medical waste management practices case study

• Research article
• Open access
• Published: 15 March 2016

Assessment of medical waste management in seven hospitals in Lagos, Nigeria

• Olufunsho Awodele 1 ,
• Aishat Abiodun Adewoye 2 &
• Azuka Cyril Oparah 3  

BMC Public Health volume  16 , Article number:  269 ( 2016 ) Cite this article

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Medical waste (MW) can be generated in hospitals, clinics and places where diagnosis and treatment are conducted. The management of these wastes is an issue of great concern and importance in view of potential public health risks associated with such wastes. The study assessed the medical waste management practices in selected hospitals and also determined the impact of Lagos Waste Management Authority (LAWMA) intervention programs. A descriptive cross-sectional survey method was used.

Data were collected using three instrument (questionnaire, site visitation and in –depth interview). Two public (hospital A, B) and five private (hospital C, D, E, F and G) which provide services for low, middle and high income earners were used. Data analysis was done with SPSS version 20. Chi-squared test was used to determine level of significance at p  < 0.05.

The majority 56 (53.3 %) of the respondents were females with mean age of 35.46 (±1.66) years. The hospital surveyed, except hospital D, disposes both general and medical waste separately. All the facilities have the same process of managing their waste which is segregation, collection/on-site transportation, on-site storage and off–site transportation. Staff responsible for collecting medical waste use s mainly hand gloves as personal protective equipment. The intervention programs helped to ensure compliance and safety of the processes; all the hospitals employ the services of LAWMA for final waste disposal and treatment. Only hospital B offered on-site treatment of its waste (sharps only) with an incinerator while LAWMA uses hydroclave to treat its wastes. There are no policies or guidelines in all investigated hospitals for managing waste.

Conclusions

An awareness of proper waste management amongst health workers has been created in most hospitals through the initiative of LAWMA. However, hospital D still mixes municipal and hazardous wastes. The treatment of waste is generally done by LAWMA using hydroclave, to prevent environmental hazards except hospital B that treats its sharp with an incinerator. In order to enhance uniform and appropriate waste management practices in the entire State, there is need for capacity building at all levels and also policies and guidelines formulations.

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Medical waste management (MWM) has become a critical issue as it poses potential health risks and damage to the environment [ 1 , 2 ]. It is also of greater importance due to its potential environmental hazards and public health risks with high propensity to result into epidemics [ 3 ].

It continues to be a major challenge, particularly, in most healthcare facilities of the developing countries where it is hampered by technological, economical, social difficulties and inadequate training of staff responsible for handling of the waste [ 4 ]. Poor conduct and inappropriate management and disposal methods exercised during handling and disposal of medical waste (MW) is an increasing significant health hazards and environmental pollution/hazards due to the infectious nature and unpleasant smell of the waste [ 5 – 7 ]. Despite the fact that current medical waste management (MWM) practices vary from hospital to hospital, the problematic areas are similar for all healthcare units and at all stages of management [ 8 ].

In Nigeria, a typical developing African nation, not many people are aware that medical waste contributes substantially to environmental pollution and hazards. This is reflected by lack of awareness and specific policy to address the menace of healthcare facility (HCF) waste, some of which is deemed hazardous [ 9 ]. It is important to note that healthcare wastes, if not properly managed, could pose an even greater threat and hazards than the original diseases. It is the duty of hospital and healthcare centers to take care of public health issues such as MW. Specific approaches that may be employed include patient care and enlightenment, ensure clean and healthy environment for workers/community [ 10 ]. Carefree handling and disposal of MW impacts both directly and indirectly on staff, patient and environment. This is because the hospitals represent a unique environment, providing healthcare to patients and work environment for medical and other staff.

In the process of healthcare delivery, medical waste is generated, which includes sharps, human tissues or body parts and other infectious materials [ 11 ]. Interestingly, there are reasonable ranges of technologies available for the treatment of healthcare wastes that may be appropriate for use in the third world countries.

The World Health Organization (WHO) estimates that each year there are about 8 to 16 million new cases of Hepatitis B virus (HBV), 2.3–4.7 million cases of Hepatitis C virus (HCV) and 80,000–160,000 cases of Human Immunodeficiency Virus (HIV) due to unsafe injections disposal and mostly due to very poor waste management systems [ 12 ].

Contaminated injection equipment may be scavenged from waste areas and dump site either to be reused or sold to be used again. The negative health and environmental impacts of MW includes transmission of diseases by virus and microorganism, defacing the aesthetics’ of the environment, as well as contamination of underground water tables by untreated MW in landfills [ 13 ]. Good medical waste management in hospital depends on a dedicated waste management team, good administration, careful planning, sound organization, underpinning legislation, adequate financing and full participation by trained staff [ 14 ].

However, it is pertinent that before any of these options is adopted, hospitals and medical facilities will need to assess the problems and put forward a management strategy that is suitable to their economic circumstances and also sustainable for use, based on local technology [ 15 , 16 ]. Paradoxically, health-care activities which are meant to protect health, cure patients and save lives have been known to also generate waste. About 20 % of these wastes pose high risk, either of infection and chemical or radiation exposure [ 17 ].

Health-care activities generate significant amounts of hazardous waste such as mercury and expired pharmaceuticals, as well as large amounts of general waste. As a matter of fact, the management of health-care waste is an integral part of a national health-care system. A holistic approach to health-care waste management should include a clear delineation of responsibilities, occupational health and safety programs, waste minimization and segregation, development, adoption of safe and environmentally sound technologies, and capacity building.

Recognizing the urgency of this problem, a growing number of countries have taken initial steps to respond to this need. These include the establishment of regulatory frameworks, development of national plans and the demonstration of innovative approaches. However, funding of health-care waste management remains very inadequate [ 18 ].

This is an issue taking central place in the national health policies of many countries however, in most urban areas in Nigeria there are often no systematic approaches to MWM and it has not received sufficient attention. This may be because very often, health issues compete with other sectors of the economy for the very limited resources available. Also, in many countries, medical wastes are still handled and disposed together with domestic wastes, posing a great health risk to municipal workers, the public and the environment [ 19 , 20 ]. Medical waste must be separated from municipal waste, but in many parts of Africa it tends to be collected along with the rest of the waste stream [ 20 – 22 ]. Furthermore, hospital wastes are still mixed with the municipal waste in collecting bins at roadsides and disposed of similarly [ 15 , 23 ].

In Korea, medical waste was often mixed with municipal solid waste and disposed of in residential waste landfills or improper treatment facilities (e.g. inadequately controlled incinerators) [ 24 ]. This is also evident as some of the hospital surveyed in Lagos mixes municipal and medical waste in their on – site storage facility (Fig.  1 ).

Improper storage of both general waste and infectious waste at one of the hospitals surveyed

The population of Lagos State is on the increase and the amount of hospital waste generated is snowballing at alarming rates due to growth of population and healthcare facilities. However, there are some problems encountered with the management of MW and they are- improper storage, frequent dumping of infectious waste with municipal waste, no uniform definition and identification of hazardous waste and low level of awareness about the management of medical waste. It is worthy to note that Lagos State has gone a step ahead of federal government of Nigeria in the management of medical waste because of their intervention programs and also the construction of several well-equipped transfer loading stations available in some parts of the State (Fig.  2 ).

Lagos State special containers for loading medical waste at a transfer loading station

Therefore, this present study assessed the medical waste management practices in selected hospitals in Lagos State and also determined the impact of Lagos Waste Management Authority (LAWMA) intervention programs on medical waste management in Lagos, Nigeria.

Design & setting

The study employed an observational cross-sectional design conducted in Surulere, Mushin/Yaba, Ikeja, Gbagada and Lagos Island areas of Lagos State. Lagos is located in south western Nigeria on the western coast of Africa. Lagos is the most populous city in Nigeria, the largest country in Africa. The metropolitan area has an estimated 300 km 2 , a group of islands endowed with creeks and a lagoon. Officially, the population of Lagos was last recorded at 7,937,932 (2006 Census). Lagos is the second fastest growing city in Africa and the seventh fastest in the world. The population is an estimated 21 million (2011) which is 10 % of Nigeria’s population, recently projected at 167 million by the National Population Commission. (Punch Newspaper- November 20, 2011). Healthcare facilities are dispersed all over the metropolis and wastes generated from these facilities are often mixed with municipal waste.

Study population

The target population of this survey consisted of selected 120 personnel (doctors, nurses, laboratory scientists and domestic workers from both private and public hospitals) in Lagos, Nigeria.

Selection of facilities

Seven (7) hospitals were selected for the exercise, using stratified, simple random and convenience sampling methods. The hospitals were stratified into private and public based on the ownership of the hospitals. This approach ensured that the various categories of hospitals operating in Lagos were included in the study and coding of the hospitals was done to ensure anonymity/confidentiality.

The studied hospitals provide general medical, surgical, pediatric, maternity and a range of specialist services. The two (2) selected public hospitals include the only federal teaching hospital in Lagos State and one out of the twenty six (26) general hospitals owned by Lagos state. Five (5) private hospitals were also selected out of the nine hundred (900) private hospitals in Lagos using both simple random and convenience sampling methods. The hospitals were coded A, B, C, D, E, F and G. The two public hospitals (A and B) are among the largest and leading healthcare institutions in Lagos and, indeed, the oldest and most advanced facilities in Lagos State. The selected private hospitals serve the low-income, middle-income and high-income earners in Lagos State.

Data collection

A catalog of the waste generated in each of the sampled hospital in the study area was carried out. The type of waste generated was identified through direct surveillance (site visitation) and use of questionnaire (sections of the questionnaire are; demographic Information, description of hospital, knowledge about the waste characterization, assessment of medical waste management practice, Information about the personnel involved in the management of waste, hospital waste management policy). In addition, the head of nurses, sanitary workers and laboratory officers were verbally interviewed with a view to obtaining the level of training of its staff. In each hospital, the questionnaires were administered to the doctors, nurses, laboratory officers and domestic workers/cleaners who were randomly selected for this purpose based on the proportion of staff in each hospital (see Table  1 ).

The method adopted for this study follows the procedure used by Longe and Williams [ 25 ]. This involves the three instruments which are Survey questionnaire administration, Site visitation and in – depth interview. There were no existing waste management policy with respect to waste generation, segregation, collection, storage, transportation and final disposal in the hospitals however; a procedure was followed due to the training received from LAWMA/John Snow Inc.

Statistical Package for Social Sciences (SPSS version 20) was used for the analysis of the data. Chi-Square statistical test of significance was used to determine the level of significance of association between variables at 95 % confidence level (±5 % sampling error). Level of significance was set at p  ≤ 0.05.

Ethical consideration and participants consent

Ethical approval for this study was obtained from Lagos State Ministry of Health thereafter, institutions Health Research and Ethics Committee (HREC) approval was obtained. The experimental procedures were explained to the individual participants and thereafter their consent to participate in the study was obtained. The participants that declined not to be part of the study were excluded. Confidentiality was assured by excluding all the names of the hospital surveyed.

One hundred and five (105) questionnaires were fully completed out of the 120 questionnaires distributed in this study, giving a response rate of 87.5 %. The mean age of respondents was 35.46 ± 1.66 years.; majority of them were females 56 (53.3 %). The mean number of years spent in the hospital by respondents is 9.73 ± 6.91 year. The majority of respondents were domestic workers (34.3 %) and nurses (31.4 %) (Table  1 ).

The survey indicates that, apart from hospitals D and G, others have records of the volume of waste which they generate. The medical wastes generated range from 0.116 to 0.561 kg/bed/day, while the total waste is about 215.56 kg/day. Thus, the average generation rate is approximately 0.181 kg/bed/day.

The various categories of waste; general, pathological, chemical, infectious, sharp and pharmaceutical were found in all the hospital units, apart from the Pharmacy which does not generate pathological waste, the laundry, kitchen, administration and engineering units also generate general wastes alone (Table  2 ).

The respondents in the various facilities had adequate knowledge of waste categorization. About 69.5 % of the respondents rightly categorized paper, food, plastics and bottles as general waste. Soiled cotton wool, swab and gloves were also classified by 69.5 % of the respondents as infectious wastes. The majority of respondents also got it right by classifying body parts, body fluids and fetuses as pathological wastes (Table  3 ). There was a significant association ( p  < 0.05) between the profession of the respondents and categorization of paper, bottles, food and plastic wastes. However, there were no significant differences ( p  > 0.05) between socio-demographic variables and categorization of soiled cotton wool, swab, specimen container, body parts, fetuses, needles and scalpels. The respondents in the various facilities had adequate knowledge of waste categorization. 61.0 % indicated that segregation should be done at the source, as against 39.0 % who indicated otherwise and 88.6 % indicated the use of safety boxes for sharp collection. About 81.9 % of the respondents also indicated the need to segregate medical wastes. The responses however differed from hospital to hospital. 85.7 % of the respondents’ agreed that medical waste could be generated from diagnosis, immunization and treatment. About 74.3 % of the respondents also knew that there are specific procedures for collection and handling of medical waste (Table  4 ). There was no significant association ( p  ≥ 0.05) between socio-demographic variables and waste segregation. There was satisfactory knowledge of color coding of wastes which is an essential factor for proper segregation of waste. About 81.9 % of all the respondents indicated that they use color code for easy identification of the wastes generated in their various facilities. The majority of respondents also rightly identified the color codes of all the wastes generated. More than half of all the respondents (58.1 %) rightly identified the color code (black) for general waste, 53.3 % identify red as the color code for pathological waste but only 33.3 % of all the respondents could identify the color code for infectious waste as yellow (Table  5 ). There was a statistically significant association ( p  < 0.05) between the profession of the respondents and the ability to identify the color coding for pathological wastes with highest association amongst the nurses and this may be due to the training received.

The result indicates that various means of on-site transportation of waste from the source of generation are utilized with wheel barrows and trolleys constituting the major means of evacuating the waste. Although, facility B has a hospital constructed truck for the same purpose.

It was likewise observed during the visits that all the surveyed hospitals outsource their waste to LAWMA medical. The treatment of waste within the hospitals is not common except for one of the public facilities (B) which uses incinerator to treat its sharp. This hospital also engages the services of an environmental officer who oversees the treatment and eventual disposal of its medical wastes. The majority of respondents are now aware that LAWMA MEDICAL is in charge of medical waste in Lagos State.

The majority of the respondents were domestic workers. The aforementioned is in contrary with the study of Joshua et al. [ 26 ] which was carried out in some primary health care centers in Zaria - Nigeria where majority (37 %) were nurses and no domestic workers were used for the survey on waste disposal and management. The involvement of the domestic workers in waste management is inevitable and logical as they are largely involved in waste collection and transportation.

It is quite clear that for efficient waste management program the quantity and variations in the waste generated in each facility must be put into considerations. The findings in this study corroborate some rates recorded in Souss-Massa-Draa, where an average rate of 0.53 kg/bed/day was recorded [ 1 ]. Furthermore, a study carried out in 2008 by Abdulla et al., showed that waste weighted average was 0.83 kg/bed/day in northern Jordan and 1.22 kg/bed/day was reported by Ruoyan et al., in 2010 as weighted average rate in Binzhou Distrinct in China [ 27 , 28 ]. The earlier study done by Longe and Williams, in Lagos State before the introduction of MWM, reported an average generation rate of 0.573 kg/bed/day [ 25 ]. The reduction that was noted in this study for the average generation rate may be attributed to the intervention of Lagos State, through the awareness and training programs organized by LAWMA medical unit for proper segregation of infectious waste, adequate categorization and disposal of the waste.

Wastes generated from the various activities performed in hospitals include general and medical wastes. The general waste emanates from food preparation, administrative activities, landscaping, housekeeping, activities of health-care establishments and may also include waste generated during maintenance of health-care premises. This type of waste may be similar to household and city wastes.

While the wastes generated in the health facilities include cultures, stocks of infectious agents, pathological, blood and other fluids, sharps, surgery and laboratory wastes, wastes from food preparation, radioactive wastes, wastes from dialysis procedures, biological wastes, cardboard, paper documents and discarded linens. Between 75 and 90 % of the waste produced by health-care facilities is non-risk or general health-care waste, which is comparable to domestic waste, while about only 25 % is regarded as hazardous and may create a variety of health risks [ 14 ].

Waste generation source, categorization, quantity and quality are the key issues to decide an effective medical waste management practice [ 1 ]. The medical staff in the surveyed hospitals had adequate knowledge of the various categories of the wastes generated.

Two-third of all the respondents rightly categorizes both the general and infectious waste which thus leads to proper segregation of the waste. A further analysis indicates that higher number of nurses rightly identified items that constitute MW more than other profession. The justification for this observation was witnessed during the in-depth interview section, where nurses displayed higher knowledge about the medical waste categorization than others. This is due to the fact that they go for more training, both in-house and those organized outside their facilities on hospital waste management and also with the inclusion of the capacity building sessions annually organized by Lagos waste management authority (LAWMA).

In general, respondents are aware of the fact that medical waste can be generated during immunization, treatment, diagnosis, medical research, given the high proportion of respondents who provided the right answer to an enquiry on this issue.

Segregation of infectious waste at the source of generation is the key to achieving a sound medical waste management. The study revealed that majority of respondents agreed on segregation of medical waste at the point/source of generation. This is consistent with the findings of Asadullah, et al. [ 29 ] which indicated that 90.4 % of respondents were of the view that segregation of waste should be at the point of generation. It is important to note that medical waste segregation is an important step in reducing the volume of hazardous waste. Such segregation is achieved by making use of labeled containers or colored liners to effectively separate infectious waste from general/domestic waste. More than three quarters of the respondents uses safety boxes for sharp collections and this is in accordance with the regulation of WHO which ensures that the sharps are properly secured and do not fall out of the container and it should only be three-quarters filled prior to disposal [ 30 ].

The high percentage of respondents using color code for identification indicates their level of understanding its essence in management of medical waste. It also helps with easy recognition and disposal of the waste. This is also consistent with the findings of Abdullah and Al- Mukhtar in 2013 where about 79.2 % of the respondents uses color coding for proper identification but contrary views was noted in the findings done in 2005 by Al-Khatib and in Zaria by Joshua et al. [ 26 ], where none of the facilities practice color coding for segregation and thus reflected in their practices [ 31 , 32 ].

There was satisfactory knowledge of color coding of wastes which is an essential factor for the proper segregation of waste. Proper segregation is achieved by making use of actual colored containers or colored liners to effectively separate infectious waste from general/domestic waste. WHO [ 30 ], proposed that hospitals should provide either plastic bags or strong plastic containers for medical wastes and that they should make use of different colored liners namely, Black, Yellow and Red (three bin system) for general, infectious and highly infectious waste respectively. Bags and containers for highly infectious waste should be marked with Biohazard symbol [ 33 ]. The use of a brown liner is also encouraged by WHO for pharmaceutical waste (expired drugs) but this is rarely used. There was a statistically significant association between the profession of the respondents and the ability to identify the color coding for pathological wastes with highest association amongst the nurses and this is also due to the training received.

Various means were utilized to transport wastes from the point of generation to the on-site storage; while wheel barrows and trolleys constituted the major means of evacuating wastes in most facilities which is similar to the findings by Joshua, et al. [ 26 ], however, only facility B used hospital constructed trucks. Medical wastes generated in hospitals are collected on a daily basis and transported to a temporary storage center within the hospital.

Such wastes are collected and transported by the means of a trolley, wheeled barrow, trucks etc. Data from this study revealed that one of the two public hospitals (hospital B) uses trucks (hospital constructed), while some use trolley and others conveys the waste by hand which could be dangerous. Although WHO stipulates that different trolleys should be used in transporting the different categories of wastes, this requirement is not adhered to in most hospitals that were surveyed. Indeed, all the wastes generated are carried with the same trolley and this could also lead to cross-contamination. Domestic staff/sanitary officers are responsible for collection of the segregated medical wastes from the wards to the on-site storage center in all the hospitals. As important as protective equipment are to anybody who handles medical wastes, the hospitals surveyed use only heavy duty gloves and this is not consistent with the recommended standard of WHO which requires the use of heavy duty gloves, boots and apron [ 33 ]. A study which was carried out in Tehran University by Dehghani et al. [ 3 ] indicated the compliance with WHO standard by using the complete personal protective wear. Safety shoes or industrial boots should also be encouraged because they help to protect the feet against the risk of sharp being accidentally dropped, thereby causing a prick. There is need to properly equip and educate those in charge of on-site transportation of wastes, given the great danger associated with this task. The use of adequate and complete protective clothing is very vital.

Medical waste treatment leads to a reduction in volume, weight and risk of infection and organic compound of the waste [ 33 ]. There are no clear policies and plans in place for managing medical waste in the surveyed hospitals, as evidenced by the absence of manuals and guidelines. On further enquiry, it was discovered that even the Ministry of Health does not have manuals or guidelines for the management of hospital wastes. Indeed, it was gathered that there is no medical waste management policy/guideline at both the national and state levels. It is important for Standard Operating Procedure (SOP) to be prepared for medical waste management in the hospitals as obtained in developed countries where definite rules and regulations exist at the national, regional and hospital levels. In the light of this it is not only the policy/legislation but also the inclusion of proper monitoring and enforcement strategy, which would further allow for proper MWM [ 9 ]. The study also noticed several reasons for poor HCWM in the hospitals but the most prevalent challenges highlighted during the interview section were lack of definite policies/legislation, lack of budget allocation, lack of rules and regulations, poor training of some hospital staff and lack of implementation/enforcement.

Despite the challenges associated with WM especially the lack of policies and regulations as stipulated by WHO. Lagos state has taken the initiatives to have a well-organized system of collecting and treating waste. The State has also taken further steps by providing the needed items like the different colored containers, liners to the hospitals at no cost. LAWMA also collects the waste for final disposal at little cost so that the hospitals can be encouraged to segregate and collect their waste appropriately. From the findings of this study, it suffices to conclude that there is little progress in the management of medical waste in Lagos State because of the following: The MWM practices among the various hospitals surveyed are similar except for hospital D which still mixes its medical and general waste. The medical waste is collected and segregated using the three colors coding system by WHO, then transfer to the on-site storage and finally transported by Lagos State to the transfer loading station where it is treated by means of hydroclave. This system is congruence with WHO specifications however; uniformity in MWM practices should be ensured in all hospitals as against the divergent of hospital D. The level of awareness and training among the workers has relatively increased due to the intervention of LAWMA and John Snow Inc. however; continuous training of the hospital staff on MWM is highly advocated. There is also a need for awareness of waste management system amongst the patient/community in order to prevent nosocomial infections and environmental hazards. Policy and regulation guidelines should be provided to all the three tiers of government (federal, state and local government) so as to improve waste management practices throughout the country as also recommended in South Africa by Pululu and Tabukeli [ 34 ].

Abbreviations

hepatitis C virus

hepatitis B virus

healthcare facility

Health Facility Monitoring and Accreditation Agency

Lagos Waste Management Authority

medical waste

Medical Waste Management

World Health Organization

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Acknowledgements

The authors thank all the staff of the surveyed hospitals for their immense support during the study.

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Department of Pharmacology, Therapeutics and Toxicology, College of Medicine, University of Lagos, PMB 12003, Lagos, Nigeria

Olufunsho Awodele

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Aishat Abiodun Adewoye

Department of Clinical Pharmacy and Pharmacy Practice, University of Benin, Benin City, Edo State, Nigeria

Azuka Cyril Oparah

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Authors’ contributions

OA: Carried out the interpretation of statistical analysis for appropriate writing of the manuscript, writing and expert review of the manuscript. AAA: Carried out the study design and execution of the research work and writing of the initial draft of the manuscript. ACO: Carried out the study design and expert review of the manuscript. All authors read and approved the final version of the manuscript.

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Awodele, O., Adewoye, A.A. & Oparah, A.C. Assessment of medical waste management in seven hospitals in Lagos, Nigeria. BMC Public Health 16 , 269 (2016). https://doi.org/10.1186/s12889-016-2916-1

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Effective medical waste management for sustainable green healthcare.

1. Introduction

2. literature review, 2.1. medical waste.

2.2. Medical Waste Management for a Sustainable Healthcare Environment

2.3. operational strategies for effective medical waste management, 3. methodology, 3.1. analytic hierarchy process, 3.2. identification of key medical waste management factors, 3.3. data acquisition process, 3.4. data collection, 4.1. consistency test, 4.2. ahp results, 4.3. experts’ opinions on the ahp results, 5. conclusions, 5.1. theoretical and practical implications, 5.2. limitations and future research directions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Lee, S.M.; Lee, D. Effective Medical Waste Management for Sustainable Green Healthcare. Int. J. Environ. Res. Public Health 2022 , 19 , 14820. https://doi.org/10.3390/ijerph192214820

Lee SM, Lee D. Effective Medical Waste Management for Sustainable Green Healthcare. International Journal of Environmental Research and Public Health . 2022; 19(22):14820. https://doi.org/10.3390/ijerph192214820

Lee, Sang M., and DonHee Lee. 2022. "Effective Medical Waste Management for Sustainable Green Healthcare" International Journal of Environmental Research and Public Health 19, no. 22: 14820. https://doi.org/10.3390/ijerph192214820

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Profile of medical waste management in two healthcare facilities in Lagos, Nigeria: a case study

Affiliation.

• 1 BEST Research Institute, School of Built Environment, Liverpool John Moores University, Liverpool, UK. [email protected]
• PMID: 23460544
• DOI: 10.1177/0734242X13479429

Proper management and safe disposal of medical waste (MW) is vital in the reduction of infection or illness through contact with discarded material and in the prevention of environmental contamination in hospital facilities. The management practices for MW in selected healthcare facilities in Lagos, Nigeria were assessed. The cross-sectional study involved the use of questionnaires, in-depth interviews, focused group discussions and participant observation strategies. It also involved the collection, segregation, identification and weighing of waste types from wards and units in the representative facilities in Lagos, Nigeria, for qualitative and quantitative analysis of the MW streams. The findings indicated that the selected Nigerian healthcare facilities were lacking in the adoption of sound MW management (MWM) practices. The average MW ranged from 0.01 kg/bed/day to 3.98 kg/bed/day. Moreover, about 30% of the domestic waste from the healthcare facilities consisted of MW due to inappropriate co-disposal practices. Multiple linear regression was applied to predict the volume of waste generated giving a correlation coefficient (R(2)) value of 0.99 confirming a good fit of the data. This study revealed that the current MWM practices and strategies in Lagos are weak, and suggests an urgent need for review to achieve vital reversals in the current trends.

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Case study: medical waste management in Bhutan

This case study describes the policies and practices that guide waste management across public and private sector health-care facilities in Bhutan.

The goal of this case study is to illustrate the protection of human health and the environment by sound management of medical waste in Bhutan.

The objectives of the case study are to:

• create legal and practical frameworks for medical waste management;
• unify the policies and practices across the public and private health sectors;
• support health-care workers and improve their knowledge of medical waste management;
• create a national waste reporting system; and
• engage in multisectoral cooperation for waste management led by the Ministry of Health.

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Open Access

Peer-reviewed

Research Article

Assessment of medical waste generation, associated environmental impact, and management issues after the outbreak of COVID-19: A case study of the Hubei Province in China

Contributed equally to this work with: Jinquan Ye, Yifan Song

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Writing – original draft

Affiliation School of Management, Nanchang University, Nanchang, 330031, PR China

Roles Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft

Affiliation Ji luan Academy, Nanchang University, Nanchang, 330031, PR China

Roles Validation, Writing – review & editing

Affiliation School of Economics and Management, Nanchang University, Nanchang, 330031, PR China

Roles Data curation, Funding acquisition, Writing – original draft

* E-mail: [email protected]

• Jinquan Ye, 
• Yifan Song, 
• Yurong Liu, 

• Published: January 24, 2022
• https://doi.org/10.1371/journal.pone.0259207
• Reader Comments

COVID-19 greatly challenges the human health sector, and has resulted in a large amount of medical waste that poses various potential threats to the environment. In this study, we compiled relevant data released by official agencies and the media, and conducted data supplementation based on earlier studies to calculate the net value of medical waste produced in the Hubei Province due to COVID-19 with the help of a neural network model. Next, we reviewed the data related to the environmental impact of medical waste per unit and designed four scenarios to estimate the environmental impact of new medical waste generated during the pandemic. The results showed that a medical waste generation rate of 0.5 kg/bed/day due to COVID-19 resulted in a net increase of medical waste volume by about 3366.99 tons in the Hubei Province. In the four scenario assumptions, i.e., if the medical waste resulting from COVID-19 is completely incinerated, it will have a large impact on the air quality. If it is disposed by distillation sterilization, it will produce a large amount of wastewater and waste residue. Based on the results of the study, we propose three policy recommendations: strict control of medical wastewater discharge, reduction and transformation of the emitted acidic gases, and attention to the emission of metallic nickel in exhaust gas and chloride in soil. These policy recommendations provide a scientific basis for controlling medical waste pollution.

Citation: Ye J, Song Y, Liu Y, Zhong Y (2022) Assessment of medical waste generation, associated environmental impact, and management issues after the outbreak of COVID-19: A case study of the Hubei Province in China. PLoS ONE 17(1): e0259207. https://doi.org/10.1371/journal.pone.0259207

Editor: Pasquale Avino, Universita degli Studi del Molise, ITALY

Received: April 21, 2021; Accepted: October 14, 2021; Published: January 24, 2022

Copyright: © 2022 Ye et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: This research was funded by The Jiangxi College Student Innovation and Entrepreneurship Training Program, grant number 202010403051”&"S202010403039" and The APC was funded by Jinquan Ye and Yun Zhong.

Competing interests: The authors have declared that no competing interests exist.

Introduction

COVID-19 pandemic is threatening human health and has resulted in many indirect influences on the environment [ 1 ]. Among them are ecological restoration due to restrictions on human activities and the increase in domestic solid waste and electricity consumption due to non-contact lifestyles [ 2 , 3 ]. In addition to domestic waste, the rapid utilization of masks, protective clothing, and large amounts of other medical supplies has generated large amounts of infectious medical waste [ 4 ]. The disposal of these medical wastes can cause several environmental hazards, which mainly include pollution of the atmosphere, waters, and soil [ 5 ]. Due to the lack of foresight and preparation for epidemics, excess low-risk medical waste is often disposed of at domestic waste standards [ 6 ], which further aggravates the impact of medical waste on human health and the ecological environment.

Due to the rapid spread of the pandemic, the resulting medical waste known for its long-term strong infectivity needs to be disposed of as soon as possible [ 7 , 8 ]. Medical waste is of great concern due to its potential harm to human health and the environment [ 9 ]. The incineration of medical waste produces a variety of harmful gases, and these gas mixtures can cause varying degrees of pollution to the air, water, and soil [ 10 ]. With the rapid increase in the number of confirmed cases, the risks of medical waste disposal and the subsequent environmental impacts are rapidly increased [ 11 ]. Therefore, it is important to estimate the amount of additional medical waste that would be generated by the pandemic and the amounts of contaminants it could produce. This can provide perspective and data to support environmental recovery in the post-pandemic era [ 12 ].

Research related to medical waste focuses on the evaluation of medical waste disposal technologies, economic benefits of medical waste disposal, medical waste production and composition management methods [ 13 ]. Earlier works on the environmental impact of COVID-19 focus on environmental recovery from reduced human activities, increased solid waste from non-contact lifestyles and disposal of plastic waste from the pandemic [ 14 , 15 ]. The above-mentioned works illustrate that many scholars are concerned about the huge environmental impact caused by waste generated during the pandemic [ 16 – 18 ], although to our knowledge, only some studies have reported on the quantification and environmental impact of COVID-19 medical waste [ 19 , 20 ]. The prerequisite for assessing the environmental impact of incoming medical waste from an pandemic is to reasonably estimate the medical waste production. The present means of predicting/ estimating medical waste production are mainly gray prediction models, field survey methods, simple linear regression methods, and empirical estimation methods, and each of these survey methods have many advantages and shortcomings. Therefore, exploring the means to estimate the amount of medical waste generated by COVID-19 and assessing its environmental impact is an urgent issue to be addressed.

In this study, first, the annual production of medical waste in Hubei province, China, was obtained by empirical calculation method and formula. Second, the actual amount of medical waste generated in a month was calculated based on the ratio of total hospital visits in that month to total hospital visits in that year. Then, the experimental results of various existing time series forecasting models were compared, and the long short-term memory (LSTM) model was selected to construct a counterfactual forecasting framework for medical waste under no pandemic conditions. By comparing the prediction results with the actual medical waste generation, the amount of additional medical waste after the occurrence of COVID-19 pandemic in the Hubei Province was calculated. Finally, the environmental impact assessment was carried out by estimating the difference of the composition and disposal of the increased medical waste under different scenarios. Four scenarios were assumed in this study, which are Business as Usual (BAU), Complete Pyrolysis (CP), More Pyrolysis (MP), and More Steam Sterilization (MS).

The rest of the paper is organized as follows. Section 2 describes the study objectives, methodology, and data sources. Section 3 reports the findings of the study and the analysis of the results. Section 4 presents the conclusions and further policy implications of this study. Section 5 discusses the limitations of the study.

Methods and data

Research subjects and scope.

The Hubei province is the epicenter of COVID-19 in China, and consequently the region producing the largest amount of medical waste [ 21 ]. Therefore, it was chosen as the subject of the study ( Fig 1 ). According to the pandemic data published by Health Commission of Hubei Province, the pandemic in the Hubei Province mainly occurred at the end of January 2020 and lasted till the end of April 2020. Therefore, this paper focuses on the pandemic medical waste production in the Hubei Province from late January to the end of April 2020 and its impact on the environment.

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https://doi.org/10.1371/journal.pone.0259207.g001

Calculation of annual production of medical waste

At present, the calculation methods of medical waste production mainly include field survey method and empirical estimation method [ 22 , 23 ]. The field survey method includes selecting several representative medical institutions in a certain area by random sampling, and then investigating the medical waste production of these medical institutions to obtain the basic situation of medical waste production [ 24 ]. However, this method is time-consuming, more expensive, and is not universally applicable. The empirical estimation method generally uses internationally accepted empirical formulas. In this study, the quantity of medical waste is calculated from the values of the variables of number of visits, bed utilization, and number of beds [ 25 , 26 ]. Therefore, the study implements the empirical estimation method to calculate the annual production of medical waste in the Hubei Province from 2014 to 2019, and these historical data are used as a basis to predict the medical waste production for each month in 2020.

There are various factors that affect the annual production of medical waste. Many researchers have conducted in-depth studies using regression models, in which the main influencing factors are the level of education, living standards of the population, level of economic development, number of beds in medical institutions, utilization rate of beds, level of medical services, number of visits [ 27 – 30 ]. It was found that the number of beds in medical institutions, the bed utilization rate, and the number of visits were the most important factors affecting the annual production of medical waste [ 31 ]. Therefore, in this study, the annual medical waste production in the Hubei Province was calculated based on the above factors for each year by applying the empirical formula Q, and the calculation formula as follows.

Medical waste in the Hubei Province for the calendar year consists of two parts. the outpatient department medical waste, and the inpatient department medical waste. In Eq 1 , B denotes the number of beds in all medical institutions in the Hubei Province in a given year, P is the bed utilization rate of that year, and M indicates the average daily amount of medical waste generated per unit bed. N is the number of visits to all medical institutions in the Hubei Province in a given year, and S is the average amount of medical waste generated per unit visit per day.

Estimation of monthly production of medical waste

According to the objective of this study, it is necessary to calculate the monthly medical waste production in Hubei Province in previous years and then use it as a basis to predict the monthly medical waste production under normal conditions in 2020. Although the number of beds, bed occupancy rate, and number of visits to medical institutions in the Hubei Province per month are not officially published, studies have shown that there is a highly positive linear relationship between the monthly medical waste production and the total number of visits to hospitals [ 32 ]. Therefore, in this study, the ratio of the total number of hospital visits per month to the total number of hospital visits in the Hubei Province in that year is used as the weight, and then the calculated values of the above annual medical waste production are multiplied by the weights of the corresponding months to obtain the monthly medical waste production as q i . The specific calculation formula is as follows.

where, ω i is the ratio of the total number of hospital visits per month to the total number of hospital visits in that year, and n i is the total number of hospital visits in month i of a year in Hubei Province.

Counterfactual predictions for medical waste

Based on the time series data estimated in the previous section, this section constructs counterfactual forecasts for the year 2020 without the occurrence of the pandemic. There are multiple prediction models to choose from for the prediction of time series data. Considering the limitation of sample size and the accuracy of prediction, this paper uses several models for prediction simulation and validates the set models by using various indicators. Finally, the LSTM model is selected to predict the amount of medical waste generated from January to April 2020. A comparison of the various predictive models is provided in Table A in S1 File .

Long short-term memory neural network.

LSTM network is a special type of Recurrent neural network (RNN) that solves the problem of long-range dependencies in data by capturing multiple aspects of past information through multiple network layers. In econometrics, LSTM provides a new tool for dealing with time series data [ 33 ]. Currently, LSTM has been applied to prediction scenarios stock selection and forecasting [ 34 ] and solar activity prediction [ 35 ]. As a variant of RNN, LSTM has a neural network repetition chain structure. With a repetition unit of not just one but four internal network layers, LSTM network is able to capture long short-term memory.

LSTM solves the very streamlined form of the long dependency problem in RNN networks. In this network, a brief LSTM memory transfer is given by c t , the h t is completed, and its relation to the output result y t is expressed by the following equation.

where c t represents the long-time part of the selective memory, the z f serves as forget gate to control the previous state of c t -1 , z i represents the memory gate that is retained, and z is the current information scaled by the tanh-function.

h t represents the short-time memory part from the current output of the gate z o and the long-time memory of Hadamard Product after tanh activation.

y t is the final output result, and similar to RNN, the output result is often ultimately obtained by the difference between the weight matrix and the obtained variation h t after Sigmoid activation. To ensure the reliability of the prediction model selection in this study, Prophet, a seasonal-Auto Regressive Integrated Moving Average (ARIMA) model is used to compare with the LSTM time series prediction model, and its results are reported in the S1 File .

Scenario assumptions for environmental impact assessment

We used a scenario-based approach to make assumptions about the composition and disposal of the estimated increase in medical waste due to COVID-19 outbreak. This will be used to conduct an environmental impact assessment. Pandemic medical waste differs from normal medical waste in two ways: 1. The nature of the waste differs: due to the infectious nature of COVID-19, and 2. The waste disposal method is different. The net value of medical waste estimated by the "Estimation of monthly production of medical waste" section was considered as infectious waste in this study [ 36 ]. Due to the lack of relevant data, our study uses the assessment data of typical medical waste as a substitute. Therefore, we used Jingmin et al. [ 37 ] proposed environmental assessment data for potentially infectious waste (Details are shown in the S1 File ). According to government information [ 38 ], due to the surge of medical waste, almost all of the waste will be disposed of using the incineration method. Accordingly, the assumptions of following scenarios were made [ 39 ].

• Business as usual (BAU) In the BAU scenario, we consider the disposal of medical waste as a continuation of the previous approach. According to relevant reports [ 40 ], as of the end of December 2019, the centralized medical waste disposal in the Hubei Province has been licensed with a total capacity of 63,000 tons/year, 61% of which adopts high-temperature incineration treatment process and the remaining 39% adopts autoclave steam sterilization treatment. In view of this scenario, our study assumes that the pandemic in the Hubei Province adds medical waste (M = 0.5), and 61% of the medical waste is disposed of by high-temperature incineration and 39% by autoclaving.
• Complete pyrolysis (CP) In the CP scenario, we refer to the study by 28. To expand the waste disposal volume, it is assumed that the Hubei Province will adopt complete pyrolysis for waste disposal. According to this, all medical waste will be disposed of by high-temperature pyrolysis.
• More pyrolysis (MP) In the scenario where pyrolysis is preferred, we assume that pandemic waste disposal is prioritized by disposal volume [ 41 ]. Due to the large amount of medical waste due to the pandemic, the pressure of waste disposal is increased, which results in increase of the proportion of pyrolysis waste. Here, 80% of the waste will be pyrolyzed at high temperatures and the remaining 20% will be sterilized using autoclaving.
• More steam sterilization (MS) In the scenario where steam disinfection is preferred, we assume that outbreak waste disposal is prioritized in terms of infection risk reduction and environmental protection. Steam disinfection method disinfects medical waste in the presence of infectious agents by degrading proteins and destroying microbial tissues. During this process, no harmful gases are released [ 42 ]. In the MS scenario, we increase the percentage of steam disinfection method in BAU such that 60% of medical waste is disinfected by steam disinfection and 40% by pyrolysis methods.

Related data sources

Annual production related data sources..

In this study, we obtained the statistics of the number of beds, bed utilization rate, and attendance of medical institutions in the Hubei Province from 2008 to 2019 by reviewing relevant information from the National Bureau of Statistics (China) (as shown in Table 1 ).

https://doi.org/10.1371/journal.pone.0259207.t001

In calculating the annual production of medical waste, the daily production of medical waste per unit bed M in Eq (1) and medical waste production per unit visit S are not directly available through official websites. For the S value, we searched the relevant literature in China and abroad [ 43 ]; the daily medical waste generation per unit visit was found to be 0.03–0.05 kg, and the value positively correlated with the economic development level. Therefore, based on the level of economic development in China, this study considers the average value of 0.04 kg/visit/day. For the M value, there are large differences among different countries and minor differences among different regions of the same country [ 44 ]. According to a study by domestic scholars [ 23 , 45 , 46 ], the medical waste generation rate in Gansu Province in 2010 was 0.59–0.79 kg/bed/day, and the medical waste generation rate in 2014 in the Enshi Prefecture, Hubei Province was about 0.37 kg/bed/day. The average medical waste generation rate in the Hubei Province in July 2016 was about 0.5 kg/bed/day. Given the development of economic conditions, infrastructure and medical services in the province in recent years, this study sets the medical waste generation rate at 0.5 kg/bed/day. A sensitivity analysis was also performed on the M value, which is the daily generation of medical waste from hospital beds, and the results are presented in the S1 File .

Monthly production related data sources.

By reviewing the relevant data from the National Health and Wellness Commission of the People’s Republic of China, we obtained all hospital visits per month in the Hubei Province from 2014–2019 as shown in Fig 2 .

https://doi.org/10.1371/journal.pone.0259207.g002

The percentage of each month was calculated based on the total number of hospital visits in each month from 2014–2019 in the Hubei Province, which is the weight of medical waste production in each month to the total medical waste production in that year.

Environmental impact-related data sources.

According to domestic and international studies on medical waste disposal, different disposal methods may be suitable for different categories of medical waste, and the disposal technology for medical waste is mainly divided into two types, incineration and non-incineration. The most common method of the latter type is autoclaving [ 47 ].

Medical waste disposal produces a mixture of hazardous gases, including carbon monoxide, sulfur dioxide, nitrogen oxides, fluoride, various metals and their compounds, dioxins, and other volatile organic compounds [ 48 ]. Among them, mercury in exhaust gases not only pollutes the atmosphere, but also enters the water and soil with the air flow, and thus degrades water sources and inhibits plant growth. The toxicity of dioxins is much higher than that of other toxic gases, and dioxin concentrations in flue gases from medical waste incineration are significantly higher than those from domestic waste incineration [ 49 ]. Sulfur dioxide in exhaust gases also contributes to atmospheric acidification, which in turn can lead to high-risk natural hazards such as acid rain [ 50 ]. Medical waste that is randomly disposed into rivers and lakes can easily lead to a decrease in lake size, changes in the acidity and alkalinity of water bodies, and the death of a large number of aquatic organisms [ 51 ]. The infiltration of many harmful substances in the soil may change its pH, reduce its fertility, and affect the survival of soil microorganisms and plant growth [ 8 , 52 , 53 ]. The sources of toxic compounds, their hazards and their emission limits are explained in detail in Table D in S1 File .

Earlier research by domestic and foreign scholars reported that a variety of hazardous substances are produced after medical waste disposal, and the amount of production depends on the employed disposal technology [ 54 ]. In this study, the main hazardous substances produced by two common disposal technologies were obtained by reviewing the relevant literature [ 37 ].

Results and discussion

Estimated monthly production of medical waste.

The monthly production of medical waste in the Hubei Province was calculated based on the annual production of medical waste and the weights of each month. We first calculated the annual production of medical waste from 2014 to 2019 by using Eq (1) and the relevant was data collected (as shown in Fig 3 ).

https://doi.org/10.1371/journal.pone.0259207.g003

Fig 3 depicts the trend of medical waste, patient visits, bed utilization rate, and number of beds in the Hubei province from 2008–2019. Plot A represents the change in the number of hospital beds, where the bars represent the number of beds in tens of thousands, which is seen to increase over time. Plot B represents the annual bed utilization rate, which is shown to fluctuate in the graph. Plot C depicts the trend of growth in the number of patient visits. Plot D represents the estimated annual medical waste generated. It is initially recognized from Fig 3 that the number of consultations and hospital beds in Hubei province show an increasing trend year after year, which is in line with previous studies [ 55 ], and such an increase may be caused by the increasing resident population and the growing industrialization. [ 23 , 56 – 58 ]. In this study, the above annual production data and the weights of each month of the corresponding year were used to calculate the monthly medical waste generation in the Hubei Province from 2014–2019 (as shown in Fig 4 ).

https://doi.org/10.1371/journal.pone.0259207.g004

From Fig 4 , it is seen that the lowest peak of monthly medical waste generation in the Hubei Province mainly occurs in February each year, and the highest peak in March each year (sometimes from May–August). The main reasons for this pattern are as follows: (1) The spring festival usually falls in February. Generally speaking, most Chinese people tend to avoid visiting medical institutions and other similar places during the most important traditional festival; (2) March follows right after the spring festival, a time when more people are willing to go out, which includes visiting hospitals for diagnosis and treatment; (3) The Hubei Province has a relatively developed tourism industry, and the May–August period is the first month after the Chinese New Year. (4) The tourism industry in the Hubei Province is relatively well developed, and May–August is the peak period for tourism, which increases the flow of people, and possibly the number of patients.

Medical waste monthly production forecast

The LSTM Model was used to obtain the counterfactual prediction of the scenario where there was no COVID-19 pandemic in 2020. The medical waste generation rates of 6765, 5838, 6864, and 6777 tons from January to April 2020 were obtained for the case of medical waste generation rate of 0.5 kg/bed/day.

New medical waste production from the outbreak

According to the pandemic data released by the Hubei Provincial Health and Wellness Commission, the pandemic broke out on January 23, 2020, and ended on April 28, 2020. According to the Hubei Provincial Department of Ecology and Environment, from January 23 to April 28, the Hubei Province safely disposed of a total of 24,357.99 tons of medical waste, which can therefore be inferred as the medical waste generated by the hospitals during the pandemic period in the Hubei Province.

To calculate the additional medical waste production during the pandemic period compared to that of the normal period, this study needs to first calculate the medical waste production under normal conditions in the Hubei Province from January 23 to April 28, 2020. According to the medical service data published by the National Health and Wellness Commission of the People’s Republic of China, under normal conditions, the number of hospital beds, bed occupancy rate, and the number of attendances on each date of the same month vary so little that it could be neglected. Therefore, under the empirical estimation method, this study assumes that the daily medical waste production in Hubei Province is the same in each month under normal conditions. Based on the predicted medical waste production in the Hubei Province from January to April 2020 (M = 0.5), the medical waste production from January 23 to April 28, 2020 under normal conditions can be calculated (as shown in the Table 2 ).

https://doi.org/10.1371/journal.pone.0259207.t002

Based on the actual production value of medical waste from the pandemic in the Hubei Province and the total normal production from Table 2 , we can obtain the net production value of new medical waste of 3366.99 tons, which is 16.04% higher than that under the normal conditions in the same period. For reference, this study also predicts the medical waste generation on normal conditions based on 0.4 kg/bed/day or 0.6 kg/bed/day. The result is presented in the S1 File .

Scenario analysis

For the environmental impact of pandemic medical waste, this study set four scenarios and calculated the impact situation of medical waste on environmental factors under various scenarios by adjusting the application ratio of two disposal technologies, and the results are shown in Figs 5 and 6 .

https://doi.org/10.1371/journal.pone.0259207.g005

https://doi.org/10.1371/journal.pone.0259207.g006

From Fig 5 , it is seen that the order of the magnitude of wastewater and sludge emissions under the four scenarios is MS>BAU>MP>CP, which implies that the high-temperature incineration method can reduce the impact of medical waste disposal on the water and soil environments. Especially for the discharge of wastewater, which contains many harmful substances, such as chloride, fluoride, sulfur dioxide, mercury, and other heavy metals. The amount of discharged wastewater is quite huge in all four scenario assumptions, and hence, the government should manage wastewater generated during medical waste disposal. It should strictly control the discharge of such wastewater and the emission standards of the concentration of various chemical substances contained in it, and simultaneously enhance the supervision and subsequent punishment of the medical waste disposal industry to ensure that the harm caused by wastewater to human health and ecological environment is minimized.

Further, it is seen from Fig 5 that chloride emissions are the highest among the waste materials discharged into the soil, which exceeds the sum of emissions of other harmful substances. Excessive chloride in the soil is likely to cause soil acidification, salinization, and even soil erosion. Therefore, for countries and regions with serious pandemic, local governments should strengthen the control of chloride content from medical waste disposal, and devise appropriate methods to collect and reuse the chloride to avoid environmental pollution caused by large amount of chloride discharge into the soil.

Fig 6 depicts that the order of magnitude of most of the exhaust gas emissions in the four scenario assumptions is CP>MP>BAU>MS. Therefore, steam sterilization method produces less exhaust gas than high-temperature incineration method, although it produces more sulfur dioxide, hydrogen chloride, and carbon dioxide gases. Among the harmful exhaust gases emitted, hydrogen chloride gas has the highest emissions. Sulfur dioxide and hydrogen chloride are easily combined with water vapor when emitted directly into the atmosphere, which can potentially form acid rain. This can have an extremely negative impact on human health and the ecological environment. Furthermore, carbon dioxide accumulates in the atmosphere, which tends to create a greenhouse effect. Therefore, countries with serious pandemic should monitor the concentration of acid gases generated by medical waste disposal in real time, organize experts and scholars to discuss and study this issue, and use cost-effective means to convert these acid gases into harmless gases.

Additionally, the emissions contain many heavy metals, among which content of nickel was the highest and lead content was the lowest ( Fig 6 ). Nickel and its compounds emitted into the atmosphere can easily form dust and affect the growth of plants when they land in the soil, and through certain chemical reactions they can also produce various carcinogenic substances. Therefore, among the many metallic substances contained in exhaust gas, the government should pay special attention to the emission of nickel metal, improve relevant laws and regulations at the earliest, and improve medical waste disposal technology. Especially for countries with serious pandemic, such as the United States [ 59 ], Brazil [ 60 ], and India [ 61 ], the government should take effective measures to reduce the large amount of nickel particles generated by medical waste disposal.

Finally, we compare the remaining three scenarios with the BAU scenario to explore the proportional change in the impact of different scenarios on environmental factors compared to that of the BAU scenario. The results are shown in Figs 7 and 8 .

https://doi.org/10.1371/journal.pone.0259207.g007

https://doi.org/10.1371/journal.pone.0259207.g008

As shown in Fig 7 , the MS scenario is compared to the BAU scenario, where both wastewater and waste are increased in the MS scenario. During the COVID-19 pandemic, the government needs to use more steam sterilization to treat medical waste to reduce the risk of infection due to the need to prevent and control the pandemic. Compared to the BAU scenario, the MP and CP scenarios result in different degrees of reduction in wastewater and waste generation. The most significant reduction in emissions is the CP scenario. In terms of direct soil emissions resulting from medical waste disposal, pyrolysis is environment friendly and sustainable due to its clean and safe characteristics [ 62 ], which allows for efficient treatment of medical waste. However, pyrolysis is preceded by pretreatment of medical waste, a process that entails significant energy costs [ 63 ]. Therefore, during the pandemic, the government needs to increase its support to relevant companies to help them improve their equipment and their processes, and if necessary, to subsidize energy.

The changes in direct air emissions from the different scenarios of medical waste disposal are then compared ( Fig 8 ). The MS scenario reduces most of the emissions compared to the BAU scenario. For example, the emission reductions for Nitrogen oxides, Carbon monoxide, Hydrogen fluorid, Hydrogen chloride are in the range of 20 to 40%. But for ammonia, ammonia gas, mercury, phenol, chromium, and chloride, their emissions are significantly increased. As organic compounds such as phenol are hazardous to humans, they may pose a health risk to the people involved in handling medical waste [ 64 ]. Therefore, governments need to regulate medical waste disposal methods during pandemic and pre-treatment of different medical wastes can effectively reduce harmful emissions. MP and CP scenarios increase the emission of heavy metals such as copper, tin, mercury and dioxins compared to BAU scenario. The first is that these heavy metals are emitted into the atmosphere in gaseous or in solid form adsorbed on fly ash, which has environmental biotoxicity and bioaccumulation, and poses a serious threat to ecology and human health. Second, the dioxins emitted into the atmosphere are transferred to the soil and easily adsorbed to the organic matter of the surface soil. Dioxins from medical waste disposal can have negative effects on vegetation and human body. Therefore, under the MP and CP scenarios, the government first needs to focus on monitoring the levels of dioxins and heavy metals in the soil around the emission sources. Third, relevant government authorities need to strengthen the supervision of medical waste disposal enterprises and update the medical waste disposal facilities and management methods of old enterprises, to minimize the harm caused by medical waste disposal to the environment.

Limitations

This study tried to restore the environmental impact caused by medical waste disposal during COVID-19 to the best possible extent. However, due to the difficulty in obtaining primary data, the study uses the assessment data of typical medical waste as a substitute. In the assumption scenarios, we tried to quantify the impact of the disposal of COVID-19 medical waste as close as possible to real-life scenarios, although due to the complexity of the realistic recycling process, it was difficult to cover all hypothetical situations.

Conclusions

In this study, we found that at a medical waste generation rate of 0.5 kg/bed/day, COVID-19 resulted in a net increase in medical waste volume of about 3366.99 tons in the Hubei Province. The possible environmental impacts under different disposal methods were modeled to provide a reference for medical waste disposal during a pandemic. the MS scenario was able to reduce most of the waste gas emissions compared to the BAU scenario, with a reduction of between 20% and 40%. The disadvantage is that the MS scenario increases the amount of wastewater and waste generated. On the contrary, the MP and CP scenarios compared to the BAU scenario lead to different reductions in wastewater and waste generation. The disadvantage of these two scenarios for medical waste disposal is that they increase the emission of heavy metals and dioxins. This provides a policy basis for how countries or regions with severe pandemic situations can safely and effectively handle medical waste.

Supporting information

S1 file. supporting material on scenario analysis, toxic inventory, and comparison of time series prediction models..

All publicly available data are in tabular form in this document.

https://doi.org/10.1371/journal.pone.0259207.s001

https://doi.org/10.1371/journal.pone.0259207.s002

Acknowledgments

Many thanks to the Editors and three Reviewers for their very helpful comments. We also would like to thank Editage ( www.editage.com ) for English language editing services.

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• Healthcare (Basel)

Healthcare Waste—A Serious Problem for Global Health

Edyta janik-karpinska.

1 Biohazard Prevention Centre, Faculty of Biology and Environmental Protection, University of Lodz, Pomorska 141/143, 90-236 Lodz, Poland

Rachele Brancaleoni

2 Bed Management Unit, Agostino Gemelli IRCCS University Hospital Foundation, Via della Pineta Sacchetti 217, 00168 Rome, Italy

Marcin Niemcewicz

Wiktor wojtas.

3 European Commission, Directorate-General Migration and Home Affairs, Rue du Luxembourg 46, 1000 Brussels, Belgium

Maurizio Foco

4 Emergency Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Pineta Sacchetti 217, 00168 Rome, Italy

Marcin Podogrocki

Michal bijak, associated data.

Not applicable.

Healthcare waste (HCW) is generated in different healthcare facilities (HCFs), such as hospitals, laboratories, veterinary clinics, research centres and nursing homes. It has been assessed that the majority of medical waste does not pose a risk to humans. It is estimated that 15% of the total amount of produced HCW is hazardous and can be infectious, toxic or radioactive. Hazardous waste is a special type of waste which, if not properly treated, can pose a risk to human health and to the environment. HCW contains potentially harmful microorganisms that can be spread among healthcare personnel, hospital patients and the general public, causing serious illnesses. Healthcare personnel are the specialists especially exposed to this risk. The most common medical procedure, which pose the highest risk, is injection (i.e, intramuscular, subcutaneous, intravenous, taking blood samples). The World Health Organization (WHO) estimates that around 16 billion injections are administered worldwide each year. However, if safety precautions are not followed, and needles and syringes are not properly disposed of, the risk of sharps injuries increases among medical staff, waste handlers and waste collectors. What is more, sharps injuries increase the risk of human immunodeficiency virus (HIV), hepatitis B and C viruses (HBV/HCV), tuberculosis (TB), diphtheria, malaria, syphilis, brucellosis and other transmissions. Disposing of medical waste in a landfill without segregation and processing will result in the entry of harmful microorganisms, chemicals or pharmaceuticals into soil and groundwater, causing their contamination. Open burning or incinerator malfunctioning will result in the emission of toxic substances, such as dioxins and furans, into the air. In order to reduce the negative impact of medical waste, waste management principles should be formulated. To minimize health risks, it is also important to build awareness among health professionals and the general public through various communication and educational methods. The aim of this paper is to present a general overwiev of medical waste, its categories, the principles of its management and the risks to human health and the environment resulting from inappropriate waste management.

1. Introduction

Healthcare facilities (HCFs) are the main healthcare waste producers. The most common term used to describe waste generated by HCFs is healthcare waste (HCW). There are several other terms such as medical waste, biomedical waste, clinical waste or health facility waste [ 1 ]. HCW is defined as all types of waste generated from HCFs, whether it is a hazardous or harmless material, and whether it is infectious or non-infectious in nature or a chemical [ 2 ]. It is estimated that HCWs constitute approx. 1–2% of total produced urban waste [ 3 ]. A total of 85% of the total amount of waste generated as a result of healthcare activities is non-hazardous. The remaining 15% are hazardous materials, which are infectious, radioactive or toxic ( Figure 1 ). The majority of HCW generators are hospitals, medical centers, laboratories, veterinary clinics, research centers, mortuaries, blood banks and nursing homes. High-income countries produce up to almost 11 kg of hazardous waste per hospital bed per day (kg/bed/day), while in low-income countries the production rate ranges up to 6 kg. However, in low-income countries, HCW is often not segregated into hazardous and non-hazardous waste, making the actual amount of produced hazardous waste much higher [ 4 , 5 ].

Standard waste composition in health facilities.

Economic conditions are an important factor in HCW management. In many industrialized countries, institutions that generate medical waste have a legal obligation to manage this type of waste. As a result, there are appropriate structures for handling each type of waste and the amount of hazardous waste generated is constantly monitored [ 6 ]. Problems in HCW management are more prevalent in developing countries that produce several hundred tons of waste daily. Studies performed in Ethiopia revealed that 35% of healthcare institutes collect and dispose of needles, syringes and other sharp objects in a way that puts healthcare personnel and the general public at a constantly increasing risk of exposure and injury [ 7 ]. These countries typically use HCW management methods such as landfilling, recycling, incineration or storage. Although HCW landfilling without pre-treatment is prohibited, it is the most common method of HCW disposal as it is a cheap and easy method. In practice, HCW is stored in open dumps in pits mixed with municipal waste and is then incinerated [ 8 , 9 ]. HCW can have a long-lasting effect on human health, both for the people handling, collecting and recycling the waste, and for the general public. The environment is also suffering from fresh water and soil contamination resulting from untreated medical waste pollution or by the process of surface waste burning [ 6 , 10 ].

The objective of this paper is to provide a general overview of medical waste issues, including their sources and categories, waste generation, the principles of waste management and the threat to human health and the environment resulting from improper waste management.

2. Categories and Sources of HCW

HCW and by-products are generated as a result of diagnosis, treatment, medical intervention or the immunization of human or animals [ 11 ]. They cover a wide range of materials and different categories as summarized in Table 1 [ 5 , 8 , 12 ].

Categories of healthcare waste.

HCW is generated in various types of healthcare units, such as hospitals, medical centers, private medical practices, veterinary clinics, clinical laboratories or pharmacies [ 13 ]. Depending on the source, different types of HCW are generated, and these are summarized in Table 2 [ 5 , 14 ].

Sources and examples of HCW.

3. HCW Production Rate

The HCW production rate in countries worldwide differs and depends on many factors. These factors include waste management methods, the type of healthcare facilities, and healthcare specializations, the amount of reusable equipment available in the facility and the number of patients treated daily [ 15 ]. However, registered HCW production is lower in developing countries than in developed countries. Detailed information on the HCW production rate in different continents and selected countries are presented in Table 3 .

Example of HCW production rate in various countries worldwide.

4. HCW Production Rate during Pandemic

The COVID-19 pandemic has been attracting global attention since December 2019, as has the area of HCW production. The World Health Organization (WHO), Centers for Disease Control and Prevention (CDC) and local governments have announced numerous guidelines, including good hygiene practices, social distancing and quarantines, in order to reduce the spread of a new coronavirus. In addition, medical personnel and the general public have been advised to use personal protective equipment (PPE), such as surgical or medical masks, non-medical face masks (including different forms of self-made or commercial masks made of fabric, cotton or other textile materials), face shields, gloves and aprons [ 37 ]. In many countries, it is recommended to wear masks in public places. According to the press conference of the Joint Prevention and Control Mechanism of China’s Council State, the daily amount of COVID-19-related HCW in China was around 468.9 tons [ 38 ]. At the peak of the pandemic, only in Wuhan, the waste generated reached approximately 240 tons of HCW per day, almost six times more than before the pandemic [ 39 ]. In Bangladesh, in April 2020, at least 14.5 thousand tons of HCW was generated across the country due to the COVID-19 pandemic. In Dhaka, an average of 206 tons of HCW per day is generated because of the pandemic [ 40 ]. In the USA, the estimated increase in HCW generation was reported to range from 5 million tons/year before the pandemic to 2.5 million tons/month during the pandemic. The drastic increase in the number of regions, countries and people infected with SARS-CoV-2 led to global problems related to proper HCW management [ 41 ].

5. HCW Management

The purpose of healthcare systems is to restore health and save patients’ lives, but sometimes adverse effects on the health of healthcare personnel and communities due to unsanitary methods of disposing of HCW is observed [ 42 ]. Poorly managed waste can cause long-term and undesirable risks to public health and is a potential source of re-infection, posing a significant threat to the environment. Therefore, the management of HCW requires special attention and should be considered a high priority [ 43 ]. The management of HCW is an integral part of national healthcare systems. Safe HCW management practices reflect on HCF service quality and cover all activities related to the generation, segregation, transportation, storage, treatment and disposal of waste [ 44 , 45 ]. Adequate management of medical waste in HCFs depends on the waste management team, good administration and organization, careful planning, legal frameworks, adequate funding and the full participation of trained personnel in this process [ 46 ]. Healthcare facilities managers are responsible for introducing and ensuring an appropriate waste management system, as well as supervising the compliance with appropriate procedures of all medical staff. Therefore, appropriate education and training systems must be available to all personnel responsible and engaged in both segregation and waste collection processes [ 47 , 48 , 49 ]. In line with WHO guidelines, waste segregation practices should be standardized across the country and included in national regulations for HCW management [ 5 ]. The key to the effective management of HCW is the segregation process at the point of waste generation. Segregation means the separation of various types of waste into different color-coded containers with liners at places where they are generated as a first step in HCW management [ 50 , 51 ]. According to WHO recommendations concerning segregation and collection, a general waste container should be black. Sharp, infectious and pathological waste containers should be marked yellow. Chemical and pharmaceutical waste container should have a brown color. It is also recommended that almost all waste categories should be collected at least once per day, or when three-quarters of the container is filled. The exceptions to this are pharmaceutical, chemical and radioactive waste, which can be collected on demand [ 52 , 53 ].

After segregation, waste is collected and transported outside the hospital or healthcare facility. The transportation of HCW is usually performed using dedicated trolleys and containers. The trolleys have to be cleaned and disinfected daily. Hazardous and non-hazardous waste has to always be transported separately [ 54 ]. The waste should be stored in designated rooms and appropriate safety and security measures should be taken. In general, non-hazardous, infectious and sharp, pathological, pharmaceutical, chemical and radiological waste should be stored separately in different places with different characteristics depending on the waste stored [ 53 ].

6. HCW Management during COVID-19 Pandemic

Since March 2020, the whole world has been focusing on the COVID-19 pandemic. It has been considered whether the spread of COVID-19 could also increase as a result of inadequate waste management. Performed studies indicated that the SARS-CoV-2 survival rate on different surface varied from 4 h on copper to up to 3 days on plastic and stainless steel [ 55 ]. The increase in waste generation during the pandemic, as well as the disposal of infected disposable masks and other PPE, has burdened waste management systems [ 56 , 57 , 58 ]. Therefore, ensuring the efficient, timely and harmless management of COVID-19 medical waste has also become a significant part of pandemic controlling [ 59 ]. In addition to introduced standards, such as proper identification, collection, segregation, storage, transport, processing and disposal, aspects such as disinfection, personnel protection and training have become part of effective HCW management [ 57 ]. It has been shown that fomites may not be as critical to the transmission of SARS-CoV-2 as initially suspected [ 60 ]. At this moment, there is no significant differences between overall COVID-19 HCW management and general pre-pandemic medical waste management [ 38 ].

7. Risk Related to HCW

HCW is potentially dangerous and a pollutant [ 43 ]. Everyone close to hazardous medical waste is potentially at risk, including those working in healthcare facilities, those handling medical waste or those exposed through careless actions. The main risk groups are physicians, nurses, healthcare support staff, patients, HCF visitors and support services workers, such as laundry workers, waste management and transportation staff and waste-disposal facility employees [ 61 ]. Globally, more than two million medical personnel are exposed to pathogens as a result of their daily work routines [ 1 ]. In conclusion, HCW poses a serious threat to human health and life especially in low- and middle-income countries. Globally, it is estimated that at least 5.2 million people worldwide die each year, including 4 million children, due to illnesses caused by unmanaged medical waste [ 40 ].

7.1. Infectious Waste and Sharps

Infectious waste is a variety of hazardous waste which, due to its pathogenic nature, pose a threat to human health. It should always be assumed that infectious waste may contain various pathogenic microorganisms [ 62 ]. HCW can transmit more than 30 dangerous blood-borne pathogens [ 1 ]. Pathogens in infectious waste that is not properly managed can enter the human body through damaged skin (rubbing, puncturing or cutting the skin), inhalation, mucous membranes or by ingestion [ 5 ]. Performed research indicates the presence of various pathogens in medical waste, as well as the possibility of their transmission routes. Therefore, it can be concluded that this type of waste poses a great potential risk to human health [ 63 , 64 , 65 ].

The greatest risk of transmission of blood-borne pathogens is caused by needle stick and sharp injuries (NSSIs) [ 66 ]. It is estimated that 600,000 to 800,000 needle stick injuries and other percutaneous injuries are reported annually in the U.S.A. In addition, around 100,000 NSSIs occur in the UK each year [ 67 ]. It has been estimated that up to 30% of hepatitis B, 1–3% of hepatitis C and 0.3% of HIV cases were caused by inappropriate HCW handling [ 68 ]. HBV is more contagious than other blood-borne viral pathogens and is approximately 100 times more contagious than HIV. Consequently, HBV poses the greatest occupational risk to non-immune healthcare personnel [ 69 ]. In addition, medical waste handlers are the group more vulnerable to HBV infection than other healthcare personnel, non-medical waste handlers or the general population [ 70 , 71 , 72 ]. The performed study showed that the prevalence of HBV and HCV was significantly higher in medical waste compared to non-clinical waste handlers. The authors clearly pointed out the reason for this situation. Poor waste management systems contributed to higher acute injuries incidences and splashes of blood and body fluids [ 73 ]. A. total of 70% of the world’s HIV-infected population comes from Sub-Saharan Africa, but only 4% of global occupational cases of HIV infection are reported from this region [ 67 ]. It is estimated that up to 5% of all HIV infections in Africa are due to unsafe injection administration, including exposure to sharps injuries during unsafe medical waste handling [ 74 ]. A study conducted in China showed low risk awareness among nurses concerning the risk of HIV infection and a lack of compliance with standard precautions in daily work [ 75 ]. Over 20 other infections can also be transmitted by NSSIs, including syphilis, herpes and malaria. While most NSSIs appear in developing countries, NSSIs are still reported in developed countries despite preventive measures taken, such as standard operating protocols and real-time injury-monitoring systems [ 35 , 76 , 77 , 78 ]. These injuries not only increase the possibility of negative health consequences, but also lead to mental stress, fear, tension and anxiety among healthcare personnel [ 79 ]. The implementation of safety protocols and compulsory training programs for healthcare professionals can reduce the prevalence of NSSIs and associated infections [ 80 , 81 ].

7.2. Chemical and Pharmaceutical Waste

Many chemicals and pharmaceuticals used in healthcare systems can be hazardous. They are usually found in small amounts in medical waste, while larger amounts can be found when unwanted or expired chemicals and pharmaceuticals are directed for disposal [ 5 ]. Chemical waste negatively affects human health and, in most cases, causes intoxication as a primary result of contact with them. Poisoning from the absorption of a chemical or pharmaceutical substance via the mucous membranes, the skin, inhalation or ingestion is the secondary result. Contact with corrosive, flammable or reactive chemicals (formaldehyde and other volatile substances) may cause injuries to the eyes, skin or mucous membranes of the respiratory tract and should be considered thirdly [ 82 ]. Pharmaceuticals enter the environment as a result of the improper handling of unused or expired pharmaceuticals, mainly disposed of into sewage systems. Pharmaceuticals have been reported in various places, such as groundwater, surface water and soil. The main groups of pharmaceuticals detected in environmental samples are antibiotics, hormones, non-steroidal anti-inflammatory drugs, beta blockers, lipid regulators and anti-depressant drugs [ 83 , 84 ]. The long-term presence of pharmaceuticals in the environment causes acute and chronic damage, behavioral changes, reproductive disorders and the inhibition of cell proliferation in animals [ 85 , 86 ]. The negative impact of pharmaceuticals on the environment is also evidenced by the development of antibiotic resistance in some bacterial strains, resulting in an accumulation of antibiotics in the environment. Therefore, it is essential to decontaminate chemical and pharmaceutical waste before placing them in landfills, as improper disposal will cause contact between environmental bacteria and antibiotics, which can lead to the evolution of antibiotic-resistant mechanisms among them [ 83 , 87 , 88 ].

7.3. Genotoxic Waste

The main routes of exposure to genotoxic waste are inhalation and skin absorption. However, ingestion and accidental injection or other sharps injuries are also possible. Exposure may also occur through contact with the patient’s body fluids and secretions (such as vomit, urine and feces) while undergoing chemotherapy [ 89 , 90 ]. Cytotoxic drugs or anticancer drugs are classified as dangerous medicaments. Acute exposure usually causes temporary symptoms, such as dizziness, headache, nausea and malaise. What is more, cytotoxic drugs possess strong irritating properties, and direct contact will lead to the appearance of local symptoms, such as rash, dermatitis, irritation of the skin, mucous membrane ulceration and irritation of the throat or eyes [ 91 ]. The side effects from prolonged or repeated exposure to cytotoxic drugs are significant and serious. An increased incidence of spontaneous abortions during pregnancy and malformations have been observed among children of females with a history of occupational exposure to anticancer medicaments [ 92 ]. Cytotoxic drugs are also not neutral to the environment, especially the aquatic environment [ 93 ]. Some cytotoxic drugs are not fully metabolized and are poorly biodegradable. They can also be resistant to conventional biological and chemical processes used in wastewater treatments and can challenge water-decontamination technology. While aquatic cytotoxic drug concentrations may stay below detection limits, they can reach alarming levels in fauna and flora through bioaccumulation and biomagnification processes. Therefore, their effect should be carefully investigated as unexpected delayed effects can be present in offspring [ 94 ]. Kovacs et al. demonstrated that long-term exposure of zebrafish to anticancer drugs impaired their DNA integrity and induced massive whole-transcriptome changes, which might affect entire zebrafish populations [ 95 ].

7.4. Radioactive Waste

The disease caused by radioactive waste depends on the type and extent of exposure. This can include headache, dizziness and vomiting, as well as much more serious problems. Radioactive waste is genotoxic and, if the radiation dose is high enough, it can also affect the genetic material. Inadequate handling of radiation diagnostic instruments can cause much more serious injuries, including tissue destruction, which in some cases requires the amputation of body parts. Extreme cases can be even fatal [ 5 , 96 ].

8. HCW Treatment and Safety Issues

The most common types of HCW treatments are steam-based treatments (autoclaving, microwave and frictional heat treatments), which are used to disinfect/sterilize highly infectious and sharp waste by subjecting them to moist heat and steam. Steam sterilization is used for sterilization instruments and for sharp and hazardous waste treatments. To reduce the volume of waste, steam sterilization can be combined with mechanical processes, such as mixing, grinding and shredding [ 53 ]. Incineration, the process of waste destruction by burning, removes hazardous materials, reduces their mass and volume and converts them into ashes. An incinerator that is not properly designed or operated, or is poorly maintained, emits toxic substances into the environment. If incinerators operate at low temperatures, they generate emissions containing dioxins and furans, which may cause health problems as they are carcinogenic [ 97 ]. Incinerators operating at 850–1100 °C and containing special gas-cleaning equipment can comply with international emission dioxin and furan standards. Dioxin-control technologies use activated carbon (AC) adsorption. Before flue gas flows into the dust-collection equipment, AC is injected to adsorb the dioxin and then is blocked by a bag filter [ 61 ]. The next method used is a chemical treatment process. It mostly relies on using disinfectants, ozone treatment and alkaline hydrolysis. Composting and vermicomposting (which uses earthworms to consume and recycle the organic waste) are successfully used to break down hospital kitchen waste, as well as other digestible organic and placental waste. Another example of a biological process is the natural decomposition of pathological waste through its burial. Non-hazardous waste should be recycled and regularly collected by the municipalities or transported by the facility to public landfills [ 53 ]. Inadequate HCW treatment can be dangerous for health. Incinerator control results in the release of small particulates that affect the functioning of the respiratory and cardiovascular systems. Volatile metals, such as mercury, lead, arsenic and cadmium, will damage the immune and neurological systems, as well as the kidneys, brain and lungs. The incineration of high-metal-content materials leads to the spread of toxic metals in the environment [ 98 , 99 ]. Various studies have shown adverse health effects in populations in the vicinity of incinerators, including cancer and reproductive dysfunction [ 100 , 101 , 102 ]. Ashes, as a result of the incineration of hazardous medical waste, are also hazardous. Bottom ash analyses of incinerated medical waste carried out in Tanzania indicate the hazardous nature of ash resulting from the presence of large amounts of heavy metals (iron, cadmium, lead, copper and manganese) [ 103 ]. Burying medical waste and depositing them in landfills is also dangerous. Medical waste is almost always contaminated with pathogens, and leaching toxic heavy metals and chemicals from solid medical waste into the soil occurs in poorly designed dump sites and landfills. The leachate can penetrate the soil and contaminate crops, surface and groundwater resources, posing a risk to human health by consuming water. To control the safety of these methods, hydro-geological conditions must be considered. Landfills should have restricted access, control scavenging, use a soil cover regularly, manage waste discharge, and control surface water and drainage [ 65 , 104 ]. An interesting solution is the possibility of thermal energy, fuel, and electric-power production from medical waste, and some studies concerning this issue have been conducted. One study showed that waste-disposable syringes treated with pyrolysis at 400–550 °C were used to produce liquid fuel. The produced pyrolysis oil had physical properties similar to that of a diesel or petrol mixture [ 105 ]. Fang et al. [ 106 ] showed that the pyrolysis of mixed medical waste, such as plastic, cotton and glass, at 500 °C can produce liquid fuel (pyrolysis oil). It can be refined by fractional condensation. In a different study, biogas from recycled medical cotton waste as a source of biogas recovery, using thermophilic bio-digestion conditions, was produced. It improved biogas yield by 92% [ 107 ]. These studies bring hope that in the future it will be possible to use medical waste to produce energy or fuel on a large scale.

9. Conclusions

Medical waste amounts have increased dramatically over the last 30 years, and health facilities around the world are producing more waste than ever before. The amount of HCW generation is rising with the increase in the world’s population, medical facilities’ multitude and with the widespread propensity to use disposable medical equipment. Due to the use of advanced technological practices and safety considerations, single-use equipment causes more waste generation [ 108 ]. Further problems include a lack of health risk awareness associated with HCW, insufficient training in proper waste management, inadequate human resources and the low priority given to this matter [ 8 ]. Studies in developing countries have shown evidence that medical waste is mixed and collectively combined with municipal waste or burned in the open air [ 8 , 96 ]. Such activities pose risks to public health and the environment. Medical waste can contain potentially harmful microorganisms that can infect healthcare professionals, patients and the general public. Potential risks include drug-resistant microorganisms that spread from HCFs into the environment. Another risk is the release of toxic compounds into the environment, such as heavy metals, dioxins and furans [ 5 , 109 ]. In order to reduce the risk associated with medical waste, it is necessary to focus on a few key aspects. Improved policies and procedures should be developed and implemented for the proper use of single-use or reusable items and the identification of recycling options. Activities may also include working with providers to make products available in materials that are more easily degraded, or that can be reused for secondary purposes. There are items that are not hazardous (such as clean packaging) and can be removed without unnecessary treatment prior to the final disposal. Another option is to minimize the impact by adjusting purchasing strategy and inventory control. This solution can also be implemented through the use of physical (steam treatment) instead of chemical disinfection, waste minimization by using less materials and finally by checking the expiration date of the products upon delivery and refuse to accept items with a short expiration date [ 5 , 110 ]. Major challenges related to the risk of HCW are misconceptions and a lack of education and awareness regarding which type of waste is hazardous and which is not. In particular, educating healthcare professionals on the proper segregation and disposal of different waste types would be very beneficial to waste reduction and proper infection control [ 111 , 112 ]. In summary, the risks of medical waste can be significantly reduced by implementing appropriate measures. This would result in fewer illnesses and accidental sharps injuries, but also less environmental pollution.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, M.B., R.B., W.W., M.F. and M.N.; supervision, M.B. and M.F.; writing—original draft preparation, E.J.-K., R.B., M.N. and M.P.; writing—review and editing, M.B., M.N. and W.W. All authors have read and agreed to the published version of the manuscript.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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