2ANALYSIS OF INFECTIOUS MEDICAL WASTE MANAGEMENT IMPLICATION ON SUSTAINABLE AGRICULTURE DURING THE COVID-19 PANDEMIC - CASE STUDY OF SUMADIJA DISTRICT
(REPUBLIC OF SERBIA)
Magdalena Nikolic1, Vladimir Tomasevic2, Dragan Ugrinov3, Brankica Pazun4,
Zlatko Langovic5
*Corresponding author E-mail: magdalenanikolic3@gmail.com
ARTICLEINFO ABSTRACT
Agriculture is the world's most important industry. According to the structure, Sumadija district is mainly composed of arable land and gardens, which make up 69%. The increased amount of COVID-19 waste generated from medical activities in rural areas needs to be properly handled due to its contagious, even lethal properties. The aim of this study is an analysis of two drivers through the generation of COVID-19 waste, Central and local treatment site, proposed transport routes, and total cost in Sumadija district. Results showed the economic costs of transportation increased 2.5 times compared to before and after the emergence of the COVID-19 pandemic. Also, the increase in health risk was correlated to the increase in the per capita cost of transportation along the transportation routes. Analyses of human health risks and detailed financial calculations gave a clear insight in infectious waste management possible influence on agriculture.
1 Magdalena Nikolic, Ph.D., Associate Professor, University "Union - Nikola Tesla", School of Engineering Management, Vojvode Misica Boulevard no. 43, 11000 Belgrade, Serbia, Phone: +381 11 41 40 423, E-mail: magdalena.nikolic@fim.rs, ORCID ID (https://orcid. org/0000-0002-2021-153X)
2 Vladimir Tomasevic, Ph.D. Full Professor, University "Union - Nikola Tesla", School of Engineering Management, Vojvode Misica Boulevard no. 43, 11000 Belgrade, Serbia, Phone: +381 11 41 40 423, E-mail: vladimr.tomasevic@fim.rs, ORCID ID (https://orcid. org/0000-0001-9845-2950)
3 Dragan Ugrinov, Ph.D., Assistant Professor, University of Economics Academy, Faculty of Europe "Kallos", Ratarski put no.8a, 11000Belgrade, Serbia, E-mail: ugrinov.dragan@ gmail.com, ORCID ID (https://orcid.org/0000-0002-5387-820X)
4 Brankica Pazun Ph.D., Associate Professor, University "Union - Nikola Tesla", School of Engineering Management, Vojvode Misica Boulevard no. 43, 11000 Belgrade, Serbia, Phone: +381 11 41 40 423, E-mail: brankica.pazun@fim.rs, ORCID ID (https://orcid. org/0000-0002-9452-5064)
5 Zlatko Langovic Ph.D., Associate Professor, University of Kragujevac, Faculty of Hotel Management and Tourism, Vojvodjanska bb, 36210 Vrnjacka Banja, Serbia, Phone: + 381 36 515 0024, E-mail: zlatko.langovic@kg.ac.rs, ORCID ID: (https://orcid.org/0000-0002-0248-0453)
Original Article
Received: 28 October 2023
Accepted: 06 December 2023
doi:10.59267/ekoPolj23041059N
UDC 616-036.21:578.834 502.13:628.4.046(497.11 Sumadija)
Keywords:
sustainable agriculture, human health, financial stability, SARS-COV2, infectious medical waste
JEL: K5, K53,P28
Introduction
The development of sustainable agriculture depends on knowledge, as a base for understanding how and why there is a need to conserve natural resources, which in developing countries are converted into agricultural land. Also, by protecting the environment, the value of arable land is maintained. This includes the economic factor one of the most important in sustainable agriculture, and its influence on markets and incentives for organic production (Stojic, Dimitrijevic, 2020). Therefore, well well-being of inhabitants must be a prerequisite for success in any activity. We witness the emergence of SARS-CoV-2 in late 2019 and its epidemic potential. The rapid spread of this virus across the world in only 2 months highlights the necessity to strengthen infectious waste management in every healthcare institution (Weston, Frieman, 2020). The practice around the world is that medical waste and other forms of clinical waste are disposed of adequately and according to regulations in a sanitary landfill or burned as waste to obtain energy. In EU countries, the United Nations Basel Convention on the Transboundary Movement of Hazardous Wastes and their Disposal has provided instructions and guidelines on waste management amid the COVID-19 pandemic as an urgent and essential public service aimed at protecting human health and the environment(Sing et al., 2020a). However, developing countries are not able to implement this practice, so medical waste, together with solid municipal waste, is disposed of in badly managed landfills in the places of greatest infection (Nzediegwu, Chang, 2020). A good example is provided by China, which since 2003, following the outbreak of severe acute respiratory syndrome (SARS) in the region, has enacted, and is implementing more than 30 legal and emergency management orders on the environmentally sound management of medical waste. Therefore, carefully observing and applying this practice can contribute to the greater safety of people, and animals, and the preservation of the environment (Singh et al., 2020b). Medical waste disposal is a global issue since it is costly. This is supported by the fact that 3.5 million tones of medical waste per year generated in the USA, are disposed of at the cost of $790 per tone (Windfeld, Brooks, 2015). Although we are faced with a pandemic and the creation of infectious waste in all healthcare units, infectious medical waste is still being transported in Serbia. Health systems need to address the problem of pandemic mismanagement (Yusefi et al., 2022). In most medical institutions in Serbia, there is no possibility of sterilizing used syringes and needles, swabs, bandages, and other infectious waste. Therefore, the set is transported to nearby regional centers, and health facilities equipped with autoclaves for sterilization and shredders. Unfortunately, Serbia still does not have modern facilities for the treatment of infectious medical waste (IMW), especially incinerators, which are necessary today. For these reasons, the COVID-19 pandemic affects the quality of life of people living in rural areas, where agriculture is the primary industry. This practice is particularly dangerous for the part of the population that lives on the infectious transport routes of this type of waste (Babaee Tirkolaee ,Aydin, 2021; Behera, 2021). Also, the lack of financial support harms the effective management of medical waste in hospitals where there is a lack of medical
waste technologies and its neutralization at the source. That refers to vehicle routing problems and transportation planning problems (Thakur, 2021; Stanojevic et al., 2022. In general, during the great pandemic, apart from public health, the waste sector was the most affected because of the role he then assumed (Barua and Hossain, 2021). That is to say, the increased amount of infectious medical waste contaminated with COVID-19 increased the risk of spreading without neutralization on site. Serbia is a developing country whose waste management practices during COVID-19 failed in many aspects (Cao et al., 2023). There are justified reasons for concern, being predominantly a rural country, rich in arable land, and unique rural tourism households (Dimitrijevic et al., 2022). The Sumadia region is synonymous with the fertile land of Serbia. According to the structure, it is mainly composed of arable land and gardens, which make up 69%. The area under cereals occupies 40.8% and orchards 9.2% of the total agricultural area of the region. Also, 64,062 inhabitants live in this part of Serbia, two-thirds of whom are actively engaged in agriculture. If we look at statistical data on the activities of the Republic of Serbia, the active agricultural population makes up 64.8% (Stojic, Dimitrijevic, 2020).
This study aimed to show how bad infectious medical waste management can be improved from the learnings of COVID-19 (Jayasinghe et al., 2023). The main goal of this paper is: to provide information on the amount of COVID-19 infectious medical waste generated during the COVID-19 pandemic; to identify existing routes of transportation through densely populated agricultural areas as gaps in existing infectious medical waste management practices; and to indicate problems and solutions to prevent potential infection: to protect farmers, agricultural land and products to the greatest extent. Therefore, the calculation of the amount of COVID-19 infectious waste as well as the cost of transportation with the number of people affected by this practice, presents opportunities for improvement in post-pandemic waste infrastructure. Insufficient COVID-19 infectious waste management affects agriculture and food systems in multiple ways. This unique opportunity to address these challenges can accelerate the transition to a more sustainable food system (Rasul, 2021).
Materials and methods
This study presents an analysis of Infectious waste management during the COVID-19 pandemic and how Serbia can change and support a novel approach to sustainable management. When it comes to agriculture, there are several concerns and considerations regarding the handling of COVID-19 waste. Contamination of Agricultural Land: Improper disposal of infectious waste in or near agricultural areas can lead to soil and water contamination. This can potentially affect the quality and safety of crops and livestock. (Devi et al., 2019); Risk to Farm Workers: Farm workers may be at risk of exposure to infectious COVID-19 if it is not managed safely. Inadequate disposal practices can lead to accidents or direct contact with contaminated materials (Elbadri, 2021). Biosecurity Measures: Agricultural operations should implement biosecurity measures to prevent the spread of diseases, including those that might be associated
with improper handling of infectious COVID-19 waste (Galanakis,2020; Fan et al., 2021; Obykhod et al., 2020)
Developing countries have poor infectious waste management, which directly increases the ratio of contaminated items to non-infectious fraction of medical waste. The average for developing countries is about 0.2 kg of infectious waste generated per day. During the COVID-19 pandemic, the assessment of healthcare waste can be conducted only by considering all medical waste generated within healthcare facilities as infectious. For this study, we use Mihai's (2020) formula for the calculation of COVID-19 waste in healthcare facilities in Sumadija district :
(At the national level)
Mw = Number of active cases of COVID-19 per day x Mwgr (kg • bed • day - 1),
where Mwgr = medical waste generation rate — 1 kg • bed • day - 1
number of active cases is available at https://www.worldometers.info/ coronavirus/#countries at the national level.
(At the subnational level)
Mw = confirmed cases of COVID-19 per day x Mwgr (kg • bed • day - 1).
Therefore we calculated the amount of infectious COVID-19 waste by multiplying the number of active cases with the amount of infectious medical waste. The data used in this research was collected from the Institute of Public Health of Serbia "Dr. Milan JovanovicBatut"(Batut, 2023). The results are presented in Table 1.
Analytical Framework
Developing countries such as Serbia struggle with reliable public data on the amount of medical infectious waste during the COVID-19 pandemic. However, data collected worldwide indicate infectious waste generation in developing countries is 2.3 times higher than in the period before the pandemic crisis. Also, the starting point for any calculation is the city of Wuhan in China where citizens generated nearly 247 tons of medical waste per day at the height of the pandemic, about six times more with only infectious waste two times more than before the pandemic (Hossain et al., 2011; Sing, Ogunseitan, 2020a). The amount of infectious waste in China during the pandemic increased 12 times (Chen et al., 2021). There are many new methodologies developed to define influential medical indicators that reflect the effects of transporting infectious medical waste (Pazun et al., 2022; Valizadeh, Mozafari, 2021; Wei, 2020). Drivers for integrated waste management are helpful tools when conducting analysis and guaranteed improvement of waste management (Ilic, Nikolic, 2016). The analytical framework is built around two waste drivers, human health and financial stability. Research conducted in China during the pandemic showed that the impact of COVID-19 on China's agricultural economy was reflected in crop production and livestock production, employment of farmers, and the overall development of agriculture. (Pan et al., 2020).
Therefore, the driver analysis provided guidelines for preventing infectious waste from reaching arable land and farmers in Sumadija district. Both drivers were analyzed through collected data to identify the amount of COVID-19 infectious medical waste and transportation routes in km and the number of inhabitants on route for COVID-19 transport through agricultural land.
Also, apart from analyses of drivers, it was found that one of the key directions to solving the problem of COVID-19 infectious medical waste transport is to establish values between 1 and 6, indicators of risk from COVID-19 spread (Nikolic et al., 2022). In a study conducted by Nikolic et al. (2022) values of waste are calculated as the quantity of waste being transferred per one route per week/number of citizens living along this route. As 5,3 times increased amount of COVID-19, IW is defined as value 6 for the highest health risk and value 1,3 for financial collapse. These values applied along with the data collected and calculated by Mihai (2020) give a clear picture of IMWS in the Sumadia district presented below.
The population living near the routes used to transport infectious waste is linked with a driver of the importance of human health. Highly infectious COVID-19 medical waste presents a direct threat to human health if not properly handled (Adyel, 2020; Borrelle et al., 2020). The value ofthis driver is in the amount of generated waste transferred per route in liters per week per the number of citizens living along this route. The range of numerically expressed significance is a value between 1 and 6 (the amount of waste in Wuhan increased 5.3 times). This indicator expresses the degree of threat to human health. Nikolic et al. (2022) defined that values from 1 to 2 are less good, values < 2 and > 3 mean very high risk values > 3 and < 6 mean extremely high risk, and values > 5 mean the risk of shock to the health society (Nikolic et al., 2022).
Financial support reflects a high-level financial problem for society as a whole. About 70% of the costs of the waste management system are allocated to the transport of waste. The financial aspect of sustainable waste management must be one of the main drivers of a sustainable system (Erdem, 2022). This driver is numerically expressed through the transport cost of the generated waste per the transfer route / the number of citizens to whom the waste was transferred for this route. The driver of financial support is a number whose volume can be greater than 1. Nikolic et al. (2022) determined that values between 1 and 1.3 mean high risk, values > 1.3 to 1.6 mean very high risk, and values >1.6 to 1.8 mean extremely high risk, while values > 1, 8 mean the risk of a shock to the financial society (Nikolic et al., 2022) The initiatives are clearly defined to find an adequate solution for the transportation of highly hazardous waste and the impact of the covid-19 infection. This research aims to improve the medical waste management system in Serbia, through a rapid assessment of potentially infectious covid-19 medical waste generated in rural areas. The endangered health of residents is clearly shown through the financial analysis of which waste is transferred for each route and to present the amount of waste that is transferred, representing a high risk for citizens who live along the transfer routes, on the example of the Sumadija administrative district.
Results and Discussion
The issue of a new category of IMW (COVID-waste) mishandled is a rising concern to public health and environmental sustainability, no matter whether the pandemic is over (Ilyas et al.,2020). Three CTSs/LTSs (Central treatment site /local treatment site) have been established/planned in the Sumadijja District.
1. CTS CHCKragujevac is in charge of eight additional places for waste collection.
2. CTS Central Clinic Kragujevac also includes the Institute of Public Health Kragujevac, the Institute for Emergency Medical Assistance, and the Institute for Dentistry.
3. In addition, an additional LTS was established in the Arandelovac General Hospital with 130 beds. This treatment facility is responsible for the treatment of waste from the Arandelovac Health Center.
The amounts of infectious medical waste in the Sumadija administrative district, by healthcare institutions of exemplary healthcare, are given in Table 1.
Table 1. Quantities of infectious waste generated in primary healthcare institutions
Collecting site (Municipality/ Community Health Centers) The population treated in CHC Amount of infectious medical waste (kg/ day) Amount of infectious medical waste (l/day) Amount of infectious medical waste (l/week) Number of containers with a volume of 240 l per week
CHC Batocina 91659 3 30 210 1 x 240l (2x120l)
CHC Knic 102291 3 30 210 1x 240l (2x120l)
CHC Lapovo 58026 2 20 140 1x 240l (2x120l)
CHC Raca 152232 4 40 280 2x 240l
CHC Topola 250000 7 70 490 3 x 240l
Institute for Workers' Health Protection (IWHP) 291612 10 100 700 5 x 240l
Source: Author's calculations
Transportation of waste is always complex due to its hazardous nature, raising the question of how to tackle this issue the best way possible with the financial aspect taken into account (Fedotkina et al., 2019). An important role is also played by the distance (distance) of health institutions from the place for the treatment of infectious medical waste. Data on the distance are given in Table 2.
Table 2. Distance of medical institutions from the place of treatment (km)
Distance (km) CTS (Central treatment site) CHC Batocina CHC Knic CHC Lapovo CHC Raca CHC Topola IWHP workers
CPT (central place for treatment) 0 27 17 16 19 40 3,5
CHC Batocina 27 0 50 4 17 67 30.5
CHC Knic 17 50 0 54 49 63 30
CHC Lapovo 16 4 54 0 19 47 19.5
CHC Raca 19 17 49 19 0 41 22.5
CHC Topola 40 67 63 47 41 0 43.5
IWHP 3.5 30.5 20.5 19.5 22.5 43.5 0
Source: Author's calculations
For the waste to reach the place of treatment, it takes a certain time, and the routes that the transport vehicle takes. Each country has its one regulations when it comes to infectious waste transportation. In Korea, medical waste is transported up to approximately 350 km, while in Germany and Japan hazardous waste(infectious and toxic) is transported up to approximately 100 km (Yoon et al., 2022). Table 3. shows the time required from the primary institution to CTS waste.
Table 3. Time required for transporting infectious waste to CTS
Transport time (min) CPT CHC Batocina CHC Knic CHC Lapovo CHC Raca CHC Topola IWHP
CPT 0 40 26 25 30 60 10
CHC Batocina 40 0 70 10 30 80 40
CHC Knic 26 70 0 70 60 80 30
CHC Lapovo 25 10 70 0 30 65 31
CHC Raca 30 30 60 30 0 60 32
CHC Topola 60 80 80 65 60 0 60
IWHP 10 40 30 31 32 60 0
Source: Author's calculations
The movement of special vehicles is defined by the routes as well as the calculation of the time of transportation of infectious medical waste to the place of treatment. A schematic view is given in Figure 1. It is obvious that in the Sumadija district distance is approximately 80km, which follows developed country regulations.
Figure 1. Proposed transport route in Sumadija district
Source: Author's analysis
Transport route 1 traces the path from CHC Raca via Topola to Kragujevac. On the given route, it passes through populated areas on the route. Figure 2. shows an overview of the populated places it passes through with the gravitating population and the total mileage of the route.
Figure 2. Number of citizens endangered by infectious waste from CHC Raca via Topola to Kragujevac
Source: Author's analysis
IMW transport route from Raca via Topola to Kragujevac with a length of 80.2 km. The vehicle used to transport IMW is a Renault Kango with a cost price of 13,516 €. Route: 160.4 km x 8 tours per month
1283.2 km x 5.2 l (average fuel consumption) - 66.73 l derivatives 66.73 l x 129.9 din/l - 8668.00 din / 74.20 € Need for oil and lubricant - 2580 din/ 22 €
Regular service and maintenance of vehicles without breakdowns, breakdowns, and accidents is for 6 months and amounts to a total of 17,050 din/ 145€.
In normal traffic conditions and road conditions concerning legal speed limits, the duration of the transport is 2 hours. Breakdowns, breakdowns, and accidents cannot be predicted. Transport route 2 traces the route from CHCBatocin via Lapovo to Kragujevac. On the given route, it passes through populated areas on the route. Figure 3. shows an overview of the populated places it passes through with the gravitating population and the total mileage of the route.
Figure 3. Number of citizens endangered by infectious waste from CHC Batocin via Lapovo
to Kragujevac
Source: Author's analysis IMW transport route from Batocina via Lapovo to Kragujevac with a length of 33.1
The vehicle used to transport IMW is a Renault Panther with a cost price of 15,210 €. Route: 66.2 km x 8 tours per month
http://ea.bg.ac.rs 1067
529.6 km x 6.5 l (average fuel consumption) - 34.5 l derivatives 34.5 l x 129.9 din/l - 4472.00 din / 38.20 € Need for oil and lubricant - 4300 din/ 36.75 €
Figure 4. Number of citizens endangered by infectious waste from CHC Knic to Kragujevac
ROUTE 3.
200000 180000 160000 140000 120000 100000 80000 60000 40000 20000 0
Kmc Golocelo Dragobraca Kragujevac Tota
Source: Author's analysis
Regular service and maintenance of vehicles without breakdowns, breakdowns, and accidents is for 6 months and amounts to a total of 17,050 din/145€. In normal traffic conditions and road conditions, concerning legal speed limits, the duration of the transport is 1 hour. Breakdowns, breakdowns, and accidents cannot be predicted. Transport route 3 traces the route from CHC Knic to Kragujevac. On the given route, it passes through populated areas on the route. Figure 4. shows an overview of the populated places it passes through with the gravitating population and the total mileage of the route.
IMW transport route from Knic to Kragujevac with a length of 20.1 km. The vehicle used to transport IMW is a Renault Boxer with a cost price of 25,590 €.
Route: 40.2 km x 8 tours per month
321.6 km x 7.9 l (average fuel consumption) - 25.4 l derivatives 25.4 l x 129.9 din/l - 3300.00 din / 28.20 € Need for oil and lubricant - 4300 din/ 36.75 €
Regular service and maintenance of vehicles without breakdowns, breakdowns, and accidents is for 6 months and amounts to a total of 19,656 din/ 168 €.
Under normal traffic conditions and road conditions, with compliance with legal speed 1068 http://ea.bg.ac.rs
limits, the duration of the transport is 45 minutes. Breakdowns and accidents cannot be predicted. Transporting through urban areas, infectious pathways of medical waste affect residents and the environment along transport routes. According to the selected operational model, the institutions/places for the treatment of infectious medical waste (IMW) are divided into two categories:
(1) a central treatment site (CTS), which processes its waste, as well as waste from assigned health facilities;
(2) a local treatment site (LTS), responsible for the safe treatment of one's waste. CTS / LTS institutions have also been tasked to collect waste from other health institutions in the district. Institutions whose infectious waste is taken for treatment are called MS institutions (institutions located at the place of origin and whose waste is transported to the place of treatment). Each administrative region has at least 1 CTS. It is usually a general hospital in the central town of the district. The exception is the districts where there are institutions of the new tertiary level of health care - clinical centers, where the CTS function is taken over by a health center or public health institute. The increased number of COVID-19 patients increases the amount of infectious waste.
We confidently claim that the transportation of medical waste covid 19 increases the risk of spreading the COVID-19 virus among the population in the Sumadija district. It is obvious that during the pandemic, health indicators, as well as infectious covid-waste, based on the calculation of health indicators for all three directions of the Sumadija region, doubled. Figure 5. clearly shows us the health risk index with a growing trend before and during the covid 19 pandemic.
Figure 5. Input values for calculation of health indicators before and during a Covid pandemic.
100%
90%
80%
70% 0,11 0,13 0,072
60%
50%
40%
30%
20% 0,055 0,065 0,036
10%
0%
1 2 3
liter per citize ns weekly during Covid 19
liter per citize ns weekly before Covid 19
Source: Author's analysis
Figure 6.Analyses of economic indicators before and during a Covid pandemic.
100% 90%
80% 70% 60% 50% 40% 30% 20% 10% 0%
2.38 2.89 1.01
1.3 1.62 0.559
euro per citizens weekly befor e Covid 19 ■ euro pel" citizens weekly during Covid 19
Source: Author's analysis
As the health risk increases, so does the per capita cost of transportation along the transportation routes. Figure 6 shows an overview of financial risk per capita with cost prices before and during the COVID-19 pandemic.
Conclusions
This paper aims to show COVID-19 infectious medical waste mismanagement in the Sumadija district. The Covid-19 pandemic has led to an increase in infectious waste generation. As a result, the amount of infectious medical waste transported through populated areas and transport routes through the Sumadija administrative district increases. Through direct analysis, it was included that both health and financial risks are doubled. It has been found that there was a 2 to 3-fold increase in the amount of infectious medical waste before and after the emergence of the COVID-19 pandemic. Additionally, the costs of transporting the waste and the cost price of IMW transport have increased by 2.5 times compared to before the pandemic. This entails a doubled risk of accidental situations, thus doubling the risk of contamination of the environment. This can potentially affect the quality and safety of crops and risk to farm workers. Inadequate disposal practices can lead to accidents or direct contact with contaminated materials. Although the length of routes within the district is below the recommended km by developed countries, no more than 80km, about 197000 inhabitants were directly exposed to the virus. The projected growing amount of medical waste in the observed District requires an increase in existing treatment and neutralization capacities and the application of new sustainable solutions. In line with the fact that Sumadija district is rich with fields, orchards, vegetable beds, vineyards alternate..., waste management should be a priority. Overall, the management of infectious COVID-19 waste affects agriculture and it should prioritize the safety of farmers, the integrity of agricultural products, and compliance with relevant regulations to prevent environmental contamination and public health risks. Proper education and adherence to guidelines are critical to achieving these goals. Therefore, recommendations include:
-The capacity of installed autoclaves can be increased by increasing their working time, to avoid additional investments.
-By decentralizing the place for treatment at the local level, the spread of the Covid-19 virus will be prevented.
- Such a general epidemiological situation could not be predicted, and therefore the solvency of the healthcare institution was put in serious jeopardy due to the incurred costs, as they must be reimbursed from their funds because they are not contracted with the Republic Fund.
Based on the results of this research, the following recommendations can be considered for future research:
To prevent the occurrence of possible accidents on the route of transportation. An integrated model to evaluate COVID-19 medical waste transportation risk by integrating an extended type-2 fuzzy total interpretive structural model (TISM) with a Bayesian network (BN) can be taken into consideration (Tang et al., 2023)
To improve the medical waste management system, quantitative statistical analysis by using the method of peer-reviewed publications originating from different geographical areas can be taken into consideration (Achuthan et al., 2022; Visser et al., 2021).
Conflict of interests
The authors declare no conflict of interest.
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