Introduction
The emergence of the COVID-19 pandemic has resulted in the need for both healthcare workers and the general population to rely on personal protective equipment or PPE to protect themselves and others from catching and spreading this Coronavirus. According to Sangkham, the increased rate of PPE use is generating large amounts of medical waste that is possibly contaminated with infectious COVID-19 particles. Sangkham goes on to argue that medical waste related to COVID-19 is posing a threat not only to communities with inadequate waste handling centers but also to the environment as pollution increases. Agamuthu and Barasarathi explore a case study on a hospital in Malaysia and its use of previously formed guidelines on how to handle medical waste and how these rules were applied during the COVID-19 pandemic. Ilyas, Srivastava, and Kim also discuss the harmful effects of bio-medical waste (BMW) generated due to COVID-19 and propose methods such as disinfection and separation of contaminated waste to mitigate some of the consequences of this BMW. Yu, Sun, Solvang, and Zhao explore another potential method for dealing with medical waste due to COVID-19 known as a reverse logistics system and based on the medical waste situation in Wuhan, China. Their reverse logistics system involves the repurposing of medical waste at the end of its cycle of use (Yu, Sun, Solvang, & Zhao 2020).
For this research project I studied the impact of COVID-19 on medical waste generated in Bloomington and how our community as well as those around the world are dealing with this increased quantity of hazardous waste. I was inspired by the previous articles to ask local hospitals how much medical waste they have had in years previous and then compare this to the medical waste generated since the emergence of the COVID-19 pandemic in Bloomington. I also inquired whether hospitals are utilizing any possibilities to replace single-use PPE with reusable PPE. To gauge the use and treatment of PPE in our community, I surveyed members of the IU Bloomington population on their use and disposal of PPE. Lastly, I researched how other countries around the world are dealing with the COVID-19 related waste generated by their communities.
Background
According to data collected by Mihai, in Romania the greatest amount of waste was generated by individuals in self-isolation rather than in quarantine or intensive care units. Therefore, the amount of COVID-19 related waste generated by individuals outside of hospitals is significant and worth exploring. Furthermore, individuals might have a greater opportunity to utilize reusable PPE and a decreased opportunity to dispose of their waste properly as compared to hospital staff, so this is also an interesting comparison. I hypothesized that hospitals have adopted unique systems to deal with increased use of PPE and medical waste that is keeping our community clean. However, as is evidenced by medical waste such as disposable masks flying around outside as litter, I assume that COVID-19 related medical waste created by individuals outside of the hospital setting are causing increased pollution in our community.
Throughout the pandemic, countries have been fighting to keep up with both the increased demand for PPE and the increased hazardous waste that is generated. Therefore, changes have been happening to the lifecyle of PPE as systems are adapting. For example, in China the waste treatment facilities adapted to a rapid increase in hazardous medical waste by utilizing mobile incinerators to dispose of PPE (Singh, Tang, & Ogunseitan 2020). Singh, Tang, and Ogunseitan also highlight that PPE is made up of a high percentage of plastics which add to the degree of environmental pollution by microplastics if not disposed of properly. These authors also report that many new methods have been discovered for the disinfection and subsequent reuse of PPE such as using hydrogen peroxide, irradiation, and addition of anti-microbial properties (Singh, Tang, & Ogunseitan 2020). According to Rowan and Laffey, the use of sterilization techniques to reuse PPE are dependent on the state of supply and demand for PPE, meaning that reuse of PPE will increase when there is a low supply of PPE, but when sufficient supplies are available, reuse will be avoided. This is concerning in the realm of environmental impact and leads to the hypothesis that medical waste generated will continue to increase as supply is adjusted to meet and exceed the needs of the population.
To mitigate the negative environmental effects of single-use non-biodegradable PPE that is currently available, sustainable methods for re-use and disposal are currently being developed and applied to the COVID-19 pandemic. In addition to the aforementioned methods for disinfection of PPE, the use of different fabrics which are pretreated is also a method that can increase the ability to disinfect and reuse PPE. For example, antimicrobial textiles are more resistant to becoming infested with the virus or losing their ability to stop the spread of infection, therefore increasing their lifespan over untreated fabrics (Karim, Afroj, Lloyd, Oaten, Andreeva, Carr, Farmery, Kim, Novoselov 2020). Therefore, hospitals who utilize PPE made from these pretreated fabrics should generate less medical waste and have greater rates of PPE reuse than hospitals who do not use these fabrics.
Litter caused by PPE is having a negative effect on animals worldwide. Fish are becoming caught inside of gloves, birds are using masks to build nests, and animals are consuming littered medical waste, just to name a few examples (Hiemstra, Rambonnet, Gravendeel, Schilthuizen 2021). In addition to negatively affecting animals, the litter seen in our communities can also increase the spread of the virus. According to Nazir, Ali, Rasul, Widemann, and Shafiq, COVID-19 viral particles can survive for up to 3 days if kept at room temperature, so masks laying around public areas such as the Indiana University campus are a hazard for both students who come across these areas and the staff and volunteers who ultimately clean up the masks.
Methods
At the beginning of my study, I took an observational approach to see how well IU is dealing with medical waste on campus and the extent to which students are littering their disposable masks both outside and inside campus buildings. I took pictures of instances of littering that I observed and used my observations to plan for my survey of the IU Bloomington population.
My survey investigated the PPE usage of members of the IU Bloomington community and their practices for reusing or disposing of this equipment. In order to collect data from the community I created a Qualtrics survey and shared it with fellow peers. As recommended by Rimando et al, an important aspect to consider when collecting data is the “literacy of the target population [and] the choice of wording in the data collection instrument.” Therefore, the questions on the survey were formulated using language that any student at a college reading level could understand, without having prior knowledge specific to the terminology of the medical field. The questions in the survey asked the students how often they have been using the following forms of PPE since the beginning of the pandemic: Face masks, gloves, and face shields. The options for frequency were daily, about every other day, about once a week, every other week, or once a month. The students were also asked whether they used disposable or reusable forms of all the PPE and how frequently they used the PPE before disposal (if applicable). Options describing the forms of PPE they used included only disposable PPE, only reusable PPE, more disposable than reusable PPE, and more reusable than disposable PPE. The options for how frequently the PPE was used prior to disposal were once, twice, three or more times and I don’t use disposable PPE. Lastly, the students were asked if they have every been guilty of littering masks outside with options of never, no more than once, occasionally, and often. As for distribution of the survey, students were contacted directly through social media and group messaging apps rather than by email to reduce the risk of a lack of willingness to participate in recipients (Lefever, Dal, Matthíasdóttir, 2006). The survey was also shared by my professor, Dr. Wasserman, with my classmates and students in his other courses.
Next, I attempted to collect data from a contact in the Dominican Republic to compare how medical waste is affecting a developing country in areas that might have less waste disposal infrastructure than there is present in Bloomington, Indiana. In order to reach this contact, Whatsapp, an online chat service, was used rather than e-mail since Salvador, Alves, Rodrigues, and Oliviera, report that there is a “high rate of unanswered questions” in data collection through e-mail. Questions asked about the effect of COVID-19 related PPE on waste generated in the DR included “Before the COVID-19 pandemic, was the waste disposal infrastructure sufficient for waste generated by communities?” “Has PPE such as masks been used regularly by communities in the DR since the beginning of the pandemic?” “Are individuals in the DR using mostly reusable or disposable forms of PPE?” “Has the usage of PPE resulted in an increase in waste generated in communities?” “If applicable, has the waste management infrastructure been able to keep up with increased waste generated due to PPE?” “Has there been an increase in litter and pollution observed due to medical waste related to the COVID-19 pandemic?” Additionally, all communication with the contact in the DR was completed in Spanish, to decrease confusion related to the language barrier on the contact’s end. This set of data collection will be further addressed in Limitations.
I also collected data from the IU Health Bloomington Hospital relating to potential changes in their medical waste generation since the beginning of the COVID-19 pandemic and PPE usage within the hospital. E-mail was used for communication with the appropriate representative from the hospital due to social distancing concerns during the COVID-19 pandemic since this method has been found to be “an effective way to collect… data” (Fritz & Vandermause, 2018). In order to overcome two limitations of email communication identified by Bowden and Galindo-Gonzalez, rapport was established with the hospital representative before research-related questions were asked, and a timeline was established with reminders sent to ensure data is received in a timely fashion. Questions that were asked of the hospital representative included “What types of PPE does your hospital utilize in order to prevent the spread of COVID-19?” “Is any of the PPE that your hospital utilizes reused or repurposed before disposal?” “Has the overall amount of medical waste generated by your hospital increased since the beginning of the COVID-19 pandemic?” “Is there data collected on the amount of medical waste disposed of annually by your hospital, if so, can this data be shared for academic research purposes?” Since the IU Health Bloomington Hospital had been in the process of moving to a new facility, I correctly anticipated that there might be issues receiving a timely response, as the hospital staff were heavily preoccupied with preparing for the move. The solution to this is addressed in the Limitations.
Lastly, I took a journalistic research approach to investigating how other countries around the world have been dealing with COVID-19 related medical waste generated by their population and if there are any future plans with how to prevent large scale environmental pollution that could potentially be caused by this hazardous waste. The countries that I studied were Rwanda, Uganda, and Denmark. Rwanda was investigated because environmental protection is a priority there and I was interested to see if this country dealt with the COVID-19 related hazardous waste in a more environmentally friendly way than other countries. Uganda was investigated since this country is already dealing with excesses in waste that overwhelm the waste disposal infrastructure, so it was interesting to see how this country would handle and added influx of potentially hazardous waste. Lastly, Indonesia was investigated since they also did not yet have the infrastructure necessary for handling all of their waste. However, this country has been working to implement new methods for disposal of COVID-19 waste.
Limitations
Unfortunately, I was not able to collect the data from my contact in the Dominican Republic as I had originally planned to and outlined in Methods. In order to make up for this loss in international data collection, I added the journalistic research on other countries to my Methods so I would still be able to see the global effect that COVID-19 related medical waste is having on infrastructure and the environment.
Additionally, as I had predicted, I was not able to contact the member of the IU Health Bloomington Hospital that oversees waste management. However, one of my classmates who works in the Emergency Department at the hospital was able to answer all but one of my original research questions and provide me with insight on PPE usage and the effect of COVID-19 on the overall waste the hospital generates.
Results
Observations on IU Campus
The image in Figure 1 below shows an instance of unintentional littering, where individuals attempted to dispose of their masks inside a trash can, but since it was overfilled, the masks began to collect on top of the lid and fly away with the wind.
Figure 1. Unintentional Mask Litter Outside of the South Entrance to the Student Recreational Sports Center on the Indiana University Bloomington Campus
Figure 2. Careless Mask Litter and Subsequent Resolution of the Littering at a Mask Station Inside the Entryway of the South Entrance to the Student Recreational Sports Center on the Indiana University Bloomington Campus.
The images in figure 2 show the same mask station at an entrance to the Student Recreational Sports Center, however the photo on the left was taken on September 27th while the photo on the right was taken on October 11th. Within two weeks after masks were being littered around this mask station, staff had strategically placed a trash can directly next to the station so that students could dispose of masks before taking a new one or after using their mask while working out.
Figure 3. Intentional Litter of Disposable Masks Hung on the Wendell W. Wright Education Building Sign.
The image in Figure 3 above is an example of blatant littering and most likely the attempt at a joke by students who decided to hang their used masks on a university building’s sign.
Survey of IU Community
According to my survey of the Indiana University community, the most frequently used form of PPE is masks, while gloves are used infrequently, and face shields are rarely utilized.
Figure 4. Data Obtained from Survey Question 5: Do you generally use disposable or reusable forms of PPE? (Ex. Disposable surgical mask vs reusable cloth mask)
Figure 4 illustrates the responses individuals gave to the question in my survey regarding the type of PPE most frequently utilized. The most frequent answer was ‘More disposable than reusable PPE’ which just under half of respondents selected and was followed by ‘More reusable than disposable PPE’ as the second most frequent response. When combining the respondents who selected ‘Only reusable PPE’ with those who selected ‘More reusable than disposable PPE’ and those who selected ‘Only disposable PPE’ with those who selected ‘More disposable than reusable PPE,’ I found that there is about a 60:40 ratio between individuals who favor disposable PPE and those who favor reusable PPE. However, according to question 6, out of those respondents who report using disposable forms of PPE, over 95% reuse their PPE with half of those individuals reporting three or more uses prior to disposal. Finally, out of the respondents who reported using disposable masks, 84% claim to never have littered their masks, and those who did admit to littering claimed to have done it no more than once.
Hospital Interview
From my interview with the hospital employee, I gained information on which types of PPE are used when interacting with COVID-19 patients, which types of PPE are reused prior to disposal, and how waste generated within the hospital has been affected by COVID-19. The types of PPE that are used include gowns, gloves, face masks, N-95 masks, and face shields. Of those forms, only gowns and gloves are disposed of in between patients while everything else is reused either with the same patient or between patients until soiled. According to the interviewee, the amount of medical waste generated in the hospital has increased due to the COVID-19 pandemic, especially when considering the single-use products such as gowns which are disposed of after every patient encounter. Additionally, she explained that not only has medical waste increased, but general waste has increased as well due to increased precautional measures taken to avoid cross-contamination between patients.
Journalistic Investigation of Rwanda, Uganda, and Indonesia
In April 2020, after the Ministry of Health began to encourage the practice of mask-wearing among Rwandan residents, the Rwanda Environment Management Authority realized the potential risks of allowing hazardous medical waste to be disposed of improperly and formulated a plan for responsibly managing the waste (Mugemana 2020). Mugemana stated that there were already guidelines in place for mask production and hospital biohazard waste disposal through incineration and deep burial. Bishumba reported in January 2021 that the plan developed in 2020 would now be fulfilled. She explains that the process included distribution of bags to households within which the residents store their PPE to keep it separated from ordinary household waste until it can be collected for proper disposal through incineration. Bishumba concludes that this proper treatment of COVID-19 related waste is another example of how Rwanda is prioritizing the environment and needs of the public health sector.
While researching Uganda, I learned that they have already been dealing with a waste problem even before the start of the pandemic and generation of PPE waste. However, I found that there are many local programs that deal with this issue and particularly work to recycle excess in plastic waste. For example, as reported by Okereke, an entrepreneur named Juliet Namujju creates fashion out of plastic waste. While working during the pandemic, Namujju found a need among her hard-of-hearing workers for masks that still make lip-reading possible (Okereke). To meet this need, Namujju designed reusable masks that have a window made of recycled plastic waste so that her workers can lip read while everyone is still safely masked (Okereke).
According to Bahagijo, Indonesia does not have a sufficient waste management infrastructure, so dealing with the infectious waste generated from the COVID-19 pandemic has put the sanitation workers there at a greater risk of exposure to the virus. However, throughout the pandemic, the Indonesian population has been encouraged to begin separating their COVID-19 waste from their general waste so that not all the mixed waste winds up in landfills (Bahraini). Although the infrastructure for managing waste is still not ideal, Indonesia is working toward dealing with hazardous medical waste more responsibly.
Discussion
Throughout my weekly observations around campus, I came across a substantial amount of littered disposable masks. Much of this litter appeared unintentional and a result of IU’s struggle to keep up with the generation of this waste, but it did appear that some masks had been left in inappropriate places intentionally. While mask stations are a necessity during the current pandemic, students need to be held accountable for keeping stations tidy and avoiding extra waste of masks, as all the masks that have fallen on the floor are no longer clean or safe for use. Unfortunately, despite efforts by the university such as the previous example, I still observed instances of seemingly intentional or at least careless littering by IU students. Piles of masks around mask stations such as the one in Figure 2 are a result of careless students when they attempt to take masks from these stations.
A surprising juxtaposition to these observations of carelessness and disrespect are the conversations I have had with fellow peers. I have spoken to multiple students who have told me that these mask stations are their main source for masks. Students reported themselves and their roommates grabbing handfuls of masks from these stations on their way to or from class, and keeping these in their home for use in the future. I was surprised to hear this from multiple accounts. It is clear that students rely on these stations when they forgot a mask and need to enter a building, however it is interesting that some students rely almost entirely on these mask stations to provide them with a constant supply of masks. It was even more intriguing to hear this after I had originally wanted to conclude that students were so lax in caring for these mask stations due to a lack of need for them. Clearly, mask stations are a necessity during the current pandemic, so students need to be held accountable for keeping stations tidy and avoiding extra waste of masks, as all the masks that have fallen on the floor are no longer clean or safe for use.
The observations of students intentionally littering masks in public outdoor spaces (Figure 3) highlights the need of our community to advocate for proper use and disposal of masks on campus and a more respectful mask-wearing culture. While improvements have been observed in how the university keeps up with the increased amounts of waste generated by disposable masks (as was seen in Figure 2), there still is room for improvement in the habits of students.
My survey of the IU community suggests that most of the PPE utilized locally is in the form of masks and that there is currently a shift from reusable to disposable masks. The interview with the hospital employee also suggests that the PPE used in our community is mostly disposable rather than reusable.
Therefore, my studies of the Bloomington community support my hypothesis that the general population is creating more pollution than our local hospital. Since the move of the hospital to the Regional Academic Health Center will greatly reduce the waste that leaves the hospital, while students and other members of the community are contributing to pollution by littering masks and not disposing of their hazardous PPE waste responsibly.
The study of how different countries are dealing with medical waste seems to suggest that the first steps countries are taking to mitigate the waste is separation from general waste and ultimate incineration. If this method proves successful in preventing pollution of the environment from COVID-19 related waste, other countries, including our community in Bloomington, might benefit from utilizing similar methods for disposal. Additionally, as seen in my research on Uganda, there are efforts being made by communities to repurpose waste, in order to assist with the burden of COVID-19 related waste as well as the demand for face masks by the general population.
Conclusion
My studies of the Bloomington community suggest that there is currently an increased use of disposable PPE which leads to more contaminated waste generation. One of the issues is littering of masks in public areas either unintentionally due to overwhelmed waste disposal infrastructure or negligence by students. To discourage mask littering by students, education could be provided about the impact this hazardous pollution has on the environment and fellow members of our community. However, the move of the IU Health Bloomington Hospital to the Regional Academic Health Center should greatly reduce medical waste pollution that may have been caused by the hospital since this center is equipped with advanced waste disposal infrastructure. Finally, countries all over the world are currently working to find the best ways to deal with the medical waste that is generated due to the COVID-19 pandemic. While it appears that improvements are being made, different countries can still learn from each other to see how best to manage this increase in hazardous waste. Local efforts to repurpose waste and serve communities during the pandemic provide a model for other communities to follow.
In the future, research into the extent of pollution caused by COVID-19 related medical waste around the globe, as well as which methods for disposal were most environmentally friendly, could be very compelling.
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