health care waste : Health Care Waste: Lessons learned?

For some observers, the findings are clear as day. When it comes to health care waste, some of the waste from the pandemic was overmanaged. Especially in the early months, when it was uncertain how infectious, for example, personal protective equipment was whose wearers had contact with actual or potential covid sufferers.

In many places, any form of protective equipment was treated as hazardous, quickly reaching the limit of disposal capacity. In China, for example, during the first wave of corona, all waste generated during the treatment of corona patients was considered hazardous and had to be disposed of accordingly. Guidelines were later changed, but in many hospitals it took until well into the second wave for the vast amounts of accumulated waste to be processed.

Yet, as is now known, COVID-19 is highly contagious, but is rarely transmitted via objects or waste. "Waste is not a vector, people are. Other pathogens are transmitted by waste and this is being overshadowed by the focus on COVID-19," says Anne Woolridge, Chief Operating Officer of Independent Safety Services Limited ISSL. ISSL is a British consultancy that specializes in the delivery of Healthcare Waste Management and Dangerous Goods Safety Advisors to the National Health Service and private sector healthcare establishments. And she adds: "There was no need to develop new technologies to deal with waste that had come into contact with the Corona virus. After all, we already have technologies that can handle much more hazardous waste." In this sense, the pandemic has not changed the health care waste sector at all.

What is also true, however: The pandemic has brought about a gigantic increase in the volume of waste in healthcare facilities and in private households, for example as a result of the use of disposable masks. Reliable figures do not exist for all countries and parts of the world. But we do know, for example: In Wuhan, at the height of the pandemic, the amount of health care waste increased to six times what the waste disposal facilities there could handle, which at peak times was about 250 tons a day. In Pattaya, on the other hand, the amount of health care waste increased tenfold during the fourth wave in August 2021.

Here's another figure: global production of disposal personal protective equipment increased by forty percent due to the pandemic. Some 129 billion disposable masks and 65 billion disposable gloves were produced worldwide per month to meet the demand created by Covid-19, according to authors of a recent paper in Environmental Science & Technology.

At the height of the pandemic, the consulting firm Forst & Sullivan calculated that, with similar increases in health care waste as in China, the U.S. alone could generate the same amount in two months as the entire world did in a year. It is obvious that the world needs new ways to deal with these masses of waste. In that sense, it's fair to say that the pandemic has completely changed the health care waste sector.

Edward Krisiunas, among others, is thinking about the consequences of this. For almost 40 years, the health care waste consultant has been involved in projects all over the world: in Africa as well as in Asia, in the USA as well as in Europe. Over the four decades of his work, Krisiunas has experienced a wide variety of ways of dealing with hazardous health care waste. His answer to the question of what the health care waste industry can take away from the pandemic therefore logically begins with: "It depends.” And then Krisiunas says: "What we have seen in health care sector has varied around the world. Large volumes of health care waste have been generated in all countries. The variability is in the available treatment and disposal systems for these waste streams. My personal experience in high income countries points to systems in place to manage the tsunami of waste that was created. Yes, there have been large volumes of wastes and we continue to see those volumes in so called hot zones, but they are managed properly."

The situation is different in some of the low-income countries, Krisiunas adds. "Countries that normally generate less than 1 kg per patient per day are now generating waste volumes on par with high income countries. These countries are providing health care services at a level closer to high income country services without the same effort dedicated to waste disposal." From this perspective, it could be said that how COVID-19 changes the health care waste sector depends on the context.

In countries with well-developed waste management, well-established collection systems, and the appropriate infrastructure, dedicated service providers are very often hired to dispose of health care waste from hospitals and other health care facilities, offering an all-around service: from the collection containers to their collection and the recycling of the waste. Until the outbreak of the pandemic, hospitals that opted for such solutions were in a comfortable position: in the best case scenario, they merely needed to renew existing contracts with disposal companies once a year or every few years.

With the pandemic, everything changed. In China, the first country to be massively affected by Corona, capacity limits were quickly reached at the height of the pandemic. In 22 cities, health care waste could no longer be disposed of in a timely manner, and in 28 cities, disposal facilities reached their limits. In an unprecedented effort, a centralized temporary plant with a capacity of 30 tons per day was built in Wuhan within two weeks. The plant was built by Gient, the leading Chinese provider of health care waste treatment equipment.

Gient's modular solutions, which have been used in the past in regions with poor waste management infrastructure, proved very useful during the pandemic, even in areas that are basically well served. Housed in containers and transportable by truck, these units have connections for water and power and can be put into operation virtually immediately after transport.

Because they are fully automated, they require only one operator. One unit processes between one and three tons of health care waste per day. However, several containers can also be set up next to each other at a single site. The major advantage of the system, apart from its scalability and rapid deployment, is the investment cost: A central stationary unit with a capacity of 3 to 5 tons costs around two million US dollars to build. Mobile and modular systems cost about a third of that.

In Europe, the disposal situation was not as drastic as in China. But in 2020, at the height of the pandemic, capacity became scarce, even in Europe. In France, the 72-hour period during which waste could be temporarily stored had to be extended to 5 days at times because disposal companies were not keeping up with their work.

"That was the moment when many hospitals also realized the disadvantages of relying on an external service provider," says Miquel Lozano, president of Tesalys, a French company that produces equipment for on-site treatment of health care waste. The smallest units Lozano's company offers are just one square meter, while the largest are five square meters. The most powerful models can process up to 100 kilograms per hour.

On-site solutions, however, can not only prevent bottlenecks in disposal, they can also be a way to reduce the carbon footprint of health care waste disposal when thought about more broadly. If they are used, the CO2 emissions of the journeys between the hospitals and the disposal sites are eliminated, as is the incineration of the waste. To date, no data has been collected on the actual extent of this effect. Tesalys has therefore commissioned the independent sustainable development agency Primum Non Nocere to carry out a study in a hospital in the south of France. The hospital, which served as the test site, has 250 beds and 16 operating rooms, and the surveys were conducted under real-life conditions. "The environmental impact study took into account all the direct and indirect modifications associated with the deployment of the on-site treatment solution," explains Lozano.

The key message of the study is impressive: using the on-site solution reduced the hospital's CO2 footprint to one-fifth of its original level. The volume of residual waste left over following on-site treatment was 76 percent less than with incineration. The study also showed that 96 percent of the shredded and decontaminated material from on-site treatment contained materials that could, in principle, be recycled. (See the box for more on the study results). If all infectious waste generated in the country - 141,000 metric tons per year before the pandemic, in 2018 - were treated on-site, it would result in a savings of 68,254 metric tons of CO2 equivalents, or in other words, 1.3 million flights between London and Paris. According to the study results, the global annual savings potential is equivalent to the annual CO2 emissions of one million cars.

A study conducted in the UK in 2008 has already shown that the recycling potential in the area of health care waste is huge. The waste in the operating rooms of a hospital was analyzed over a period of two weeks. It was found that even in this extremely sensitive environment, 40 percent of the waste was basically recyclable. In most countries, however, recycling health care waste is an option that is rarely used, not least because of legal restrictions.

The pandemic has led to an increase in health care waste, the classification of which as hazardous or non-hazardous, infectious or non-infectious was initially very unclear. In the meantime, these issues have largely been clarified. The major challenge now, experts agree, is to consider how to minimize the ecological impact of materials used in pandemic response.

During the COVID19 pandemic, as numerous hospitals and healthcare facilities around the world struggled to manage massive increases in waste, a topic that otherwise receives little attention came into the public eye: how to deal with health care waste. The challenges it exposed existed, even before the pandemic. Now, however, the critical mass may have been reached to tackle them. In any case, the conditions are favorable.

Technically, waste management has long been equipped to handle even dangerous, highly infectious health care waste. However, the waste caused by COVID19 is generally not one of them.

COVID-19 caused massive capacity bottlenecks. In Wuhan, for example, at the height of the pandemic, six times as much health care waste was generated daily as could be processed.

Mobile modular container systems, such as those used in China, can be a solution to quickly create additional treatment capacity. They can be retrofitted both on-site and at existing waste treatment facilities.

On-site treatment can reduce the carbon footprint of health care waste to one-fifth of what it would be if recycled outside of health care facilities.

Health Care Waste recycling offers great potential that is currently underutilized due to regulatory and logistical hurdles.

In countries with poor waste management infrastructure, the main challenge remains preventing health care waste from ending up untreated in landfills or dumps.

In a long-term perspective, the COVID19 pandemic may be an occasion for health sectors to find a new balance between the use of disposable materials and sustainability.