COVID-19 showed that the world was unprepared to cope with a surge in medical waste — but it also presents an opportunity to fix a problem that has huge implications for mitigating climate change, fighting pollution, and creating resilient health systems.

When COVID-19 reached Lao People’s Democratic Republic in early 2020, the country faced a waste problem — the volume of hazardous waste from its response to the pandemic, including masks and other personal protective equipment, quadrupled from 0.5 kilograms to 2 kilograms on average per person per day.

But it also saw an opportunity. By then, the government and various sectors were years into efforts to shore up Lao PDR’s health system against climate impacts that were already making themselves felt — among them longer and lengthier dry periods that affect water quality and quantity, depriving rural healthcare facilities of water needed for adequate hygiene and sanitation for four to five months a year.

Since 2014, the Ministry of Health had been prioritizing the development and implementation of water, sanitation and health (WASH) policies and strategies and basic health facility environmental standards and health care waste management regulations.

“WASH has had challenges as it require an investment for infrastructure and regular operation and maintenance. During 2020, funding to support COVID responses globally has created opportunities to fund investments in issues such as WASH that are both longstanding national priorities and important components of the pandemic response”, said Dr Phonepaseuth, Director General, Department of Hygiene and Health Promotion, MOH, Lao PDR.

The funds unlocked by the pandemic led to rapid expansion of Lao PDR’s WASH and waste efforts and the introduction of a comprehensive package of interventions for making hospitals “safe, clean, green and climate resilient”. WASH and environmental health indicators were integrated into regular health systems monitoring. This allowed for rapid identification of gaps and for the health sector and healthcare facility managers to be held accountable for maintaining adequate WASH services and promoting sustainable technology solutions.

Staff using an autoclave installed in Lao PDR healthcare facility to dispose of medical waste. Photo: Ministry of Health, Lao PDR

The volume of hazardous waste from the response to COVID-19 in Lao PDR quadrupled from 0.5 kilograms to 2 kilograms on average per person per day. Photo: Ministry of Health, Lao PDR.

Like other developing countries, we face challenges to manage many different types of plastic waste, masks, PPEs, vaccination waste and laboratory waste. The volume of waste increased, and tonnes of waste was generated from quarantine and isolation places,” Dr Phonepaseuth said.

Unlike many countries, however, Lao PDR had a head start in tackling its share of what would quickly balloon into a global mountain of pandemic-related waste that exposed weaknesses in waste management infrastructure and systems.

A new WHO report provides a conservative glimpse of that mountain, based on a United Nations initiative to level the playing field as much as possible (especially for smaller, developing economies) by pooling procurement of lifesaving PPE for the COVID-19 response. The initiative distributed one and a half billion units of single-use PPE, weighing about 87,000 tonnes — all of which is presumed to become waste.

But the estimate leaves out the PPE classified as “reusable”, such as face shields and gowns, as well as any PPE procured privately or outside of the initiative, and any of the extra masks used by the public. It also excludes the over 140 million test kits also shipped by the initiative, with the potential to generate 2,600 tonnes of non-infectious waste (mainly plastic) and 731,000 litres of chemical waste (one third of an Olympic size swimming pool). It also excludes the 8 billion of doses of vaccine that have been administered globally, which produces waste in the form of glass vials, syringes, needles and safety boxes for disposal.

The scramble to meet PPE needs was understandable: early in the pandemic, health care worker infection rates were four times greater than that among the general public, making it a matter of life-or-death.

Unfortunately, far less attention and fewer resources were dedicated to supporting safe waste management for this PPE, other necessary infection prevention and control requirements and mitigating climate change and adverse environmental impacts from waste, especially plastic waste. With 30% of the world’s health care facilities (60% in the least developed countries) unequipped to handle existing waste streams, the surge in biomedical waste put at risk the safety of healthcare workers and others involved in processing waste, such as millions of informal waste workers, as well as communities living near waste facilities; threats included needle stick injuries, infections, and pollution from open burning of waste (for example, the majority of plastic in COVID-19 test kits). It also posed a grave threat to the environment.

Most countries built on or repurposed existing resources and processes — or they innovated their way through. The WHO report draws on 11 case studies, including Lao PDR’s experience, distilling a number of solutions that exist, including reducing PPE through safe and rational use, eco-friendly packaging and shipping, the development and use of safe and reusable PPE (for example, gloves and medical masks), the use of recyclable or biodegradable materials, investment in non-burn waste treatment technologies, reverse logistics to support centralized treatment and recycling, and more local and regional production and just-in-time shipments.

"A systemic change in how health care manages its waste would include greater and systematic scrutiny and better procurement practices," said Dr Anne Woolridge, Chair Health Care Waste Working Group, ISWA and Chief Operating Officer, Independent Safety Services Ltd.

There is growing appreciation that health investments must consider environmental and climate implications, as well as a greater awareness of co-benefits of action. For example, safe and rational use of PPE will not only reduce environmental harm from waste, it will also save money, reduce potential supply shortages and further support infection prevention by changing behaviours.

Safe and rational use of PPE can yield tangible rewards, as the Great Ormond Street Hospital for Children NHS Foundation Trust in the United Kingdom found through its campaign to reduce unnecessary glove use — one of the report’s case studies.  Overuse of gloves was a longstanding problem even before COVID-19, resulting in missed opportunities for hand hygiene, unnecessary financial costs and adverse environmental impacts, and, in terms of volume, made up the greatest proportion of PPE waste of all items procured by the UN COVID-19 global system.

Gloves Are Off: Safer in our hands” campaign, which began in 2018, focused heavily on education and training of nurses and as many staff groups as possible (healthcare assistants, porters, occupational therapists, physiotherapists, pharmacists, the hospital’s school staff) across the Trust, reinforced by monitoring and quarterly feedback to staff with information on infection rates, gloves/plastic and occupational health referrals for sore hands.

Most healthcare workers found reducing glove use to be a logical change once the research and evidence was presented to them,” Nicola Wilson, Practice Educator at Great Ormond Street Hospital (GOSH) in London. “The education where the team not only taught the topic, but engrained the ‘Gloves Are Off’ into IV practice worked best. Empowering our nurses to think about the key principles and to risk assess themselves worked to give them confidence in their decision making as to when gloves were required,

The campaign led to a reduction of 21 tonnes of plastic compared to the year before its implementation, “the weight of three and a half Tyrannosaurus Rex”, and a fall in glove orders of over 4.3 million, saving the hospital a whopping £108,330 — as well as, incidentally, healthier hands from the reduction in glove use — with no resulting rise in infections.

Anxiety in the midst of the COVID-19 pandemic caused staff to return to previous habits of overuse of gloves and PPE among staff. Having established the campaign a year previously, the trust returned to these principles once prompted by supportive national guidelines.

When it comes to responding quickly to a crisis, fortune favours the prepared. The COVID-19 waste challenge and increasing urgency to address environmental sustainability and climate change requires strong systems that safely and sustainably reduce and manage health care waste — including through strong policies and regulations at all levels, regular monitoring and reporting, behaviour change support and workforce development, and increased budgets and financing — structures and that need time and resources to be built and established.

Lao PDR had already laid the groundwork to take that opportunity, through its ongoing national, multi-agency efforts at the crossroads of healthcare and climate adaptation and mitigation. COVID-19 served as a catalyst to scale up existing efforts by focusing political leadership and effective national partner coordination on COVID-19 financing for sustainable waste solutions.

Lao PDR’s early national, multi-agency efforts at the crossroads of health and climate primed it to unlock financing for sustainable waste solutions when COVID-19 hit. Photo: Ministry of Health, Lao PDR

Its experience also shows just how intimately linked everybody’s mandates are, and, two years into the pandemic, the world is starting to reflect on how future health-threatening crises could be tackled.

COVID-19 exposed the cracks in the system at a crucial time in the race towards the 2030 Global Goals. Waste management is linked to many of the goals, not least Good Health and Wellbeing (Goal 3), Clean Water and Sanitation (Goal 6) and Responsible Consumption and Production (Goal 12). It is clear more radical and immediate actions are needed to address climate change. Mitigation demands a closer look at the carbon contributions from established processes, including whole-of-life product and waste management; pollution is a growing problem; and climate-resilient healthcare systems addressing safe and sustainable management of health care waste.

Countries, regions and cities are looking to build back better. At the recent UN climate change conference, COP26, a diverse group of 51 countries, including low and very high carbon emitters, committed to creating climate-resilient health systems; 45 also committed to transforming their health systems to be more sustainable and low-carbon, Lao PDR among them.

COVID-19 has forced the world to reckon with the gaps and neglected aspects of the waste stream and how we produce, use and discard of our health care resources, from cradle to grave,” said Dr Maria Neira, Director, Environment, Climate Change and Health at WHO. “Significant change at all levels, from the global to the hospital floor, in how we manage the health care waste stream is a basic requirement of climate-smart health care systems, which many countries committed to at the recent UN Climate Change Conference, and, of course, of a healthy recovery from COVID-19 and preparedness for other health emergencies in the future.

One respiratory physiologist in the UK illustrates the scale and scope of the waste problem by taking us through her day.

“Every day we see patients with respiratory disorders in a medium-sized hospital in the UK. We are a small team, but in bigger hospitals there will be more people repeating the daily routine I do with patients. I wear PPE each day that protects me from their respiratory secretions.

We see on average 10 patients a day; this means 10 sets of PPE consisting of apron, FFP3 mask, visor and gloves. Masks come in a box of 10, so you already dispose of a box every day. In the box, each mask is wrapped individually in plastic. The aprons come in a box of 15, but again, each of these individual aprons is individually wrapped. My visor is wrapped individually in plastic too, with a film over the front, which again is waste. Some visors have film on both sides.

So, every day I throw packing away into the general waste:

Per week that means:

I don't really know what happens to this packaging, except that it goes to landfill.

My 10 sets of PPE (mask, visor, apron, gloves) per day are put into infectious waste for incineration— that’s 50 in a week. And we are a very small team.

I also perform lateral flow detection tests, which generate a lot of plastic waste.

In all that's a lot of waste. We want to be protected but the packaging that comes with this equipment seems excessive and does not serve a real purpose. It is not a sterile environment like an operating room. There must be a way to change which would be at least one step in reducing health care waste.”

Download the publication: Global analysis of health care waste in the context of COVID-19

Read the press release: Tonnes of COVID-19 health care waste expose urgent need to improve waste management systems

Sudden increases in the volumes of health care waste from the COVID-19 response exposed cracks in waste management everywhere

Keeping health workers safe and protecting the environment is possible

Follow the waste hierarchy model for safe and sustainable health care waste management

Nearly 1/3 of personal protective equipment shipped cannot be safely bagged or stored

The COVID-19 response is generating a mountain of extra waste

WHO's work on health care waste management

Environment, climate change and health