Vaccines Save Lives, but Who Handles the Waste? Exposing the Hidden Risks of Immunisation

Vaccination programmes are measured by the diseases they prevent, the populations they reach and the strength of their delivery systems. However, behind every administered vaccine lies another responsibility that receives considerably less scrutiny: managing the needles, syringes, contaminated materials and discarded packaging left behind. When these materials are improperly handled, a programme designed to protect public health can expose workers, communities and the environment to preventable hazards.

A study titled "The Hidden Side of Immunisation Success: A Mixed-Methods Implementation Research Study of Immunisation Waste Management in Nepal," published in the journal Vaccines, examines this overlooked dimension of immunisation delivery. Conducted by Madan Kumar Upadhyaya, Abhiyan Gautam, A.S.M. Shahabuddin, Bibek Kumar Lal, Sanjay Kumar Mahaseth and colleagues, the research exposes substantial weaknesses in waste management across selected Nepali healthcare facilities.

Based on assessments of 246 facilities, 74 interviews and observations of eight outreach sessions, the researchers identified widespread open burning, inadequate treatment infrastructure, limited worker protection and fragmented institutional accountability. Their central finding challenges conventional measures of healthcare readiness: formal management structures and established regulations do not necessarily translate into safe operational practices.

The governance paradox: Rules exist, but responsibility remains fragmented

Nepal's immunisation system operates within a federal governance structure in which national authorities oversee vaccination programmes while local governments carry responsibility for basic healthcare services and waste management. This division creates coordination challenges because the institutions responsible for delivering vaccines are not necessarily those managing the resulting waste.

The study found that 92.7% of assessed facilities reported having Health Facility Operation and Management Committees. However, only 38.6% of these committees met at least monthly, while healthcare waste management was a standing agenda item in just 15.9% of facilities with Immunization Coordination Committees. Institutional presence, therefore, provided little assurance of sustained attention to waste-related responsibilities.

Operational accountability was similarly weak. Only 29.3% of facilities reported having a designated waste-management focal person, and fewer than half of those individuals had received formal training. Health-worker orientation on healthcare waste management was reported in approximately one-third of facilities, suggesting substantial gaps between administrative expectations and workforce preparedness.

Access to regulatory guidance presented another difficulty. Although Nepal established national healthcare waste management standards in 2020, verified hard copies were available in only 11.8% of surveyed facilities. Interviews revealed discrepancies between municipal officials, who considered digital access sufficient, and frontline personnel who were sometimes unaware of the standards.

Financing further weakened implementation. Dedicated waste-management budgets existed in just 6.9% of facilities, and most facilities reporting such allocations considered them insufficient. Supervisory visits addressing immunisation waste had not occurred in 56.9% of facilities, leaving operational weaknesses largely outside routine oversight.

These findings identify a structural disconnect between governance and execution. Facilities may possess committees and formal responsibilities without the financial resources, trained personnel or supervisory mechanisms required to translate policy into consistent practice. Strengthening existing arrangements therefore requires clearer accountability rather than simply establishing additional administrative structures.

From segregation to disposal: Where the safety chain breaks down

Waste segregation represents one area where the study identified measurable progress. Researchers observed separation at the point of generation in 81.3% of facilities, indicating that many frontline services had adopted at least some practices intended to distinguish hazardous materials from general waste.

However, this apparent progress concealed weaknesses further along the disposal process. Labelled waste containers were observed in only 38.6% of facilities, while segregation bins or trolleys were present within immunisation service areas in just 15%. Interviews also revealed that materials initially separated during collection were sometimes recombined during final disposal.

The distinction is operationally significant. Segregation cannot deliver its intended benefits when hazardous and non-hazardous materials ultimately enter the same disposal system. The researchers found that partial compliance at individual stages frequently failed to produce safe management across the entire waste-handling chain.

Storage infrastructure was particularly inadequate. No healthcare waste storage area was identified in 87% of facilities, while only 8.9% had a fully designated storage area. Smaller facilities frequently lacked dedicated infrastructure, although interviews showed that some larger hospitals also struggled with insufficient space relative to their waste volumes.

Disposal practices presented the clearest indication of system-wide weakness. Open burning was reported for sharps waste in 67.1% of facilities and non-sharp waste in 72%. Only 9.8% practised waste treatment before disposal, despite the national standards governing safer waste-management procedures.

Autoclaving was reported for sharps in 9.3% of facilities and non-sharp waste in 4.9%. Even where autoclaves existed, interviews revealed problems involving maintenance, functionality and operator training. Some equipment was primarily used to sterilise clinical instruments rather than treat healthcare waste.

The researchers linked continued open burning principally to limited access to practical alternatives. Respondents frequently recognised that burning conflicted with national guidance but lacked appropriate treatment infrastructure. This suggests that awareness campaigns and training alone cannot resolve disposal failures without parallel investments in equipment, maintenance and waste-collection services.

The unprotected workforce behind immunisation delivery

The study identifies occupational safety as a particularly neglected component of immunisation waste management. Workers responsible for collecting, transporting and disposing of potentially infectious materials often operate without comprehensive protective arrangements, despite their direct exposure to hazardous waste.

Only 21.1% of facilities reported that all immunisation waste-handling personnel had received hepatitis B vaccination. The corresponding proportion for tetanus vaccination was 64.6%, indicating uneven occupational immunisation protection across the assessed facilities.

Reported barriers were predominantly administrative and logistical. Among facilities where at least one waste handler lacked hepatitis B vaccination, 52.1% cited the absence of a ministerial directive, while 40.7% reported vaccine unavailability. Lack of awareness was also identified, but the findings indicate that individual unwillingness was not the principal explanation.

Protective equipment availability presented a similarly incomplete picture. At least one form of personal protective equipment was available in 65.9% of facilities, although this did not indicate access to comprehensive protective sets. Gloves and masks were considerably more common than eye protection, face shields and other specialised equipment.

Interviews revealed that waste-handling duties frequently fell to office assistants and support personnel as additional responsibilities rather than formally assigned roles. Some workers lacked dedicated training, while respondents described inconsistencies between equipment availability and actual use.

The research consequently raises questions about how occupational protection is incorporated into public health programmes. Extending vaccination eligibility, establishing reliable supply arrangements and recognising waste handling as a defined responsibility could address weaknesses that cannot reasonably be corrected through individual behaviour alone.

Outreach immunisation introduced additional vulnerabilities. Across eight observed sessions, five disposed of non-sharp waste locally through dumping, burial or burning rather than transporting it to the parent facility. None maintained records documenting waste generation or transportation.

Although the outreach observations were not nationally representative, they demonstrated how limited transport arrangements, time pressure and inadequate operational guidance can undermine safety beyond permanent healthcare facilities. Expanding vaccination access therefore requires corresponding attention to the logistics of collecting and returning hazardous materials.

Beyond vaccine coverage: Rethinking what immunisation success requires

The research contributes to a broader understanding of healthcare performance by demonstrating that administrative readiness and functional implementation are different measures. Its combination of facility assessments, direct observations and interviews allowed researchers to identify weaknesses that conventional reporting arrangements might overlook.

The investigation also extends attention beyond major hospitals to peripheral facilities and community outreach settings. These environments are especially relevant to understanding how waste-management requirements operate where staffing, physical space, supervision and infrastructure differ substantially from larger healthcare institutions.

Nevertheless, the findings require careful interpretation. The study covered four of Nepal's seven provinces, and seasonal access constraints excluded some remote local government areas. Its cross-sectional design cannot establish causal relationships, while several indicators relied partly on self-reported information.

Observations of outreach activities were limited to eight sessions, and the researchers did not directly measure environmental contamination or occupational disease outcomes. The findings therefore establish significant weaknesses in management practices without quantifying the resulting health burden or demonstrating which interventions would be most effective.

For policymakers, the evidence supports coordinated action across administrative levels. Federal authorities could clarify occupational vaccination provisions and outreach-specific requirements, while provincial supervisors could systematically assess waste management alongside established immunisation performance measures.

Municipal governments could strengthen dedicated financing for storage, treatment, collection and maintenance. Incorporating facility-level waste records into routine health reporting would also improve visibility over a system currently constrained by limited information about waste generation and disposal.

The researchers advocate a phased, costed approach rather than isolated interventions. Such planning would allow infrastructure, workforce protection, supervision and reporting improvements to be prioritised according to operational needs and available resources.

The study exposes a weakness in assessing healthcare success primarily through service delivery. Vaccination protects populations against disease, but its effectiveness as a public health undertaking also depends on managing the materials and occupational risks generated during delivery.

For resource-constrained health systems, the central challenge is ensuring that service expansion does not outpace the supporting infrastructure required for safe operations. Nepal's findings show why waste management must become an accountable, financed and routinely monitored component of immunisation programmes rather than an administrative responsibility addressed only when problems arise.

A stronger immunisation system is not merely one that administers vaccines efficiently. It must also protect the personnel handling their waste and ensure that the final stages of vaccine delivery do not introduce avoidable risks into the communities those programmes serve.