By Sarah Hannan Prior to Covid-19, Sri Lanka struggled with managing its clinical waste with illegal and irresponsible dumping observed on several occasions with outsourced private companies failing to adhere to the guidelines that were agreed upon. With a highly infectious virus still threatening to derail the country’s day-to-day activities, it has also presented more challenges that need to be tackled, with short-term and long-term plans. Most of the general public seem to have opted against the use of reusable face masks, even though the disposable surgical masks and other personal protective equipment (PPE) are to be spared for the use of the healthcare workers. The Sunday Morning spoke to the Western Province Solid Waste Management Authority Director Nalin Mannapperuma to inquire whether they have monitored an increase in waste generation over the past two months owing to Covid-19. “The waste generation for the Western Province alone has significantly reduced; from the average garbage that is generated in the province, we saw a drop of 40%. When people stay at home, the amount of garbage that is generated seems to have significantly reduced, partly because they are not bringing in single-use plastics to the city and there was a reduction in people going outdoors and ordering takeout.” We asked whether there was an increase in disposed single-use face masks and gloves, to which Mannapperuma noted that it was only during the month of March and April that they observed a significant number of disposable face masks and gloves being disposed from households that were observing home quarantine. “With community clusters reducing and no more isolated areas in effect, we do not see much of the PPEs disposed from households. The waste that is generated from hospitals and quarantine centres around the country as well as the Western Province is managed separately according to the guidelines issued by the Ministry of Health,” Mannapperuma added. In April, the Ministry of Health and Indigenous Medical Services published their Preparedness and Response Plan for Covid-19, in which special attention was given to clinical waste management on this plan and the authorities noted that further improvement was required with the waste disposal methodologies. Solid waste management Most of the time, clinical solid waste is taken away from the hospital by a private company and is often not monitored to ensure proper disposal. Clinical waste from Kandy, Karapitiya, and the National Institute of Infectious Diseases (IDH) is brought to the incinerators located at Muthurajawela for disposal, the publication indicated. Liquid clinical waste management also needs improvement. Greater attention is required to bringing in remedial measures to prevent contamination, environmental pollution, and spread of Covid-19 infection through improper waste management. The Ministry has estimated a budget of $ 515,000 to attend to the immediate needs of infection prevention and control (IPC). The funds are to be utilised to train staff in IPC measures, waste (clinical) management, training on PPE use – how to put on (donning) and remove (doffing) (specifically removal of PPE after work) – and shall provide training on logistics to improve supply chain management. Waste disposal (clinical) methods are to be strengthened with training, and the Ministry will assess IPC measures in each of the hospitals that are identified to treat Covid-19 patients. An IPC monitoring tool and an external assessment system as part of quality assurance too is to be developed in the coming months. The medium-term needs with an estimated budget of $ 131,440,000 will look at strengthening IPC measures based on detailed assessment in each of the 107 secondary and tertiary care institutions. Apart from that, incinerators are to be provided for selected hospitals so their clinical waste need not be transported all the way to Muthurajawela for processing. Solid waste management at hospitals is to be strengthened with the adoption of guidelines. The Ministry is also looking to upgrade sewerage systems in 45 line ministries and 42 provincial hospitals and in addition to that, to inculcate behavioural change and community support for personnel measures – hand washing facilities are to be built in field clinics. Managing healthcare waste The Ministry agrees that the healthcare waste (HW) generated by the institutions is on the increase and as sources of infections, this waste needs to be properly managed. Therefore, a guideline on this aspect is essential to develop plans and implement them to manage this problem effectively. HW generated by medical institutions could transmit infectious diseases to people who are exposed to them. Improper disposal can have harmful effects on the environment as well. While every healthcare facility (HCF) is responsible for the proper management of waste it generates until its final disposal, the Ministry of Health has listed guidelines to be used in any state or private health facility. HW can be broadly categorised into hazardous and non-hazardous (general) waste. Non-hazardous waste includes all waste that has not been contaminated with infectious or hazardous substances such as blood, body fluids, and chemicals (e.g. paper, leftover food, fabric). General waste can be managed by the local authority. While hazardous waste is categorised as infectious, pathological, sharps, chemical, pharmaceutical, and radioactive. Infectious waste: Blood, body fluids or items contaminated with them, microbiological waste, and waste from isolation wards. Pathological waste: Human body parts, foetuses; similar waste from surgery and autopsies; animal carcasses, organs, and tissue infected with human pathogens. Sharps: Syringes with needles, scalpel blades, razors, infusion sets, contaminated broken glass, blood tubing, and other similar materials. Chemical waste: Could be in the form of solid, liquid, and gaseous chemicals generated in the laboratory by the use of solvents, reagents, disinfectants, and other chemicals, which may be toxic, corrosive, flammable, explosive, or carcinogenic. Pharmaceutical waste: Outdated or residual medications of all kinds. Radioactive waste: Solid, liquid, or pathological waste contaminated with radioactive isotopes of any kind. Faeces, vomit, and urine from patients treated with radioactive substances. Safe HW management procedures aim at containing infections and reducing public health risks both within and outside the HCF. Waste minimisation and segregation Recycling procedures should be implemented to minimise the quantity of HW generated. All non-contaminated plastic items should be collected separately to be picked up by local contractors capable of recycling them. All non-contaminated and unbroken glassware which are not reused should be segregated and sent for recycling. Broken glassware should follow the stream of sharp waste. Segregation consists of separating different types of waste based on the type of treatment and disposal practices. It should take place at the point of generation of waste. Different colour coded containers should be used. Colour code used in health waste management

• Infectious waste – yellow
• Sharp waste – yellow with a red stripe
• General waste – black
• Biodegradable waste – green
• Glass waste – red
• Paper waste – blue
• Plastic waste – orange

Waste collection and on-site transportation i. Waste collection a) Hazardous waste should be collected in yellow polythene bags of minimum 300 μm gauge with the international biohazard symbol placed in yellow bins. b) Sharp waste should be placed in specific cardboard or plastic boxes which are puncture proof and leak proof. Sharps boxes should be designed with a small opening so that items can be dropped in but no item can be removed. Box should be of yellow colour with red stripes and have the biohazard symbol on it. c) General waste should be placed in black polythene bags of minimum 200 μ gauge. For recyclable non-hazardous waste refer DGHS circular of 01/12/2006. ii. Onsite transportation Waste should be collected from each ward on a regular schedule. When handling waste for transportation, sanitary staff should wear protective clothing at all times including face masks, aprons, boots, and heavy-duty gloves. All yellow bags should be sealed with appropriate adhesive tape and removed from the bins. The sharps boxes should be closed when ¾ full. Waste should be collected in a trolley or cart which is easy to load and clean. The trolley should not be used for any other purpose. The collection route should be direct from the point of collection to the central waste storage facility. Waste storage A separate central storage facility should be provided for storage. Non-hazardous waste which is to be taken away by local government authorities should be stored separately from hazardous waste. The central storage facility should be totally enclosed and sealed from unauthorised access. It should be inaccessible to animals, insects, and birds. It should be easy to clean and disinfect. It should have a good water supply, drainage, and ventilation systems.