Amid COVID-19, Reverse Logistics Management of Health Care Industry Makes Complicated
Amid COVID-19, Reverse Logistics Management of Health Care Industry Makes Complicated
Globally, reverse logistics of health care industry is one of the crucial public health concerns with a huge environmental threat. Over the last decade, the growth of the medical sector around the world combined with an increase in the use of disposable medical products has contributed to the large amount of medical waste being generated. Medical waste including home care materials contains highly toxic metals, toxic chemicals, pathogenic viruses, and bacteria. As a result, several studies showed that this health care waste can present a mechanism for transmission of severe health problems as it contains highly toxicity chemicals.
As per World Health Organization, the waste which is generated by health care activities includes a broad range of materials, such as used needles, syringes, diagnostic samples, blood, chemicals, pharmaceuticals, medical devices, and radioactive materials. The WHO also reported that poor management of health care waste may cause infection, toxic effects, injuries, and risks for polluting the environment as well as affecting health care workers, waste handlers, patients, family members, and even the community people at large scale.
One might say that when serious patients are not properly treated in the government hospitals and sometimes even patients have to lie on the floor or do not get any doctor to see them, how can we expect proper management of medical waste? Indeed it is not an irrational question. Human health concern is not something our policy makers are worried about. Whether it is about food adulteration or the medical waste, no one seems to be concerned.
But the private hospitals, clinics and diagnostic centers are always telling us that they do not compromise with health issues. Though the private hospitals, clinics and diagnostic centers are charging high from patients in the name of safe medical facilities, most of them do not properly manage the medical waste.
Health Care Waste Management Process in Bangladesh
Proper management of health care waste in hospitals means the effective segregation of waste and the separate handling and disposal of each segregated waste category. This cannot be achieved without the commitment of senior directors and the motivation of medical and support staffs.
Most hospitals and diagnostics centers do not know how to handle and dispose medical waste. 38.1% of the handling staffs have not received any training to handle medical waste. One study shows that among doctors, about 8.0% practiced properly, 32.0% improperly and 60.0% were unaware of disposal practices. Among nurses it was about 5.0% the proper way, 35.0% the improper way, and 60.0% unaware.
Hospital wastes, including the waste collected from home care poses a significant threat to human health and environment. In Bangladesh, many people get treatment at home from the local doctor. Caregivers and family members throw away the used needles, syringes, and other items in open areas. Then children use the used items as their playing and fun instruments. Proper waste management strategy is needed to ensure health and environment safety.
In Bangladesh, the medical waste generation rate is estimated to be 0.8 to 1.67 kg/bed/day, so that annual medical waste generation rate will be 93,075 tons per year. About one fifth of this waste would be classified as highly hazardous waste by World Health Organization’s (WHO) guidelines. As per the situation in Dhaka, about 840 clinics, hospitals, and diagnostics centers produce medical waste. However, until recently; there has been an improper process of medical waste management in Dhaka City. Besides, Bangladesh does not have any particular chemical policy.
It is an alarming situation that waste generated inside the hospitals were collected without any separation by untrained, unprotected, and unaware cleaners. Waste collection was carried out using open bucket (44.4%) and plastic bowl (23.9%). Medical wastes were disposed of in several places: the City Corporation’s dustbin, a pit near the hospital (dig a hole), an open field/road side, or at the canal water/ river. Most waste was disposed in municipal bins (59.0%) without any separation. A common step of disposal of medical waste in Bangladesh is as shown in Figure.
After an operation, they put waste in plastic boxes (sometimes in open boxes). Then the cleaners put the medical waste in a hole or city corporation dustbin with solid waste. Waste pickers collected and sold the waste for recycling. City cleaners took the rest of the waste at the city corporation burning area.
Poor people collect the waste and sell it for recycling. Most of the clinical wastes (e.g. syringes, needles, saline drips, discarded food, gauze, vials, and ampoules) are collected by women and children who re-sell those despite of the deadly health risks. Almost 85.0% of sharp injuries are caused between their usage and subsequent disposal. It also said that more than 20.0% of those who handle them encounter “stick” injuries. Another study showed that people use an average of 3.4 injections per year, in which 39.3% were administered with reused equipment for low level of management.
The ultimate disposal of waste including those wastes collected and transported directly the residual substance from various waste processing plants that are of no further use. The options available for disposal are open dumping, sanitary land filling and Incineration.
Majority of the hospitals, clinics and diagnostic centers in the country do not have any waste management treatment plant nor do they give proper attention to the problem of hospital waste management. Till today, all the hospitals discharge their liquid pharmaceutical and chemical waste into the general sewers or drains because none of them have any proper liquid waste management system. Liquid waste is mainly generated from patients' service units, operation and surgical units, laboratories and other health-care units. As a result, the water bodies in Bangladesh are being polluted by the liquid wastes.
PRISM
(Project in Agriculture, Rural Industry, Science and Medicine) Bangladesh, an
NGO, is the sole organization involved with medical waste management. They
collect medical waste from hospitals and clinics in open drums and transport
them to disposal sites in covered vans. Subsequently, PRISM Bangladesh with the
financial support from Canadian International Development Agency (CIDA) has
recently developed a disposal facility for low cost clinical waste treatment
and management in Dhaka City. The city corporation has allocated one acre
(0.405 hectare) of land in Matuail, a dumpsite near the city limit for the
final disposal of clinical waste. It is inadequate to handle all the clinical
wastes of the city with the limited facilities of final disposal. They expanded
their operation in Sylhet, Rangpur, Narayanganj city corporation areas as well
as Jessore and Savar municipalities. They only manage medical waste generated
from hospitals and clinics though some are excluded from their services in the
above mentioned areas. Five times more medical waste is generated outside
Dhaka.
Policy guidelines and legal aspects
The Medical Practice, Private Clinics and Laboratories (Regulation) Ordinance, 1982, amended in 1984, says nothing in particular about medical waste management. It describes some criteria for obtaining a license to establish a hospital or clinic, but this merely states the necessity for proper accommodation with hygienic environment. The Environment Policy, 1992, Environment Protection Law, 1995 (2000), Poribesh Adalat Ain, 2000; and the Environment Conservation Rules, 1997 formulated by the Department of Environment, Ministry of Environment (MOE) and Forests categorize hospitals and clinics with other industries, saying that hospitals and clinics should be built only in non - residential areas, a directive which is hardly followed. The existing environmental law is too generic and it is clear that clinical waste requires separate environmental guidelines. The City Corporation Act and the Urban Local Government Ordinance
In our country, where problems remain unsolvable even with stricter laws, enacting rules is 'a white elephant' to our medical governance. Rule no. 8 of the Medical Waste Management and Processing Rules devises to establish dumping zones in seven divisional areas. However, only Dhaka has the only specialized dumping ground for the disposal of medical wastes; that too is very insufficient to meet the demands of increasing number of hospitals in Dhaka.
Waste Generation in COVID-19
Now the human race is fighting against Covid-19 infection. Covid-19 is also producing large quantities of hazardous medical waste, with personal protective equipment (PPE) used in hospitals being the main component. World Health Organization (WHO) standard PPE are one time use—every set of PPE becomes hazardous medical waste after being used for a single time. Health care facilities are not exempted from having such behavior while the disposal of used PPEs is seen in the garbage containers. These affairs are evident enough to portray the level of unawareness about hazardous waste management, a vital affair associated with the pandemic.
Besides PPE, the maximum amount of waste was generated from used hand gloves. There are other types of hazardous waste like facial tissue, gauze pieces, masks, oxygen masks, test tubes of naso pharyngeal swabs, saline bags, disposable syringes, needles etc that are being used to treat patients.
Bangladesh was already struggling with poor medical waste management before the corona virus pandemic. Based on this practical situation, the questions arise: “How are we going to handle the additional amount of hazardous waste generated from households or health care facilities? Are we equipped with proper incineration facilities or other relevant techniques to take care of this infectious waste?”
Being contagious in nature, Covid-19 has the potential of further transmission through additional carriers, and waste collectors and people living next to these open dumping zones are several of them. Around 40,000 informal waste collectors work across the country. The ones who are working are at high risk of getting infected by Covid-19 as they work without adequate protection.
Some waste contaminates soil; some contaminates the air and the rest of ends up in the Bay of Bengal through rivers. Unplanned medical waste dumping in coastal districts may harm the biodiversity of the Suburbans as well as the marine ecosystems of Bay of Bengal, as the virus can live up to 120 hours in water. Medical waste can cause serious damage to the wildlife of the Suburbans. Cats, Tigers, and other animals already tested positive for Covid-19 abroad and they can infect other animals of their type. How it can infect fish, aquatic mammals and marine lives are not clear so far.
However, unsealed collection and transportation of Covid-19 waste over such long distances is certainly dangerous, and medical waste workers are also unwilling to handle this waste. During the lock down in Dhaka the number of operational waste collectors or waste management workers has been reduced by almost 50%. If the workers do not collect, how can the hospitals designated for Covid-19 treatment dispose of their waste? Some hospitals that have a backyard are putting their waste into a ditch and burning it. Ideally, medical waste must be burnt under controlled environments at more than 850 degree Celsius, and the flue gas should be released into the environment after filtering harmful particles.
The medical waste and healthcare hazards generated in pandemic outbreak are highly infectious and dangerous; the treatment of them at a centrally located incineration plant may dramatically increase the treatment risk on population exposure and is thus minimized in the optimal solution.
The only way of dealing with this Covid-19 related waste is through the incineration process, the thermal treatment of waste with more than 850C. Unfortunately, we are not in a position of dealing with such treatment for the waste as there are no central, controlled incineration facilities for the waste management industry in this country and waste management is done by the informal sector.
Study findings show that, in some provinces of China it is advocated to use cement kilns and other industrial furnaces as the alternate way for the burning of hazardous waste. It is possible to attain the desired temperature in such controlled facilities. In view of that, given of our condition, we have a number of cement industries, and in this dire situation, we can think of using their controlled furnaces to do away with this hazardous waste.
Also the “brick kilns” can serve as potential incinerator facilities as they can attain the high level of temperature with pollutant trapping techniques. As the majority of brick kilns are located within the verge of Dhaka, Narayanganj, Gazipur, and Chittagong, and so are the Covid-19 patients, brick kilns can be regarded as “blind man’s stuff” for the infected cities’ waste disposal system.
Recommendations:
ü Emphasized on waste
segregation at the source by introducing different color code bags or
containers that will help proper channeling of the hospital waste.
ü Hospital Authority should
provide proper disposal site for the time being before any system developed
ü The waste management
system in a hospital should be clearly set out in a waste management plan. All
the staffs should be well aware of it, if necessary new members and staffs
should be trained for better outcomes.
ü Implement polluter pays
principle where hospital should be pay for their wastes.
ü The City Corporation
should take initiatives for regional waste treatment plan by providing places
for medical waste dumping.
ü The government needs to
upgrade the waste disposal system and consider the international principles as
their guideline for better practice in hospital waste management.
ü Strict law policy should
be made and future plans of waste management should emphasis on waste tracking
system.
ü Build strong
communication across the Ministry of family Welfare, Ministry of Environment,
City Corporation, Local authorities and NGOs should communicate for better
waste management.
ü Integration of waste
minimization into national purchasing policies
ü More private companies
should be encouraged to come forward and take initiative to manage the medical
wastes
ü Government should take
initiative to establish a national and regional infrastructure for final
disposal of health-care waste through landfill, incineration or otherwise like PRISM
Bangladesh
ü Routine monitoring of
impact through process indicators (number of health-care establishments with
safe waste management systems) and outcome indicators (e.g. number of accidents
involving health- care waste).
ü As a safe disposal method, incineration is the only viable option while dealing with the final disposal of Covid-19 waste. In the given circumstances and with numerous challenges of waste management, concerned authorities should look to surrogate options (industrial furnaces, cement, and brick kilns) that will settle the challenges with Covid-19 hazardous waste and further transmission of this disease through possible carriers to the community.
Conclusion
Health
Care waste management is still an ignored phenomenon in Bangladesh. It is also
intimate component of improved environment and public health. The environmental
management of hospital means proper management of clinical waste has become an urgent
necessity. At present, there exists a rule of clinical waste management in
Bangladesh and it contains only disposal system and ignored the responsibility
of hospital authorities about waste management. Therefore, it is necessary to
upgrade the rules appropriately for the management of clinical wastes.
Identification of the hazardous and infectious waste and their segregation from
the general waste is necessary at the source of generation of clinical wastes.
Primary segregation of hazardous waste is mandatory. Separation at the point of
generation and safe handling should be practiced to combat occupational health
hazards. Contextually appropriate treatment facilities are urgently required
for the disposal of clinical waste. Institutional co-operation and government
body collaboration (City Corporation, DOE) may find better solutions for proper
management and treatment technology concerning infectious waste; autoclaves can
be introduced into small clinics and laboratories to help with disinfection.
References:
o
“Overview
of Clinical Waste Management Approach in Bangladesh: An Example of PRISM
Bangladesh” by Golam Moinuddin, PhD
o
“Medical
Waste Management (MWM) in Dhaka, Bangladesh: It’s a Review” by Emdadul H. Syed,
Mahmuda Mutahara, and Mosiur Rahman
o
“Hospital
waste management: Bangladesh” by Tarannum Dana
o Reverse Logistics Network Design for Effective Management of Medical Waste in Epidemic Outbreaks: Insights from the Coronavirus Disease 2019 (COVID-19) Outbreak in Wuhan (China)
Author:
Saad Aadnan Kabir CSCP
Co-Founder,
AdvantEdge Bangladesh
aadnan.kabir@gmail.com
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