By the end of 2021, the COVAX Facility hopes to deliver at least 1.8 billion doses of COVID-19 vaccines to 92 low- and middle-income countries. Laid end-to-end, this amount of single-use syringes and needles could circle the world multiple times. During the COVID-19 outbreak in Hubei Province, China, in 2020, infectious medical waste increased by 600% from 40 to 240 tons per day, according to the Asian Development Bank.
As countries race to vaccinate their populations, the amount of hazardous, clinical waste they produce will rise. In places where formal waste collection systems are generally poor, experts warn of a looming crisis.
“The supply side of pandemic response is much more glamorous and attractive to international organizations, manufacturers, funders, and lenders,” said Alice Street, senior lecturer in social anthropology at U.K.’s University of Edinburgh, who has conducted research on waste management in low- and middle-income countries.
“The dirtier side of pandemic response, which is dealing with all the waste, is just constantly delegated to governments, countries, and under-resourced health systems,” she said.
In June 2020, the International Finance Corporation, a member of the World Bank Group, warned the impact of COVID is likely to cause existing hazardous waste treatment capacity in developing countries to be overwhelmed, leading to stockpiling and potentially inadequate disposal.
This could result in increased transmission of diseases from incorrectly-treated used syringes and air pollution from toxic fumes when clinical waste is burned in open pits.
Multilateral development banks providing finance for vaccine procurement and the COVAX facility require countries to submit waste management plans. COVAX is also providing waste handling guidelines as well as additional training and infrastructure support. But experts want funders and agencies to give waste management greater attention to ensure the entire process of delivering vaccines — from start to finish — is safe.
Prerequisites for loans
When ADB announced its first loan to a country to procure COVID-19 vaccines in March 2021 — $400 million to the Philippines — it included a prerequisite for the country to provide a waste management assessment. The Asian Infrastructure Investment Bank, which has co-financed the deal with a further $300 million, told Devex it considered country readiness when making decisions about loans, including having waste management plans in place.
The Philippines has a waste management plan, and the bank confirmed it would monitor its COVID-19 vaccines project implementation and compliance.
Similarly, the Council of Europe Development Bank approved €25 million ($29 million) of funding for Kosovo to purchase COVID-19 vaccines in March. This loan agreement framework included a condition that the country ensure “a medical waste management plan and relevant documentation is created in all health centers.”
The World Bank also told Devex it requires COVID-19 projects it funds to include measures to protect health workers and populations from potential infection or risks caused by medical waste mismanagement. If the country has limited waste management capacity, the bank will establish and implement a medical waste plan to meet its requirements.
In all these cases, borrowers are ultimately responsible for managing medical waste.
Gavi, the Vaccine Alliance, which co-leads the COVAX Facility with the Coalition for Epidemic Preparedness Innovations, WHO, and UNICEF, requires all countries eligible for donor-subsidized doses to outline their waste management capabilities.
“The dirtier side of pandemic response, which is dealing with all the waste, is just constantly delegated to governments, countries, and under-resourced health systems.”— Alice Street, senior lecturer in social anthropology, University of Edinburgh
As part of the COVAX agreement, UNICEF and WHO provide guidance on practical steps for how to prepare a waste management plan, including the disposal of syringes, vials, and other COVID-19 related waste. They also provide sharps boxes with vaccine deliveries — plastic containers that can be sealed once filled with used syringes.
UNICEF’s deputy director for operations in Supply Division in Copenhagen, Gisela Henrique, said hazardous or medical waste disposal should be managed through national or local laws in each country.
“The method should be safe, respect the environment and comply with national laws and codes on health and safety. Open-air incineration is not recommended due to the environmental risks,” Henrique said. UNICEF has also been strengthening waste management systems at country level by procuring incinerators and providing technical assistance.
But despite these intentions, University of Edinburgh’s Street says the approach of banks and COVAX is risky because the waste management plans they receive could be inaccurate.
“You might have incinerators at every health facility in a country, but how many of them are used?” she asked. Devex asked UNICEF, the World Bank, and AIIB for more details on how it would check countries’ waste handling processes and monitor their operation as vaccines were rolled out. None of the organizations provided the details by the time of publication.
Street is part of DiaDev, a research team, which has investigated diagnostic devices in global health, including waste management. When the project visited Sierra Leone in 2018-19, three years after the country received emergency investment in waste management capacity during the Ebola outbreak, it found that of 40 community health centers in western urban and rural districts in Sierra Leone, 70% had an incinerator.
But of these, only 15% were operating. Some could not access the correct fuel to power them. Others, constructed during the Ebola epidemic, had been badly designed for the climate and had cracked.
As a result, facilities were burning waste, including syringes and needles, in open pits, releasing dangerous, toxic fumes. These pits do not reach the high temperatures required to disintegrate sharps, so subcontracted waste handlers either buried or transported the remaining waste to public dumps.
Speaking to Devex in March just before Sierra Leone began rolling out its COVID-19 vaccines, Dr. Patrick Turay, medical director of the Holy Spirit Hospital in Makeni, said setting up a robust COVID-19 waste disposal plan for the “huge collection of injections and syringes” would be a “big challenge.”
“Some of the [health] facilities are right in the interior in the villages,” he described. “It’s very difficult to map out how each facility will dispose of its waste.” While his hospital has its own incinerator, Turay said the Ministry of Health and Sanitation had not asked the setting to provide information about its waste management capabilities when drawing up a plan for vaccine implementation, only to provide a list of staff members. Currently, the facility is not being used as a vaccination center.
Needlestick injuries are the obvious outcome of mishandling of clinical waste. WHO estimates that among 35 million health care workers worldwide, about 3 million receive percutaneous exposures to bloodborne pathogens each year, and more than 90% of these cases occur in low and middle-income countries.
This means about 40% of hepatitis B and C infections and 2.5% of HIV infections in health care workers are attributable to occupational sharps exposures. It is not just COVID-19 transmission that is risked if waste is badly managed.
Global union federation Public Services International’s health and social services officer Baba Aye describes countries' preparedness for managing the extra waste the vaccinations will generate as “a looming crisis of its own.”
Speaking to heads of health workers’ unions in countries including Liberia and the Democratic Republic of Congo, he found that with local attention turned to getting vaccines in the first place, building waste handling capacity has been forgotten. “[Health workers] have been trying to increase the number of hands in hospitals themselves, not for waste management,” he says.
Aye is also concerned that despite the best intentions of multilateral organizations, governments will flout guidelines on waste management because they lack enforcement mechanisms. “The best you have, in most instances, are recommendations and guidelines,” he says of what organizations have to offer. “We would be very happy to see them doing much more than that.”