The increasing amount of hazardous medical waste becomes an issue particularly since the Covid-19 outbreak that led to the rising waste generation rate produced by the patients as well as the healthcare providers. To date, cities, regencies, and healthcare facilities are still lacking the capacity to deal with medical waste, which would further exacerbate due to the increase of medical waste as a result of the Covid-19 pandemic.

Based on the Indonesian Minister of Health Decree No. 1204 year 2004, medical solid waste consists of infectious waste, pathology, sharp objects, pharmaceuticals, cytotoxic, chemical, radioactive, pressurized containers, and waste with high heavy metal content. Furthermore, United Nation Environment Program (UNEP) defined medical waste as all the waste generated by healthcare facilities, medical laboratories, and biomedical research facilities, as well as waste from minor or scattered sources such as home health care[1].

The management of hazardous medical waste produced by healthcare facilities and households is under the authority of the Ministry of Environment and Forestry’s (KLHK) Directorate General of Waste and Hazardous Waste Management[1], in contrast the management of household and household-like Solid Waste Management (SWM) is within the scope of the Ministry of Public Works’ Directorate of Settlement Environmental Sanitation Development[2] (shows Figure 1).

Figure 1 Responsibility of institutions manage the medical hazardous waste

[1] Direktorat Jenderal Pengelolaan Sampah, Limbah dan B3

[2] Direktorat Pengembangan Penyehatan Lingkungan Permukiman

In terms of managing hazardous and healthcare waste, government has created some regulations, such as follow:

Government Regulation (PP) no. 18/1999, which contains the standardized practice of every hospital must have a waste management facilities, whereas clinics must adequately dispose healthcare wastes.

• PP no. 101/2014 on the management of hazardous and toxic wastes.
• The regulation of Ministry of Health (Permenkes) no. 7/2019 on Hospital Environmental Health, whereby chapter III, section F.1.b contains the organizing safeguards for hazardous and toxic waste (B3).
• The regulation of Ministry of Environment (Permen LH) no. 18/2009 on permit procedure for B3 waste management.
• The regulation of Ministry of Environment and Forest (Permen LHK) no. 14/2013 on symbols and labeling of B3 waste.
• Permen LHK no. 56/2015 on procedures and technical requirements for B3 waste management of health facilities.
• The Ministry of Environment and Forestry (KLHK) issued guidelines for the Management of Infectious (B3) waste on Circular No. SE.2/MLHK/PSLB3/P.LB3/3/2020 on March 24, 2020. The circular explained about the steps that must be undertaken by healthcare facilities. First, to collect and store infectious waste from health facilities in closed containers within two days since the waste is generated. Second, transport or destroy “hazardous waste (B3)” waste using incineration or autoclave. Third, carry B3 waste to the hazardous waste processing plant.[2]
• The House of Representatives (DPR) has reportedly requested the government to streamline the role of KLHK through the directorate to add medical waste treatment points, especially in areas that are exposed to or affected by the Covid-19.[3]

Status of medical waste management in Indonesia

Medical waste management still needs attention from all stakeholders concerned. According to the data from the Health Ministry in November 2019, there were 296 tons of medical waste per day generated from 2,852 hospitals, 9,909 public health centers (Puskesmas) and 8,841 clinics. However, not all healthcare facilities able to manage their waste, whereby reportedly only 96 of the existing healthcare facilities have incinerators, and the rest are not working.[4] Another problem has proved by critical interviews with the Local Environmental Agency (DLH) in several cities and regencies in Indonesia. It appeared that no record was available on how healthcare manage its wastes throughout the city/regency.

Data from KLHK in 2018 indicated the volume of medical wastes from 2,813 hospitals in Indonesia reached 242 tons per day but only 87 kilograms in average waste is ready for treatment. This insufficient occur because most hospitals do not have the facilities to treat and destroy the medical waste, hence the involvement of third parties to carry out the treatment. Moreover, this also posed another problem as third parties reportedly sorting and retrieve wastes that still have economic values[5], which may increase the risk of contamination to the waste sorters.

In Indonesia, 85 health service facilities have B3 waste processing permits, distributed in 20 provinces. Eighty-two processing units use incinerators and the rest use autoclaves. In addition, there are five business entities managing B3 medical waste in Java and Kalimantan, with a processing capacity around 151.6 tons per day. In West Java, authorities have enlisted PT Jasa Medivest, a company specializing in medical waste disposal and a subsidiary of province-owned PT Jasa Sarana, to process medical waste produced across the province.[6] On the government side, KLHK signed four cement companies as third parties to destroy medical waste, which are PT. Semen Padang, PT Semen Indonesia, PT Indocement, etc. Since then, 152.89 tons total estimation medical waste has been destroyed.

Even in normal conditions prior to the pandemic, Indonesia still encounters medical waste management problems. [7] Therefore, both private parties and governments need to invest in establishing medical waste treatment services in all regions, since transportation and distance are main concern.

The Expected Increase of Healthcare Waste Generation Rate During Covid-19 Outbreak

KLHK predicted that medical waste would increase during the pandemic, particularly waste from 132 referral hospitals for COVID-19 patients as well as wastes in the form of used protective gear and other single-use medical equipment.[8] However, there is no available data on amount of medical waste in Indonesia.

Regarding simulation by Public Health Faculty, University of Indonesia, there will be 600,000 people who would be infected by Covid-19 and consequently will produce new medical waste. Based on China cases, the average infected patient reportedly contributed 14.3 kilograms of medical waste per day. This waste increased up to 6,067 tons/day from 4,902 tons/day after Covid-19 infected 81,000 people.

In Indonesia, for instance Rumah Sakit Pusat Infeksi (RSPI) Sulianti Saroso Jakarta – which is the referred hospital for Covid-19, reported a significant rise in medical waste after Covid-19 pandemic. On average, 20 Personal Protective Equipment (PPE) are generated per patient, while nurses and doctors are wearing the single-use PPEs when they treating patients. By using incinerator, RSPI has destroyed 130 kg of medical waste in February 2020 and climb up to 500 kg as per March 2020.

The estimated amount of infectious medical waste that Jakarta may expect based on China’s experience compared with the other ASEAN cities is presented in the table below.

Table 1. Estimated amount of infectious medical waste

(Source: ADB, 2020)[9]

Local governments may estimate the potential increase in tonnage over time with the following formulae:

IP x 3.4 kg = IHI

Where:

IP: Estimated Infected Persons

IHI: Infectious Medical Waste Increase per Day of Outbreak

In the case of Indonesia, there were 6,248 infected persons as of April 19, 2020.[10] Therefore, the estimated infectious medical waste generation is 20.24 tons/day. Based on the University of Indonesia’s estimation of 600,000 infected persons, if this were to occur, then the waste generated in total by then would be 1,994 tons/day.

Transportation and Disposal

A standard procedure of transportation is also crucial to minimize risk when transferring medical waste. Carry transportation on waste would require certification from KLHK. It also requires sterilized vehicles, trained drivers and waste collectors, dedicated routes, and vehicle tracking systems. Training must be conducted for crews who will be exposed to household infectious medical waste.[9]

Infectious medical waste is separated by hospital staff at the time of packing. It has been treated with a 0.5% chlorine solution on double bag before on-site temporary storage. There are a variety of disposal methods: sterilization through steam (autoclave) or irradiation before disposal in a licensed landfill and disposal through incineration on-site or at a remote specialist facility.

If these resources begin to be overwhelmed, alternative ways are available for a temporary capacity increase. First, as a temporary measure, secure facilities can be used as temporary storage in anticipation of additional emergency resources becoming available in the medium term. Second, mobile incineration or autoclave units may be used to support the existing infectious medical waste infrastructure.

The World Health Organization (WHO) recommended guidelines to safely collect all medical waste during the care of Covid-19 by using bags and to be later disposed of or treated, preferably onsite. Best practices for safely managing health care waste should be followed, including assigning responsibility and sufficient human and material resources to dispose of such waste safely.

The International Solid Waste Association (ISWA) further advised that all infectious health care waste produced during the care of Covid-19 patients should be treated as infectious waste, "normal" procedures followed for management and safe disposal or treatment, or both, preferably on- site. If waste is moved off-site, it is critical to understand where and how it will be treated and destroyed, requiring traceability measures to register and ensure its adequate destination. All who handle health care waste should wear appropriate PPE and perform hand hygiene after removing it. [11]

It is also important to highlight that unfortunately many developing countries still lack infrastructure to treat healthcare and other infectious and hazardous waste. In those cases, and as an exceptional measure, the waste produced in healthcare facilities during the Covid-19 pandemics shall be sent to be stored in sanitary or engineered landfills on a separated area, isolated from the regular waste, and with immediate daily cover.[12]

China has been a success as role model to cope with healthcare waste on cement industrial. Medical waste from hospitals that are fighting the novel coronavirus epidemic in central China's Hubei Province has been burned in cement kilns as part of the efforts to contain the spread of the disease. The medical waste was disinfected before entering the company's large cement kiln. Bags of medical waste would be disintegrated and gasified immediately in the pre-recalcine with a temperature of about 1,150 degrees celsius. The remaining waste would continue to be burned in the rotary kiln at a temperature of about 1,400 degrees Celsius. All the waste would eventually be turned into cement after thorough incineration.[13]

Vulnerable groups at risk

Improper disposal of infectious medical waste at landfills would increase the risk of vulnerable groups such as scavengers, waste transporters, cattle breeders, and residents living near the landfill, including women and children. When medical waste is dumped, it should be ensured that no human or animal will be able to be in contact with it. In case medical waste is brought to the disposal site, waste workers should be informed and take special precautions like wearing masks and gloves. In any case, workers should keep a distance and avoid any direct contact with the waste.

Scavengers, waste sorters and transporters cannot apply physical or social distancing completely because they have to work daily, hence the potential to be exposed to the danger of infectious waste.

Moreover, if masks, gloves, or PPEs were not worn when sorting the waste at the landfill, it would increase their chance for getting the infection.[14] Coordination and supervision of the Covid-19 medical waste problem must be carried out immediately, so that it would not be a medium of transmission to these vulnerable groups.

There is currently no evidence that direct, unprotected human contact during the handling of health care waste has resulted in the transmission of the Covid-19 virus. However according a study published in the New England Journal of Medicine (2020), the virus can persist for up to a day on cardboard and for longer on metal and plastic.[15]

The Journal of Hospital Infection analysed how long the SARS-CoV-2 virus remained on the surface of objects. In stainless steel, the corona virus can last up to five days, metal materials for five days, aluminium and operating gloves last two to eight hours, wood for four days, glass for four days, plastic for eight hours to six days, whereas paper for four to five day. Therefore, potential contagion from infectious medical waste still pose a direct threat to these vulnerable groups.

Conclusions and Recommendations

Medical waste represents a small part of the total waste stream, but given the increasing generation rate due to Covid-19, it is classified as dangerous waste. Even though, some local hospitals have incinerators and have a waste separation policy in place, an effective and simple procedure should ensure that the most dangerous components, are sent to the incinerator. This also should be separated with domestic waste. Unfortunately, separation procedure on medical waste has not been confirmed at all hospital and health facilities. Most of them are having inadequate facilities to correctly handle on their waste.

As a solution, a medical waste incinerator are required at hospital and health facilities. Incinerator should be over 1,200o Celsius and have a residence time of 2 seconds when processing this waste. Due to local cost constraints, a proper disposal area at the site for pre-treated medical and other special wastes may need to be considered. The other alternative is autoclaving the medical waste either at source or centrally at the SWM site. To sum up, infectious waste should be disinfected at the hospital or medical clinic and then deposited in a dedicated location within the landfill cell, along with household and other hazardous waste.

The relevant policies planned but still in need of enforcement. Hospitals/clinics that do not treat the hazardous medical waste properly should be given punitive penalties. Third party hazardous waste treatment operators that do not comply with the standards would also need to be penalized.

Medical waste disposal equipment includes sanitary landfills, medical incinerators, and medical autoclaves that are used to deal with pre-pandemic waste amounts. Other resources including mobile incinerators, industrial furnaces, and cement kilns could be assessed for use if existing systems are overloaded and capacity is limited.[16] The government may seek collaboration with cement kilns for incineration of medical waste all throughout the country. Incentives to lure cement companies to be involved may also need to be established. Also, KLHK is advised to explore the possibilities for donors to provide technical assistance and grant/loan to cover investment costs (CAPEX). Overall, it is a huge task to create good medical waste management system, however there are some base that can be applied in countries. It entails waste assessment and valuation of existing practices, assessment of waste management options, expansion of a waste management plan, declaration of institutional policies and guidelines, founding of a waste management organization as needed, distribution of human and financial resources, execution of plans according to a set timelines, agenda of periodic training, monitoring, evaluation and continuous development.[17]

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References

[1] UNEP IETC, 2012. Compendium of Technologies for Treatment / Destruction of Healthcare Waste. https://wedocs.unep.org/bitstream/handle/20.500.11822/8628/IETC_Compendium_Technologies_Treatment_Destruction_Healthcare_Waste.pdf?sequence=3&isAllowed=y

[2] https://zonautara.com/2020/03/27/tindaklanjuti-se-menteri-lhk-eman-minta-warga-perhatikan-limbah-apd/

[3] http://dpr.go.id/berita/detail/id/28296/t/Pemerintah+Diminta+Efektifkan+Peran+KLHK+Kelola+Limbah+Medis+Akibat+Covid-19

[4] Quoted from a report by the Health Ministry in November 2019. https://tirto.id/limbah-medis-covid-19-bahaya-laten-yang-menghantui-masyarakat-eLjq

[5] Ramadhan, 1 April 2020. Limbah Bekas Penanganan COVID-19 Harus Diapakan? https://www.asumsi.co/post/limbah-bekas-penanganan-covid-19-harus-diapakan

[6] The Jakarta Post, April 1, 2020. Government braces for increasing medical waste during pandemic. https://www.thejakartapost.com/news/2020/04/01/government-braces-for-increasing-medical-waste-during-pandemic.html

[7] Quoted from Direktur Kesehatan Lingkungan Kementerian Kesehatan Imran Agus Nurali. https://tirto.id/limbah-medis-covid-19-bahaya-laten-yang-menghantui-masyarakat-eLjq

[8] The Jakarta Post, April 1, 2020. Government braces for increasing medical waste during pandemic. https://www.thejakartapost.com/news/2020/04/01/government-braces-for-increasing-medical-waste-during-pandemic.html

[9] ADB, 2020. Managing Infectious Medical Waste during the COVID-19 Pandemic. https://www.adb.org/sites/default/files/publication/578771/managing-medical-waste-covid19.pdf

[10] https://www.worldometers.info/coronavirus/

[11] WHO and UNICEF, 19 March 2020. Water, sanitation, hygiene, and waste management for the COVID-19 virus. https://www.who.int/publications-detail/water-sanitation-hygiene-and-waste-management-for-covid-19

[12] International Solid Waste Association (ISWA), 8 April 2020. Waste Management During the Covid-19 Pandemic: ISWA’s Recommendations. https://www.iswa.org/fileadmin/galleries/0001_COVID/ISWA_Waste_Management_During_COVID-19.pdf

[13] Xinhua, 25 February 2020. Coronavirus medical waste burned in cement kiln. http://www.xinhuanet.com/english/2020-02/25/c_138816329.htm

[14] Ramadhan, 1 April 2020. Limbah Bekas Penanganan COVID-19 Harus Diapakan? https://www.asumsi.co/post/limbah-bekas-penanganan-covid-19-harus-diapakan

[15] New England Journal of Medicine, April 16, 2020. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. In: https://www.theverge.com/2020/3/26/21194647/the-covid-19-pandemic-is-generating-tons-of-medical-waste

[16] ADB, 2020. Managing Infectious Medical Waste during the COVID-19 Pandemic. https://www.adb.org/sites/default/files/publication/578771/managing-medical-waste-covid19.pdf

[17] UNEP, 2020. https://www.unep.org/news-and-stories/story/healthcare-waste-what-do-it

I Kadek Dian Sutrisna Artha. (2020). Medical Waste Management During and Post-Covid 19 Pandemic. SMI Institute, PT Sarana Multi Infrastruktur (Persero). Diakses , dari