The gloves are the last piece of equipment to take off in the house, while in hospitals the order is reversed. The last one is a mask, but two pairs of gloves are worn and the hands are disinfected between each piece of equipment removed. Those are the recommendations from the Institute of Public Health. The Centre of Investigative Journalism of Montenegro (CIN-CG) has been advised that US adheres to recommendations valid to date, while the EU is preparing a new protocol.

The Institute of Public Health of Montenegro (IPH) has warned that when masks and gloves upon return home are put away, they should never be left at arm’s length.

“It is important not to leave the used equipment on the surfaces, especially not on the kitchen cabinets and tables, but to immediately dispose of any protective equipment after its use. At home, gloves are last removed and hands are washed immediately afterwards. In healthcare institutions, the order is different. The last one is always a mask, two pairs of gloves are worn and the hands are disinfected between removals of each piece of equipment”- the Institute recommended, answering CIN-CG’s questions.

Waste generated during the care of suspected and confirmed cases of COVID-19, according to IPH should be disposed of as infectious, with no additional control measures required.

The Inspection Affairs Authority told CIN-CG that everyone involved in the process has been warned to pay extra attention to the proper disposal of infectious medical waste.

Head of the Operational Section of the National Coordinating Body for Communicable Diseases Mrs Vesna Miranović emphasized that quarantine waste disposal is “an extremely demanding project involving hundreds of people on a daily basis”.

“The waste is placed in a single bag in the quarantine room. It is then disposed of in another closed bag, and all the common waste is put at one place. The companies then come, collect it appropriately and take it to a place where it is permanently destroyed. We have taken care of each segment”, Miranovic said at a news conference.

At the same conference, IPH Assistant Director Dr Senad Begić added that there is currently no scientific evidence that municipal waste from a person positive for the virus poses a threat to the environment, but that they have nevertheless increased precautionary measures.

The IPH site includes the following recommendations for the waste management of suspected COVID-19 cases: care must be taken not to contaminate hands when removing gloves, which means that the outside of gloves, which should always be “regarded as contaminated”, must not be touched. Good hand hygiene is also a must.

According to the company Ekomedika, in the first quarter of this year, “due to seasonal winter infections”, around thirty tons of infectious waste has been taken from medical institutions.

Infectious waste accounts for approximately 80 percent of all medical waste. It also contains microorganisms that can cause disease in humans. It is made up, among other things, of materials and things that have been in contact with an infectious patient.

“We expect a slight increase in quantities in the coming period due to the current situation”, Stojanka Šolaja, a representative of this company specializing in medical waste treatment, told CIN-CG.

Although the materials that have been in contact with infected patients or health care workers who have taken care of these patients are treated “in the same way as all infectious waste” in terms of selection, safe packaging and transportation, she points out that they are, nevertheless, more cautious.

“We have taken extra precautionary and disinfection measures while over-taking infectious waste packages at delivery, and added new packaging layers. It is the recommendation by the Institute of Public Health to disinfect and increase wearing of protective equipment, as a form of prevention. We follow all the IPH recommendations and those of other reference institutions” Šolaja said.

The Clinical Center of Montenegro (CCM), in which the first victims of the COVID-19 passed away, did not reply to CIN-CG whether they disposed of the used medical materials and equipment in a standard manner, or in accordance with some new special procedures.

However, they explained that the management of medical waste begins when health care is provided by means of proper classification in a “cost-effective manner that minimizes health and environmental risk” and that it is carried our by trained staff using adequate packaging.

“The waste is classified in packaging units adapted to its characteristics, quantity, method of temporary disposal, and transport to the final treatment. Bag holders, or waste bins, are installed in all places where medical and municipal waste are generated at the same time. All used sharp objects, including needles, are collected in specially designed hard plastic disposable packaging. Packages are filled up to two-thirds of the total volume, and are marked with labels on which the date and place of waste generation (wards, dispensary, hall…) and the signature of the responsible person who handles it are required”, they explained to CIN-CG.

Waste bags are transported by special trolleys to a treatment site – a medical waste treatment plant within the CCM, or to a municipal waste disposal site.

“This transport is performed by employees who maintain cleanliness. The trolleys are cleaned daily after waste removal” the Clinical Center answered.

The Inspection Affairs Authority (IAA) confirmed to CIN-CG that their ecological inspection has controlled since January “certain entities that generate medical waste while performing their activities.”

“Since the beginning of 2020, several decisions have been adopted in order to eliminate irregularities, which primarily concerned the submission of data on generated quantities of medical waste during 2019 to the Agency for Nature and Environmental Protection,” the IAA replied.

IAA’s public relations department claims that, due to the spread of the COVID-19, they had warned everyone “from manufacturers, collectors, processors and others that they must pay extra attention to the proper separation, packaging and disposal of this type of waste”.

For possible non-compliance with these obligations, the Law on Waste Management stipulates misdemeanor fines for legal entities of up to 40,000 euros, and for responsible persons up to 4,000 euros,” IAA explained.

Podgorica’s Public utility “Cleanliness” has confirmed to CIN-CG that they are also taking over the waste from the infected people.

“Employees of the Public utility, with adequate protective equipment, and in accordance with a pre-established procedure, take over the waste directly in front of the housing units of persons confirmed to be ill with COVID-19. Before that, the disinfection of waste, which is properly packed in multiple bags, is carried out by the Institute of Public Health. The waste collected in this way is taken away by a specially designed vehicle to a company that is authorized for the proper treatment of medical waste,” the Communal Service explained.

Public utility from Ulcinj claims that they adhere to the instructions received from the Institute of Public Health.

“Every day, workers get new masks and gloves for field work. The places around containers are covered or disinfected with gas lime and the trucks are washed and disinfected with chlorine”, Skender Kalezici, head of this company, said.

The management of Public utility from Niksic also confirmed that all workers are obliged to use protective masks over their faces and gloves for preventive reasons. Workers carry out their work by “hooking the municipal waste container to the truck and emptying it with the help of hydraulics so they have no contact with the waste in the containers.”

Public utility from Tivat explained that they had distributed “masks that were sewn by local tailors” to their workers and that each of them “uses thick rubber gloves as protective equipment, which are disinfected with asepsol at the end of each shift”. Containers and surface area around them, as well as garbage trucks and streets, are disinfected with chlorine.

Special procedures have also been introduced in large retail chains. At the end of the shift, workers at “Voli” supermarkets dispose of protective masks and gloves in a specially designed hermetically sealed bag. The rest of the waste is taken over by the Public utility company, Olivera Suskavcevic, a public relations representative of the company, told CIN-CG.

She emphasized that in order to protect consumers in all markets, warehouses and the complete logistics system, the company implements enhanced hygiene and sanitary measures in accordance with the recommendations of the competent institutions.

“Transparent plexiglas partitions have been installed in the markets, which will reduce the daily contact between employees and consumers at the cash registers. Our workers are equipped with gloves and masks, and a dispensary with fluid for hand disinfection is prominently displayed in all markets” Suskavcevic said.

The “Franca” market company also told CIN-CG that they are trying to protect employees and customers in the best possible way.

“From day one, since the use of masks and gloves is required, all employees have been explained how to use them properly. Hygiene in all facilities is at the highest possible level in order to prevent contamination of employees in the workplace”, Franca marketing department said.

Protective equipment is also provided to employees in markets, bakeries and pharmacies.

The measures taken in Montenegro are no different from those in the region and the rest of the world.

The US Center for Disease Control and Prevention (CDC) said that the medical waste originating from healthcare facilities that treat patients with COVID-19 is no different than other infectious waste. The CDC also provided instructions to its medical workers, similar to those of the Montenegrin Institute of Public Health, explaining step by step how not to touch the outside of the glove or the front of the mask.

Although no specific measures have yet been prescribed in the management of infectious waste in the European Union countries, the Croatian Ministry of Environmental Protection and Energy stated to CIN-CG that they have been working on it.

“With regard to different rules regarding the disposal of medical waste associated with suspected or confirmed cases of COVID-19, or medical workers treating those patients, a protocol is currently being developed at EU level for the collection and disposal of household waste of suspected or confirmed cases. The Republic of Croatia participates in its elaboration and will, upon its completion, apply it. “There are currently no specific national protocols for household waste”, Đurđica Požgaj, head of Department for Waste, told CIN-CG.

As for the health care facilities, she added that Croatia complies with the policies, according to which infectious waste must be collected separately and should not be disposed of; rather it should be  sterilized and treated in appropriate “incineration or energy generation” devices.

Dragan Mladenovic, from the Serbian Environmental Protection Agency, said that in Serbia 3.7 thousand tons of medical waste was generated in 2018, out of which 3.4 thousand tons was hazardous infectious waste.

“All waste generated by patients who are infected with the COVID-19 represents a dangerous infectious medical waste and as such must be sterilized before being dumped”, Mladenovic emphasized.

Ekomedika company: Higher costs

“Costs are certainly higher due to increased security measures and increased consumption of protective equipment, disinfectants, multiple visits, changes of working hours and on-call duty, and it is realistic to expect higher consumption of certain consumables. In the current situation, the necessary measures must be taken to deal with the new situation as successfully as possible”, Rade Djikanovic, head of the Processing Center at Ekomedica, told CIN-CG.

He explained that the producer of medical waste is obliged to distribute it properly at the place of origin, place it in appropriate packaging, pack it, label it and then place it in a temporary storage area. Pick-up and transport are accompanied by an appropriate form containing information on the producer, type and quantity and other technical details.

Ekomedika, which has been performing this job since 2011, has five trucks and two smaller vehicles. All of them are equipped to guarantee safe loading and unloading, as well as safe transportation. Emergency circuit breakers and disinfection are also provided. Djikanovic notes that additional preventive and protective measures are being taken when transporting infectious waste. This also means disinfecting the packaging of prepared waste at the point of pick-up and the additional packaging.

Djikanovic also explains that the treatment of infectious and sharp medical waste is done by sterilization, a process that destroys all microorganisms and battery spores. In that process, there is no combustion, no operation under increased pressure, no use of chemical substances, microwave radiation and the like.

“Waste weight is reduced by about 30 percent, waste volume by about 50 percent. Technology is “ecofriendly”. The process is automated and one treatment cycle of about 100 kilograms of waste takes 30 minutes”, said Djikanovic.

He points out that the generated waste has the characteristics of mixed municipal waste, it is of an unrecognizable form, hazardous properties have been removed and it is disposed of as such.


More work when vaccines arrive

The amount of medical waste has also increased in Bosnia and Herzegovina – Alen Nogic from Aida Commerce points out.

“There is a certain decrease in secondary medicine (dentists, aesthetic, surgery, fertilization, etc.), which is quite normal because it works at reduced capacity, or not at all. Primary medicine itself is recording an increase in the amount of waste due to the new situation, although the awareness of those who make the selection at the place of its generation is also being raised”, he told CIN-CG.

As he points out, in the process of medical waste treatment nothing is left to chance.

“The disposal process is performed at a temperature of maximum 166 degrees Celsius, so that there is no case of virus resistance”, he said.

The growth of infectious medical waste is also expected at Zagreb-based Recol, a company that has been treating it for 25 years and has hundreds of clients across Croatia.

“Like everywhere else, Croatia lacks medical equipment, so our doctors must be rational, which reduces the amount of waste itself. The fact is that a large number of people will have to be vaccinated when we get vaccines. Then, a slight increase in infectious waste can be expected”, Bojan Breberina, a representative of the company, told CIN-CG.

                                                                                                                             Miloš RUDOVIĆ


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