Healthcare Waste – Collateral Damage of the COVID-19 Pandemic

Bunnany Pekar, CRNA, ARNP

Have you ever thought of where the needle and syringe you just used to perform a knee aspiration and injection end up?  What happens to the aspirated fluid that you send to lab for analysis?  How about the countless plastic gloves, face mask, and all the other PPEs that you donned and doffed each day for the last 2 years of the pandemic?

Most of us have not thought beyond what we diligently do every day:  safely discarding the needle in the sharps bin or properly discarding the dirty gown we donned during central line placement in the proper biohazard bin.  We apply our knowledge of the yearly required OSHA blood borne pathogen modules expertly, separating each component of trash into the appropriate receptacles. 

But where do these biohazard wastes go after they leave the hospital or clinic?  How do we process this waste? What impact do processing, or lack of appropriate waste handling have on the environment?

Risks of Transmission and Exposure

According to the WHO (2018), there are 16 billion injections worldwide each year.  Unfortunately, not all of those needles are properly disposed of. Injections with contaminated needles and syringes in low and middle-income countries continue to occur. We have made progress, but reuse of injection devices is still causing disease worldwide. This practice is still responsible for approximately 34,000 new HIV, 1.7 million Hepatitis B, and 315,000 hepatitis C infections worldwide.  

It is not just needle sticks that are hazardous. Waste handlers are at immediate risks for injuries and exposure to toxic or infectious materials, especially in emerging countries.

Types of Healthcare Waste

The amount of medical waste produced by healthcare facilities is staggering. According to a report by a medical waste management company, hospitals produce 33 pounds of medical waste per day per staffed bed. The, U.S. produces more than 5.9 million tons of waste annually.  Where does it all go?

There are essentially two different types of health care wastes:  unregulated and regulated medical waste.  The majority (approximately 75-90%) of health care waste is unregulated medical waste. This Includes household types of waste like paper and plastics that have not been in contact with patients.  This type of waste is routinely disposed of based on local or state regulations.  The remaining medical waste is considered infectious and Is regulated.  

Regulated medical waste must be handled with care. This Is the type of waste that can pose a threat to public health. These threats could be either by direct contact or environmental contamination.  

Regulated Healthcare Waste

The WHO classified 8 types of regulated medical waste.  

1. Infectious waste – Waste that may transmit infection from viral, bacterial, or parasitic sources to humans. These include lab cultures, tissues, swabs, equipment and excreta
2. Sharps – Sharp waste, such as needle, scalpels, knives, blades, etc.
3. Pathological – Human tissue or fluids i.e. body parts, blood, other body fluids
4. Radioactive – Unused liquid in radiotherapy or lab research, contaminated glassware, etc.
5. Chemical – Expired lab reagents, film developer, disinfectant
6. Pharmaceuticals – Expired and contaminated medicines
7. Pressurized containers – Gas cylinders and gas cartridges
8. General waste (UMW) – No risk to human health. Does not contain blood or any related bodily fluid, i.e.: office paper, wrapper, kitchen waste, general sweeping, etc.

Examples of regulated wastes that we encounter every day are pictured below:  

Due to public health concerns, the need to properly dispose of regulated medical waste is a booming business.  In 2012, the U.S. spent up to $2.5 billion for the proper disposal of medical waste. After an annual growth of 4.8%, in 2017, the annual market was $3.2 billion. 

Effects of the Pandemic on Healthcare Waste

The CV-19 pandemic accelerated the demand for this business even further.  At this time about 30% of health care facilities in the U.S. are not equipped to handle existing waste loads, let alone the additional load from CV-19.  Think about the following scenarios.  There are 140 million test kits out there with the potential to fill the equivalent of one third of an Olympic size swimming pool from their various components. There about the 8 billion doses of vaccines administered globally producing 144,000 metric tons of additional waste in the form of needles, syringes, safety boxes. 

We have not even discussed the discarded PPEs from health care providers.  Where do you think the plastic gloves, shields, and gowns end up?  What about the equipment that is discarded by the public?  If you look around, you will see discarded masks and gloves all over the place.  There are many masks that have ended up in the ocean and floated on your local beach.

Global Healthcare Waste Processing is not Standardized

A joint WHO/UNICEF assessment found that only 58% of sampled facilities from 24 countries had adequate systems in place for the safe disposal of health care waste.  The health care sector is under increasing pressure to reduce its carbon footprint and minimize waste being sent to landfills.  Also, there is a proliferation of plastic waste which has a negative impact on water and food quality as well as overall ecosystem health.  

Treatment and disposal of healthcare waste may pose health risks indirectly through the release of pathogens and toxic pollutants into the environment. Some countries burn their waste behind medical facilities.  When I went on my mission trips to Cambodia, I realized that they did not have any bins for needles and other sharp waste.  Every piece of trash was lumped together and taken to the back of the facility and burned.  Unfortunately, there Is no way to determine that the heat is hot enough to kill pathogens. We can’t ensure that sharps are appropriately destroyed in the process. 

The other concern is the release of potential chemicals from plastics to the environment.  However, this was the practice that was acceptable by the localities I was at.  I suspect this is also the medical waste practice of other emerging countries. U.S medical facilities contract with medical waste companies to handle their regulated and unregulated waste.

Ways to Manage Healthcare Waste

Medical waste companies employ essentially four steps to manage regulated medical wastes:  collection, storage and transporting, treatment, and disposal.    The disposal of improperly treated or untreated medical waste in landfills can lead to contamination of drinking, surface, and ground water.  

Below is a synopsis of how some of the regulated medical waste is treated according to the type of medical waste.  Once they are properly treated, they are considered waste and can be disposed of in landfills or in the regular sewage. 

Incineration of waste has been widely practiced in the U.S.  However, inadequate incineration or the incineration of unsuitable materials results in the release of pollutants into the air and in the generation of ash residue. Also, some materials can emit byproducts such as dioxans and furans during incinerations that are carcinogenic and require special incinerators with cleaning equipment to catch them.  Also, heavy metals such as lead, cadmium (in batteries), mercury are toxic to the environment during the incineration.  

We are currently battling two different wars:  CV-19 pandemic and the emergence of a global problem just as we are starting to potentially be shifting from pandemicity to endemicity.  It appears that this pandemic forces us to take a closer look at all aspects of health care, not just human resources but the health care waste stream before it creates another significant global public health issue. 

Some Thoughts…

I leave you to think about what you can do to help reduce waste and healthcare waste in the future mitigate another serious global issue:

1. Do we need to don all aspect of PPE when we encounter a potentially infectious patient?  It depends on the level of interaction needed that is based on acuity.  Of course, we need to protect ourselves from an infectious disease and should don proper PPE.  However, during rounds, you observe your CV-19 positive patient sitting in bed watching TV or having a meal, on their cell phone, or engaging in conversation with visitors – do you need to put on your PPE to determine that they are stable?  Could you call them on their bedside phone to discuss your daily plan?  Could you round with the patient’s primary nurse?
2. Can PPEs be reused or repurposed?  
3. Not all PPEs are considered regulated medical waste and need to be separated accordingly.  The cost of regulated medical waste is about 10 times that of regular waste for hospital organizations.  This creates more strain on smaller institutions and critical access hospitals that are already feeling the financial squeeze. 
4. Are there alternatives to plastics gloves such as biodegradable gloves or gowns?  What about reusable gowns?  During this pandemic, there are more than 90 million gloves used by health care providers each month.  These rubber gloves take more than 100 years to break down. Conversely, latex gloves degrade at the fastest rate, though it has some clinical disadvantages in the context of someone with a latex allergy.  However, Medrux has developed biodegradable gloves that would decompose in five years and potentially less costly than traditional gloves when all costs are considered.  
5. Though not necessarily a health care waste issue, bottled water waste is becoming a global problem.  

Bottled Water Waste

Would each of us commit to using nondisposable metal containers for water instead of buying bottled water? Though recycling of plastics is about 32% (2015 data), there are more than 2/3 of plastic bottles that are not recycled.  Americans used about 2.5 million plastic bottles every hour, with bottled water making a significant percentage of it.  The waste created by plastics bottles is not even the worst part, as the bottling process consumes about 1/3 of a 1% of the US energy consumption.  

Some people do not drink from the tap. Bottled water may not be a pure as we think it is.  Some plastics also contained BPA, which is harmful to your health.  Although some companies advertise BPA-free plastics, chemicals known as phthalates have the potential to leach from the plastic into the water. This is especially true in situations where water sits in the plastic bottle for a long time and is exposed to sunlight or heat. Phthalates are known endocrine disruptors. They have the potential to mess up your hormones.

Lastly, people are concern that bottled water is cleaner than tap water.  The Natural Resource Defense Council (NRDC) tested more than 1000 bottles of water and concluded that it is not any cleaner or safer that tap water.  If you are concerned about drinking tap water, you may consider a reverse osmosis filtration system.  

We all have an important part in improving our own health and our neighbor’s health.  If each one of us start small, we can still have a big impact on overall population health.

References:

Beals, R. K.  (2022).  WHO report points to tons of dangerous COVID-19 refuse — these waste-management stocks are poised to gain from it.  Retrieved Biomedical Waste Solutions (2021).  Medical waste disposal:  definitive guide.  Retrieved from Medical Waste Disposal – Definitive Guide 2021 [Infographic] (biomedicalwastesolutions.com)

Biomedical Waste Solutions (2021).  Medical waste disposal:  definitive guide.  Retrieved from Medical Waste Disposal – Definitive Guide 2021 [Infographic] (biomedicalwastesolutions.com)

Medrux gloves.  Retrieved from https://medrux.com/biodegradable-gloves/

O’Malley, I.  (2022).  WHO warns of threats from COVID medical waste to environment, human health.  Retrieved from WHO warns of threats from COVID medical waste to environment, human health (yahoo.com)

Padmanabhan, K. K., & Barik, D. (2019). Health Hazards of Medical Waste and its Disposal. Energy from Toxic Organic Waste for Heat and Power Generation, 99–118. https://doi.org/10.1016/B978-0-08-102528-4.00008-0

Postman, A.  (2016).  The truth about tap.  Retrieved from The Truth About Tap | NRDC

Water and Home Living (2016).  6 reasons to stop buying bottled water.  Retrieved from 6 Reasons to Stop Buying Bottled Water | Water-Right (water-rightgroup.com)

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