Medical Waste Management and Disposal Methods During COV-19 in Jordan-

A Case Study at King Hussein Cancer Center

Raghda Bawaneh, Ala Jallad, Farah Armoti, and Dr. Mahmoud Dar Assi

Ms. Engineering Management, Faculty of Engineering, Jordan

Abstract
Governments and healthcare organizations are facing numerous difficulties managing infectious
waste during the COVID-19 pandemic, caused by the tremendous increase in the medical waste
quantity. In the presence of the poor infrastructure and the lack of proper medical waste disposal
methods in Jordan, a serious revision of medical waste management plans should be taken into
consideration, decision-makers are responsible for managing carefully COVID-19 related medical
waste disposal methods with careful consideration of the pandemic impact on hospitals and
healthcare institutions. Hence, the main purpose of this paper is to help decision-makers evaluate
and assess possible medical waste disposal methods. This study illustrates King Hussein Cancer
Center (KHCC) as a case study by verifying and evaluating possible alternatives for the center.

Keywords: waste management · COVID-19 pandemic · incinerator. disposal. medical waste. decision tree.
simulation. decision making.

1. Introduction
Waste is measured as hazardous as it shows the presence of infectious, reactive, corrosive, volatile,
flammable, bioaccumulative, annoying, or sensitizing characteristics. It has been reported that the
risks arising from medical waste in developing countries have generally been of great concern to
environmental health engineers Sangodoyin and Osaigbrovo, 1992{1}.
Medical waste, known to be infectious and can spread diseases easily and quickly, it has different
types which include pathology, biohazards, pharmaceutical, trace chemotherapy, immunizations,
waste generated in autopsy and necropsy, waste produced in research relating to the production or
testing of microbiological, waste created in research using human or animal pathogens, sharps and
laboratory waste that causes a potential risk of infection to humans or any extra wastes that are
produced from medical care bodies, such as medical laboratories, hospitals, clinics, and dental
clinics Jang et al, 2006; Marinkovic et al, 2008{2}.
As in many other developing countries, the generation of regulated medical waste (RMW) in
Jordan has increased significantly over the last few decades. Despite the serious impacts of RMW
on humans and the environment, only minor attention has been directed to its proper handling and
disposal Medical waste management in Jordan: a study at the King Hussein Medical Center. {3}

The generation of medical waste will continue to increase considering the health care services in
Jordan's development and growth; therefore, a professional medical waste system must be
implemented and controlled in each hospital in Jordan British Journal of Healthcare Management {4}.
Journal of Air & Waste Management Association {5. Medical Waste Disposal: Air & Waste: Vol 44, No
10 (tandfonline.com) was interested in medical waste disposal methods the most used techniques
include internal segregation, containment, and incineration which has been found to be the most

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effective method overall for destroying infectious and toxic material, volume reduction, and
weight reduction in the medical waste stream, incineration destroys the broadest variety of medical
waste constituents and can recover energy from the medical waste stream. Incineration also is an
appropriate alternative to the burial of human pathological remains.

Towards the end of 2019, a new pandemic hit globally, affecting millions of people worldwide
and causing a tremendous rise in the number of patients and a huge load on the health sector. As a
result (Sarawut Sangkham) {6. Face mask and medical waste disposal during the novel COVID-
19 pandemic in Asia - ScienceDirect mentioned that the number of medical wastes has also
increased which mandated the health sector to think about new ways for medical disposal, the
threat of unsafe disposal of medical waste will spill over into environmental pollution is palpable
and immediate, a recent study found that human coronaviruses can remain active on inanimate
hard surfaces (such as metal, glass, or plastic) for up to nine days. Although some Asian countries
still do not follow proper management strategies and insufficient solid waste containers are one of
the major problems that lead to the contamination of infectious waste in solid waste containers in
the general community, the threat will be greater in developing countries that do not have sufficient
resources for solid waste management.

The rest of this paper is organized as follows. KHCC profile, materials, and methodology section
discussing the research methodology adopted in this study. Result and discussion which includes
the current regulatory status and waste management in KHCC, methods of disposal for the last
four years at the Center and the cost related to each method, and how to use the Precision Tree and
Monte Carlo to clarify the best disposal method should the center go with based on the uncertainty
discussed in this study, and the probability of medical waste generated per ped per day, Conclusion
section presents the conclusions and the future scope of the study.

1.1 The King Hussein Cancer Center Profile:

The King Hussein Cancer Center (KHCC) was established in 1997{7. www.KHCC.jo, honorably
bearing the name of His Majesty the late King Hussein of Jordan. The King Hussein Cancer Center
(KHCC) is the only specialized cancer center in the Middle East treating both adult and pediatric
patients. KHCC is a non-governmental, not-for-profit comprehensive center dedicated entirely to
cancer care. It has a capacity of 380 beds and currently treats more than 12666 new patients per
year. The mission of King Hussein Cancer Center (KHCC) is to provide state-of-the-art
comprehensive cancer care to the people of Jordan and the Middle Eastern region.

2. Methodology:
The purpose of this study is to determine the proper solid waste disposal method for KHCC, data
on solid waste (infectious, high infectious, and chemotherapy) quantities and costs between the
period of (2017-2020) were obtained from the KHCC safety department, based on the collected
data, it was possible to assess the spread and increment of solid waste produced by KHCC within
the period of the study, and in reflection to the raise of cases infected by the novel Coronavirus in
Jordan, On the other hand, the data collected from KHCC, enabled us to estimate the average
generation rate of the medical waste in terms of kilogram per bed per day. The data collected were

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subjected to statistical analysis to determine parameters like the mean, median, average, standard
deviation, and coefficient of variance. The second phase of analysis was by employing the data
generated using Precision Tree, and @Risk tools {8. Robert T. Clemen, Terence Reilly - Making Hard
Decisions with DecisionTools-Cengage Learning (2013).pdf, to determine the cost and risk
accompanying each of the discussed disposal methods, based on the results founded from the
analysis, a method of disposal was recommended to be obtained by KHCC.

3. Results and Discussion

3.1 Current Regulatory Status (KHCC)
In Jordan due to high levels of tourism, a high level of medical specialized medical centers in the
country. In Jordan, there are 110 Hospitals (state and private). The expansion of healthcare services
has increased the quantity of medical waste generated. An estimated 11 ton/day (2012) of medical
waste hazardous is produced all over the country. Other references reported 7.5-ton medical waste
per day which is equivalent to 2700 ton/year subjected to a tremendous increase resulting from the
hit of the novel coronavirus in 2020.

With the capacity of 380 beds, and the increasing number of patients that receive medical care at
KHCC, the center is dealing with a 43.9% increase in medical waste in the past four years (2017-
2020) resulted from the center’s expansion in 2018, and the effect of the novel coronavirus hit in
2020, today the center is producing an estimated 570 ton/year of medical waste hazardous. The
current method of disposal taking place at KHCC is to transfer the medical waste to Clean City
(1), costing the center around 773,693 JD/year.

3.2 Current Medical waste management at KHCC:

By the beginning of 2020 and after the COVID-19 pandemic number of cases started to increase
in Jordan medical waste quantity at KHCC has rapidly increased, therefore, more precautions were
required to manage the way of disposal and treatment of medical waste, if waste is not managed
properly it may lead to spread the virus consequently, the number of confirmed cases will be
increased as the quantity of medical waste increased, the existing protocol of waste management
shall be improved to protect the patients and visitors of KHCC, during COVID-19 the disposal
capacity of medical waste was insufficient this required KHCC to find a new way for disposal by
sending all types of medical waste to a private incinerator (clean city) to make sure the proper
disposal and treatment is implemented under the regulations of the Ministry of Health and the
Ministry of Environment.

3.3 Methods of Disposal:

The study is undertaken to analyze and compare three methods of medical waste disposal in terms
of efficiency, cost, and expected monetary value, these options were considered after the
evaluation of the existing and available methods of waste disposal for KHCC, the first option to
be examined is for KHCC to purchase a (private) incinerator with the capacity of 2000-3000
kg/day, Incineration is a thermal process that transforms medical wastes into inorganic,
incombustible matter thus leading to a significant reduction in waste volume and weight. The main
purpose of any medical waste incinerator is to eliminate pathogens from waste and reduce the
waste to ashes. The incinerator will thermally decompose medical waste in the pyrolytic chamber

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through an oxygen-deficient, medium-temperature combustion process no less than (900°C),
producing solid ashes and gases. The gases produced in the pyrolytic chamber are burned at a high
temperature no less than (1200°C), it has an initial capital investment of (425,400JD), an annual
operating cost of 85,000JD, a cost per unit (.14JD/kg), investing in the incinerator will eliminate
the of transferring the waste to other location consequently reducing the time needed for the waste
disposal, also the center can take advantage from the ash produced by the incinerator in making
building bricks for civil works after making sure the ash is free from any heavy metal or radioactive
materials. The second option is to transfer all medical waste to the clean city located 38km away
from KHCC, the transfer will require no capital investment cost, however, it will cost (192 JD/ton)
for transportation, and (3000 JD/ton for high infectious waste, 1500 JD/ton for pathogens waste,
2750 JD/ton for chemotherapy waste,900 JD/ton for infectious waste) as incineration fees. The last
option is to fragment the waste into two types (chemotherapy and high infectious waste to the
incinerator, infectious waste to shredder) part of which can be disposed of with a medical waste
shredder, the other part will be transferred and disposed of in Clean City, the costs, in this case,
will consist of the shredder capital investment of (10,000 JD), the shredder’s operation cost of (500
JD/moth), and the transportation and incineration fees of the other part.

3.4 Cost
The average of medical waste generated in the KHCC was increased in the last few years and it’s
getting riskier with the appearance of the new Coronavirus(COV-19) that increase the cost of
disposal, treatment, and transportation of the medical waste for each kg of waste, about the data
obtained since 2017 KHCC was using the first method which is using the shredder for treatment,
besides, sending the rest of medical waste to a special incinerator(clean city ) for disposal and
treatment, to be more specific in cost of disposal and treatment of medical waste KHCC was
treating some kind of medical waste in the shredder as a cost of (.70 JD/Kg) for the infectious and
high infectious waste inside KHCC without any transportation or storage cost, on the other hand,
the center was paying (2.75 JD/Kg) for chemotherapy waste (1.5 JD/Kg) for pathogens waste and
(1.15 JD/Kg) for some of the infectious waste and a transportation cost of (192JD/ton) outside
KHCC.

Generated waste in 2017 of chemotherapy waste was ( 38611 kg), pathogens waste was (1515 kg)
infectious waste was (332,394 kg) and high infectious waste of ( 5879 kg), so we spent about (
106180 JD/kg/year ) for disposing of the blue bag, ( 2272.5 JD/kg/year) for disposing of the
pathogens waste which discarded in the yellow bag also,(1439 JD/KG/year) for some of the yellow
bag ~ 1252 kg of waste in addition to the transportation waste of (192 JD/ton), and the rest was
treated in the KHCC shredder by (2359147 JD/kg/year).

Generated waste in 2018 of chemotherapy waste was ( 44500 kg), pathogens waste was (1653
kg) infectious waste was ( 436637 kg) and high infectious waste of ( 8532 kg), so we spent
about ( 122375 JD/kg/year ) for the blue bag, ( 2479 JD/kg/year) for the pathogens waste,(
1209 JD/KG/year) for some of the yellow bag ~ 1052 kg of waste in addition to the transportation
waste of (192 JD/ton), and the rest was treated in the KHCC shredder by (310881 JD/kg/year).

Generated waste in 2019 of chemotherapy waste was ( 32738 kg), pathogens waste was ( 1753
kg) infectious waste was ( 509620 kg) and high infectious waste of ( 9671 kg), so we spent

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about ( 90029 JD/kg/year ) for the blue bag, ( 2629 JD/kg/year) for the pathogens waste,(
1743.4 JD/KG/year) for some of the yellow bag~ 1516 kg of waste in addition to the
transportation waste of (192 JD/ton), and the rest was treated in the KHCC shredder by ( 362443
JD/kg/year).

In the year 2020, and the due to the existence of COVID-19, this reflects negatively on cost and in
the quantity of waste generated as mentioned , chemotherapy waste was ( 29317 kg), pathogens
waste was ( 1756 kg) infectious waste was ( 501930.4 kg) and high infectious waste of (35438
kg), but at the beginning of 2020 the shredder was insufficient for disposal so kHCC decide to
send all types of medical waste to the outside incinerator with a new contract for one year and a
new price offer, we spent about ( 80658.875 JD/kg/year ) for the blue bag by using the same price
(2.75 JD/ kg),and the same price (1.5 JD/Kg/year) ~ 2634 JD/kg/year for the pathogens waste,(
451737.36 JD/KG/year) as a 0.90 JD/Kg for infectious waste, for the high infectious waste of(3
JD/kg) ~ 106314 JD/Kg/year, in addition to the transportation waste of (192 JD/ton), so in this
study, a recommendation shall be made for KHCC with the best way of disposal for the coming
years taking in consideration the likelihood of a new disease emerged.

The mean of generated medical waste per bed was increased from 189 kg/bed/day in the year 2017
to ~243 kg/bed/day in the year 2020.

3.5 Data analysis using (Precision Tree & @Risk)

Using the data and cost collected from KHCC an analysis was done in two phases, at first
comparison was done using Precision Tree between three methods of waste disposal: buying a new
incinerator, transferring all medical waste types for clean city, or using shredder incorporation with
the clean city, the purpose of this analysis was to obtain the expected value of using each method.
This decision also came with its uncertainties, the WHO has revealed that the pandemic may stay
active till the end of 2021 given that a vaccine was developed and distributed to all countries by
the beginning of 2021, extra resources have mentioned that there could be a new pandemic shortly
which might lead to an extra increment in the medical waste quantities, however, there also could
be a probability that COVID-19 might end earlier than expected and no pandemic would be active.

The second phase was done by simulating existing data considering the results of the first analysis,
to study the efficiency of the chosen method.

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3.5.1 Decision making (data generation)
Table 4.1, 4.2, and 4.3 represents the cost for the three scenarios (uncertainties) and their predicted
probabilities for the upcoming two years, these numbers were used to construct a decision tree
Figure 4.1, to study the expected value for each of the proposed methods in respect to each of the
expected scenarios.

Table 3.1: Scenario 1 – COVID-19 remains active till 2021 80% probability.
Cost Buying the Transport-Clean city Clean city + Shredder
Incinerator
Capital Cost 425400 NA 10000
Operation cost/year 85000 NA 6000
Cost/Unit/year 83.16 633907 633907
Transportation fees/ton NA 114048 5184
Total 510483.16 747955 639091
*All costs are in Jordanian Dinars.

Table 3.2: Scenario 2 – New pandemic 10% probability.

Buying the Transport-Clean city Clean city +
Incinerator Shredder
Capital Cost 425400 NA 10000
Operation cost/year 85000 NA 6000
Cost/Unit/year 77.56 94401.4 94401.4
Transportation fees/ton NA 106368 5184
Total 510477.56 200769.4 99585.4
*All costs are in Jordanian Dinars.

Table 3.3: Scenario 3 – No pandemic 10% probability.

Buying the Transport-Clean city Clean city +
Incinerator Shredder
Capital Cost 425400 NA 10000
Operation cost/year 85000 NA 6000
Cost/Unit/year 108.108 122721.82 122721.82
Transportation fees/ton NA 148608 6144
Total 510508.108 271329.82 128865.82
*All costs are in Jordanian Dinars.

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3.5.2 Decision tree (data representation)
Figure 3.1: Decision tree constructed by Precision Tree tool.

As shown in the decision tree, the lowest expected value (lowest cost), shows that buying an
incinerator by KHCC will have the lowest cost a year for the other two options.
Choosing to buy a private incinerator would be recommended relying on the expected monetary
value alone, however, the risk associated with this decision shall be taken into consideration, this
will be discussed in the next section when understanding the probabilities associated with the
chosen method.

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3.5.2 Simulation
The following simulation represents the probability of the quantity of medical waste produced by
KHCC in kilograms per bed per day, this simulation was done to assure the efficiency of the
capacity of the proposed incinerator.
Figure 4.2 shows that there is a 73% probability that the center will produce 4.5kg/bed/day or less
and a 91% probability that it will produce 5kg/bed/day, which mean that with the center’s
maximum capacity of 380 beds it will produce 1900kg/day or less 91% of the time.

Figure 3.2: simulation representing the waste amount in kg/bed/day.

The result of the simulation also indicates the benefits associated with buying a private incinerator
instead of relying on other sources of disposal.

4. Conclusions:
The emergence of the COVID-19 pandemic has resulted in a high burden to the medical services
and hospitals in increasing the number of annual wastes therefore an urgent global call for waste
management is needed, this paper discusses the implications of the pandemic on the healthcare
sector, presenting King Hussein Cancer Center as a case study. The center faced a critical situation
regarding the methods of discarding the increasing amount of medical waste produced during the
pandemic. As part of solving this problem, KHCC was facing three alternatives of medical waste
disposal methods were discussed. After assessing the costs and uncertainties surrounding each
alternative, a recommendation was made based on the results drawn out using PrecisionTree &
@Risk tools. Accordingly, a recommendation for healthcare institutions and decision-makers was
made to consider using such decision tools in determining and assessing decisions.

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 5.References
1. Review of medical waste management in Jordanian health care organizations
2. Country report on the solid waste management in Jordan
3. Medical waste management in Jordan: A study at the King Hussein Medical Center.
4. Review of Medical Waste Management in Jordanian Healthcare organizations.
5. Medical Waste Disposal: Air & Waste: Vol 44, No 10 (tandfonline.com)
6. Face mask and medical waste disposal during the novel COVID-19 pandemic in Asia -
ScienceDirect
7. www.KHCC.jo
8. Robert T. Clemen, Terence Reilly - Making Hard Decisions with DecisionTools-Cengage
Learning (2013).pdf
9. Medical Waste Management in Al- Basheer State Hospital-Current Situation and Future Prospects.
10. Management of Hazardous Medical Waste Treatment in Egypt.
11. World Health Organization.