Masks, protective clothing, cotton swabs, needles, syringes... This medical waste from hospitals, cabins, isolation points and nucleic acid testing points has almost exceeded the production of the past year in less than three months of the epidemic.
At the press conference on the epidemic situation in Shanghai on May 24, it was revealed that since March 1, Shanghai has accumulated 68,500 tons of medical waste, with each Shanghai resident generating more than 2 kilograms of medical waste, "reaching more than 1,400 tons per day at its peak, which is 6 times that of usual".
In the annual report data on solid waste pollution in large and medium-sized cities released by the Ministry of Environment, in the most recent year, in 2019, the total amount of medical waste in Shanghai was 55,700 tons, which was more than 10,000 tons less than the medical waste output in the three months during the epidemic in 2022.
Since the COVID-19 pandemic in 2020, environmental practitioners have experienced the power of the surging medical waste. Dai Xiaojuan, senior project manager of the Public Environmental Research Center and has long been engaged in policy and regulation research in the field of environmental protection and enterprise pollution prevention and control management, explained to Eight Point Jianwen: "Medical waste in the epidemic has a particularly prominent feature, they are not only in hospitals, fever clinics, centralized isolation and treatment points, and even nucleic acid testing points, etc., also produce medical waste. Especially in centralized isolation points, domestic garbage has actually become medical waste. ”
At the press conference, during the epidemic, the medical waste generated in Wuhan soared from more than 40 tons per day before the epidemic to more than 240 tons per day at its peak. According to CCTV, "Before January 16, there was only one medical waste treatment company in Wuhan, Han's Environmental Protection, and even if it was running at full capacity, it could only dispose of 50 tons per day."
Since then, the emergency of medical waste caused by the epidemic has been staged in almost every epidemic-related city - hospitals, cabins and large-scale nucleic acids will cause a surge in medical waste.
According to a research report by Ping An Securities, as of February 8, 2020, when the number of new crown infections in China reached more than 70,000, the number of new medical waste had reached 17,000 tons, most of which came from hospitals and cabins, and urgently needed to be disposed of in a timely manner. On Weibo, you can see the complaints of nearby residents: medical waste is piled up in a certain cabin hospital, and there have been positive cases in 3 residential communities next to the cabin, "the cases are concentrated in buildings near the direction of the cabin, and the source cannot be traced to other sources of infection."
In some small and medium-sized epidemics, the amount of medical waste generated by large-scale nucleic acids cannot be ignored.
In August 2021, during the epidemic in Yangzhou, it was reported that 28.8 tons of medical waste were generated in 24 hours at 812 nucleic acid testing points in the main urban area of Yangzhou, and these medical wastes only came from the nucleic acids of the city of more than 4.5 million people.
A practitioner in the field of medical waste treatment revealed to Eight Points Jianwen that in a small western city that has not erupted in a large-scale epidemic, after 2020, its medical waste treatment institutions have increased the daily treatment capacity of medical waste from the previous 10 tons to 20 tons by purchasing mobile equipment and restarting old equipment that has not yet been scrapped, which finally meets the needs of medical waste treatment generated by the nucleic acid of more than 3 million local residents when the epidemic is spread.
The above-mentioned practitioners also mentioned that fortunately, the local treatment equipment has just been upgraded from 5 tons to 10 tons before the epidemic, and the old equipment has not been discarded, "if the medical waste treatment capacity of only 5 tons in the past collides head-on with the demand for 20 tons of medical waste per day in the epidemic, it will not be so easy to deal with."
However, the situation that the old equipment has not been updated is often the norm for local medical waste treatment institutions during the epidemic.
Since the outbreak of the new crown epidemic, the amount of medical waste generated in the mainland has increased suddenly. Xu Xiaofang, senior engineer of the Basel Convention Regional Center for Asia and the Pacific, told Eight Point Health News: Even without the epidemic, the medical waste disposal facilities in many cities on the mainland (especially megacities and large cities) are already in a state of near-full capacity operation of more than 90%, and the emergency collection and disposal capacity is insufficient.
According to the data of Zhiyan Consulting, in 2016, the amount of medical waste generated in mainland China was 2.146 million tons, and the processing volume was only 747,000 tons, and the total amount of medical waste that was treated was less than 35%.
In 2018, Hu Hualong, deputy director of the Solid Waste and Chemical Management Technology Center of the Ministry of Ecology and Environment, publicly stated that the load rate of medical waste facilities in 76 cities, including Beijing, Shanghai and Hainan, exceeded 100%, and nearly one-third of the facilities in the country were basically in full or overloaded operation.
In the Wuhan epidemic, the problem of medical waste can still be solved through the national rush, and today, when the epidemic is normalized, the treatment of medical waste that has multiplied in various places has almost become the most important but easily overlooked corner of epidemic prevention and control. Therefore, in relevant reports, almost every epidemic situation, the local need to rebuild medical waste through hazardous waste facilities, domestic waste facilities transformation, mobile equipment and other emergency supplements.
So, are these emergency expansion treatments enough to eliminate all the environmental hazards caused by medical waste? What is China's medical waste disposal capacity? And what kind of challenges will the normalized nucleic acids that are being rolled out across the country pose to this fragile treatment system?
Mobile risk sources and weak collection and transportation systems
As a special category of hazardous waste, medical waste is at the top of the National Hazardous Waste List because of its potential infectivity.
The "Regulations on the Management of Medical Waste" issued after SARS in 2003 clearly stipulate that "the state implements centralized and harmless treatment of medical waste".
This means that the collection and transportation of medical waste needs to be more than a "bumper" - closed-loop management to prevent the spread of diseases.
A number of experts said that the existing medical waste infection control in the mainland is doing a good job, and occasionally workers complain of being scratched by sharp objects but have not caused infection. At the same time, judging from public reports, there has been no new crown infection due to the transportation of medical waste, but the risk of its infection transmission cannot be ignored.
In the face of thousands of medical institutions in a city, dozens of tons of medical waste production every day and even hundreds of tons after the outbreak of the epidemic, wanting to "Nissan Nissin" tests the effectiveness of the medical waste collection and transportation system.
Due to the high barriers to entry for medical waste treatment and urban planning, some cities have only one centralized medical waste disposal facility; And in terms of location, in order to minimize the treatment of odors and emissions, such facilities are generally located in the suburbs far from the city.
"Short board of collection and transportation", a term that has frequently appeared in the medical waste management documents of governments at all levels in the past two years. To this end, various provinces have put forward the goal of "each county (city, district) to build a medical waste collection, transfer and disposal system by the end of June 2022", and setting up temporary storage points is a more convenient method.
In March this year, Li Yinchang, deputy director of the Department of Ecology and Environment of Sichuan Province, introduced at a press conference that in order to solve the problems of untimely collection of hazardous waste, unsmooth transfer and high disposal costs, the province has simultaneously promoted the construction of 58 centralized collection pilot projects to open up the "last kilometer" of hazardous waste collection.
A person in charge of a medical waste enterprise in the western region said that the collection and transportation of medical waste in more than 100 hospitals in the city is completed by 10 2-ton transport trucks, and as for the primary medical institutions such as township health centers, individual clinics, and clinics, most of them are transported to the county-level people's hospital for temporary storage.
On the one hand, the weak collection and transportation system is limited to the inconvenience of grass-roots transportation, the long transportation distance, and the small amount of waste, but the more important reason is that in the medical waste treatment charging standards, the collection and transportation costs are not separately calculated.
Medical waste is mostly charged by the number of beds/patients and the weight of waste. The China Commercial Industry Research Institute found that the charging standard is roughly between 2500-4000 yuan / ton. Taking Sichuan Province as an example, medical institutions above the second level charge 2 yuan / day according to the establishment of beds, and below the second level are charged 2 yuan / kg by weight. And since SARS, the increase in medical waste charges has been limited.
Located in the main urban area, with convenient transportation and a huge amount of abandonment, large medical institutions have become the "fragrant food" in the mouths of enterprises. International experience generally believes that the amount of medical waste generated by the inpatient department is 0.8kg / bed per day, taking the hospital with 5000 beds as an example, in the state of full beds, 4 tons of medical waste are generated every day, and the payment is 10,000 yuan. The disposal enterprise only needs two transfer vehicles, and 4 transfer personnel can complete the task.
In some "small facades", the same 2-ton transfer truck may need to run to 20 medical institutions to be full. In the case of fixed equipment operating costs and medical waste disposal costs, the freight increases, and enterprises naturally "pick fat and pick thin". Some enterprises delay the collection time as much as possible, from once a day to once every four or five days.
Jiang Feng, who was an international coordination expert (2006-2018) of the United Nations Industrial Development Organization (UNIDO) and the Ministry of Environmental Protection's "China Medical Waste Sustainable Environmental Management Project", concluded based on the experience of many places that when medical institutions are located 60 kilometers away from medical waste disposal plants, or when the amount of medical waste generated is less than 50 kg/day, the willingness of centralized disposal enterprises to collect on time will be significantly reduced.
If the previous epidemic tested the processing capacity, then the normalization of nucleic acids that emerged in 2022, thousands of nucleic acid sampling points throughout the city, undoubtedly put forward higher requirements for this collection and transportation system.
During the epidemic in Yangzhou last August, 100 environmental volunteers were mobilized at the nucleic acid sampling point in the main urban area of 812 to reduce the burden of transfer by setting up collection points. At the press conference on May 24 this year, Luo Hailin, deputy director of the Shanghai Municipal Bureau of Ecology and Environment, mentioned when introducing the medical waste collection and transportation mode and standard after the 15-minute nucleic acid detection ring was laid out: For convenient and mobile sampling points, the nucleic acid sampling personnel or staff will transport the sampled medical waste to the testing institution together with the testing sample, and the medical waste disposal unit will collect and transport it centrally.
Sun Ning, director of the Environmental Planning Institute of the Ministry of Ecology and Environment, suggested in 2017 that a separate medical waste collection and transportation qualification should be implemented, allowing the separation of collection and transportation and treatment, gradually reducing costs, and the disposal cost should be reasonably allocated between the receiving and transportation enterprises and the treatment enterprises.
The production of dioxins in medical waste is 6 times that of general hazardous waste
Incineration is an easy technology path to quickly dispose of the surge in tonnage demand for medical waste. However, whether it is high-temperature incineration or residue incineration after disinfection, the widespread distribution of chlorine makes medical waste more of a dangerous "gift" - dioxins, a persistent organic pollutant (POPs), a first-class carcinogen.
The stable structure allows dioxins to exist in the environment for a long time and are continuously enlarged through the accumulation of biological chains, and for humans at the top of the biological chain, these toxicities are magnified more than 70,000 times than they were originally, and they are highly toxic, fat-soluble, and long-distance migratory.
As early as 2001, dioxins were listed as the first targets for control by the Stockholm Convention on Persistent Organic Pollutants. In 2007, the mainland submitted a national implementation plan to the Secretariat of the Convention that hazardous and medical wastes were more hazardous in terms of the production of dioxins incinerated by unit quality waste, and were listed as a source of pollution that needed to be prioritized for control.
Compared with hazardous waste, the dioxin emissions of medical waste incineration are more alarming. A 2014 study by Chen Jia et al. of Zhejiang University showed that the average concentration of dioxins in the fly ash of medical waste incineration was as much as 6 times that of hazardous waste.
At present, the emission standard for medical waste incineration flue gas dioxins in mainland China is 0.5ng I-TEQ/m3. However, for this kind of accumulated poison, even if the emissions are all up to standard, the total amount has soared, and many environmentalists still mentioned to Eight Points Jianwen that they should pay attention to dioxin control.
In terms of the chlorine content required to produce dioxins, studies have shown that medical waste accounts for 4.56% to 7.52%, and other hazardous wastes account for 0.03% to 2.5%. This is closely related to the special use of medical waste, Chen Yang, a researcher at the School of Resources and Environment of the University of the Chinese Academy of Sciences, told Eight Points Kenwen that from chlorine in medical sodium chloride solutions to chlorine in polyvinyl chloride organic macromolecules, these chlorine sources combine with benzene ring macromolecules, which may cause the formation of dioxins in the pyrolysis incineration process.
Chen Yang said that through activated carbon injection, deacidification and dust removal and other exhaust gas deep purification technology for terminal control, in the incinerator through rapid heating, to ensure combustion efficiency and quenching cooling process control, but also including the source control of chlorine reduction from the source, the three aspects are unified, are conducive to controlling the generation and emission of dioxins.
But the reality is not optimistic. The results of the above-mentioned study by Chen Jia et al. show that only 43.90% of the flue gas dioxin emissions in 41 medical waste incineration disposal facilities meet the standard. In 2017, Li Jiafu et al. of Tianjin University analyzed 12 medical waste incinerators across the country and found that the dioxin equivalent concentration in the flue gas was 0.031~3.463 ng I-TEQ/m3.
The embarrassment of dioxins is that they can hardly be monitored in real time like particulate matter such as pm2.5 and acidic compounds such as sulfur dioxide. Jiang Feng explained that because dioxins are trace pollutants, it often takes several days from sampling to pretreatment and analysis, and the annual supervisory monitoring is 1 to 2 times.
Not only dioxins, incineration will also produce highly toxic substances such as polycyclic aromatic hydrocarbons and polychlorinated biphenyls, acidic gases such as sulfur dioxide and nitrogen oxides, and heavy metals represented by mercury. Non-incineration disposal will produce odors, VOCs (volatile organic compounds) and so on.
Sun Ning, director of the Environmental Planning Institute of the Ministry of Ecology and Environment, wrote in 2017 that compared with other hazardous wastes, the amount of medical waste generated is small, and for a long time it has not been the focus of environmental supervision of local environmental protection departments at all levels, and the state has not carried out an overall survey of the emission of standards, and the online monitoring facilities for medical waste exhaust emissions are mostly a "decoration".
The Shenzhen Zero Waste Environmental Protection Public Welfare Center counted the monitoring data published by 56 enterprises from December 13, 2019 to March 13, 2020, and then found that the average daily value of enterprises exceeded the standard accounted for 22.9%, and the average number of enterprises exceeding the standard reached 6.5 days. From February 13 to March 13, 2020, the proportion of enterprises with an average value exceeding the standard reached 25.7%, and the average number of polluting enterprises exceeding the average value was 53 hours.
Zero Waste also analyzed the violation records of 482 medical waste disposal enterprises from 2017 to 2019, and found that there were more violations and violations in excess of standard discharge, exhaust gas emissions, medical waste and ash residue management, and the cumulative fine amount of incineration disposal enterprises reached 13.565 million yuan.
Behind the frequent violations is the fact that the disposal fees for medical waste have not increased for many years. Sun Ning once pointed out that some enterprises with a strong sense of social responsibility can still encourage the maintenance of operational services, while some enterprises reduce technical requirements and emission requirements through various ways and methods at the expense of the environment.
Chen Yang also said that activated carbon injection is beneficial for adsorption of dioxins, but the adsorption capacity of activated carbon is limited, and it is affected by factors such as temperature and moisture, resulting in unsatisfactory treatment effects and is not easy to supervise. In the future, efforts need to be made in technological substitution and new technological innovation to promote the solution of the problem of stable standards of dioxins.
The plight of medical waste in primary medical institutions
While medical waste treatment enterprises complain about high operating costs and slow increases in treatment costs, medical waste production enterprises and hospitals are also complaining about treatment costs. Price has become a shadow between medical waste production enterprises and treatment enterprises.
Under the medical waste franchise system, the most difficult is the primary medical institutions.
"Each prefecture-level city has built at least 1 centralized medical waste treatment facility that meets the operational requirements" and "the harmless disposal rate of medical waste in cities at or above the county level has reached 99%" are the action goals of the national medical waste construction in the past two years. Chen Yang said that the core problem of county-level medical waste centers lies in operation and maintenance, because the amount of medical waste that can be treated is small, it is difficult for related treatment enterprises to continue to stabilize revenue, so reliable measures should be taken, such as centralized disposal center operation, increase operating fee subsidies, increase the charging standards for medical waste treatment, etc., to ensure continuous and stable operation.
On the other hand, even the municipal medical waste centers do not have comprehensive treatment capacity. According to the person in charge of the medical waste enterprise in the western region, the city can handle infectious and injurious medical waste, and as for the chemical and medicinal properties, it often needs to be sent to the provincial capital city for treatment. Sun Ning also pointed out that the destination of chemical and pharmaceutical waste that cannot be treated by non-incineration treatment technology is often unknown. Many industry insiders said that the hospital sewers are mostly their potential flows.
In-place storage is another way to reduce costs. For the medical waste generated by medical institutions in remote areas, Jiang Feng suggested that we can follow the experience of other countries, rebuild closed and refrigerated storage points, and reasonably extend the storage time, such as three months to half a year, to ensure safety and save transportation costs.
During the "two sessions" in 2022, Hua Yawei, member of the National Committee of the Chinese People's Political Consultative Conference and vice president of Henan Provincial Cancer Hospital, from the perspective of the infectivity of medical waste, proposed to revise the "Regulations on the Management of Medical Waste" and its supporting policies, and implement a medical waste disposal model that combines centralized disposal and hospital self-disposal.
Jiang Feng, from the perspective of "reducing the whole to zero, shortening the collection and transportation-treatment process, and reducing the cost of treatment", said that we should try to promote the harmlessness of hospital medical waste on the spot. He explained that by purchasing small facilities for crushing, steam disinfection and sterilization, the remaining residue can be regarded as domestic garbage disposal, "like an office shredder" is lightweight and low-cost, and has been widely implemented abroad.
Jiang Jianguo, a professor at Tsinghua University's Institute of Solid Waste Control and Resource Utilization, told Eight Points that centralized disposal can reduce risks and improve safety. As early as BEFORE SARS, large domestic hospitals had built their own incineration equipment, and small medical institutions had no processing capacity to mix with domestic garbage or flow into the black market, so if local disposal is taken, a strict regulatory plan is essential.
Of course, whether it is handled locally or centrally, Jiang Feng said: We all prefer to see a fair and competitive market. In the face of the only medical waste treatment enterprise in the city, medical institutions have no choice and are often in a weak position, and it is a fair path to introduce other market competition entities or give the right of choice to the hospital.
An environmental expert told Eight Points Jianwen that in the current situation, many cities have fewer medical waste treatment facilities, and those enterprises that monopolize the treatment of medical waste in a city are close to full load, which is unreasonable. Imagine, in this case, once the epidemic occurs, the excess medical waste can often only rely on foreign aid from other cities, but what if the epidemic occurs in many places at the same time, or the medical waste surge occurs at the same time?
"Improving the capacity of medical waste collection and centralized disposal in key areas and strengthening the construction of emergency disposal facilities for medical waste is the key to the current disposal of medical waste," Xu Xiaofang told Eight Point Health News.
China's emphasis on medical waste treatment began with the SARS epidemic, and the two-year COVID-19 epidemic has forced us to re-examine the treatment of medical waste in emergency situations, and whether this shock can cause a devastating and decadent reshaping may remain to be seen.
Recognizing the problem is only the first step, and how to truly translate this understanding into changes in the entire industry is still a difficult problem. The current situation, in the words of environmental experts, is to constantly "patch the policy". However, in order to solve the problem well, so that the medical waste treatment system can respond freely in the normalization and emergency state, it is more necessary to think and plan for "far-reaching".
Yan Yucheng and Yan Shengnan | writing
Li Shanshan | responsible editor
This article was first published on the WeChat public account "Eight Points Health" (ID: HealthInsight)
Respect the original copyright, unauthorized reproduction shall not be reproduced, infringement responsibility at your own risk