International Journal of Waste Resources

Managing Medical Wastes During the Covid-19 Pandemic in Nigeria

Michael Ugom^* Department of Geography, Taraba State University, Jalingo, Nigeria
^*Correspondence: Michael Ugom, Department of Geography, Taraba State University, Jalingo, Nigeria, Tel: +2348134146945, Email:

Received: 20-Jun-2020 Published: 20-Jul-2020, DOI: 10.35248/2252-5211.20.10.386

Introduction

The outbreak of the novel corona virus has raised enormous concerns globally. Thus, on the 30th of January 2020, the World Health Organisation (WHO), declared it as a global health emergency. On the 11th of February 2020, WHO announced a name for the novel corona virus as Covid-19 [1,2].

Which was first reported on the 31stof December 2019, at the Chinese WHO office as a case of an unknown pneumonia from Wuhan, China.

The easy spread of this virus made people to wear face masks as a precautionary route, use gloves and hand sanitizer on a daily basis which have resulted in the generation of a massive amount of medical waste in the environment. As the corona virus outbreak expands across nation, there is increasing concern about how to deal with waste arising from potentially infectious patients, staff caring for them and medical laboratories. Healthcare facilities are establishments that provides medical facilities such as; diagnostic, therapeutic, as well as rehabilitative services.

These facilities emits very high quantity of solid waste on a per capita basis [3]. Medical wastes are regarded as those wastes that are generated as by- products of healthcare ranging from the Doctors, surgeries, Dentists, hospitals and laboratories. It constitutes materials that can be contagious through body fluids or tissues during diagnosis, research or treatment. There exists different types of medical wastes with various categories. Medical wastes in the United Kingdom, are separated into two main types namely; hazardous and nonhazardous wastes, whilst, in the United States and some other parts of the world, there exists four major types of medical wastes namely; General, infectious, Hazardous and Radioactive wastes.

Healthcare waste in Nigeria, falls under the category of infectious waste [4]. This category of wastes houses culture and stock of infectious agents, pathological waste and waste generated from surgery or autopsy that were in contact with infectious agents.

Other hazardous materials used by healthcare facilities that later become a source of waste includes; chemotherapeutic agents, formaldehydes, solvents, anesthetic gases, antineoplastic chemicals, photographic chemicals, radionuclides, mercury, and other toxic, corrosive and miscellaneous chemicals. Additional wastes from incinerator exhaust, laundry–related and kitchen wastes are also generated [5].

Many of the same categories of medical wastes can be used interchangeably depending on the country and region. According to the World Health Organisation, medical wastes are classified into the following;

1. Infectious wastes: Anything that is infectious and contaminate

2. Sharps: Wastes like needles, scalpel, broken glass and razors.

3. Pathological wastes: Human tissues, fluids or body parts,

4. Pharmaceutical wastes: Unused and expired drug or medicine, like cream, pills and antibiotics.

5. Genotoxic wastes: Cytotoxic or other hazardous toxic wastes that are carcinogenic, mutagenic or teratogenic.

6. Radioactive wastes: Waste containing potentially radioactive materials.

7. Chemical wastes: Liquid wastes, typically from machine, batteries and disinfectants.

8. General or other wastes: All other non-hazardous wastes.

Holistically, between 75 and 90 % of the waste produced by healthcare facilities are regarded as being non-risk (that is noninfectious, non- hazardous) general waste as compared to domestic wastes. The remaining 10– 25% of healthcare waste is regarded as “hazardous” and may pose a variety of environmental and health risks.

Biomedical wastes are hazardous since they may host potential virus particles beneath human tissues, items contaminated with blood bags, needles, syringes or any other sharp object, body fluids such as; plaster casts, cotton swabs, beddings which are contaminated with blood or other body fluids etc. Thus, infected waste is such waste that is assumed to contain or harbour pathogenic organisms (disease causing bacteria, fungi, viruses, or parasites) insufficient concentrations or quantity which may be liable to cause disease in susceptible hosts.

If medical wastes are not well managed or handled through the adherence of guidelines and proper techniques, there are chances of community based spreading of Covid-19 which may exceed the limit and rate of infections as increase mortality rates.

Experts in medical wastes presume that unlike household or industrial wastes, medical wastes generated during this pandemic should be classified and treated as being hazardous and should be handled and disposed separately.

People can be infected directly through pores in the skin or by ingestion and inhalation with objects such as inhalers or ventilating pipes.

During this pandemic, medical and hazardous waste such as infected masks, gloves, ventilators and other protective equipment needs to be discarded correctly, or it will have detrimental effects on the health of humans and the environment. Owing to this, safe handling and final disposal of wastes can be seen as vital in effective emergency response.

Masks and gloves constitutes enormous amount of medical wastes which are improperly disposed in developing nations during the Covid-19 pandemic.

While it is clearly seen that waste and discarded Personal Protective Equipment (PPE) from laboratories, hospitals and medical testing centres are considered medical waste, In the case of the Covid-19 pandemic, what is classified as medical waste really depends on the location or industry the waste is coming from.

At this period when the world has been ravaged with the novel corona virus, poor medical waste practices should never be brushed off as trivial or unimportant, being that improperly disposed medical wastes can have huge consequences not only to the health of workers but for the environment and the community as well. Hence, no safety precaution is too minor to observe to the fullest extent in this regard.

As stated earlier, the waste produced from Healthcare activities poses a higher potential for infection and injury than any other type of waste.

Therefore, whenever waste is generated, safe and reliable methods for it's handling is therefore necessary as any form of inadequate and inappropriate handling of healthcare waste may have consequential public health effects and a significant impact on the environment. Thus, sound management of healthcare waste is a crucial component of environmental health protection.

One thing is certain, as the pandemic grows, so will waste generated grow. Thus, handling and containing such wastes will continue as a challenge until the crisis ebbs.

Aim

The aim of this research is to evaluate the effective management strategies for medical waste generated during the test and treatment of Covid-19 patients

The major waste in focus are; used facemasks, surgical gloves, ventilators and other associated wastes from treatment and isolation centres of Corona virus pandemic.

Objectives

The Objectives of this study includes the following;

1. To evaluate the effects of medical wastes generated during the Covid-19 pandemic

2. To evaluate the various alternative ways employed in handling and managing enormous medical wastes generated during the Covid-19 pandemic

3. To identify effective strategies for the management of exponentially increased medical waste over a short time.

4. To assess healthcare workers' involvement in medical waste management in public and private hospitals during the wake of covid-19

Justification for the Study

Personal Protective Equipment (PPEs) are crucial to protecting healthcare workers and other stakeholders who are involved in the treatment of Covid-19 patients. The use of Personal Protective Equipment such as medical masks is necessary for Covid-19 symptomatic and asymptomatic patients in order to minimize transmission to other people. This suggests why medical waste should be handled with utmost care since it is different from domestic/household waste. Sterilization and incineration of designated facilities with medical waste contaminated with saliva from a Covid-19 patients should be done to curtail community infection since such can be a potential source for transmission of the virus (Figure 1).

Figure 1: Covid-19 Situation Report.

Literature Review

During the latest two decades, outbreaks of several infectious and deadly diseases, such as; Severe Acute Respiratory Syndrome (SARS) in 2003, the Marburg hemorrhagic fever in 2007, the H1N1 influenza in 2009, the Ebola virus in 2014, and the Middle East Respiratory Syndrome Coronavirus (MERS- Cov) in 2014, has not only resulted into a large number of deaths, but also harshly affected the economic development of so many countries across the world.

Corona virus disease (COVID-19) was discovered in Wuhan, China in December 2019. As of May 21, 2020, COVID-19 has spread to 188 countries and regions. There have been more than 5 million confirmed cases worldwide and more than 300,000 deaths have been reported to the World Heath Organisation.

The spread of COVID-19 may be increased by the inadequate waste management. With the rapid rise in the number of conf irmed cases, the amount of COVID-19 related medical waste also increased significantly. The daily COVID-19 related medical waste in China is about 468.9 tons according to the press conference for the joint prevention and control mechanism of China’s state council (the state council Office-Peoples republic of China, 2020). Ensuring that COVID- 19 related medical waste is timely, orderly, efficiently, and harmlessly disposed has also become an important part of the battle against the pandemic.

The management of medical waste involves many departments and a large number of individuals thereby requiring a kind of inter – departmental collaboration [6]. This abruptly overwhelmed existing medical transport and disposal infrastructure around hospitals.

Oruonye [7], reveals that there is no officially approved dumpsite in Jalingo the state capital of Taraba, Nigeria. It was also stated that the tertiary healthcare facilities in the State has no proper safe disposal facilities of infectious medical waste at the moment. From the past few years, there has been an increasing public concern on the management of healthcare wastes generated globally. Potential health and environmental risks are associated with medical waste accruing from sharps, human tissues or body parts and other infectious materials [8]. Approximately 15–25% (by weight) of medical waste is considered infectious. Despite the current medical waste management practices varying from hospital to hospital, the troubling areas are similar for all healthcare units and at all stages of management, including waste segregation, waste collection, waste packaging, waste storage , waste transport, waste treatment and disposal [9]. Improper waste management can cause tremendous environmental pollution problems, unpleasant odours, and growth of insects, rodents and worms. It could lead to the transmission of diseases such as; typhoid, cholera, and hepatitis through injuries from sharps contaminated with human blood [10]. It is of great importance to manage medical waste appropriately to avoid health risks and damage to flora, fauna, and the environment.

The virus is thought to spread mainly from person-to-person through respiratory droplets and close contact, and the aerosol maybe a potential transmission channel. Studies have shown that SARS-CoV-2 can survive on plastic and metal objects for up to 2-3 days, and there was extensive environmental contamination by confirmed patient.

Thus, the management of medical waste can be a vital way to control the source of the Infection.

Many studies have focused on medical waste in countries such as Jordan [11], Iran, Egypt, Mauritius [12], Turkey [13], Brazil [14], Mongolia, the United States of America [15], the United Kingdom [16], and India [17]. In many developed countries, specific rules and regulations have been implemented for hospital waste management systems and thus, these systems are more effective than those in many developing countries. In many developing countries such as Iran and India, there exists inadequate and insufficient waste treatment facilities as well as protective measures and efficient training of personnel [18].

From the reverse logistics perspective, the increasing amount of medical waste from the COVID-19 outbreak needs to be collected and treated in a timely, safe and effective manner in order to curtail the virus spread and the risk to humans.

During the outbreak of Covid-19, surplus amounts of medical and hazardous waste are generated, including infected face masks, gloves and other protective equipment, as well as a higher volume of non-infected items of the same nature. Effective management of healthcare waste requires appropriate identification, collection, separation, storage, transportation, treatment and disposal of waste as well as important associated aspects including disinfection, personnel protection and training of stakeholders. This requires a substantial structural change in waste management, from the sorting process to the collection of waste, waste treatment to the safety protocol of the waste collection workers. In the European Union (EU) Personal Protective Equipment (PPEs) such as; face masks, gloves, tissues and other contaminated waste are required to be double-bagged. In Germany, food containers which normally would be classified as recyclable waste now have to undergo treatment as hazardous waste if there is a risk of contamination with pathogens.

Incineration and steam sterilisation (90min, 1200C) are the common modules for thermal treatment of hazardous medical waste. The residue of these processes are safely handled after the adequate decontamination cycle in accordance with non-hazardous solid waste regulation [19].

Unfortuntely, the major challenge is that COVID-19 is creating a waste surge that can exceed treatment capacity by a large margin. An open quetion is whether to utilise the MSW incineration capacity for medical waste in this critical situation. Norway for instance, allows a temporary change in landfill permit and grants permit to carry waste elsewhere to cope with the medical waste surge. A current debates dealing with this unexpected crisis is to have onsite, mobile or of f -site treatment [20]. In China onsite and mobile treatment is considered preferably due to it's flexibility in responding to shifting demands.

Waste segregation is an important element in ensuring efficient healthcare waste management. Separating hazardous from nonhazardous waste will apparently, reduce the volume of waste required for specialized treatment. Other elements of health care wastes management include waste classification, waste minimisation, labelling, colour coding, labelling, transport, storage, treatment and final disposal.

Dangers of Medical Waste from Health and Environmental Perspectives

Health Risks

According to relevant literatures reviewed, without proper treatment medical waste can pose a serious threat for healthcare workers, and the general populace. Other associated dangers of medical wastes includes drug-resistant microorganisms that can become infectious and spread from health facilities into the open environment.

Health risks that can be caused by improper treatment of medical waste includes; injuries from sharp objects like syringe, exposure to toxic pharmaceutical drugs such as substances with mercury components or dioxins, cytotoxic drugs and antibodies. Other health risks associated with medical wastes are handling or incineration of medical waste from the disinfection, sterilization or treatment activities and air pollution arising from incineration and thermal injuries from open burning.

Operators of waste management such as; scavengers and waste pickers are vulnerable due to the limited safety equipment at their disposal. It is important to take cognisance of the possible risks for scavengers and unregulated waste operators who picks these wastes without the right procedure in landfills or waste disposal sites as well as during waste sorting and treatment processes.

Environmental Risks

Health risks aside, medical waste discared without a consideration for the need to protect the environment might pose consequential threats ranging from pollution of drinking surface water sources and ground water

In addition, burning medical waste without appropriate or standard equipment can release hazardous materials such as dioxin that is carcinogenic in nature (Figure 2).

Figure 2: Discarded Syringes.

Principles and Strategies for Handling Healthcare Wastes

Principles for handling healthcare wastes includes; Minimization and Recycling, Sorting and handling, Collection and Storage, Transportation, and Treatment and Disposal.

Minimization and Recycling

The reduction of waste generated during the outbreak of the covid-19 pandemic must be encouraged by the following practices: Reducing the amount of waste from the source, Choosing products that generates less waste, Preventing wastage: in the handling of waste, or during cleaning activities, Choosing equipment that are reusable in the production of covid-19 Personal Protective Equipment (PPEs) (Figure 3).

Figure 3: Medical Waste.

Sorting

Sorting of medical wastes consists obviously of varying types of waste. There are two important principles that must be followed in sorting wastes. The simplest way to identifying the different types of waste and to encourage people in sorting them is to collect the various types of waste in a separate container or plastic bags that are colour-coded.

This should be done with a close proximity to the site where the wastes were produced.

There is no point in sorting wastes that undergo the same treatment process.

Collection and storage

Wastes should be collected daily and must never be allowed to accumulate where it is produced. A daily collection program and collection round must be planned. Each type of waste must be collected and stored separately with different known signs on the containers.

Infectious wastes must never be stored in places that are open to the public.

The personnel in charge of collecting and transporting wastes must be informed to; collect only those with yellow bags and sharps containers precautionary measures such as wearing of gloves and immediate replacement of bags should be ensured.

Transportation

Effective means of conveyance of medical wastes must meet the following requirements; they must be easy to clean (with a 5% active chlorine solution), they must be easy to load and unload; they must not have any sharp corners or edges that could damage the containers for the waste; they must be clearly marked.

Furthermore, off-site means of transport must meet the following requirements: they must be closed in order to avoid any spilling on the road; they must be equipped with a safe loading system (to prevent any spilling inside or outside the vehicle). The body producing the waste is responsible for packaging and labelling the waste to be transported outside the hospital. Prior to packaging and labelling, there should be a conformity with the national legislation on the transportation of dangerous substances with the Basel convention.

Treatment and disposal

Choice of treatment and disposal method depends on a number of parameters. These include a reliable means of transportation, the quantity and type of waste produced, availability of waste treatment site near the waste generating facility, availability of National legislation on health care waste management, groundwater level, regular supply of electricity in the area etc. Health risks for staff in handling and treatment of waste should be taken into consideration. The purpose of protective measures is to reduce the risks of accident/exposure or the consequences.

Materials and Method

The study employed descriptive mode of data collection with secondary materials obtained through a web-based generic search from Worldometer and the Nigeria Centre for Disease Control open source data collection.

Results and Discussions

According to the World Health Organisation, healthcare workers, waste handlers, patients and the populace are susceptible to infections, injuries and risks from healthcare wastes.

The World Health Organization (WHO) says it is pertinent to segregate all medical wastes from the point of generation, treatment and disposal. An estimated 160 million injections are administered annually globally, but not all these needles and syringes are properly disposed after use [21-26].

Several measures have been instituted by Nigeria's Federal Government through the newly established Presidential Task Force on Covid-19 jointly supported by the Federal Ministry of Health to help mitigate the spread of the virus and ensure protection of Nigerians against the virus.

Measures in place by Nigeria's Federal Government includes an initial lockdown of non-essential activities in some parts of the country and a current ban on domestic and international flights. Parts of efforts to phase out and gradually ease the lockdowns, include the following;

1. Mandatory use of face mask/covering in public spaces

2. Mandatory provision of handwashing facilities/sanitisers and extensive temperature checks in all public spaces.

3. Maintaining a Physical distance of 2 metres between people in workplaces and other public spaces

4. Nationwide curfew from 10pm to 4am to limit social interactions as a measure towards reducing the risk of transmission of COVID-19.

5. Routine access to markets and locations of economic activities

6. Restrictions in opening of places of worships (Mosques, Churches, etc) following strict guidelines by state government on physical distancing and other non-pharmaceutical interventions.

7. Prohibition of non-essential interstate travel except goods and services that provides essential value.

Nigeria Centre for Disease Control (NCDC) have continually expand laboratories for the testing of COVID-19. Currently, there are thirty- seven (37) laboratories in NCDC ’ s molecular laboratory network with the capacity to test for COVID-19 across Nigeria.

The statistics globally are scary and Africa, Nigeria inclusive, is not immune to the coronavirus pandemic. At present, According to Wordometer there is a global case of 8,298,470 of the Corona Virus with a 446,905 deaths and a recovery case of 4,347,337. Reports from the Nigeria Centre for Disease Control (NCDC), shows a Covid-19 cases from 16th of June, 2020 as 17148 cases been confirmed, 5623 cases discharged and 455 deaths recorded in 35 states and the Federal Capital Territory.

Nigerian doctors union is demanding that the government provide members with more personal protective equipment and hazard pay in treating patients infected with COVID-19, At least 10 doctors have died of COVID-19, the highly contagious disease caused by the coronavirus. Researchers has expressed concern that an estimated 200 doctors have tested positive for the disease.

Medical experts in Nigeria have advocated that there is also the risk of transmission of infections in the community when used Personal Protective Equipment (PPEs) are not properly discarded as a medical waste. Usage of PPEs is essentially for healthcare workers and certain categories of sick persons in the hospital environment. Persons who have respiratory symptoms or infections; cough, colds, catarrh, sneezing among others can use facemasks to prevent spread of infections to other persons.

Nigerian government could adopt the strategies developed by the Lagos State Waste Management Authority, where proactive measures are taken to restrict access of waste pickers to its landfills. Special waste collection buckets to collect disposable PPEs could be provided in buildings (residential, government and hospitals) and in public places. Such waste collection buckets could be emptied, at least daily, by trained personnel who would then decontaminate or dispose the PPE following Nigeria Centre for Disease Control (NCDC) guidelines (NCDC, 2020). Used plastic bottles could be decontaminated with a 70% alcohol solution, as per NCDC guidelines, before reuse in packaging local drinks and herbal medicines.

Recommendations

Oftentimes, Healthcare facilities in Nigeria are constructed and flagged off without considerations on the Environmental Impact Assessment (EIA). The regulatory agency, Nigeria's National Environmental Standards and Regulations Agency (NESREA) must rise to the challenge of environmental pollution from healthcare facilities.

There is a need for community engagement prior to the establishment of Public Health institutions as a measure to ensuring the development of a robust Environmental Impact Assessment (EIA) document and Environmental Management Plan (EMP) so as to stem issues associated with negative impacts of the healthcare facility on the social, biophysical environment and health of mankind. NESREA should also ensure thorough monitoring and enforcement of the proposed laws and regulations.

Medical laboratories in hospitals are among the most infectious group with highest healthcare waste as it contains teratogenic chemicals, mutagenic and virulent pathogens. Adequate measure in ensuring that Laboratories have a standard waste tracking protocol in compliance with the international standard should be taken in consideration.

REFERENCES

1. https://covid19.ncdc.gov.ng/
2. acrplus.org/en/municipal-waste-management-covid-19
3. Coker AO, Sangodoyin AY, Ogunlowo OO. Managing hospital wastes in Nigeria. Proc of the 24th WEDC Conf. Islamabad, Pakistan.1999:70–72.
4. Federal   Environmental      Protection Agency FEPA.     Guidelines and standard for industrial effluents, Gaseous emission and hazardous waste management in Nigeria. 1991.
5. USEPA. Guides To Pollution Prevention Selected Hospital Waste Streams. EPA/625/-20/009.
6. Peng J, Wu X, Wang R, Li C, Zhang Q, Wei D. Medical Waste Management Practice during the 2019-2020 Novel Coronavirus Pandemic: Experience in a General Hospital. American Journal of Infection Control. 2020.
7. Oruonye ED, Ahmed AY. Covid-19 and challenges of management of infectious medical waste in Nigeria: A case of Taraba State. International Journal of waste resources. 2020.
8. Baveja G, Muralidhar S, Aggarwal P. Medical waste management–an overview. Hospital Today. 2000;5(9):485– 486.
9. Tsakona M, Anagnostopoulou E, Gidarakos E. Hospital waste management and toxicity evaluation: a case study. Waste management. 2007;27(7):912-20.
10. Abdulla F, Qdais HA, Rabi A. Site investigation on medical waste management practices in northern Jordan. Waste management. 2008;28(2):450-8.
11. Mohee R. Medical wastes characterisation in healthcare institutions in Mauritius. Waste management. 2005;25(6):575-81.
12. Birpınar ME, Bilgili MS, Erdoğan T. Medical waste management in Turkey: A case study of Istanbul. Waste management. 2009;29(1):445-8.
13. Da Silva CE, Hoppe AE, Ravanello MM, Mello N. Medical wastes management in the south of Brazil. Waste management. 2005;25(6):600-5.
14. Patil AD, Shekdar AV. Healthcare waste management in India. Journal of Environmental Management. 2001;63:211– 220.
15. https://www.healthcareguys.com/2020/04/24/the-role-of-medical-students-during-the-covid-19-pandemic/
16. https://thehill.com/blogs/congress-blog/healthcare/486057-waste-disposal-measure-could-help-limit-the-spread-of
17. Bourouiba L. Turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of COVID-19. Jama. 2020;323(18):1837-8.
18. https://www.cdc.gov/infectioncontrol/guidelines/environment%20al/background/me%20dical-wast%20e.ht%20ml
19. Jang YC, Lee C, Yoon OS, Kim H. Medical waste management in Korea. Journal of environmental management. 2006;80(2):107-15.
20. http://www.gov.cn/xinwen/gwylflkjz53/index.htm
21. Lee BK, Ellenbecker MJ, Moure-Ersaso R. Alternatives for treatment and disposal cost reduction of regulated medical wastes. Waste management. 2004;24(2):143-51.
22. https://covid19.who.int/?gclid=EAIaIQobChMIgb_zqdbd6gIVhjUrCh3uDAWPEAAYASAAEgIMp_D_BwE
23. Prüess A, Giroult E, Rushbrook P. Safer management of wastes from Healthcare Activities. World Health Organization, Geneva. 1999.
24. Tudor TL, Noonan CL, Jenkin LE. Healthcare waste management: a case study from the National Health Service in Cornwall, United Kingdom. Waste management. 2005;25(6):606-15.
25. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public?gclid=EAIaIQobChMIi-WwlNjd6gIVz38rCh2KcgzFEAAYASAAEgLcKfD_BwE
26. https://www.who.int/water_sanitation_health/medicalwaste/077to112.pdf