Mumbai: Sanitation workers and rag pickers are at risk from handling unmarked medical waste emerging from homes where COVID-19 patients are quarantined, medical experts and waste management specialists warned. Discarded masks, gloves and tissues could be potential sources for the spread of this highly contagious virus, they said.
Recent reports have illustrated the dangers of dumping medical waste related to the treatment and containment of the virus:
- In Pune, face masks dumped by users in household garbage were being collected by rag pickers, The Indian Express reported on March 23, 2020. "There is no mechanism for collection and disposal of masks and medical waste generated by more than 2,000 people under home-quarantine across the district for having a travel history or showing COVID-19 symptoms," the report said.
- In Thane, a man was caught putting over 100,000 used face masks out to dry so that he could resell them in the market, the Times of India reported on March 12, 2020.
- A heap of medical waste was found lying in the open in Delhi's Sharan Vihar area, The Indian Express reported on April 1, 2020. Discarded face masks, tunics, gowns, caps and syringes were found in the dump.
"Face masks used by the general public could be a source of infection for sanitation workers as well as the environment if not discarded properly," said Renu Bharadwaj, former dean and head of the microbiology department at the Byramjee Jeejeebhoy Government Medical College in Pune. "These could be points in hotspots for the viruses to multiply because they have microorganisms sitting on them. We need to decontaminate the waste with sanitisers before throwing them or put them in paper bags. The ideal solution is to use reusable cloth masks that can be washed and reused."
Sales of masks, sanitisers and other safety essentials saw a surge in India in February 2020 in the early phase of the outbreak, leading to shortage by mid-March. But this growing use of safety gear was not guided by rules of hygienic disposal, Bharadwaj pointed out. The contaminated waste is often thrown into household bins, endangering the lives of sanitation workers and the environment, she said.
A set of guidelines on the handling, treatment and disposal of waste generated during treatment, diagnosis and quarantine of COVID-19 patients was released by the Central Pollution Control Board (CPCB) on March 18, 2020. Under these, isolation wards in hospitals have to maintain separate colour-coded bins for the segregation of waste. A dedicated bin, labelled 'COVID-19', needed to be kept in a separate, temporary storage room and should only be handled by authorised staff. Separate deployment of sanitation workers in these wards for biomedical waste management was also recommended. The board also asked for a record of the waste generated in isolation wards.
For quarantine camps and home care of the suspected patients, the CPCB advised collection of biomedical waste in yellow bags and the bins containing these should be handed over to authorised collectors.
Most hospitals follow the Bio-medical Waste Management (BMWM) Rules 2016 and more rigorously so in the times of COVID-19. But it is waste disposed of by quarantined households, where there is limited awareness about the issue, that could expose solid waste/sanitation workers to bigger risks, said experts.
"It is very critical to manage this waste related to COVID-19, be it mask, gloves, the hazmat suit," said Satish Sinha, associate director at Toxics Link, an NGO that works on municipal, hazardous and medical waste management and food safety. This waste could infect rag pickers, children or the poor living on the streets, he added.
It is also important to ensure that this waste does not reach common dumping grounds, said environmental scientist Kishore Wankhade of World Resources Institute-India, a research organisation.
The novel coronavirus gets transmitted through direct touch and contaminated surfaces and objects, according to a government document on the use of personal protective equipment (PPE). Sanitary staff involved in cleaning frequently-touched surfaces and linen are at moderate risk and are supposed to use N-95 masks and gloves.
Adherence to the basic rules of waste segregation is still low in India. Waste generators are supposed to segregate the waste at source and then hand it over to the authorised waste pickers or collectors, according to the Solid Waste Management Rules, 2016. But there have been instances where households and societies do not comply with these rules.
There is even more limited awareness about the need for separate disposal of biomedical waste generated by households, as we explain later. Waste management systems will need to now include more specific COVID-19 related rules, experts told us.
As many as 5,194 cases of COVID-19 have been reported in India, as of 8 a.m. on April 8, 2020, according to Coronavirus Monitor, a HealthCheck database. While 402 patients (7.4%) have recovered, 149 (2.9%) have died. As of 9 p.m. on April 7, 2020, India had tested 114,015 samples, of which 4,616 individuals have been confirmed positive, data from the Indian Council of Medical Research show. Each patient is tested multiple times.
Sanitation workers at risk
"Healthcare associated infection by the virus has been documented among healthcare workers in many countries," said the government document on PPE use. "The people most at risk of COVID-19 infection are those who are in close contact with a suspect/confirmed COVID-19 patient or who care for such patients."
But sanitation workers, like frontline health workers, too should be provided with PPE, suggested Sinha of Toxic Links.
"Sanitation workers are highly at risk, like the medical professionals, police and community health workers who deal with COVID-19 patients," said Shaileshkumar Darokar, faculty member at the Centre for Study of Social Exclusion and Inclusive Policies at the Tata Institute of Social Sciences in Mumbai. "Doctors, nurses and other health workers know about the precautions to be taken but sanitation workers do not and that makes them vulnerable."
Sanitation workers in Chennai recently reported anxiety about handling domestic waste mixed with used face masks discarded by households, The New Indian Express reported on March 24, 2020.
Rag pickers and waste collectors who make a living from the informal recycling industry too are at risk, as this Indian Express report suggested. "This is a major source of livelihood for them and due to them the sector is able to achieve very high collection rates, thereby increasing the efficiency of the waste management ecosystem as a whole," the government had informed the parliament on March 6, 2020.
India generates 608 tonnes of bio-medical waste per day (in 2018), of which 87% or 528 tonnes is treated, according to a government reply to Rajya Sabha (parliament's upper house) on March 17, 2020. However, 27,427 instances of violations of government rules were reported in 2018, or 75 instances every day on average, against healthcare facilities (HCF) or common biomedical waste treatment and disposal facilities (CBWTFs). Of these, 16,960 of HCFs/CBWTFs were issued show-cause notices/directions, the reply said.
Complaints received by the government for violation of rules related to the disposal of biomedical waste included its mixing with general waste, fears of "virus spreading", illegal dumping of hospital waste in agricultural land, burning of obsolete medicines and so on.
Biomedical waste generation per day increased by 18% from 517 tonnes in 2016 to 608 tonnes in 2018. Currently, there are 200 common biomedical waste treatment facilities in operation in India and 28 more are being installed.
'Workers must have safety gear, waste be incinerated'
CPCB rules are being followed rigorously, said officials at Ramky Enviro Engineers Ltd (REEL), a Hyderabad-based company that handles biomedical waste in 18 cities and 20 facilities across the country for around 350,000 healthcare establishments including hospitals, clinics, research labs and so on.
"We are strictly following the relevant guidelines issued by the CPCB," said Masood Mallick, joint managing director, REEL. "Waste arising from COVID-19 is packaged in double bags and transported in separate, designated vehicles and incinerated in dual chambers that operate at 1050 degree Celsius as soon as the waste reaches the designated treatment facility."
The staff has been issued coveralls, masks, safety goggles, gloves, footwear and boot covers and trained to deal with biomedical waste, as per Mallick. They are also expected to disinfect all surfaces and vehicles. Given that most small hospitals and clinics are shut, the generation of biomedical waste has remained constant but the company is dealing a lot more with discarded face masks, gloves and tissues, he added.
Sanitation workers should not be engaged directly in handling solid waste generated by households without protective gear, said Deepak Saxena, professor at Indian Institute of Public Health, Gandhinagar. "The government can only advise but the community needs to act responsibly when it comes to disposal of household waste," he said.
(Mallapur is a senior analyst with IndiaSpend.)
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