    equipment supplier. In addition, in case of common waste treatment in Vientiane capital, a

    waste transport van will be procured. Equipment and supplies (trolleys, containers, bins,

    plastic bags, labels) for each of the 7 hospitals will also be procured. In addition, the sewage

    treatment (disinfection) system for the isolation rooms at each of the 7 hospitals will be

    procured and installed.

    (iii) Consulting services for healthcare waste management training to the local trainers as well as

    the staff of the 7 hospitals. The local trainers will be training the healthcare staff for the

    subsequent years.

    (iv) Procurement of consumables. The project will fund operating costs for the waste

    management system at each of the 7 hospitals. These will include fuel for the waste transport

    van, steam (for the autoclave technology) and electricity for the treatment technology, and

    supplies (e.g. bags, plastic labels)

    In addition, the consultant will evaluate if it is feasible to treat the infectious wastes generated from NCLE at one of the hospitals in Vientiane.

3. Immediate measures for healthcare waste management at central and provincial hospitals. This

    activity focuses on only the “immediate” measures for healthcare waste management until the system

    covered under the previous activity (item no. 2) is established. This activity involves provision of materials and supplies (containers, bags, labels) to implement the existing healthcare waste management guidelines in Lao PDR.

4. Upgrading of the existing laboratory at NCLE (if funded). If this activity is funded, the adverse

    impacts during construction (e.g. dust, noise, management of construction waste, disturbance of traffic, water supply, sewage management) will be mitigated by including in the construction contract a clause regarding observation of standards for good construction practices.

5. Health laboratory-related personal hygiene measures. If proper hygiene measures are not taken,

    AI may spread to humans. For this reason, SOPs will be prepared for the collection, handling, and transportation of suspected AI specimens to the NCLE laboratory as well as handling of these specimens at the NCLE laboratory. In addition, PPE will be procured and supplied to the staff collecting, handling, and analyzing the suspected AI specimens. Training and then refresher training courses will be given to the staff on personal hygiene measures.

6. Waste management at the NCLE laboratory. Currently infectious wastes from the

    serology/virology, bacteriology and toxicology laboratories of NCLE are collected separately from the garbage and treated on site by autoclaving. The treated wastes and garbage are stored in an open-top basket and collected by the municipality twice a week for disposal. As the same autoclave is currently

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    used for the disinfection of laboratory glassware as well, NCLE is in need of treatment of infectious wastes and glassware in separate equipment. This need will be addressed under the subject project.

    This activity will be conducted jointly with the above-mentioned item (no. 2) on healthcare waste management in hospitals. Accordingly, a consultant will be engaged to identify the quantity of infectious 3waste generated from the NCLE laboratory (currently estimated to be about 0.15 m/day) (and the three

    hospitals in Vientiane). The consultant will evaluate alternative options for waste management (joint treatment with the hospital wastes in Vientiane capital or a dedicated treatment system at the NCLE laboratory) and devise an optimum scheme. The consultant will prepare a waste management plan for the NCLE laboratory solid (this plan will address all waste types, including infectious wastes, sharps, liquid wastes, and common wastes). If a dedicated infectious waste treatment system at the NCLE laboratory is found to be the optimum solution, then this treatment system will be procured and installed at the NCLE laboratory (otherwise the wastes will be transported to the hospital that will have the common treatment system). In addition, various supplies (e.g. bins, bags, labels) will be procured. The NCLE staff will be provided training on waste management.

Component 4: Information, Education, and Communication. No environmental or personal hygiene

    issues are anticipated.

Component 5: Program Coordination and Regulatory Framework. Stockpiling of PPE to the

    frontline workers as well central- and provincial-level MoH and MoAF workers who are involved in the management of AI outbreaks is envisaged. However, no environmental issues are anticipated.

6. IMPLEMENTATION ARRANGEMENTS OF THE PROJECT

    The overall project coordination will be provided by the National Avian Influenza Coordination Office (NAHICO). The Lao PDR agencies responsible for implementing the various project components are:

    Component 1: Department of Livestock and Fisheries (DLF) of the Ministry of Agriculture and

    Forestry (MoAF)

     Component 2: Department of Hygiene and Prevention (DoHP) of the Ministry of Health

     (MoH)

     Component 3: Department of Curative (DoC) and NCLE of the MoH

    Component 4: NAHICO for overall coordination. Implementing agencies include the MoH,

    MoAF, Ministry of Information and Culture, and mass organizations (youth,

    trade, and women’s unions)

     Component 5: NAHICO for overall coordination with the Ministry of Foreign Affairs, Ministry

    of Justice, MoH, and MoAF.

    The international implementing agencies and their respective funding sources are as follows:

    ; World Bank through its own resources and through PHRD fund (Government of Japan) and

    AHIF (multi-donor trust fund)

    ; WHO through its own resources, Government of USA, and Government of Luxembourg

    ; UNICEF through the Government of Japan

    ; FAO through the Government of Germany, Government of Japan, and U.S.AID (Government of

    USA)

    ; AED (consulting firm) through U.S.AID (Government of USA).

7. CONSULTATION AND DISCLOSURE OF THE PROJECT’S ENVIRONMENTAL

    MANAGEMENT PLAN

    This Environmental Management Plan has been consulted with the representatives of the Ministry of Health and the Ministry of Agriculture and Forestry (MoAF). Upon establishment of the National Avian

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