Heliyon 7 (2021) e06313

Contents lists available at ScienceDirect

Heliyon
journal homepage: www.cell.com/heliyon

Research article

Challenges and actions to the environmental management of Bio-Medical

Waste during COVID-19 pandemic in India
Mrinalini Goswami a, Pranjal J. Goswami b, Sunil Nautiyal a, *, Satya Prakash a
a
Centre for Ecological Economics and Natural Resources (CEENR), Institute for Social and Economic Change (ISEC), Nagarabhavi, Bangalore 560 072, India
b
Bioaxia Private Limited, India

A R T I C L E I N F O A B S T R A C T

Keywords: The outbreak of COVID-19 has engendered a global health crisis along with diverse impacts on economy, society
BMW and environment. Efforts to combat this pandemic have also significantly shot-up the quantity of Bio-medical
Healthcare waste Waste (BMW) generation. Safe disposal of large quantity of BMW has been gradually posing a major challenge.
Safe disposal
BMW management is mostly implemented at municipal level following regulatory guidelines defined by
Environmental health
Waste management regulations
respective states and the Union. This article is a narrative of the status of BMW generation, management and
regulation in India in the context of COVID-19 crisis. The article is based on comparative analysis of data on BMW
generation and management from authentic sources, a systematic literature review and review of news reports. In
the current pandemic situation where media has been playing a significant role in highlighting all the concerns
related to COVID-19 spread and management. Assessing the ground situation regarding effectiveness of prevailing
BMW management facilities, requirement and suggestions can provide insights to the subject with policy im-
plications for India and countries as well. The discussion has been built on different dimensions of BMW man-
agement during the pandemic including existing infrastructures, capacity utilisation, policy guidelines,
operational practices and waste-handlers aspects. The results on state-wise analysis of reported BMW quantity and
active COVID-19 patients also reveal some non-linear relationship between the two variables. Delhi, the National
Capital is situated at a better position in terms of BMW management as compared to other studied states. The
findings are expected to provide valuable insights to the policy makers and other relevant authorities to evaluate
adequateness as well as efficiency quotients of entire BMW management landscape. Some of the critical obser-
vations of this article are also expected to offer impetus for enhancing national disaster preparedness in future.

1. Introduction genotoxic, cytotoxic, other toxic chemicals and biologically aggressive

pharmaceuticals (WHO, 2017). Management of BMW in improper way
Growing medical technologies and modern facilities in hospitals for result in several problems including spread of infectious diseases and
providing better healthcare have contributed in subsequent increase in different forms of environmental pollution (Rai et al., 2020). It has been
quantity of waste generated from health care facilities. The term “Health established that 10–25% of BMW is dangerous (Rao and Ghosh, 2020)
Care Waste” or “Bio-Medical Waste” includes all the wastes from any and that part of the waste possess physical, chemical, and/or microbio-
medical procedure in healthcare facilities, research centres and labora- logical risk to anybody exposed or is associated in handling, treatment,
tories (WHO, 2017). The activities generating Bio-Medical Waste (BMW) and disposal of waste. Report of the Special Rapporteur UN Human
may be in healthcare, research or diagnostic facilities with one or more of Rights Council focuses on the adverse effects that the unsound manage-
the activities such as diagnosis, treatment, immunization of human be- ment and disposal of medical waste may have on the rights to life and
ings and animals and production or testing of biological materials. recommending additional measures that relevant stakeholders can
Biomedical waste also includes waste produced during any healthcare consider to make improvements in the safe and environmentally sound
activities taken place at home. The types and characteristics of the con- management and disposal of BMW (Human Rights Council-United Na-
tents determine how hazardous is the waste. The classification is based tions, 2011).
on presence of infectious substances, radioactivity, presence of sharps,

* Corresponding author.
E-mail address: [email protected] (S. Nautiyal).

https://doi.org/10.1016/j.heliyon.2021.e06313
Received 23 October 2020; Received in revised form 24 January 2021; Accepted 15 February 2021
2405-8440/© 2021 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Goswami et al. Heliyon 7 (2021) e06313

Apart from the health risks associated direct contact with BMW, risk 2. Methodology
of adverse impact on human health can also be associated due to expo-
sure to emissions of highly toxic gases during incineration. Improper The research is based on secondary data, a systematic literature review
operation or deficiency in operation of the small- scale incinerators may and review of news articles. A systematic investigation of all the scientific
result in incomplete waste destruction, inappropriate ash disposal and articles and reliable media articles available in web domain pertaining to
dioxins emission, which can 40000 times higher than emission limits set the subject in the current context of COVID-19 pandemic has been done.
forth on Stockholm Convention (Batterman, 2004). In India, to deal with Identification of issues regarding BMW-COVID and environmental and
the problems associated with BMW, under the provision of Environment health impacts of its mis-management, status of reporting on collection
(Protection) Act 1986, Bio Medical Waste (Management and Handling) and disposal etc. has been done with the help of review of recent litera-
Rules, 1998 was notified; these rules apply to all the persons who tures. Data on BMW generation, treatment and disposal across the states as
generate, collect, receive, store, transport, treat and handle or dispose well as data on COVID-19 positive cases have been collected from various
BMW in any form. Later, it was revised (2016), thereafter amended government portals [Central Pollution Control Board (CPCB), State
(2018) to boost the segregation, transportation, and disposal for reducing Pollution Control Board (SPCB)s, Ministry of Health and Family Welfare
environmental impact (BMWM Rules, 2018). (MoHFW), Ministry of Environment, Forest and Climate Change
The COVID-19 pandemic has created a global health crisis along with (MoEFCC) and Indian Institute of Technology, Delhi (IITD)]. Detailed
diverse impacts on environment, economy and society. It has posed state-wise analysis is carried out at two levels, one for 13 States/Union
various challenges to the existing regulations and management practices Territories (UT)s and another for six states which are with relatively high
regarding BMW worldwide. Wuhan in China witnessed a rise of health- impact of COVID-19. Number of total positive cases was considered for
care waste generation by 600% in the middle of COVID-19 outbreak selection of states. Data synthesis and statistical analysis (descriptive
(Jiajun, 2020). Restriction in recycling to prevent the spread of the virus, analysis, correlation, multivariate regression) have been done in MS-
increase in generation and improper treatment have posed alarming Excel. Selected data has been used to develop maps using ArcGIS.
situation (Zambrano-Monserrate et al., 2020). The management of BMW A systematic review of research articles has been done to document
during this pandemic has been highlighted as major concern by several the on-going scientific discussion on COVID-19 related BMW (Yang et al.,
researchers (Wang et al., 2020; Boora et al., 2020; Gupta and Agrawal, 2018; Mardani et al., 2019; Moher et al., 2015). The exploration of sci-
2020; Misra et al., 2020; Shammi et al., 2020), which can increase the entific articles is based on a few criteria viz.- time limit (March–October
risk of further contagion through different pathways. 2020), English language, combination of search terms (Biomedical
As the increased generation of BMW is inevitable during COVID-19 waste/Hospital waste/Medical waste/BMW þ India), presence in Web of
outbreak, safe handling, treatment and disposal of waste must be prior- Science and Scopus. Further refinement in the selection process has been
itized for minimizing contamination of land, water and air. This paper done as presented in the Figure 1. Recent studies which were screened in
has attempted to examine the existing situation of BMW in terms of its the fourth level and didn't qualify for review mostly include mention
generation, handling and treatment during this current pandemic situa- about safe disposal of PPE, risk of contamination from waste
tion in India. It has also looked into the regulatory changes formulated at mis-handling, hazards of BMW and biomedical waste management reg-
various levels to deal with adverse consequence of COVID-19 related ulations (Panda et al., 2020; Tabish et al., 2020; Sharma et al., 2020;
BMW (BMW-COVID). Bashir et al., 2020; Misra et al., 2020).

Research article review:

All English language ar cles during March-October 2020 with occurrence of:
(Biomedical waste/Hospital waste/ Medical waste/BMW+India)
(45)

Removal of duplicate ar cles (43)

Select ar cles in journals appearing in Web of Science and

Scopus (28)

Artcles results and discussion for India or

including India (24)

Any of the following appearing in

the abstract (21):
Biomedical waste/Hospital waste/
Medical waste/BMW

Selec on of artcles
BMW as core (15)

Detalied
review
(11)

Figure 1. Criteria and selection process for BMW-COVID-19 literature pertaining to India for review.

2
 M. Goswami et al.
Table 1. Brief description of reviewed articles on Biomedical Waste during COVID-19.

Sl. No. Author Title Focus area Findings Remark

1 Sharma et al. Challenges, opportunities, Biomedical, plastic and food Contamination from virus-laden Review paper mostly based on
(2020) and innovations for effective waste management BMW and health risks of general waste management
solid waste management during during COVID-19 sanitation literature
and post COVID-19 workers, increased plastic waste
pandemic and
food waste. Need of building
resilience
to face future catastrophe.
2 Kulkarni and Repercussions of COVID-19 pandemic Global overview of MSW Increased burden on MSW, mixing Review paper with evidences from
Anantharama on MSW management: Challenges and management during of BMW current pandemic
(2020) opportunities COVID-19 outbreak. and risk of disease transmission
through
solid waste handling, impact of
increasing
BMW on MSW management
system.
3 Ilyas et al. Disinfection technology and strategies for Disinfection technologies for Emergence of new type of BMW. A Review paper on waste
(2020) COVID-19 hospital and bio-medical waste handling COVID-19 waste combined management practices in a few
management approach by environmental and COVID-19 affected countries.
medical
researchers to adopt appropriate
technique.
4 Ramteke and Novel coronavirus disease 2019 (COVID-19) Potential impact of COVID-19 on Highlights the need for Review article mostly from disease
Sahu (2020) pandemic: considerations for the biomedical BMW administrations, focuses where considerations for transmission point of view and
waste sector in India option working methodology or extra further measures towards BMW general implication in BMW sector
moderation measures might be fitting. management
3

5 Das et al. Biomedical Waste Management: The Irrational use and disposal of PPE, mixing The indiscriminate disposal of Short article based on literature
(2020) Challenge amidst COVID-19 Pandemic of BMW with other wastes and other BMWs in the
ill-management practices general garbage posing risk to the
susceptible
community
6 Somani et Indirect implications of COVID-19 towards Effects of COVID-19 restrictions on the Automation and mechanization of Review article on environmental
al. (2020) sustainable environment: An investigation environment in India. Investigate the waste impact of COVID-19. Status of
in Indian context impact of COVID-19 on waste management. management system is required BMW generation and management
capacity in India was discussed
7 Vanapalli et Challenges and strategies for effective plastic Plastic waste management during pandemic Proper segregation and safety Review article in general for
al. (2020) waste management during and post measures for plastic waste and discussion on
COVID-19 pandemic plastic waste in BMW. precautions for plastic waste as
Contaminated BMW part of BMW
should not be part of MSW
8 Kumar et al. COVID-19 Creating another problem? Life Cycle Assessment of PPE kits under two Disposal of coverall has the It is a comprehensive study to
(2020a) Sustainable solution for PPE disposal disposal scenarios, namely landfill and maximum impact, assess environmental impacts of
through LCA approach incineration (both centralized and decentralized) followed by gloves and goggles, in PPE and findings have potential to
for six environmental impact categories terms of contribute towards making policy
GWP. The incineration process decisions
showed high
GWP but significantly reduced

Heliyon 7 (2021) e06313

impact w.r.t. other
environmental and health
impacts. High overall
impact of landfill disposal
compared to incineration.
The decentralized incineration has

(continued on next page)

M. Goswami et al. Heliyon 7 (2021) e06313

There have been several methodologies for news review and content

impact of COVID-19, BMW is one

on the basis of secondary data. It

Review article on environmental

highlighting the vulnerability of

impacts of face masks estimated

problem of waste management

gives an insight to the massive
analysis, which have been evolved with the evolution of modern mass

The study presents potential

media (Duan and Takahashi, 2017; Media literature review guide: How

It is a short review article

to conduct a literature review of news sources, https://www.lib.sfu.ca/).
of the components Information from mass media can be very useful to evaluate emerging

sanitation workers
scientific ideas and concerns across geographical locations and over time
(Antilla, 2010). Criteria-based compilation environmental news database
shows that environmental information occupies certain columns and
Remark

spaces in different media (Amiraslani and Caiserman, 2018).

BMW-COVID-19 being a recent phenomenon creating emergency situa-
tions across the world, all latest developments regarding BMW have been
covered uniformly by all the leading dailies in India; which has been
established through a screening of all online news platforms including
Discussion on reducing impacts of
waste, haphazard use and disposal
Negative consequences of COVID-

of disinfectants, mask, and gloves

implementation of medical waste

procedures, guidelines and strict

online editions of leading English dailies, web-based news portals and

19, such as increase of medical

and good payment and health

Policy to safeguard sanitation
emerged as environmentally

online versions of weekly, bi-monthly and monthly magazines. Other

equipment, ensure regular
them adequate protective
through standardisation,

than considering circulation score, 10 expert opinions have been recor-

t related to COVID-19.

workers by providing

ded to identify top five daily newspapers with online editions. The
waste management

highest scored five newspapers have been selected for the review. The
sound option.

selected newspapers include The Hindu, The Times of India, The Hin-
managemen

insurance.

dustan Times, The Indian Express and The New Indian Express. News
Findings

articles have been selected for review by using Google Search Engine
(News) for March–August 2020, searching each month separately. Search
phrases/terms used include COVID-19, BMW, Medical Waste India,
Biomedical Waste, Hospital Waste and India, where COVID-19 and India
were constant in all the searches with any of the other terms. For each of
the search, first 50 news articles were screened and all the five selected
Positive and negative environmental impacts

newspaper articles were studied to extract the required information. All

A rapid estimation of face mask and medical

the listed relevant news articles have been distributed in five groups
consequences related with the COVID-19

based on content of the articles.

waste generation and environmental

A study on socioeconomic status

3. Results and discussion

of the COVID-19 pandemic.

3.1. Discussion on BMW-COVID-19 in scientific literature

of Sanitation workers
and vulnerability

The papers qualified for the review counted 11 and are presented
in the Table 1. Among those studied, nine are review articles and two
pandemic.
Focus area

are based on analysis of secondary data (Kumar et al., 2020a;

Sangkham, 2020). Three review articles have COVID-19 related BMW
as their core focus (Ilyas et al., 2020; Ramteke and Sahu, 2020; Das et
al., 2020) and the rest mostly discussed both positive and negative
environmental consequences of COVID-19. In that holistic environ-
mental discourse, BMW received position as the negative externality
Environmental effects of COVID-19 pandemic

Face mask and medical waste disposal during

Sanitation workers at the frontline: work and

of the highest degree. The linkages of Biomedical waste management

and potential strategies of sustainability

with other wastes, namely, municipal solid waste and more specif-
vulnerability in response to COVID-19
the novel COVID-19 pandemic in Asia

ically food waste and plastic waste have been emphasized (Kulkarni
and Anantharama, 2020; Sharma et al., 2020; Vanapalli et al., 2020).
Mixing of waste, improper handling and safety measures, inadequate
treatment facility, lack of mechanization and automation, increasing
share of plastic wastes, risk of disease transmission and vulnerability
of waste handling workers are some of the major concerns emerged
from the studied literatures. Studies with implementable
goal-oriented objectives leading to suggestions with policy implica-
tions, like the one by Kumar et al. (2020a) are need of the hour to deal
Title

with the massive problem of BMW management with many

un-estimated health and environmental impact. In that study, life
cycle assessment of PPE shows that decentralized incinerator is a
better option for PPE waste management as compared to centralized
Jungari (2020)

facilities including both incinerator and landfill. It has been observed

Islam (2020)

Sangkham
Rume and

that there is insufficient studies on safety aspects of BMW

Salve and
(2020)
Author

management.
Table 1 (continued )

3.2. Discussion on BMW-COVID-19 in mass media

A total of 74 newspaper articles have been reviewed to assess the

Sl. No.

types of information available in mass media on COVID-19 related BMW

10

11

from March 2020 to August 2020 across different states of India. All
9

4
M. Goswami et al. Heliyon 7 (2021) e06313

Table 2. Estimation of COVID-19 positive cases and pattern of BMW-COVID generation in selected states.

State/UT Number of Percentage of infected BMW-COVID- 19 Assumed patients in Per capita BMW No. of HCFs No of Captive
COVID-19 cases to total population (tons in Aug 2020) Hospital* (1in 5 active) ** generation having Captive Incinerators Operated
(kg/day) Treatment Facilities by HCFs
Maharashtra 1224000 1.07 1359 33400 1.36 218 4
Andhra Pradesh 630000 1.27 118.8 17868 0.22 0 0
Tamilnadu 547000 0.81 481 10732 1.49 0 0
Karnataka 526000 0.82 588 16344 1.20 2985 3
Uttar Pradesh 358000 0.18 408.8 9865 1.38 10 10
Delhi 250000 1.32 296.1 2402 4.11 3 0

*Based on average daily active cases; ** WHO estimation.

Date Sources: CPCB, GoI; Census of India, GoI.

documented news articles with relevant analysis parameters are in 3.3. COVID-19 cases and BMW management; a state-wise overview
Annexure-1. When the news articles were grouped into five aspects of
BMW management, it was observed that the group “monitoring, action Central Pollution Control Board Annual Report- 2018 (CPCB, 2018)
and penalty” has the highest number of news articles, followed by mentions that 28 Indian states have arrangements for environmentally
regulation and notification (Annexure-2a). During initial days of the safe disposal of BMW. Those states have 200 authorized Common
pandemic i.e. the month of March, the number of reports was the highest Bio-medical Waste Treatment and Disposal Facilities (CBWTFs) and
as compared to other studied months; where, emphasis was largely on remaining seven states (Goa, Andaman Nicobar, Arunachal Pradesh,
regulatory guidelines and CPCB notifications for proper management of Lakshadweep, Mizoram, Nagaland and Sikkim) do not have CBWTFs. In
BMW. It also highlighted the inadequate infrastructure and resources for addition to those facilities, there are 12,296 captive treatment and
BMW management. Reporting on monitoring, management initiatives disposal facilities installed by Healthcare Facilities and authorised by
and penalty gradually increased with the spread of virus from May to concerned State Pollution Control Board/Pollution Control Committee
August, when violations of BMWM Rules 2016 were apparently (SPCB/PCC). As per CPCB Annual Report for the year 2018, the total
increasing. Mixing of BMW with household solid waste, deceased pa- number of healthcare facilities is 2,60,889, which is estimated to generate
tients' beddings and other non-hazardous wastes from quarantine homes about 608 MT per day of BMW, out of which 528 MT is treated and
and COVID-care centres, which led to increased quantity of BMW and disposed through either CBWTF or Captive disposal facility (CPCB, 2018).
associated problems in treatment facilities were reported in 12 articles Results of a research in Pune city revealed 69.2% of the hospitals had a
across the country. Figure 3 represents state-wise news reporting in the biomedical waste management facility (Kulkarni and Yeravdekar, 2020).
five leading dailies, where highest reporting has been observed in India's utmost effort in combating this pandemic have significantly
Maharashtra with 20 news articles covering all the five aspects of BMW shot-up the quantity of waste generated from healthcare facilities,
management. Rest of the articles cover other 15 states/UTs of the quarantine facilities and laboratories etc. This manyfold increase in
country. Concerns regarding safe handling and health of waste workers hospital waste generation is likely to exert pressure on the waste man-
have been reported in seven states. agement system and may bring a situation of jeopardized environment

0 1 2 3 4 5 6 7
70000.00 180
Ac ve COVID19 cases (no. of individual in

60000.00 160
140
50000.00
BMW kg/day

120
40000.00 100
80
thousand)

30000.00
60
20000.00
40
10000.00 20
0.00 0
Maharastra Andhra Tamilnadu Karnataka U ar Delhi
Pradesh Pradesh

BMW-COVID 19 kg/day in Aug2020 BMW-COVID 19 kg/day in July2020

BMW-COVID 19 kg/day June2020 BMW generated kg/day (2018)
Avg Ac ve cases '000 (per dayin Aug) Avg Ac ve cases '000 (per day in July)
Avg Ac ve cases '000(per day in June)

Figure 2. Active COVID-19 patients, corresponding BMW-COVID-19 generated during June–Aug 2020 and business as usual BMW generation in top six affected states
(Source: CPCB, 2018, NGT, 2020a)

5
M. Goswami et al. Heliyon 7 (2021) e06313

Figure 3. Change of active cases of COVID-19 in selected states/Union Territories high impacts of COVID-19.

and community health. Under conventional situations, India generates a In Kerala, according to another media report, COVID-19 related BMW
much lower quantity (0.3–1kg/bed/day) of BMW as compared to rose by more than 13000kg per day within a week (between 13–18 May,
Netherlands (2.7 1kg/bed/day), France (2.51kg/bed/day) and USA 2020), which is 2–2.5 Tonnes/day increase in quantity (Times of India,
(4.51kg/bed/day) (CPCB, 2015). India's reported BMW generation per 22nd May 2020). The National Green Tribunal, Principal Bench Order of
bed per day is even lower than other developing countries; for example, July 20, provide information that available capacity for incineration of
Bangladesh generates 1⋅63–1⋅99 kg per bed per day in Dhaka (Rahman et COVID-19 biomedical waste in India is about 840 Metric Tons (MT). It is
al., 2020). In Europe, Suez (a company engaged in treatment, disposal estimated that about 55% of cumulative incinerator capacity in the
and energy recovery of BMW) has presented some estimates of increase country is being utilised. However, there may be capacity limitation in
in Biomedical waste generation during this pandemic. Their facilities in specific areas or cities when the available capacity of CBWTFs in a
different locations with impacts of COVID-19 have observed momentous coverage area of 150 km may not be adequate due to spike in generation
increase in the quantity received for treatment; Sausheim (Haut-Rhin) of biomedical waste (NGT, 2020a).
plant in Grand Est has an increase of 40%, a 50% rise in VALO'MARNE in Estimation of BMW generation in India varies 0.3kg–1kg BMW per
Ile-de-France and a 30%–50% increase in Netherlands. The hospitals in bed per day and statements of medical practitioners reveal approximately
Wuhan, China are generating six times more waste during the peak of 15 times increase in BMW in case of treating COVID-19 patient (Hin-
COVID-19 outbreak than any normal day prior to the crisis (The Verge, dustan Times, 18th April, 2020), 4.5kg-15 kg of BMW production per
2020). COVID-19 patient per day is a rational figure to consider for the

6
M. Goswami et al. Heliyon 7 (2021) e06313

Figure 4. Change in generation of BMW-COVID in states/Union Territories high impacts of COVID-19.

estimation in India. Calculation considering lower value can come close where there was a decrease in number of cases over the three months.
to the reported waste generated only in case of Delhi (4.1kg/day/patient Andhra Pradesh exhibits the highest rise is active cases (22.25 times)
as in Table 2). with a decrease in BMW-COVID-19 generation (0.7 times change) from
Average daily active patients and generation of BMW-COVID-19 June to August. The changes in active case and corresponding BMW
(daily average) for three months (June–August) in top six affected generation per day are comparable in case of Maharashtra, Delhi and
states have been presented in Figure 2. Average daily BMW generation Tamil Nadu.
during 2018 is presented as three-dimensional bars in the figure. Kar- The percentage change in average daily active cases from June to
nataka and Maharashtra generate the highest amount of BMW in non- August in 13 states/Union Territories are presented in Figure 3. Among
COVID-19 situations with 65 MT per day and 62 MT per day respec- the studied states/Union Territories, only Delhi has experienced a
tively. BMW-COVID-19 generation in these two states have reached decrease in average daily active cases and the decline accounts 74% from
approximately 44 MT per day in Maharashtra and 19MT in Karnataka. June to August. However, the corresponding change in BMW-COVID
Maharashtra also tops the list of states with bedded healthcare facilities quantity is just -12.6%. On the other hand, two states (Madhya Pra-
with 19,647 HCFs, followed by Uttar Pradesh, Gujarat and Karnataka. desh and Andhra Pradesh) have shown 75% and 95% increase in average
Increase in number of average daily active cases from the month of June daily active cases over the two months with whimsical decrease in BMW-
to August varies from 2.34 to 22.25 times in top five states except Delhi COVID generation, i.e. 110% and 39% respectively (Figure 4). In non-

7
M. Goswami et al. Heliyon 7 (2021) e06313

Figure 5. Generation of BMW-COVID and treatment facilities in states/Union Territories with high impacts of COVID-19 [Note: White pixels in all the above three
maps (3–5ca) represent no data regions].

Table 3. Summary of regression analysis (Confidence level 95%).

Variables June 2020 July 2020 Aug 2020

R 0.815 0.909 0.77
Standard Error 88.54 130.80 232.54
Significance F 0.0007 1.69E-05 0.0021
Intercept 120.99 85.91 116.26
X Variable 1 0.008 0.0083 0.0059

COVID-19 situation, Karnataka is the largest producer of BMW followed been studied for 13 states/UT of India which have been at the top in
by Maharashtra, Tamil Nadu and Uttar Pradesh. The overall change in terms of total COVID-19 positive cases. These studied states/UT have 158
active COVID-19 cases and generation of COVID-19 related BMW has of total 198 CBWFTs of India (Figure 5). The increase in average daily

8
M. Goswami et al. Heliyon 7 (2021) e06313

active cases for 12 states of India has been observed over three months, adequacy of treatment facilities in some of the highly affected states, viz.-
viz.- June–August 2020. Karnataka, Maharashtra, Telangana, Uttar Pradesh, Gujarat, Haryana and
Maharashtra is the worst affected state due to the current pandemic, Madhya Pradesh.
and in non-COVID-19 situation, it is among the top BMW generating
states in India and with comparatively better management facilities. 3.4. Interventions of regulatory authorities in BMW-COVID-19
Annual report of Maharashtra Pollution Control Board (MPCB) management
(2018–19) states that the state has 60,414 healthcare facilities, where
50,440 kg/day of BMW is generated from bedded hospitals, 11,793 kg/ Considering the magnitude of problem associated with BMW man-
day is generated from non-bedded hospitals and 185 kg/day is generated agement during pandemic, Central Pollution Control Board (CPCB) has
from other sources. The state has 34 treatment facilities, out of which 29 initially formulated guidelines (Guidelines for Handling, Treatment and
have incinerators and five are deep burial facilities. There are three Disposal of Waste Generated during Treatment/Diagnosis/Quarantine of
incinerator-based facilities within Bruhanmumbai Municipal Corpora- COVID-19 Patients) based on current knowledge on COVID-19 and from
tion (BMC) to deal with BMW. Pollution Control Boards of specific states other contagious diseases like HIV, H1N1 etc, and existing practices in
have also formulated and issued guidelines for Management of BMW managing infectious and hazardous wastes. CPCB has been issuing spe-
with specific instructions for implementation. It is also seen that quantity cific guidelines about segregation, collection, storing, transportation and
has gone down in some days during that period, which is dubious in disposal of BMW generating from the COVID-19 treatment facilities. The
reality looking at the increasing number of active patients in the city. guidelines further stipulated that the Common Bio-Medical Waste
Officials attribute such discrepancies to improper segregation of waste at Treatment Facilities (CBWTF) operators “shall ensure regular sanitisation
the source. of workers involved in handling and collection of biomedical waste and
Among the six states (Table 2) the percentage of population reported that they should be provided with adequate personal protective equip-
as infected with COVID-19 varies from 0.18 (Uttar Pradesh) to 1.32 ment”. PPE has been suggested as mandatory for all medical personnel
(Delhi) till August 2020. Estimation of patients in hospitals have been with probable exposure to the virus including ambulance staff, persons
done as per WHO report (WHO, 2020a) that one in five COVID-19 pa- involved in handling of any material exposed to COVID-19 care facilities.
tients worldwide is to be given medical care in hospital. The quantity of Four revisions of the guidelines have been done to incorporate spe-
BMW-COVID thus calculated has shown 4.11kg per patient per day in cific needs and tasks to be followed. First two revised guidelines specif-
Delhi; whereas, the same is remarkably low (0.22–1.49 kg per day per ically provide instructions on
patient) for other five states. Among all six states/UTs, Andhra Pradesh
and Tamil Nadu don't have any healthcare facility with captive treatment  Duties and responsibilities of persons of State Pollution Control
or incinerator facility. In such case, reports of low generation of Boards, Pollution Control Committees, Urban Local Bodies and per-
BMW-COVID indicates mis-management of hospital wastes. Considering sons involved in handling of wastes in Common Biomedical Waste
number of active cases across the states as the explanatory variable, a Treatment Facilities and persons operating sewage treatment plants
bivariate regression analysis has been done and the results are presented at healthcare facilities
in Table 3. The analysis reveals that in the month of July (2020), the  Segregation of waste at the point of generation
correlation between number of active cases and quantity of BMW-COVID  Management of general waste from quarantine facilities
has the highest R value (0.909) as compared to the preceding and pro-
ceeding months. Looking at the changing pattern of strengths of the National Green Tribunal, India, expressed the need for further revi-
correlation over the three months, it may be rational to assume that sion of the guidelines so that all aspects of scientific disposal of liquid and
collection and reporting improved from June to July. The result is sug- solid waste management are taken care of not only at institution level but
gestive of situations where either COVID-19 related hospital waste was also at individual levels, such as manner of disposal of used Personal
done in proper manner or there was a drastic decline in need of hospi- Protection Equipment (PPE), without the same getting mixed with other
talization for active patients in the month of August, even after a sharp municipal solid waste causing contamination. Administrations and the
rise in active cases from June to August. management of the service providers are required to provide adequate
Waste producers' behaviour, segregation of waste, human resource PPEs for the human resources handling BMW as prescribed in the
capacities (staff and authorities), a well-established transportation sys- guidelines. Training of the staff on proper provided disposal of waste
tem with treatment and disposal infrastructures, and monitoring func- material arising from COVID-19 care facilities is another key precau-
tions are some of the factors influencing management of waste (Amitha tionary measure to be conducted to prevent exposure risks to contami-
and Manoj, 2020; Di Foggia and Beccarello, 2020; Datta et al., 2018). nated substances.
BMW in India is basically handled by third party organizations linked to Subsequent revisions (CPCB, 2020a) of the Guidelines incorporated
municipalities. Capacities and compliance of those organizations play a guidance on
major role in safe management of BMW (Rahman et al., 2020). Health-
care facilities with registration, legal recognition and linkage to third  Segregation of general solid waste and BMW
party waste management companies can be important determinants in  Safety of waste handlers and sanitation workers
adequate collection and reporting of actual BMW generated.  Providing training to waste handlers about infection prevention
Non-compliance of regulatory norms by healthcare facilities is highly measures
prevalent in non-COVID-19 situation in India; where, only in 2018, State  Electronic tracking of BMW through an App “COVID19BMW”
Pollution Control Boards and Committees have recorded 27427 HCFs or  Disposal of used PPEs
CBWTFs violating BMWM Rules, 2016 (MoHFW, 2020). Government
data shows that India has more than 2 million hospital beds in 97382 Technology enabled monitoring and tracking of BMW from genera-
hospitals. There are 68467 HCFs are running without authorization in the tion to safe disposal became essential for efficiency optimization. CPCB
country. In addition to it, inadequate capacity of the existing facilities is developed COVID-19 waste tracking software named “COVID19BMW”,
likely to contribute to this intricate situation of BMW-COVID manage- which can track BMW at the time of generation, collection and disposal.
ment. Report dated 17th June (NGT, 2020b) revealed that in the month of This application was designed for waste generators, CBWTF Operators,
May (2020), most of the states (to name- Assam, Bihar, Kerala, Tamil State Pollution Control Boards/Pollution Control Committees and Urban
Nadu, Delhi, Uttarakhand, Orissa, Rajasthan, Goa) didn't have adequate Local Bodies. The average daily quantity of COVID-19 related BMW
capacity to treat the growing quantity of BMW, where 70–90% of the generation is about 169 MT in August 2020, as reported from the data
states' CBWFT- capacity was utilized. A positive aspect reported was collected through the APP (CPCB, 2020b).

9
M. Goswami et al. Heliyon 7 (2021) e06313

3.5. Changing composition of BMW and disposal risks reduction; but it will be prudent to keep in mind the potential spike of
emission of hazardous elements from the incinerators. Incomplete
Amid sudden influx of Corona-virus patients in various healthcare burning in incinerator operation can result in production of dioxins,
facilities across India, disposal of BMW-COVID is becoming a major which are unintentional by-products of waste combustion. Dioxins, a
challenge. With approximately five million confirmed cases of COVID-19 group of persistent organic pollutants (POPs) are referred to the family of
and one million active cases by mid-September, India has second largest structurally and chemically related polychlorinated dibenzo para dioxins
number of Corona-virus infected individuals in the world. Immense (PCDDs), polychlorinated dibenzofurans (PCDFs) and certain dioxin-like
environmental health consequences, may arise due to improper man- polychlorinated biphenyls (PCBs) with similar toxic properties (WHO,
agement of BMW; due to highly contagious nature of the Corona virus, it 2016). Risk of adverse impact on human health like reproductive and
can lead to serious situation by amplifying the status of COVID-19 spread, developmental problems, can also be associated due to exposure to
if appropriate and adequate measures are not implemented in each stage emissions of highly toxic gases. Chronic exposure to dioxin can also lead
of BMW management. During the fight against COVID-19, it is expected to damage to the immune system, endocrine mechanisms, nervous sys-
to increase the amount of BMW from healthcare centres, quarantine and tem and they are known carcinogens (WHO, 2017; Rai et al., 2020; Rao
testing facilities. The quantity of BMW related to coronavirus disease in and Ghosh, 2020; Vilavert et al., 2015). Due to the chemical stability of
the district has increased by 585% between April and June months, dioxins, these toxins can stay longer in the body and have the ability to be
showed data compiled by Biotic (Hindustan Time, 30thJune 2020). Along accumulated in fatty tissues. The estimated half-life of dioxin is 7–11
with the normal constituents of BMW, in case of COVID-19 related years (WHO, 2016). Burning of medical devices made up of polyvinyl
treatment procedures also generate huge quantity of Personal Protective chloride (PVC) is the largest dioxin producers in the environment (Mat-
Equipment (PPE), primarily consisting of gloves, masks, goggles, face tiello et al., 2013). In addition, medical waste with metal component can
shield, shoe cover and hazmat (coverall) suits, used by the frontline act as a catalyst for dioxin formation. Standards for dioxin and furan
healthcare personnel. The discarded PPEs are to be collected in Yellow emission from incinerators have been modified in the amended BMWM
and Red bags as classified under the BMW guidelines and to be disposed Rules, 2016. Standard for dioxin and furans has been set at 0.1 ng TEQ
with utmost care at Common Bio-medical Waste Treatment and Disposal per cubic meter. Another pollution associated with incineration is
Facilities (CBWTFs). The yellow category waste also includes human and disposal of bottom ash which are enriched with heavy metals and other
animal anatomical waste, placenta, foetus, soiled waste, pre-treated toxics (Vivek et al., 2019). Indian scientists have proposed a strategy to
microbiological and biotechnological waste, pharmaceutical and cyto- dispose the PPE kits (nonwoven polypropylene) by converting to liquid
toxic waste; linen and mattresses (BMWM Rules, 2016). The prescribed fuel by catalytic pyrolysis method (Jain et al., 2020).
disposal method of BMW including PPEs, is incineration or plasma py-
rolysis or deep burial. As polymer polypropylene, polyethylene, PVC and 3.6. Capacity building of sanitation workers
PET are used in making the PPEs, if proper procedures are not followed,
disposal procedure may lead to potential environmental risks. Plastics Similar to the frontline warriors like doctors and nurses in the
mixed with other materials lowers the recyclability and infected plastic healthcare setup, sanitation workers are equally important group of
waste may pose high risk of viral transmission to the people in the stakeholders engaged effective management of COVID-19 pandemic.
recycling job (Tenenbaum, 2020; Sharma et al., 2020). The National According to a study conducted by Dalberg Advisors (2017), there are
Green Tribunal (NGT), India, has urged the State Pollution Control Board estimated to be 5 million sanitation workers in India, where 50% of them
and Pollution Control Committee to put in serious efforts to mitigate the are women. These workers are considered to be among one of the most
possible risk of unscientific disposal of the BMW arising out of the vulnerable and marginalized communities in the socio-economic ladder.
handling of the COVID-19 disease. One of the major concerns is lack of awareness about the hazards of
Other important issue, which needs a careful consideration is the biomedical waste among people exposed to or handling the waste at
potential environmental impact of disposal of non-biodegradable BMW various levels. Awareness generation and training of the human re-
(PPEs and other equipment), as there is a huge spike in number of such sources dealing with collection and disposal of BMW are the key areas for
items. A consolidated UN inter-agency demand forecast for PPEs sug- ensuring safety and minimizing risks. Studies show that non-technical
gested the needs for Low Income Countries (LICs) and Middle Income hospital staff and undergraduate medical students do not have
Countries (MICs) for the remainder of 2020 is 2.2 billion surgical masks, adequate knowledge on BMW management (Pandey et al., 2020;
1.1 billion gloves, 13 million goggles and 8.8 million face shields. Based Choudhary et al., 2020). A study in Pakistan during the current pandemic
on simulation exercises on the use of PPE during previous outbreaks with shows that less than half of the healthcare workers are aware about safe
similar transmission modes, such as Severe Acute Respiratory Syndrome disposal of hospital waste such as personal protective measures (Kumar
(SARS) and Middle East Respiratory Syndrome (MERS), WHO recom- et al., 2020b). CPCB guidelines on COVID-19 related BMW management,
mends the need of 25 units of gown, 25 units of medical masks, 50 units instructed various authorities to provide training to waste handlers on
of gloves, 1 unit each of N95 mask and face-shield each day per patient infection prevention measures, hand hygiene, respiratory etiquettes, so-
(UNICEF, 2020). Based on WHO modelling, an estimated 89 million cial distancing, use of PPE etc. CPCB also created audio-visual awareness
medical masks, 76 million examination gloves and 1.6 million goggles generating material for relevant stakeholders (CPCB, 2020).
per month would be needed globally. WHO estimates that PPE produc-
tion needs to be increased by 40% to meet the global demand (WHO, 4. Discussion
2020b).
According to market assessment report the demand for Polypropylene It is encouraging to witness that the Central Pollution Control Board
(PP) in India grew at a CAGR of around 8.51% during 2015–2019 period. (CPCB) has been in the forefront to come up with timely guidelines to-
As a response to the pandemic outbreak and call by WHO (WHO, 2020b), wards BMW-COVID-19. There are apparent challenges and gaps in
there has been a surge in manufacturing of Personal Protective Equip- implementing the guidelines due to inadequate infrastructure across the
ment (PPE), demand for polypropylene gained and expected to grow states and inconsistent operational efficiency of implementing agencies.
further in coming years (Businesswire, 2020). By mid-May according to Though there have been many revisions in regulatory guidelines for
media report, around 600 companies started manufacturing about better management of BMW during this pandemic, no significant
450000 PPE suits per day, which is mostly contributed by textile sector improvement of management efficiency has been observed over the
manufacturing units (NDTV, 2020; Mezzadri and Ruwanpura, 2020). study period. Weak monitoring system and low accountability are to be
As incineration is the most preferred choice of disposal of CBWTF in rectified through a strong penalty-based monitoring at each level. In spite
India because of its potential for pathogen destruction and volume of regulations in place for segregation of healthcare waste for safe

10
M. Goswami et al. Heliyon 7 (2021) e06313

disposal, mixing with municipal solid waste and other plastic waste is a than the other states. Observations show manifold increase in domestic
major challenge in BMW-COVID-19 management in India (Sharma et al., consumption of PPE and this trend is expected to continue. Media reports
2020; Kulkarni and Anantharama, 2020). The gap between policy and have been affirming the intricacies regarding management of increased
implementation, more specifically pertaining to infrastructure, capacity quantity of BMW across the globe. The authorities need to adopt inno-
and monitoring to be bridged. Strategies are essential to collaborate with vative strategies to manage plastic waste generated due to this pandemic
private and public sector entities for innovation and technology inte- and in this regard, the collaboration with scientific community will be
gration to overhaul these manifested breaches. Considering the quantity paramount. It is revealed in both the reviews, scientific literature and
of waste generated, technology for recycling and resource recovery media articles, that there is a critical need for emphasis on capacity
should be given priority. building of the BMW handlers with proper training and providing them
Incinerators, shredder, sharp pit, encapsulation, deep burial and with modern equipment for safe and effective management of hazardous
chemical disinfection, which are obligatory for BMW management were waste.
found non-existing in 60%–90% of hospitals. Study in four states (West
Bengal, Bihar Uttarakhand and Jharkhand) of India shows that 72% of 5. Conclusion
hospital wastes are not segregated and 74% of the hospitals are not
connected to any CBWTF (WHO, 2017). Though most of the hospitals are This article provides an overall position of India in management of
tied to a centralized waste management facility, open dumping is still BMW during the outbreak of COVID-19. There is a need to evaluate the
prevalent in the country, which is either by the healthcare facility or by entire BMW management infrastructure and necessary investments have
the treatment facility while on the roadside while transporting the waste. to be made for expansion to improve the capacity and coverage. Such
High prevalence of open dumping (56%) and irregular collection by expenditure will worth its value and will ensure safe and sound BMW
CBWTF vehicles, low level of staff awareness etc. are some of the major management with adequate capacity to get the country prepared for any
lacuna that affecting hospital waste management (WHO, 2017). Pollu- future disaster. Stringent monitoring mechanism, operational and func-
tion Control Committees (SPCBs/PCCs) for the year 2018, about 27427 tional efficiency of CBWTFs and transparency aspects are other important
instances of violations under Bio-Medical Waste Management Rules, elements, where constant focus from the relevant authorities is required
2016 were reported against Healthcare Facilities (HCFs) or Common to ensure safe and proper disposal of the BMW. More emphasis on
Biomedical Waste Treatment and Disposal Facilities (CBWTFs). Another innovation of environment-friendly technologies and capacity building
report (ASSOCHAM-Velocity MR report, 2018) revealed that in India, the of healthcare workers and waste-handlers are other concerns to be
major challenges pertaining to BMW management are under-reporting of prioritized for safe collection, treatment and disposal of BMW. The
waste generated and handling capacities, operation of healthcare facility experience of BMW management in this global crisis can be a learning for
without authorization, lack of awareness among the people involved in authorities to develop a well-equipped system for safe disposal in post-
handling of BMW at different levels. Study in Bhutan during this COVID-19 scenario and to provide insights for disaster preparedness in
pandemic has also identified lack of healthcare workers capacity and future.
weak implementation of National guidelines as major shortcomings in
proper management of BMW (Zimba Letho et al., 2021). Another study in Declarations
Saudi Arabia revealed that the healthcare workers are well-aware of the
safety precautions to be taken but have low level of knowledge about Author contribution statement
waste management procedure in their healthcare facilities (Aleanizy and
Alqahtani 2020). Sunil Nautiyal, Mrinalini Goswami, Pranjal J. Goswami and Satya
There are several loopholes in the existing system of BMW manage- Prakash: Conceived and designed the experiments; Performed the ex-
ment in the country which might have posed grievous toiling situation in periments; Analyzed and interpreted the data; Contributed reagents,
BMW-COVID-19 management. Lack of awareness, strong need of training materials, analysis tools or data; Wrote the paper.
for technical and non-technical staff, improper segregation etc. are some
of the concerns to be addressed for enhancing efficient implementation Funding statement
(Pandey et al., 2020; Krishna et al., 2018; Archana et al., 2016; Goyal et
al., 2017; Soyam et al., 2017; Sudeep et al., 2017). This shortcoming may This research did not receive any specific grant from funding agencies
be attributed to inadequate functioning of institutional and financial in the public, commercial, or not-for-profit sectors.
mechanisms for surveillance, monitoring, incentives and penalty. CAG
report (Comptroller and Auditor General of India GoI, 2017) on BMW in Data availability statement
Maharashtra emphasized the need of implementation of the Rules with
adequate administrative and regulatory framework. The Data included in article/supplementary material/referenced in
non-compliances and initiatives for BMWM are in a bi-directional impact article.
loop; specifically, functioning of healthcare establishments without
authorization amplify the threats, which certainly alienate significant Declaration of interests statement
quantity of BMW unaccounted further resulting in discrepancies in
planning. Costs for safe treatment and disposal of hazardous health-care The authors declare no conflict of interest.
waste are typically more than ten times higher than those for general
waste in non-pandemic situation (WHO, 2018); whereas is India, it has Additional information
been identified that shortage of fund is the prime problem in imple-
menting BMWM efficiently (Datta et al., 2018). This cost estimation Supplementary content related to this article has been published
might have increased considerably when it comes to managing COVID-19 online at https://doi.org/10.1016/j.heliyon.2021.e06313.
related BMW.
It is evident from the above results and analysis that there are existing Acknowledgements
gaps in infrastructure, capacity, monitoring, disposal and awareness
levels required for effective management of BMW in India. Not all states We extend our sincere thanks to Dr. HUU HAO NGO, Associate Editor
have adequate facilities and resources to manage BMW as prescribed by – Environment, Heliyon and four anonymous reviewers for their valuable
the authorities. Some of the states like Maharashtra, Karnataka, Gujarat suggestions, thought providing insights and constructive comments to
and Delhi have comparatively better BMW management infrastructure improve the paper. This has helped the authors to revised paper and

11
M. Goswami et al. Heliyon 7 (2021) e06313

improved overall scientific outcomes of this interesting study on Ilyas, S., Srivastava, R.R., Kim, H., 2020. Disinfection technology and strategies for
COVID-19 hospital and bio-medical waste management. Sci. Total Environ. 749,
contemporary issue in India. We are thankful to the Director, Institute for
141652.
Social and Economic Change (ISEC), Bengaluru for support and facilities. Jain, S., Bhawna, Y.L., Kumar, S., Singh, D., 2020. Strategy for repurposing of disposed
Views expressed here are of the authors only and not of the organization PPE kits by production of biofuel: pressing priority amidst COVID-19 pandemic.
with which they are affiliated. Biofuels.
Jiajun, W., 2020. Cement Industry in China Assisted with Disposal of Covid-19 Healthcare
Waste. https://www.zkg.de/en/artikel/zkg_Cement_industry_in_China_assisted_with_
References disposal_of_Covid-19_healthcare_3535100.html.
Krishna, C., Nisar, J., Iyengar, K., Das, S.R., 2018. Awareness about biomedical waste
Aleanizy, F.S., Alqahtani, F.Y., 2020. Healthcare Workers Awareness and Knowledge of management among hospital staff in a tertiary care hospital in Tumkur. Indian J.
Covid-19 Infection Control Precautions and Waste Management: Saudi Arabia Cross Prev. Med.
Sectional Study. Kulkarni, B.N., Anantharama, V., 2020. Repercussions of COVID-19 pandemic on
Amiraslani, F., Caiserman, A., 2018. From air pollution to airing pollution news: multi- municipal solid waste management: challenges and opportunities. Sci. Total Environ.
layer analysis of the representation of environmental news in Iranian newspapers. 743, 140693.
J. Int. Commun. 24 (2), 262–282. Kumar, J., Katto, M.S., Siddiqui, A.A., Sahito, B., Jamil, M., Rasheed, N., Ali, M., 2020a.
Amitha, A.J., Manoj, V., 2020. Evidence-based analysis of patterns of challenges in solid Knowledge, attitude, and practices of healthcare workers regarding the use of face
waste management by Urban local Bodies in India. In: Sustainable Waste mask to limit the spread of the new coronavirus disease (COVID-19). Cureus 12 (4).
Management: Policies and Case Studies. Springer, Singapore, pp. 167–181. Kumar, H., Azad, A., Gupta, A., et al., 2020b. COVID-19 Creating another problem?
Antilla, L., 2010. Self-censorship and science: a geographical review of media coverage of Sustainable solution for PPE disposal through LCA approach. Environ. Dev. Sustain.
climate tipping points. Publ. Understand. Sci. 19 (2), 240–256. Mardani, A., Streimikiene, D., Cavallaro, F., Loganathan, N., Khoshnoudi, M., 2019.
Archana, B.R., Gupta, V., SreeHarsha, S., 2016. Awareness of biomedical waste Carbon dioxide (CO2) emissions and economic growth: A systematic review of two
management among health care personnel in Bangalore, Karnataka. Indian J. Publ. decades of research from 1995 to 2017. Sci. Total Environ. 649, 31–49.
Health Res. Dev. 7 (3), 17–20. Mattiello, A., Chiodini, P., Bianco, E., Forgione, N., Flammia, I., Gallo, C., et al., 2013.
Assocham-Velocity MR Report, 2018. Unearthing the Growth Curve and Necessities of Bio Health effects associated with the disposal of solid waste in landfills and incinerators
Medical Waste Management in India. Assocham, India. in populations living in surrounding areas: a systematic review. Int. J. Publ. Health
Bashir, M.F., Ma, B.J., Bilal, K.B., Bashir, M.A., Farooq, T.H., Iqbal, N., Bashir, M., 2020. 58, 725–735.
Correlation between environmental pollution indicators and COVID-19 pandemic: a Mezzadri, A., Ruwanpura, K., 2020. How Asia’s Clothing Factories Switched to Making
brief study in Californian context. Environ. Res. 187, 109652. PPE–But Sweatshop Problems Live on. The Conversation UK.
Batterman, S., 2004. Assessment of Small-Scale Incinerators for Health-Care Waste. World Ministry of Home and Family Welfare, 2020. Press Note released on 07 FEB 2020 12:
Health Organization, Geneva, 21 January. 49PM by PIB Delhi. https://pib.gov.in/PressReleaseIframePage.aspx?
Bio-Medical Waste Management Rules, 2016. National accreditation board for hospitals PRID¼1602353.
and healthcare providers [online]. http://nabh.co/Announcement/BMW_Rules Misra, V., Bhardwaj, A., Bhardwaj, S., Misra, S., 2020. Novel COVID-19–Origin, emerging
_2016.pdf. challenges, recent trends, transmission routes and Control-A review. J. Contemp.
Bio-Medical Waste Management (Amendment) Rules, 2018. https://pib.gov.in/Pressrele Orthod. 4 (1), 55–56.
aseshare.aspx?PRID¼1526326. Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P.,
Boora, S., Gulia, S.K., Kausar, M., Tadia, V.K., Choudhary, A.H., Lathwal, A., 2020. Role of Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-
hospital administration department in managing Covid-19 pandemic in India. J. Adv. analysis protocols (PRISMA-P) 2015 statement. Syst. Rev. 4 (1), 1–9.
Med. Dent. Sci. Res. 8 (5). NGT, 2020a. BEFORE THE NATIONAL GREEN TRIBUNAL PRINCIPAL BENCH, NEW
Businesswire, 3rd June 2020. India Polypropylene Market Assessment 2015-2030 - DELHI. In reply to: Scientific Disposal of Bio-Medical Waste arising out of Covid-19
Tremendous Growth Opportunities in the Manufacturing of PPE - treatment- Compliance of BMW Rules 2016. https://greentribunal.gov.in/gen_pdf_
ResearchAndMarkets.Com. https://www.businesswire.com/news/home/2020060 test.php?filepath¼L25ndF9kb2N1bWVudHMvbmd0L2Nhc2Vkb2Mvb3JkZXJzL0R
3005330/en/India-Polypropylene-Market-Assessment-2015-2030—Tremendous. FTEhJLzIwMjAtMDctMjAvY291cnRzLzEvZGFpbHkvMTU5NTM
Choudhary, M., Verma, M., Ghosh, S., Dhillon, J.K., 2020. Assessment of knowledge and xOTc1NjEyNjg2OTQ2ODc1ZjE2YTVjY2JjMDM5LnBkZg¼¼.
awareness about biomedical waste management among health care personnel in a NGT, 2020b. BEFORE THE NATIONAL GREEN TRIBUNAL PRINCIPAL BENCH. Report on
tertiary care dental facility in Delhi. Indian J. Dent. Res. 31 (1), 26. Scientific Disposal of Bio-Medical Waste arising out of Covid-19 treatment-
Comptroller and Auditor General of India, GoI, 2017. Report of the Comptroller and Compliance of BMW Rules 2016. https://greentribunal.gov.in/sites/default/files/ne
Auditor General of India (Civil) for the Year 2016. Government of Maharashtra. ws_updates/Status%20Report%20in%20O.A%20No.%2072%20of%202020.pdf.
https://cag.gov.in/content/report-no5-2017-local-bodies-government-maharashtra. NDTV, 19th May 2020. https://www.ndtv.com/india-news/from-zero-india-now-manu
CPCB, 2020a. Guidelines for Handling, Treatment, and Disposal of Waste Generated factures-4-5-lakh-ppe-suits-a-day-to-fight-coronavirus-2231742. https://www
during Treatment/Diagnosis/Quarantine of COVID-19 Patients - Rev. 4. Central .ndtv.com/india-news/from-zero-india-now-manufactures-4-5-lakh-ppe-suits-a-day-
Pollution Control Board. Government of India. https://cpcb.nic.in/uploads/Projects to-fight-coronavirus-2231742.
/Bio-Medical-Waste/BMW-GUIDELINES-COVID_1.pdf. Panda, R., Kundra, P., Saigal, S., Hirolli, D., Padhihari, P., 2020. COVID-19 mask: a
CPCB, 2020b. Report on COVID-19 Waste Management. Central Pollution Control Board. modified anatomical face mask. Indian J. Anaesth. 64 (14), 144.
https://cpcb.nic.in/uploads/Projects/Bio-Medical-Waste/COVID19_Waste_Man Pandey, A., Pandey, A.S., Sharma, P., 2020. Revised biomedical waste management
agement_status_August2020.pdf. guidelines, 2016- knowledge, attitude and practices among healthcare workers in
CPCB, 2015. Annual Report 2014-15. Central Pollution Control Board. Ministry of various healthcare facilities of Central India. Int. J. Sci. Res. 8 (12).
Environment & Forests, GOI. Rahman, M.M., Bodrud-Doza, M., Griffiths, M.D., Mamun, M.A., 2020. Biomedical waste
CPCB, 2018. Annual Report 2017-18. Central Pollution Control Board. Ministry of amid COVID-19: perspectives from Bangladesh. Lancet Global Health.
Environment & Forests, GOI. Rai, A., Kothari, R., Singh, D.P., 2020. Assessment of available technologies for hospital
Dalberg Advisor, 2017. Sanitation Worker Safety and Livelihoods in India: A Blueprint for waste management: a need for society. In: Waste Management: Concepts,
Action. https://www.susana.org/_resources/documents/default/3-3483-7-15427 Methodologies, Tools, and Applications. IGI Global, pp. 860–876.
26162.pdf. Ramteke, S., Sahu, B.L., 2020. Novel coronavirus disease 2019 (COVID-19) pandemic:
Das, A., Garg, R., Ojha, B., Banerjee, T., 2020. Biomedical waste management: the considerations for the biomedical waste sector in India. Case Stud. Chem. Environ.
challenge amidst COVID-19 pandemic. J. Lab. Phys. 12 (2), 161. Eng. 100029.
Datta, P., Mohi, G.K., Chander, J., 2018. Biomedical waste management in India: critical Rao, V.V., Ghosh, S.K., 2020. Sustainable bio medical waste management—case study in
appraisal. J. Lab. Phys. 10 (1), 6. India. In: Urban Mining and Sustainable Waste Management. Springer, Singapore,
Di Foggia, G., Beccarello, M., 2020. Drivers of municipal solid waste management cost pp. 303–317.
based on cost models inherent to sorted and unsorted waste. Waste Manag. 114, Rume, T., Islam, S.D.U., 2020. Environmental effects of COVID-19 pandemic and
202–214. potential strategies of sustainability. Heliyon, e04965.
Duan, R., Takahashi, B., 2017. The two-way flow of news: a comparative study of Salve, P.S., Jungari, S., 2020. Sanitation workers at the frontline: work and vulnerability
American and Chinese newspaper coverage of Beijing’s air pollution. Int. Commun. in response to COVID-19. Local Environ. 25 (8), 627–630.
Gaz. 79 (1), 83–107. Sangkham, S., 2020. Face mask and medical waste disposal during the novel COVID-19
Goyal, K.C., Goyal, S.N., Goyal, R., 2017. Analysis of bio-medical waste management in pandemic in asia. Case Stud. Chem. Environ. Eng. 100052.
private hospital at Patiala State of Punjab, India. Octa J. Environ. Res. 5 (1). Shammi, M., Bodrud-Doza, M., Islam, A.R.M.T., Rahman, M.M., 2020. COVID-19
Gupta, N., Agrawal, H., 2020. It will Be a different world for surgeons post-COVID-19 pandemic, socioeconomic crisis and human stress in resource-limited settings: a case
lockdown. Indian J. Surg. 1. from Bangladesh. Heliyon, e04063.
Hindustan Times, 18th April 2020. 10% of Gurugram’s Biomedical Garbage Is Related to Sharma, H.B., Vanapalli, K.R., Cheela, V.S., Ranjan, V.P., Jaglan, A.K., Dubey, B., Goel, S.,
Covid-19. https://www.hindustantimes.com/gurugram/covid-19-waste-accounts-for Bhattacharya, J., 2020. Challenges, opportunities, and innovations for effective solid
-10-of-gurugram-s-biomedical-refuse/story-Zf4FZR0UuPM8MIwrlPBvdP.html. waste management during and post COVID-19 pandemic. Resour. Conserv. Recycl.
Human Rights Council, United Nations, 2011. Report of the Special Rapporteur on the 162, 105052.
Adverse Effects of the Movement and Dumping of Toxic and Dangerous Products and Somani, M., Srivastava, A.N., Gummadivalli, S.K., Sharma, A., 2020. Indirect implications
Wastes on the Enjoyment of Human Rights. Calin Georgescu, 18th Session, 4th July. of COVID-19 towards sustainable environment: an investigation in Indian context.
https://noharm-global.org/sites/default/files/documents-files/1683/A-HRC-18-3 Bioresour. Technol. Rep. 11, 100491.
1_en.pdf.

12
M. Goswami et al. Heliyon 7 (2021) e06313

Soyam, G.C., Hiwarkar, P.A., Kawalkar, U.G., Soyam, V.C., Gupta, V.K., 2017. KAP study Vivek, J.M., Singh, R., Sutar, R.S., Asolekar, S.R., 2019. Characterization and disposal of
of bio-medical waste management among health care workers in Delhi. Int. J. ashes from biomedical waste incinerator. In: Advances in Waste Management.
Commun. Med. Publ. Health 4 (9), 3332–3337. Springer, Singapore, pp. 421–435.
Sudeep, C.B., Joseph, J., Chaitra, T., Joselin, J., Nithin, P., Jose, J., 2017. KAP study to Wang, J., Shen, J., Ye, D., Yan, X., Zhang, Y., Yang, W., Li, X., Wang, J., Zhang, L., Pan, L.,
assess biomedical waste management in a dental college in south India. World J. 2020. Disinfection technology of hospital wastes and wastewater: suggestions for
Pharm. Pharmaceut. Sci. 6, 1788–1794. disinfection strategy during coronavirus disease 2019 (COVID-19) pandemic in
Tabish, M., Khatoon, A., Alkahtani, S., Alkahtane, A., Alghamdi, J., Ahmed, S.A., Mir, S.S., China. Environ. Pollut. 114665.
Albasher, G., Almeer, R., Al-Sultan, N.K., Aljarba, N.H., 2020. Approaches for World Health Organization, 2016. Dioxins and Their Effects on Human Health. https
prevention and environmental management of novel COVID-19. Environ. Sci. Pollut. ://www.who.int/news-room/fact-sheets/detail/dioxins-and-their-effects-on-h
Res. 1–11. uman-health#:~:text¼Short%2Dterm%20exposure%20of%20humans,endocrine%
Tenenbaum, L., 2020. The Amount of Plastic Waste Is Surging Because of the Coronavirus 20system%20and%20reproductive%20functions.
Pandemic Forbes. https://www.forbes.com/sites/lauratenenbaum/2020/04 World Health Organization, 2017. Report on Health-Care Waste Management (HCWM)
/25/plastic-waste-during-the-time-of-covid-19/#7c4e661f7e48. Status in Countries of the South-East Asia Region (No. SEA-EH-593). World Health
The Verge, March 26th, 2020. The COVID-19 Pandemic Is Generating Tons of Medical Organization. Regional Office for South-East Asia.
Waste. https://www.theverge.com/2020/3/26/21194647/the-covid-19-pandemic World Health Organization, 2018. Health-care Waste Fact sheet Updated February 2018,
-is-generating-tons-of-medical-waste. Media centre. http://www.who.int/mediacentre/factsheets/fs253/en/.
UNICEF, 2020. COVID-19 Impact Assessment and Outlook on Personal Protective World Health Organization, 2020a. Media Statement: Knowing the Risks for COVID-19.
Equipment. https//www.unicef.org/supply/stories/covid-19-impact-assessment-a https://www.who.int/indonesia/news/detail/08-03-2020-knowing-the-risk-for-
nd-outlook-personal-protective-equipment#:~:text¼A%20consolidated%20UN% covid-19.
20inter%2Dagency,and%208.8%20million%20face%20shields. World Health Organization, 2020b. Shortage of Personal Protective Equipment
Vanapalli, K.R., Sharma, H.B., Ranjan, V.P., Samal, B., Bhattacharya, J., Dubey, B.K., Endangering Health Workers Worldwide. https://www.who.int/news-room/detail/0
Goel, S., 2020. Challenges and strategies for effective plastic waste management 3-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-
during and post COVID-19 pandemic. Sci. Total Environ. 750, 141514. worldwide.
Vilavert, L., Nadal, M., Schuhmacher, M., Domingo, J.L., 2015. Two decades of Yang, B.Y., Qian, Z., Howard, S.W., Vaughn, M.G., Fan, S.J., Liu, K.K., Dong, G.H., 2018.
environmental surveillance in the vicinity of a waste incinerator: human health risks Global association between ambient air pollution and blood pressure: a systematic
associated with metals and PCDD/Fs. Arch. Environ. Contam. Toxicol. 69, 241–253. review and meta-analysis. Environ. Pollut. 235, 576–588.

13