Managing healthcare waste: Issues and challenges

Climate change is the biggest crisis affecting human and planetary health in the 21st century. The healthcare sector, perceived as a healer, contributes to the climate crisis in many different ways. Along with direct greenhouse gas (GHG) emissions (4.6% of the total emissions), Canadian healthcare facilities are responsible for producing 200,000 tons of waste, leading to 23,000 years of life lost annually from early death or disability.1 There is limited data available on medical waste management in Canada, but in the U.S., 4 billion pounds of waste is generated annually by healthcare sector. As per one report from Hamilton Health Sciences, 11 kilograms (kg) of medical waste are produced daily for each patient, leading to an annual production of over 500 tonnes of hazardous waste.2 All of this implies that a reduction in healthcare waste can contribute towards solving the issue of climate crises in a major way. There are management strategies to address the issue of medical waste, however there is strong need for a systems-based approach that will curb the problem of healthcare waste and emissions to create a sustainable healthcare sector. This article will highlight the various types of healthcare waste, the issues associated with traditional disposal practices and the importance of healthcare waste management strategies. Read: Exciting times for the treatment of the common molluscum contagiosum skin disease In our last article, we highlighted the paradox in which climate crises lead to greater healthcare demands, and increased healthcare initiatives further add to climate crises. This paradox requires us to identify the gaps, face the challenges and develop the tools to mitigate the effects of healthcare pollution, thereby ending the vicious cycle. In the pursuit of improving, maintaining and restoring human health, our current healthcare systems have neglected to consider environmental health and the relationship between human health and environmental health. Under such a scenario, the human race is destined to suffer from several health issues. However efficient a healthcare system may be, it cannot succeed in ensuring human health without being mindful of environmental health. What is healthcare waste? The terms “medical waste” or “healthcare waste” refer to all waste generated by healthcare facilities. Major sources of medical waste are hospitals, clinics, diagnostic centres, laboratories, research centres, blood banks, mortuaries and autopsy centres. Pharmacies, dental clinics, physician’s offices, and home-based healthcare services contribute comparatively lesser amounts of waste. Types of healthcare waste and their classification As per World Health Organization, approximately 85% of the overall medical waste created consists of general healthcare waste (non-hazardous) that does not pose any particular risk to human health or the environment.3 It includes materials that have not been in contact with patients, such as glass, paper, packaging material, metal, food or other wastes that are similar to household wastes. These types of waste can be disposed of like general municipal waste. Read: Environmental contamination by antineoplastic drugs common in oncology pharmacy and patient care areas The remaining 15% includes healthcare waste that is generated during patient diagnosis, treatment or immunization. It is regarded as hazardous and may create a variety of health risks if not managed and disposed of in an appropriate manner. Hazardous waste Hazardous medical waste may be classified into different categories depending on the source, type and risk factors associated with its handling, storage, transport and ultimate disposal (Fig 1). These include (a) infectious health-care waste; (b) sharps; (c) anatomical and pathological waste; (d) chemical and pharmaceutical waste; and(e) radioactive waste. Regulated Medical Waste (RMW) or Biohazardous medical waste is that part of healthcare waste that may be contaminated with body fluids like blood or other potentially infectious materials, thereby posing a significant risk to transmitting infection. Things like Personal Protective Equipment (PPE), dressings, surgical gloves, swabs, bandages and cultures fall under the category of regulated medical waste. Sharps Improper and irresponsible disposal of hazardous waste can lead to serious impact on human health and the environment. For example; 16 billion disposable syringes are used per year worldwide. Not all of these are disposed of in a safe manner. Contaminated syringes or needles have the potential to spread the infection while sharps (constitute 1% of all healthcare waste) like needles, broken glass, blades, and scalpels also pose a risk of inflicting injuries along with transmitting infection. In Mexico, 13 of 69 waste pickers interviewed reported 22 needle stick injuries during the past 12 months. A number of children in Baghdad were admitted to the hospital on developing symptoms of infections after coming in contact with healthcare waste.4 As per the World Health Organization (WHO), a person who experiences one needle stick injury from a contaminated needle risks becoming infected with hepatitis B virus (30% risk), hepatitis C virus (HCV—1.8%) and human immunodeficiency virus (0.3%).3 Read: Environmental racism: New study investigates whether Nova Scotia dump boosted cancer rates in nearby Black community In December 2007, Karachi-based newspaper The News International published an article quoting studies conducted by Calin Georgescu which revealed that a large number of garbage pickers/scavengers, mainly children, were suspected to have contracted HCV as a result of needle-stick injuries during the collection of used syringes and other clinical waste for recycling.5 An outbreak of TB among workers in a regional medical waste treatment facility in the US highlighted the hazards related to aerosolized microbiological wastes.6 This is a matter of violation of human rights arising from negligent disposable of hazardous healthcare wastes. Chemical waste—surprising sources Over-prescribing and over-treatment are identified as main culprits of adding to GHG emissions. As per one estimate, about one third of laboratory tests were found to be of little value. Full blood examination of one patient has a carbon footprint of 116 g CO2 e/test.7 To put this data into context, there are about 14 billion lab tests ordered in the U.S. alone—the cumulative effect of these emissions on the environment are not negligible. Anesthetic gases from healthcare facilities, with a global warming potential up to 2000 times greater than carbon dioxide, contribute greatly to emissions. It has been estimated that only 5% of these gases actually enter a patient’s system and the rest are vented out as medical waste. Audit studies revealed that recycling anesthetic wastes alone could save 30% of the cost allocated for clinical waste disposal, annually. Plastics Plastics constitute a major part of healthcare waste as they are used in countless medical products ranging from diagnostic kits, glucometers, latex gloves, masks, prosthetics, engineered tissues, intravenous bags, dialysis tubes, sutures, bone cement, oximeters and glucometers. The invasion of plastics in medical field since 1970s, launched a trend towards viewing disposable as synonymous with safety. The use of disposables is a great step to minimize the chances of transmission of infections; however, it creates a heavy load on the planet. As per a report published by EcoSchools, Canada; by the year 2025, 8500,000 to 9500,000 million tonnes of ocean plastic will be from medical facilities [8]. The ethical dilemma: Safety vs. sustainability It seems that there is an inherent ambiguity, a tug-of-war-like debate on the use of reusables vs. disposables. While the pro-environmental sentiment guides us to opt for reusable syringes to decrease the volume of waste; safety protocols emphasize the importance of disposables to reduce the probability of cross-contamination. A thorough analysis of such contradictory situations reveal that a middle way can be designed which can ensure both safety and sustainability. For example: opting for pre-filled injections rather than manually filling the syringes can reduce the generation of waste significantly. As per a study conducted by The Royal Liverpool and Broadgreen University Hospitals NHS Trust, the use of prefilled syringes decreases the amount of waste generated by reducing the number of steps required to perform a saline flush procedure from 14 to 6. In addition to increasing both staff and patient confidence, the pre-filled syringes aids in saving time as well as cost. In cases where use of disposables is mandatory to ensure patient safety, over packaging should be discouraged to reduce the plastic wastes. The cardboards and plastics used in packaging should be recycled to reduce their footprint. Plastic disposables in healthcare are not only a waste generation issue, but they also negatively affect human health, particularly in vulnerable populations such premature babies, infants, children and the elderly. DEHP i.e. di- (2-ethylhexyl) phthalate, a chemical used to confer flexibility and transparency to medical equipment like IV tubes and blood bags etc., have been found to easily leach on coming in contact with bodily fluids and tissues. Research at John Hopkins Bloomberg school, Baltimore suggested that premature babies can be exposed to levels of DEHP 4000 to 160,000 times higher than the desired value. DEHP causes disruption of normal hormonal functions, increased inflammation, disrupted development of lungs, brains, and eyes in animals.9 In addition to disposable and reusable, a third option also exists: i.e., reprocessed items, wherein “single-use devices (SUDs) are cleaned and sold after ensuring their sterility. A proactive and environmentally conscious approach can go a long way in minimizing the impact of healthcare practices on human health. For example, at The Ottawa Hospital, breast pump equipment which had been sterilized and reused by hospitals was suddenly labeled by the manufacturer as single use, implying that the plastic tubing had to be thrown out after each feed. On being questioned by hospital leaders, the company compromised and marked the equipment as single patient—so that one patient could use the same equipment during the course of her hospital stay.10 Methods of waste disposal and their drawbacks In Canada approximately 97% of waste requiring final disposal is sent to landfills while 3% is incinerated. Medical waste disposed of in landfills risks being leached into soil and water, thereby posing a danger to human health. In addition, such landfills produce carbon dioxide (CO2), methane, nitrous oxide and other potent GHGs. As the major portion of medical waste is comprised of plastics and heavy metals, incineration at high temperature can lead to the generation of toxic by-products such as dioxins, dibenzofurans, and mercury. In the U.S. alone, the emission of these toxins adds an annual burden of 470,000 disability adjusted life years (DALY1[a]).11 Due to the drawbacks associated with incineration, the healthcare industry is shifting its focus to alternative strategies such as autoclaving and microwaving. Autoclaving, more popular in research laboratories, is the most environmentally friendly and safe technique for medical waste processing. Hamilton Health Sciences has successfully reduced incineration practices and now autoclaves half of their hazardous wastes.2 The Canadian healthcare system is largely governed by provincial regulations. Generally, self-regulation policies are implemented wherein individual healthcare institutions are responsible for conducting their own healthcare waste/emission audits and taking actions to curb issues of healthcare waste. Lack of transparency, proper guidelines, policies, awareness, education and tools are the major hurdles in popularizing and adopting sustainable healthcare practices. Unless the effect of healthcare waste is quantified, it is difficult to visualize its impact on human health and environment. The first step in addressing the problem of healthcare wastes and emissions is to pursue a thorough Life Cycle Assessment of healthcare waste—something we need to do urgently and immediately. Aska Patel is a pharmacist, and an entrepreneur, with a passion for digital delivery of healthcare and environmental sustainability. She completed her Bachelors of Pharmacy and Doctor of Pharmacy degree from the University of Waterloo. Aska has worked as a pharmacist in community, hospital, government and home care settings. Aska recently launched her entrepreneurial venture, Acuvise Consultancy Inc., providing healthcare consulting while joining a digital health venture as a startup advisor, and launched a podcast, Diverse Conversations Podcast, where she discusses the future of pharmacy, healthcare, and healthtech with global industry leaders. Rajni Ratti, a sustainability consultant at Acuvise Consultancy Inc., holds a doctorate in Green Chemistry & Catalysis and worked on carbon dioxide utilization project during her post-doctoral research. With a strong background in Botany and Zoology she can efficiently amalgamate her expertise on various subject areas like toxicology, environmental sciences, biochemistry for creating sustainable systems. Having written several successful research proposals, she is an established grant writer. She has published her research results in various international journals of high repute and is often invited to review research papers from American Chemical Society, Wiley, Springer to mention a few. References: Environmental impact means Canada’s health sector harms as it heals, Renato Discenza, Dec. 11, 2021, Toronto Star Hamilton Health Sciences. 2018 Sustainability Report: Hamilton Health Sciences; 2018 World Health Organization. Health-care waste: WHO; 2018 Acharya A, Gokhale VA, Joshi D, IOSR J. Appl. Chem. 6 (2014) 21-27. Hospital waste spreading Hepatitis, The News International (Karachi), 24 Dec. 2007 Weber AM, Boudreau Y, Mortimer VD, A tuberculosis outbreak among medical waste workers; J. Am. Biol. Safety Assoc., 5 (2000) 70-81. McAlister S, Barratt AL, McGain F. The carbon footprint of pathology testing. Med J. Aust 213(2020) 11477- 477.e1 An unsuspected miscreant : The healthcare industry’s effect on plastic pollution;, Hamidah Oderinwale, March 2019, The Eco school. Toxic levels of chemical in plastic medical devices could endanger preemies, Abby Philips, Nov. 2014, The Washington Post Are disposable hospital supplies trashing the environment?; W. Glauser, J. Petch, S. Pendharkar, Aug 18, 2016, Healthy Debate Petre M-A, Bahrey L, Levine M, van Rensburg A, Crawford M, Matava C. A national survey on attitudes and barriers on recycling and environmental sustainability efforts among Canadian anesthesiologists: an opportunity for knowledge translation. Can. J. Anes. 66 (2019) 72-86 Cheetham B and Johnson A. Syringes and Sustainability: Planet, People and Profit. The Royal Liverpool and Broadgreen University Hospitals NHS trust. Sept 24, 2013. https://networks.sustainablehealthcare.org.uk/sites/default/files/resources/syringe_case_study_0_0.pdf [a] One DALY represents the loss of the equivalent of one year of full health. DALYs for a disease or health condition are the sum of the years of life lost to due to premature mortality (YLLs) and the years lived with a disability (YLDs) due to prevalent cases of the disease or health condition in a population.11

Managing healthcare waste: Issues and challenges

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