Medical Waste Management during COVID-19 Pandemic: A Study of Sukraraj Tropical & Infectious Disease Hospital and Bir Hospital Presented by: Ojeshwi Risal Human and Natural Resources Studies Department of Development Studies Kathmandu University, School of Arts Background Waste (also known as rubbish, trash, refuse, garbage, junk, litter) is unwanted or useless materials. According to the (World Health Organization, 2018) , health care waste is generated by institutions such as hospitals, health centers, medical research institutes, pharmaceutical manufacturing plants, pharmacies, blood banks, and home health care activities. ● Health facilities and diagnostic procedures generate two categories of garbage: general trash and hazardous waste. ● The garbage generated by healthcare operations is classified as general waste in 85 percent of cases, while the rest is classified as hazardous waste in cases when it is contagious, toxic, or radioactive. Each year, 274 hospitals in Nepal generate a total of 10,520 tonnes of non-hazardous healthcare waste and 3,094 tonnes of hazardous medical waste. (UNDP, 2017). ● ● The COVID-19 pandemic has caused an increase in medical waste and viral transmission, requiring modern treatment techniques to reduce risk to healthcare personnel, trash handlers, and others. ● COVID-19 virus transmits largely by droplets of saliva or nasal discharge when an infected person coughs or sneezes, according to the World Health Organization. ● Waste management systems failed very quickly as a result of the coronavirus disease 2019 (COVID19). Statement of Problem ● The study’s goal is to examine how well healthcare institutions handle trash while providing data that may be used to these facilities effective management of medical waste. ● The health institutions in Nepal are working hard to achieve high standards in the treatment of medical waste, but their efforts are being hampered by limited resources and insufficient skills. ● According to the report published by MOHP, health care institutions in Nepal produced approx 20,18,450 Kilograms of health care risk waste annually (assuming 0.5 kg per patient per day) in 2001 (MOH 2003). Objective of the research The main objective is to understand the current practices of medical waste management in two hospitals of Kathmandu Valley, namely Sukraraj Tropical & Infectious Disease Hospital and Bir Hospital 201 MoH The specific objectives of the study are outlined below: Cina ● To study the present methods of hospital waste management. ● To identify the challenges of medical waste management among the selected hospital during COVID-19 ● To explore the consequences, especially the environmental risks associated with medical waste. Research Questions General Question How Sukraraj Tropical & Infectious Disease Hospital and Bir Hospital manage the medical waste? Specific Questions i. What are the present methods of minimization, segregation, collection, storage, treatment, and disposal of hospital waste? ii. What are the challenges among the selected hospital during COVID-19? iii. What are the environmental risks associated with medical waste? Rationale / Justification of the study 2001 The problem of Health Care Worker disposal in the hospitals and other healthcare MH establishments has become an issue of increasing concern, prompting hospital administration to seek new ways of scientific, safe and cost-effective management of the waste, and keeping their personnel informed about the advances in this area. The need for a proper health care waste management system is of prime importance and is an essential component of quality assurance in hospitals. Limitations of the research 1 The study solely focuses on solid medical wastes only. 2 3 The number of incoming patients in the hospital fluctuates but the bed remains constant. This study assumes that all the beds present in the hospital are occupied. The study examines and characterizes medical wastes from the selected hospitals as a whole, not from different departments of the hospitals. Literature Review In the eighteenth century, nothing was understood about sanitation or how to properly dispose of medical waste around the world. Lister found in the 1870s that the fast spread of illness in hospitals was due to a lack of effective 2001 cleanliness and medical waste disposal processes. (Gregory & Tulchinsky, n.d.) MH The COVID-19 pandemic has placed a great deal of pressure on healthcare systems worldwide, including the management of medical waste. The literature review found that both Sukraraj Tropical & Infectious Disease Hospital and Bir Hospital have implemented measures to properly manage medical waste during the COVID-19 pandemic. Literature review also provides valuable insights into the medical waste management practices in Nepal during the COVID-19 pandemic and can serve as a useful reference for other healthcare facilities facing similar challenges. Research Methodology Research design Mixed method research Data analysis 2001 SamplingMH technique Purposive sampling - Methods as designed by Creswell mixed method Excel Descriptive frequency table Data Collection Study area & Sample size Bir hospital and Sukraraj Tropical & Infectious Disease Hospital 20 Research participant, 10 on each hospital - Documentation review Questionnaire Key informant interview Observation Continue…. Data Triangulation, Validity and Reliability - - - This study used several data gathering approaches and instruments to guarantee triangulation, which verified the findings. These methods include semistructured interviews and questionnaire-assisted interviews. Questionnaires were created based on the study’s goals using clear, intelligible language and subjected to supervisor review to verify reliability. Ethical Consideration - - - To protect the rights of the participants in the study, sufficient time was allotted for them to express their views on the research questions. Before utilizing their responses in the study, informed consent was obtained from the participants and the necessary permissions were obtained to ensure the proper use of their data. Any secondary data used in the research has been properly acknowledged and referenced to ensure compliance with ethical standards. RESULT & DISCUSSIONS Study Site 1947 B.S. Sukraraj Tropical & Infectious Disease Hospital also popularly known as Teku Hospital No. of beds: 458 19 33 A.D Bir Hospital No. of beds : 100 Categorization and Types of Waste Generated S.N. Hospital Name Types of waste categories Infectious 1. 2. Non infectious Bir Hospital Sukraraj Tropical & Infectious Disease Hospital Types of waste generated Hospital Name Infectious Bir Hospital Non infectious Sharps Soiled dressing, amputated body parts, Fruit peels, plastic bottles, Syringe needles, gloves, etc. leftover foods, paper, broken glass, blades, cardboard, wrap paper. etc. Sukraraj Tropical & Infectious Genotoxic wastes, gloves, gauze, rubber Paper, bottles, fruit peels, Scissors, rubber Disease Hospital tubes, body parts, masks discarded food items, tube, broken glass, plastics, etc. Amount of Waste Generated per day S.N. Hospital Name Total beds Waste category and amount generated in kg/day Infectious 1. 2. Bir hospital Sukraraj Tropical & Infectious Disease Hospital (Teku hospital) Total Total waste generated in kg/day Noninfectious 458 60 320 380 100 12 65 77 72 385 457 TRAININGS Frequency of trainings S.N. Hospital Name Type of Trainings 1. Bir Hospital Practical Trainings Sukraraj Tropical & Infectious Disease Hospital hand wash, waste segregation, autoclave guidelines, infection control, personal protective equipment SAFF (waste handle, transportation) COVID-19 pandemic 2. NA 3-6 months Waste Minimization Bir Hospital Teku Hospital Wastes are reduced, reused and recycled. Wastes are reduced and recycled Reduced: Procurement of reusable items Reduced: X ray files replaced by CDs. Reused: linens Use of cloth bags instead of plastic bag while buying medicines. Recycled: Saline pipes, paper, plastic, metal Waste Segregation Bir Hospital Teku Hospital Hard plastic containers of 50 liters are used for general and infectious wastes. Hard plastic containers of 50 liters are used for infectious and noninfectious wastes. Color coding system: Black: Biodegradable wastes Light Blue: Plastics Green: Paper Dark Blue: Bottles and cans Red: Infectious wastes However, steel containers are used for genotoxic wastes. Language used in the Labels: Nepali and English. Color Coding System: Black: Biodegradable Green: Paper Red: Infectious Language used in the labels: Nepali and English Waste Collection Bir Hospital The generated wastes are collected by waste management staff that are hired by the private contractor. Time of waste collection in a day: Infectious & Noninfectious wastes: 2-3 times Sharps are collected every 4 days. Protective equipment such as masks, caps, goggles, boots, aprons and gloves are used while handling waste. Teku Hospital Wastes are collected by waste management staff. Infectious and non-infectious wastes are collected twice a day, once at 7:30 am and at 2pm. Personal Equipment used: Apron, long boot, mask, gloves, cap, long forceps and glasses. Waste Storage Bir Hospital Wastes are stored in the basement of the Trauma Center. Noninfectious wastes are separated While infectious wastes are kept near the autoclave machine area. Wastes are stored for 15 days. Teku Hospital Infectious waste: Autoclaving area Noninfectious waste: Separated and stored in cabinets Beside recyclable items, wastes are stored for 24 hrs. Recyclable items: 2 times per month Waste Transport Bir Hospital Depending on the nature of wastes, different waste trolleys are used for transportation of waste. Both infectious and non-infectious wastes are transported through the same path. Teku Hospital Waste trolley designed for transportation is used. All wastes are transported through the same path. Waste Treatment Bir Hospital Wastes are treated before disposal. Infectious wastes are autoclaved, and sometimes chemical disinfectants are used. - Chemical disinfectants (sodium hypochlorite acid) are used for genotoxic and radioactive wastes. No. of autoclave present: 2 Model of Autoclave: NAT Purchased Year: 2008 Teku Hospital - - Infectious: Autoclave and chemical disinfectants Chemical disinfectants used: Hypochlorite solution for genotoxic waste, Dettol, phenyl and virex. No. of autoclave present: 1 Model of autoclave: ARKO Purchased year: 2011 Waste Disposal Bir Hospital - - - Pathological wastes such as Placenta, amputated body parts are buried. Treated infectious wastes are then collected by the private vendor and dumped in an unknown location. Recyclable materials are utilized either by selling them or making handicrafts. Teku Hospital Use of burial pit (placenta and amputated body parts) outside hospital premises. Treated infectious wastes are taken by the municipal waste management unit. Bir Hospital Waste Disposal : 45k Earnings from recyclable items : 40k Sukraraj Tropical & Infectious Disease Hospital Waste Disposal: 36k Earning from recyclable item: 30k Norvic. I. Hospital Waste Disposal : 36k Earnings from recyclable items:30K C O S T Challenges for managing the health care waste during COVID-19 - During the peak of the COVID-19 pandemic, hospitals across the world became centers of attention. COVID-19 can contaminate objects and wastes, presenting a health risk if not managed effectively. One of the measures to fight COVID-19 was the use of face masks and PPE. Checklist to Manage COVID-19 waste management Bir Hospital - PPE should be worn all time while handling and transporting waste from designated area to Personal Protective Earnings from recyclable items : 40k treatment zone. Equipment Staff should select appropriate PPE to prevent risk of infection and overuse of PPE - Waste minimization Waste Reduction at source Preference to recyclable and reusable items Use separate color-coded containers/bins to discard Sukraraj Tropical & Infectious Disease generated waste. Hospital Waste Disposal: 36k layered waste bags Use double Waste Segregation Dispose Earning from recyclable item:sharps 30k in puncture proof container Seal the bag before transporting Spray the bag with 1 % sodium hypochlorite solution before transporting to treatment zone or Waste Disposal : 36k temporary storage point Waste Collection and labeling - Norvic. I. Hospital Earnings from recyclable items:30K Bir Hospital Waste Transportation Place the waste bag in a close trolley while transporting to the treatment zone or temporary storage point. Disinfect Earnings from recyclable items : 40k the trolley and waste containers with 1% hypochlorite solution daily and after each use. Waste storage - Waste should not be stored more than 24 hours in a temporary storage area. Waste treatment - Treat the waste with Autoclave, Friction Heat system or any other waste treatment technology Treat for 60 minutes at 121 to 135 degree Celsius Sukraraj Tropical & Infectious Disease If treatment zone is not available within healthcare Hospital Waste Disposal: facility 36k coordinate with waste treatment provider Earning from recyclable item: 30k Waste disposal Treated waste can be discarded as regular waste. Norvic. I. Hospital Waste Disposal : 36k disinfect if PPE is reusable. Earnings from recyclable items:30K Safely remove PPE and dispose if it is non- reusable and Discussion ● ● ● ● ● Both hospitals have implemented training programs for healthcare workers to ensure that they understand the proper methods of handling and disposing of medical waste. The results also say that these hospitals have taken appropriate steps to ensure the safe and effective management of medical waste during the pandemic. However, ongoing monitoring and assessment of these practices are necessary to ensure their continued effectiveness and to identify any areas for improvement. Considering the global transmission of COVID-19, excessive biomedical waste has become a new major threat to public health as well as to the environment during this pandemic. (WHO, 2020) For instance, in August 2021, scientists discovered a fish trapped in a medical latex glove during a canal cleanup in the Dutch city of Leiden, prompting them to investigate whether there was a broader problem. Environmental Risk ● ● ● ● ● Improper incineration and disposal of hazardous waste can pollute air, water and soil. Open collection and disposal of hazardous waste may cause air borne contamination and hence increase air borne infection. The leftover ash when buried can leak into the ground resulting in both soil pollution and groundwater contamination. Improperly treated waste into the landfill or river system can damage aquatic life and spread water borne infection like cholera, typhoid, hepatitis, and so on. Hospital waste into the virgin soil may transfer drug resistant characteristic into the normal bacteria PHOTOS OF BIR HOSPITAL & TEKU HOSPITAL Photos of Respondents CONCLUSION ● COVID-19 has caused a significant increase in medical waste production. ● Both the hospitals reduce risk of cross-contamination and disease transmission through proper waste separation, record-keeping, and safe disposal. ● The COVID-19 epidemic has exposed the flaws in the healthcare waste management system and the urgent need for change. ● Develop better waste management methods to ensure safety of healthcare staff, patients, waste handlers, and environment. ● The COVID-19 pandemic has highlighted the shortcomings of the healthcare waste management system, but the experiences of Bir Hospital and Sukraraj Tropical & Infectious Disease Hospital demonstrate that medical waste may be managed in a way that protects public health and the environment. Thank you! ☺ References Aliyu, L. D. (2020). Global Failure of Leadership and the COVID-19 Pandemic: A Lesson for the World. Ultrasound Obstet Gynecol, 14(4), 301-303. CDC. (n.d.). Framework for Implementation of COVID-19 Community Mitigation Measures for Lower-Resource Countries . CDC. Retrieved November 25, 2022, from https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/community-mitigation- measures.html Cennimo, D. J., & Stuart, M. (2020). Coronavirus Disease 2019 (COVID-19): Practice Essentials, Background, Route of Transmission. Medscape Reference. Retrieved November 25, 2022, from https://emedicine.medscape.com/article/2500114-overview#a1 Denzin, N. K., & Lincoln, Y. S. (2000). The discipline and practice of qualitative research. Handbook of qualitative research, 2(1), 1-20. Fullerton, K. (2017, September 29). The Environmental Hazards of Medical Waste. Sense & Sustainability. Retrieved November 25, 2022, from https://www.senseandsustainability.net/2017/09/29/dumped-medical-waste-hazardous-to-the- environment/ Johnson, R. B., & Onwuegbuzie, A. J. (2004). Mixed methods research: A research paradigm whose time has come. Educational researcher, 33(7), 14-26. Khanal, S. N. (2020). Waste Management - Policy and Legal Measures. Kumar, R. (2018). Research methodology: A step-by-step guide for beginners. Sage. MOHSW. (2006). Medical Waste Management Monitoring Plan. Retrieved November 1, 2022, from www.mohsw.gov.np Mugenda, N. G., Momanyi, G., & Naibei, K. I. (2012). Implications of risk management practices on financial performance of sugar manufacturing firms in Kenya. AFRREV IJAH: An International Journal of Arts and Humanities, 1(1), 14-29. Poudel, K. (2020). How do COVID-19 hospitals manage health care waste? swasthyakhabar.com.np UNDP. (2017). From pilots to policies: Improving medical waste management. Retrieved November 2, 2022, from https://www.np.undp.org/content/nepal/en/home/presscenter/articles/2017/06/13/fm-pilots-topolicies-improving-medical-waste-management.html UNEP. (2020). Waste Management during the COVID-19 Pandemic From Response to Recovery. UNEP - UN Environment Programme. Retrieved November 25, 2022, from http://www.unep.org WHO. (2007). Core Principles for Achieving Safe and Sustainable Management of Health Care Waste. Retrieved November 21, 2022, from www.who.int WHO. (2014). Safe Health Care Waste Management. Retrieved November 11, 2022, from www.who.int WHO. (2017). Water Sanitation. WHO. Retrieved November 25, 2022, from http://www.who.int/water_sanitation_health/facilities/waste/hcwprinciples.pdf WHO. (2018, February 8). Health-care waste. World Health Organization (WHO). Retrieved November 25, 2022, from https://www.who.int/news-room/factsheets/detail/health-care- waste WHO. (2020, July 21). Safe waste management during COVID-19 response. Retrieved November 25, 2022, from https://www.who.int/indonesia/news/detail/21-072020-safe- waste-management-during-covid-19-response References Chin, A. W., Chu, J. T., Perera, M. R., Hui, K. P., Yen, H. L., Chan, M. C., ... &; Poon, L. L. (2020). Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe, 1(1), e10. Hiemstra, A. F., Rambonnet, L., Gravendeel, B., & Schilthuizen, M. (2021). The effects of COVID-19 litter on animal life. Animal Biology, 71(2), 215-231. Kulkarni, B. N., & Anantharama, V. (2020). Repercussions of COVID-19 pandemic on municipal solid waste management: Challenges and opportunities. Science of the Total Environment, 743, 140693. Selvaraj, S., Prasadh, S., Fuloria, S., Subramaniyan, V., Sekar, M., Ahmed, A. M., ... & Fuloria, N. K. (2022). COVID-19 Biomedical Plastics Wastes—Challenges and Strategies for Curbing the Environmental Disaster. Sustainability, 14(11), 6466. Haji, J. Y., Subramaniam, A., Kumar, P., Ramanathan, K., & Rajamani, A. (2020). State of personal protective equipment practice in Indian intensive care units amidst COVID19 pandemic: a nationwide survey. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine, 24(9), 809. Ilyas, S., Srivastava, R. R., & Kim, H. (2020). Disinfection technology and strategies for COVID-19 hospital and bio-medical waste management. Science of the Total Environment, 749, 141652. Peng, J., Wu, X., Wang, R., Li, C., Zhang, Q., & Wei, D. (2020). Medical waste management practice during the 2019-2020 novel coronavirus pandemic: Experience in a general hospital. American journal of infection control, 48(8), 918-921. Johannessen, L., Dijkman, M., Bartone, C., Hanrahan, D., Boyer, M. G., & Chandra, C. (2000). Healthcare waste management guidance note (p. 68). World Bank, Health Population and Nutrition Team. Lakshmi, B. S., & Kumar, P. (2012). Awareness about bio-medical waste management among healthcare personnel of some important medical centers in Agra. Int J Eng Res Tech, 1(7), 1-5. Manyele, S. V., & Anicetus, H. (2006). Management of medical waste in Tanzania hospitals. Tanzania Journal of Health Research, 8(3). Matee, V. E., & Manyele, S. V. (2016). Assessment of sharps waste management practices in a referral hospital. African Journal of Environmental Science and Technology, 10(3), 86-95. Mol, M. P. G., & Caldas, S. (2020). Can the human coronavirus epidemic also spread through solid waste?. Waste Management & Research, 38(5), 485-486. Nemudryi, A., Nemudraia, A., Wiegand, T., Surya, K., Buyukyoruk, M., Cicha, C., ... & Wiedenheft, B. (2020). Temporal detection and phylogenetic assessment of SARS-CoV-2 in municipal wastewater. Cell Reports Medicine, 1(6), 100098. Njiru, M. W. (2015). ASSESSMENT OF THE AWARENESS AND PRACTICE ON MEDICAL WASTE MANAGEMENT AMONG HEALTHCARE PERSONNEL AT KENYATTA NATIONAL HOSPITAL, IN NAIROBI (Doctoral dissertation, JKUAT). Pepin, J., Abou Chakra, C. N., Pepin, E., Nault, V., & Valiquette, L. (2014). Evolution of the global burden of viral infections from unsafe medical injections, 2000–2010. PloS one, 9(6), e99677. References Klemeš, J. J., Van Fan, Y., Tan, R. R., & Jiang, P. (2020). Minimising the present and future plastic waste, energy and environmental footprints related to COVID-19. Renewable and Sustainable Energy Reviews, 127, 109883. Ramteke, S., & Sahu, B. L. (2020). Novel coronavirus disease 2019 (COVID-19) pandemic: considerations for the biomedical waste sector in India. Case Studies in Chemical and Environmental Engineering, 2, 100029. Rodriguez-Morales, A. J. (Ed.). (2013). Current topics in public health. BoD–Books on Demand. Sangkham, S. (2020). Face mask and medical waste disposal during the novel COVID-19 andemic in Asia. Case Studies in Chemical and Environmental Engineering, 2, 100052. Selvaraj, S., Prasadh, S., Fuloria, S., Subramaniyan, V., Sekar, M., Ahmed, A. M., ... & Fuloria, N. K. (2022). COVID-19 Biomedical Plastics Wastes—Challenges and Strategies for Curbing the Environmental Disaster. Sustainability, 14(11), 6466. Ilyas, S., Srivastava, R. R., & Kim, H. (2020). Disinfection technology and strategies for COVID-19 hospital and bio-medical waste management. Science of the Total Environment, 749, 141652. Madhukumar, S., & Ramesh, G. (2012). Study about awareness and practices about health care waste management among hospital staff in a medical college hospital, Bangalore. Iranian Journal of Basic Medical Sciences, 3(1), 7-11. The Record. (2020, September 6). Bir Hospital designated 'COVID-19 Special Hospital' - The Record. The Record Nepal. Retrieved November 2, 2022, from https://www.recordnepal.com/bir-hospital-designated-covid-19-special-hospital WHO. Core Principles for Achieving Safe and Sustainable Management of Health Care Waste.2007. [Online].Available at: World Health Organization, 2. (2020). WHO DirectorGeneral’s remarks at the media briefing on 2019-nCoV on 11 February 2020. World Health Organization (WHO). (2018, February 8). Health-care waste. World Health Organization (WHO). Retrieved November 2, 2022, from https://www.who.int/newsroom/fact-sheets/detail/health-care-waste Yenesew, M. A., Moges, H. G., & Woldeyohannes, S. M. (2012). A cross sectional study on factors associated with risk perception of healthcare workers toward healthcare waste management in health care facilities of Gondar Town, Northwest Ethiopia. International Journal of Infection Control, 8(3). Wang, C., Horby, P. W., Hayden, F. G., & Gao, G. F. (2020). A novel coronavirus outbreak of global health concern. The lancet, 395(10223), 470-473. Ma, Y., Lin, X., Wu, A., Huang, Q., Li, X., & Yan, J. (2020). Suggested guidelines for emergency treatment of medical waste during COVID-19: Chinese experience. Waste disposal & Sustainable Energy, 2(2), 81-84.
