Sage Journals: Discover world-class research

Abstract

Objective:

To map the global research on the impact of plastic-based health products and their packaging across the product lifecycle in order to inform equitable, sustainable governance for the role of plastics in health products.

Design:

A scoping review of primary research and systematic reviews examining plastic-related outcomes in the context of health products or packaging using a systematic search of the MEDLINE, EMBASE, SCOPUS, GEOBASE and Compendex databases November 2024 with no date or language restrictions.

Setting:

Studies spanning global and disciplinary contexts.

Participants:

Primary research or systematic reviews that examined plastic-related outcomes in the context of health products or packaging.

Main outcome measures:

We descriptively analyzed characteristics and outcomes of the included articles according to the product lifecycle stage.

Results:

We screened 14,695 articles and included 572 articles published between 1960-2024. Only 8% (45/572) of articles studied more than one lifecycle stage. The evidence is otherwise siloed by focus, setting, and discipline: articles focused on clinical use and storage outcomes (266/572, 46.5%), were conducted primarily in high income countries (230/266, 86.5%) and within biomedical disciplines (207/266, 86.5%); articles focused on end-of-life outcomes (n=257/572, 44.9%) were conducted more frequently in middle-income countries (158/257, 61.7%), and within engineering and environmental sciences (208/257, 80.9%). We documented a multi-decade interest in plasticizer leaching from plastic devices and packaging.

Conclusions:

A research agenda that is lifecycle oriented, prevention focused, and precautionary will produce robust, actionable evidence to support treaty decision-making and implementation. We conclude with recommendations for research priorities that include interventions to reduce the use of plastics in healthcare, to measure the health and environmental impacts of the chemicals in plastics, and identification and assessment of safe, toxics-free, sustainable alternatives.

Keywords

health policy < non-clinical environmental issues < public health < non-clinical other ethics < ethics < non-clinical

In 2022, the United Nations Environment Assembly adopted a resolution to negotiate a legally binding global treaty on plastic pollution;¹ negotiations remain ongoing. Because plastics pose negative health and environmental impacts across their lifecycle, from production to use to end-of-life, concern for population health has driven efforts to address plastic pollution.² Public health advocates urge that the treaty include a standalone ‘Article on Health’; make reference to health throughout the document; and that decision-making and implementation be guided by the precautionary principle and scientific evidence.³ To inform treaty development and implementation, it is important to understand what scientific evidence is available and whether and how it might inform interventions to mitigate or prevent the multiple harms from plastics.

One specific paradox the treaty could address is that, despite the risks to health posed by plastics and plastic pollution, healthcare is increasingly reliant on plastics in the design, manufacture, and packaging of health products.^4–7 Ranging from durable equipment, implantable devices, single-use clinical supplies, and personal protective equipment (PPE) to single-use products for producing and transporting biopharmaceuticals (i.e. blood products, vaccines), these health products contain plastics that can enhance durability, portability, or sterilisability. Accelerated by the coronavirus 2019 pandemic, drivers of increased use of plastic, single-use clinical supplies and PPE include perceptions of greater safety, affordability, and convenience.⁸ Yet, there remains limited evidence that single-use products mitigate infection transmission,^5,9 and concerns about the toxicity and migration of plastic ingredients have persisted for decades.¹⁰ Meanwhile, the production of healthcare-associated waste and pollution is clear: people around the world discarded approximately 3.4 billion single-use face masks every day.¹¹

Public health advocates, including the WHO, have argued for the importance of ensuring access to safe, effective and quality assured health products while also preventing and mitigating risks and harms from plastics, including advocating for approaches that reduce the production and use of plastics.^6,7 In contrast, a coalition of oil-producing nations and industry stakeholders has strongly opposed reducing plastic production, advocating instead for plastics waste management including circular economy approaches that emphasise recycling.⁴ The pharmaceutical industry, while supportive of globally harmonised plastic regulations, advocates for a risk-based approach to assessing the environmental impacts versus the benefits of plastics in healthcare and the need for extended compliance periods and limited exemptions where no feasible and safe alternatives exist at sufficient quality and scale.¹²

There are critical questions for the governance of health products around how to promote access while addressing the harms of plastic production, use, and pollution. To support decision-making, transparent evidence-to-decision frameworks are needed to incorporate scientific evidence in a structured way including evidence related to need, feasibility, and equitable access.¹³ Thus, it is essential to understand what evidence is available including: What health products and plastic ingredients have been studied, and in what contexts? What health, environmental, utility, and socioeconomic outcomes have been measured? Mapping the existing evidence across these dimensions can inform a research agenda that addresses priority actionable problems. We therefore conducted a scoping review to identify the characteristics of and patterns in the global evidence on the impacts of plastic-based health products and their packaging across the product lifecycle.

Methods

We conducted a scoping review, reported according to the PRISMA guidelines,¹⁴ and adopted rapid review methods.¹⁵ The specific aims were to:
Identify and categorise the research focus and outcomes of articles that examine the impacts of plastics and their ingredients (i.e. plasticisers) in the context of health products and packaging;

Analyse patterns in the research agenda according to article characteristics including study setting, date, discipline, and funding;

Describe research priorities to inform equitable, sustainable governance of the impacts of plastics in health products and their packaging.

To achieve these evidence mapping aims, we undertook this project in collaboration with a knowledge user (DD) who identified the need to map the evidence base. We first pre-registered the protocol and search strategy on November 22, 2024 (doi.org/10.17605/OSF.IO/R4ZBN). However, the search returned a high volume of articles reporting highly heterogeneous study designs, thus, we amended the protocol to focus on evidence mapping rather than synthesis and adopted rapid review methods.¹⁵ Rather than extracting or synthesising study findings, we amended the protocol on 25 February 2025 to adopt rapid review methods for the search, screening, and data extraction methods to inform the ongoing plastic treaty negotiations in a timely fashion (doi.org/10.17605/OSF.IO/R4ZBN); because we elected to include all study designs and did not extract study findings, we did not assess methodological quality or risk of bias.

Search strategy

We used the Population, Concept, Context framework¹⁶ to develop a comprehensive search strategy, in consultation with a librarian, structured around three domains: (1) health products and packaging; (2) plastics; and (3) relevant outcomes (Table 1). To capture literature across disciplines, we tailored each search for: MEDLINE, EMBASE, SCOPUS, GEOBASE and Compendex (search terms available at: doi.org/10.17605/OSF.IO/R4ZBN). We ran all searches on 5 November 2024.

Table 1.
Domains of keywords used to build our search strategy.

Concept Illustrative keywords

Health product

Medicines containers Pharmaceutical, medication, medicine, or drug packages, sachets, bottles, blister packs, or vials

Drug administration devices Pharmaceutical devices, canisters, spacers, inhalers, injectors, pens, ‘pre-filled,’ ‘single dose’

Clinical supplies Syringes, tubing, mini bags, IV bags, catheters

Respiratory and anaesthesia devices Oxygen or anaesthesia masks, devices, tubing

Medical devices Health products, medical devices, ‘single-use’ or ‘disposable’

PPE Gloves, gowns, face masks, procedure masks, surgical masks, face shields

Plastic

Plastic materials Plastic, bioplastics, polymers, polyvinyl chloride, polyethylene, polypropylene, polystyrene, cyclic olefin

Outcomes

Environmental Lifecycle assessment, greenhouse gas, climate change, carbon emission, carbon footprint, ozone depletion, fossil fuel, pollution

Health Toxicity, leaching, exposure, infection control, safety

Utility/socioeconomic Cost, durability, portability, affordability, convenience, equity, accessibility

Waste Hazardous waste, medical waste, plastic waste, waste management, solid waste, toxic waste, waste reduction, waste minimization, waste diversion, waste audit, waste segregation, contamination, footprint, biohazardous waste, waste treatment

Eligibility

We included articles that reported:
Primary research or systematic reviews and measured empirical outcomes;

On a marketed health product for human use and/or its packaging; and

On a health product/packaging that explicitly contained plastics, bioplastics, or plastic ingredients (i.e. plasticisers).

There were no restrictions on language or date of publication. We excluded articles reporting studies of:
Complex medical interventions using plastic components (e.g. surgical procedure) but did not measure plastic-specific outcomes;

Interventions to decrease or increase the use of a plastic health product without directly measuring plastic-related waste or impact;

Plastic ingredients in pure form, such as di(2-ethylhexyl) phthalate (DEHP) or Bisphenol A (BPA), where a health product was not the source.

Screening

References were de-duplicated using Covidence¹⁷ and Zotero,¹⁸ then screened in Covidence. We developed, piloted, and refined a screening manual on 20 studies. Pairs of reviewers (NW, DH, SN, MD, AB, and QG) independently screened all titles and abstracts, then full texts, with discrepancies resolved through discussion or adjudication by a third reviewer. Articles written in a language not spoken by the authors were translated using Google Translate.¹⁹ For feasibility, we excluded articles that were not available through the University of Toronto holdings or Interlibrary loan system (n = 30).

Data abstraction

We created, piloted, and refined a structured data abstraction instrument using a subsample of 20 articles (coding manual available at: doi.org/10.17605/OSF.IO/R4ZBN). We extracted data on:
Publication details (e.g. journal, title, year);

Author affiliations;

Industry affiliation, funding, and conflict of interest;

Study characteristics (e.g. study aim, country, discipline, design, sample type);

Type of health products (e.g. PPE, medical device); types of plastic (e.g. polypropylene, plasticisers);

Characteristics of exposure/intervention and comparators/control conditions;

Outcomes studied (e.g. outcome type, lifecycle stage, measures).

Pairs of reviewers (NW, DH, MD, AB, and QG) independently extracted data from 20% of included articles, resolving discrepancies through discussion, finding a high level of agreement on publication, author, and study characteristics, and types of health products and plastics. Due to this high level of agreement, one reviewer (NW, MD, AB, and DH) then extracted data on the remaining 80%, however, a second reviewer (QG) independently verified critical data that had greatest bearing on the review's results and conclusions, that is, the characteristics of the exposure/intervention, comparators/control conditions and outcomes studied for completeness and accuracy.¹⁵

Data analysis

Given the volume of articles, we did not group articles by study; the article was the unit of analysis. We descriptively analysed the characteristics of the included articles using frequencies and pivot tables in Excel and categorised study outcomes according to the lifecycle stage(s) of the product studied.

Findings

We screened the titles and abstracts of 14,695 articles from five databases and 1,436 full texts. A total of 572 articles met our inclusion criteria (Figure 1).

Figure 1.
PRISMA flow diagram.

Study characteristics

The characteristics of included articles are summarised in Table 2; the full data set is publicly available for download (doi.org/10.17605/OSF.IO/R4ZBN). Most included articles were published in environmental studies journals (235/572, 41%), conducted in high-income countries (369/572, 65%), and published from 2020 onwards (364/572, 64%). Most articles disclosed funding from government or not-for-profit sources (327/572, 57%) and declared no author conflicts of interest (369/572, 65%); most article authors were solely affiliated with academic institutions (254/572, 44%). A small proportion (<10%) of studies reported industry funding, authors with industry affiliation, or authors with financial conflicts of interest.

Table 2.
Summary of characteristics of included studies.

Study characteristic N %

Year of publication

2020s 364 63.6

2010s 74 12.9

2000s 61 10.7

1990s 46 8.0

1980s 18 3.2

1970s 8 1.4

1960s 1 0.2

572 100

Author affiliation

Academia 254 44.4

Mixed (academic, public, non-profit, health system) 195 34.1

Industry collaboration 51 8.9

Health system 32 5.6

Government 20 3.5

Industry only 19 3.3

Unknown 1 0.2

572 100

Industry affiliation

None 501 87.6

Pharmaceutical industry 24 4.2

Medical device industry 19 3.3

Consultancy 18 3.2

Manufacturing 7 1.2

Unknown 2 0.4

Fossil fuels industry 1 0.2

572 100

Funder type

Government/not-for-profit 327 57.2

No info 120 21.0

For-profit 55 9.6

None 49 8.6

Mixed 21 3.7

572 100

Conflicts of interest reported

None 369 64.5

No info 183 32.0

Yes 20 3.5

572 100

Study location – region ^a

European Region 208 36.4

Western Pacific Region 154 26.9

Region of the Americas 132 23.1

South-East Asian Region 48 8.4

Eastern Mediterranean Region 23 4.0

African Region 5 0.9

Multi-region 2 0.4

572 100

Study country – income status ^b

High-income 369 64.5

Upper-middle-income 146 25.5

Lower-middle-income 53 9.3

Low-income 3 0.5

Mixed income 1 0.2

572 100

Health product(s) – type

Personal protective equipment 302 52.8

Medical device 221 38.6

Vascular access catheters, dialysis supplies, intravenous infusion and transfusion bags and tubing 165 28.9%

Airway devices 16 2.8

Drainage and feeding devices 11 1.9

Wound care 5 0.9

Implantable devices 4 0.7

Durable equipment (incubator) 1 0.9

Packaging 28 4.9

Multiple 41 7.2

572 100

Lifecycle stage focus

Use/storage 266 46.5

Disposal/recycling 146 25.5

Decomposition 103 18.0

Multi-stage 45 7.9

Sanitisation/reprocessing/sterilisation 11 1.9

Shipping/distribution 1 0.2

572 100

a
Countries grouped by WHO region.
b
Country income status determined by World Bank classification.

Figures 2 and 3 illustrate the growing and evolving research focus on plastic health products and their packaging over time, with a notable surge in studies of PPE and its ingredients (i.e., polypropylene in face masks) following the onset of the coronavirus 2019 pandemic. Other notable trends include a growing interest in plastic packaging and macro/micro/nanoplastics in the context of health products, while there remains a multi-decade interest in plasticisers such as DEHP in the context of medical devices.

Figure 2.
Category of plastic health products in studies over time.

Figure 3.
Most prevalent categories of plastic studied in the context of health products over time.

The role and impact of plastics across the health product lifecycle

Included articles largely reported study outcomes on a single stage of the health product lifecycle; only 8% (45/572) of articles reported outcomes pertaining to more than one lifecycle stage. The only articles that reported outcomes on extraction, production/manufacturing, and procurement were those that assessed the full lifecycle of a product (e.g., cradle-to-grave lifecycle assessments). The largest proportion of articles reported outcomes on the use phase, which included the use of plastic health products in clinical practice and storage (as the use phase for packaging) (266/572, 46.5%). We noted patterns in terms of lifecycle stage focus by country (Figure 4) and discipline. Articles focused on the use phase (266/572, 46.5%) were concentrated primarily in high-income countries in the European and Americas Regions (204/266, 76.7%), and within biomedical disciplines (207/266, 77.8%). Articles focused on the end-of-life (257/572, 44.9%) ‒ disposal and decomposition ‒ were largely conducted within lower and upper middle-income countries (158/257, 61.5%) and engineering and environmental sciences disciplines (208/257, 80.9%).

Figure 4.
Study lifecycle stage focus by country setting and discipline.

Outcomes evaluated

We categorised study outcomes by type and mapped these according to study design and level of evidence (Table 3).

Table 3.
Types of outcomes measured categorised by health product lifecycle stage, level of evidence, and study design.

Lifecycle n (%)^a Level of evidence n (%)^b Study design Sample type Outcome type Outcomes n (%)

Shipping 1 (0.2%) Experimental 1 (100%) Stability study Drug Utility Product stability in different plastic containers 1 (100)

Use/storage 266 (46.5%) Systematic review 1 (0.4%) Systematic review of RCTs Human Health Clinical complication rate comparing plastic and non-plastic devices 1 (0.4)

Experimental 205 (77.1%) Migration/ leaching studies Drugs, medical devices, and PPE Health Quantity and characteristics of plasticisers, heavy metals, and microplastics leached from plastic packaging, drug containers, or medical devices during storage or use 59 (22.2)

In vitro exposure studies Simulants Health Quantifying exposure to leachates or microplastics released from simulated use of plastic health products 17 (6.4)

Cell cultures Health Cytotoxic effects of exposure to plastic health products used in clinical care or their leachates 12 (4.5)

In vivo exposure studies Animals Health Toxic effects of exposure to plastic health products used in clinical care or their leachates; Quantifying exposure to leachates from health products used in clinical care; Clinical complications 6 (2.3)

Humans Health Quantifying exposure to leachates or microplastics released from use of plastic health products (blood, urine, air samples) 9 (3.4)

Prospective randomised controlled, crossover, and parallel group clinical trials Humans Health, Utility Clinical complication rates; ease of use; procedure effectiveness/success comparing plastic medical device to alternative 26 (9.8)

Prospective non-randomised controlled, and crossover clinical trials Humans Health, Utility Clinical complication rates; ease of use; procedure effectiveness/success comparing plastic medical device to alternative 3 (1.1)

Stability and adsorption studies Drug Utility Drug stability; degree of drug adsorption; degree of light transmission; and plasticiser leaching in different plastic containers 35 (13.2)

Permeability studies PPE Utility Permeability and breakthrough/failure rates of different PPE plastic materials 27 (10.2)

Durability studies Catheters, airway masks, misc. medical devices and PPE Utility Durability; changes in surface properties; flammability; breakage rate of plastic devices and PPE when exposed to environmental stressors and use 9 (3.4)

Hemostasis study Blood samples Utility Time to hemostasis in blood samples collected in different plastic containers 1 (0.4)

Analytic 9 (3.4%) Chromatography/ mass spectrometry Medical devices and PPE Health Presence and concentration of DEHP, phthalates, and other plasticisers in plastic health products 9 (3.4)

Observational/ descriptive 51 (19.2%) Prospective observational studies Humans and medical devices Health, Utility Quantifying exposure to leachates or microplastics released from use of plastic health products (blood, urine, air samples); Clinical complication rates for plastic versus alternative devices 23 (8.7)

Retrospective observational studies Humans Health, Utility Frequency of clinical and technical (breakage) complications comparing a plastic and other medical device; Quantifying exposure to leachates or microplastics released from use of plastic health products (blood, urine, air samples) 17 (6.4)

Cross-sectional surveys Humans and medical devices Health, Utility Frequency of clinical and technical (breakage) complications comparing a plastic and other medical device; presence and quantity of plasticisers 11 (4.1)

Sanitisation/sterilisation 11(1.9%) Experimental 11 (100%) Sterilisation and washing intervention studies PVC infusion sets and face masks Utility Changes to plastic material properties; structural damage; strength/durability 8 (72.7)

PPE Environmental Release of microplastics; volatile organic compounds from plastic materials to environment 2 (18.2)

Infusion set Health Toxic effects of sterilisation exudates from treating plastic 1 (9.1)

Disposal 146 (25.5%) Experimental 89 (61.0%) Landfilling, upcycling/ recycling experiments (incl. pyrolysis, steam gasification, hydrocracking, incineration) Waste PPE, packaging, medical devices and construction materials or composites containing waste health products Utility Performance (durability, strength, other mechanical properties) of material made with plastic health product waste; Mass loss/degradation of plastic health product waste; Quantity and characteristics of yields from plastic health product waste 87 (59.6)

In vitro exposure studies Rats, bacteria Health Toxic effects of recycling process outputs from plastic health product waste 2 (1.4)

Observational/ descriptive 57 (39.0%) Cross-sectional survey PPE Environmental Quantity, composition, density, and distribution of PPE litter 38 (26.0)

Mixed health product waste Environmental, Cost Quantity and weight of mixed health product plastic waste AND cost of labour, wasted supplies or waste management 10 (6.9)

LCA (end-of-life) Mixed health product waste Environmental, Health Environmental impacts of disposal methods of mixed health product waste (ReCiPe methodology; CML-IA baseline) 7 (4.8)

Mixed health product waste Environmental, Utility, Cost, Social Environmental impacts of disposal methods of mixed health product waste (ReCiPe methodology); energy recovery; degradation time; operational costs; social acceptability 1 (0.7)

Material flow analysis Mixed health product waste Environmental Quantity and weight of mixed health product waste generated 1 (0.7)

Decomposition 103(18.0%) Experimental 103 (100%) In vivo exposure studies Animals Health Toxic effects resulting from health product microplastic or leachate exposure 13 (12.6)

Cell cultures, soil samples Health Cytotoxic or toxic effects resulting from health product microplastic or leachate exposure 22 (21.4)

Simulated biofouling, weathering, sorption, and terminal velocity studies PPE Environmental Characteristics and kinetics of microplastic release or leachates; sinking/floating rates; biodegradation and characteristics of microbial community (biofouling); sorption characteristics; degradation behaviours of decomposing PPE 52 (50.5)

In situ biofouling, weathering, sorption, and terminal velocity studies PPE Environmental Characteristics and kinetics of microplastic release or leachates; sinking/floating rates; biodegradation and characteristics of microbial community (biofouling); sorption characteristics; degradation behaviours of decomposing PPE 16 (15.5)

Multi-stage 45 (7.9%) Experimental/ observational 9 (20.0%) Mixed experimental (in vivo, in vitro, in situ) and observational (environmental surveys) PPE, medical devices, animal, human, cell cultures Environmental Measures of quantity and characteristics of waste, decomposition, and environmental toxicity 9 (20.0)

Observational/ descriptive 36 (80.0%) LCA Medical devices and PPE Environmental Environmental and human health-related impacts (using LCA methodologies) 30 (66.7)

LCA, lifecycle costing and Material Flow Analysis Medical devices and PPE Environmental, Health, Cost Environmental and human health-related impacts (using LCA methodologies); lifecycle costing; social impacts 6 (13.3)

a
Column percentage; N = 572.
b
Row percentage.

Types of outcomes. The largest proportion of articles reported only health-related outcomes (244/572, 42.7%) including rates of clinical complications from procedures using plastic health products and quantifying toxic exposure or effects of exposure to plastic products or their leachates (e.g., microplastics, plasticisers). A similar proportion reported only utility-related outcomes for human subjects (e.g. ease of use) or for packaging or medical devices (e.g. stability during storage) (223/572 39.0%). Thirty percent (172/572) measured exclusively environmental impacts, while 3% (17/572) measured social or financial outcomes such as acceptability or cost. Eighteen percent (104/572) reported outcomes across multiple categories, with most examining both health and utility outcomes.

Lifecycle focus

We then mapped outcomes across the lifecycle and describe the nature of the evidence for these phases (Table 3).

Shipping/distribution

One article reported an experimental study measuring the effects of plastic versus glass containers on the viability of stem cell therapies transported under different conditions.

Use/storage

The majority of articles focused on use and storage (n = 266) were experimental studies (205/266, 77.1%), most frequently migration and leaching experiments (59/266, 22.2%), which sought to quantify and characterise leachates (including plasticisers, heavy metals, and microplastics) from plastic containers or packaging, blood or infusion bags and tubing, and PPE under laboratory conditions. Forty-four (44/266, 16.5%) experiments quantified exposure to leachates and measured toxic and cytotoxic effects through simulating use, in vitro studies, or in vivo studies in humans and animals. Experiments including human subjects were randomised controlled and crossover trials (29/266, 10.9%) typically comparing single-use plastic medical devices (e.g. laryngeal airway mask or plastic catheter) with a non-plastic standard of care (e.g. reuseable silicone airway mask or metal needle) and measured rates of clinical complications and procedure effectiveness. Experiments focused on utility outcomes were largely pharmaceutical and blood product stability and adsorption studies (35/266, 13.2%) comparing different types of plastic and non-plastic containers.

Observational (51/266, 19.2%) evidence on the use phase included prospective and retrospective studies in humans exposed to plastic medical devices and clinical supplies during hospital stays or invasive procedures, for example, the concentration of leachates or microplastics in blood or urine, or the rates of clinical or technical complications.

Sanitisation/sterilisation

Eleven articles reported experiments testing the effects of sterilisation on face masks (3/11, 27.3%) or PVC infusion sets (5/11, 45.5%) and the laundering of face masks (3/11, 27.3%) on the products’ physiochemical material properties, including structural damage, breakage, microplastic release or plasticiser migration. One article reported toxicity of sterilisation by-products within mouse cell cultures.

Disposal

Of the articles focused on disposal (n = 146), 95.2% (139/146) were published since 2020 and 78.1% (114/146) focused on PPE. Most articles focused on the disposal phase reported experiments (87/146, 59.6%) which sought to test various interventions for processing or ‘upcycling’ plastic health product waste. These experiments assessed the efficiency of methods such as pyrolysis, gasification, melt blending, and hydrothermal processing in terms of the rate of mass loss of waste and the quantity and characteristics of byproducts. Articles also reported outcomes related to the performance, in terms of durability, strength, or other mechanical properties, of construction materials (e.g. concrete, cement, asphalt) or fabricated composites incorporating various proportions of health product waste, largely waste face masks and PPE. Eight articles used lifecycle assessment methodologies, focused only on the disposal phase, to assess the environmental impacts of different disposal methods for mixed health product waste (e.g. pyrolysis versus incineration versus landfilling). Two articles reported outcomes related to health, measuring the toxic effects (in rats and in vitro) of disposal methods for plastic health products.

About 1/3 of articles focused on disposal were cross-sectional studies that sought to quantify plastic health product waste. These included environmental surveys measuring the density and distribution of PPE litter and waste audits of healthcare settings.

Decomposition

All articles reporting studies of the decomposition phase were experiments (n = 103). Most commonly, the experiments simulated weathering and biofouling of PPE under various conditions including UV, freshwater, or seawater exposure and measured the characteristics and kinetics of microplastic release, leaching, or microbial colonisation (52/103, 50.5%). Sixteen articles reported experiments conducted in situ (16/103, 15.5%), and 13 (13/103, 12.6%) in vivo, which measured the toxic or cytotoxic effects of microplastics or leachates from plastic health products on animals, cell cultures, or soil samples.

Multi-stage

Just 8% (45/572) of articles reported outcomes pertaining to more than one phase of the product lifecycle, the majority of which employed a cradle-to-grave lifecycle assessment to estimate environmental and human health-related impacts from the extraction of raw materials through to end-of-life using a variety of established methodologies such as ReCiPe, TRACI, or IMPACT + (32/45, 71.1%); others reported only ‘cradle-to-gate’ (4/45, 8.9%) assessments that did not account for end-of-life.

Discussion

This review presents a novel effort to comprehensively map the research on the impacts of plastics in healthcare. By mapping the global evidence across scientific fields, interventions, and outcomes, patterns within the evidence base are indentified from which we offer three key insights: the evidence is siloed by lifecycle focus and discipline; consistent with policy debates, there remains a focus on disposal and coping with excess plastic waste; and there are persistent concerns about the toxicity of plastic materials and ingredients.

The first finding demonstrates that current evidence largely focuses on the use or the end-of-life phases of a product, which is siloed by discipline. The former stems from medical research disciplines focused on clinical and utility outcomes and, less so, the health impacts of plastics in clinical care. The latter, dominated by engineering and environmental sciences, is focused on developing and testing disposal methods and understanding the environmental impacts of discarded PPE. This division points to a major weakness in the evidence-base: limited interdisciplinary work and a failure to account for the full health product and plastics lifecycle. A lifecycle oriented and interdisciplinary evidence-base will be critical to address plastic production, use, and pollution, in both research and governance.

A second major finding concerns the challenge of managing excess plastic waste from health products. There was an evident increase in the number of articles published since 2020 addressing outcomes related to plastic waste and pollution in the context of PPE, reflecting broader policy and public health concerns.^20–22 This included a proliferation of articles evaluating upcycling or disposal methods of face masks. Early treaty negotiations proposed an exemption for plastic health products used in emergencies.⁶ However, due to the gravity of the plastics waste problem and its disproportionate burden on low- and middle-income countries,^21,23,24 such an exemption (i.e. for PPE in contexts of emergency) will likely be burdensome and inequitable in its impacts. A growing body of evidence suggests that few plastics produced are actually recycled and that recycling can exacerbate, rather than mitigate, the harms of plastics.²⁵ Thus, research and evidence-informed governance approaches should shift focus from managing to preventing the generation of plastic waste.

A third key finding related to the decades-long concern around the leaching of plastics and their additives, primarily plasticisers, from health products or packaging and their impacts on human health, pharmaceutical and blood product quality, and the environment. Included articles have reported outcomes related to the toxicity of plasticisers used in health products, such as DEHP, since the 1980s. Since 2007, the European Directive 2007/47/CE classified DEHP as a toxic product restricting its use in medical devices.²⁶ This led medical device manufacturers to quickly find alternatives (e.g. TOTM, DEHT, DINCH).²⁷ Moreover, our findings highlight increasing concerns in recent years related to the release of micro- and nanoplastics from plastic health products, emphasising the urgency of addressing plastic toxicity. To develop a robust evidence base, rather than studying the benefits and harms of plastic health products or product categories, a future research agenda should focus on measuring the effects ‒ on health and the environment ‒ of the chemicals that make up plastics and identifying safe alternatives. The subsequent evidence can support regulatory intervention to end the production and use of toxic chemicals and the substitution of similar hazardous chemicals.

Strengths and limitations

A strength of this review is its multidisciplinary scope, as we intentionally selected databases from a range of disciplines. Given the breadth of the search, we will have missed relevant studies, for example, by failing to capture terms specific to manufacturing processes and the full range of medical devices, especially in other languages. Further, included articles reported highly diverse study designs, precluding structured assessment or comparisons of methodological quality or risk of bias. However, this review provides a global and systematic snapshot of characteristics of the evidence base, permitting the future development of more focused evidence syntheses.

Conclusion

There exists a large, heterogeneous body of evidence pertaining to the role and impact of health products containing plastic, developed since the 1960s and burgeoning following the global coronavirus pandemic. In light of this evidence base, we emphasise the value of a research agenda that is lifecycle oriented, prevention focused, and precautionary. Rather than studying the benefits and harms of specific marketed products, a robust and actionable evidence base should measure the health and environmental impacts of the chemicals that make up the plastics that healthcare is reliant on. Future research priorities should include interventions to reduce the use of plastics in healthcare, identification and assessment of safe, toxics-free, sustainable alternatives, and full lifecycle assessment of the impacts of plastics in health products and their packaging.

Supplemental Material

sj-docx-1-shr-10.1177_20542704251409014 - Supplemental material for Mapping the evidence on the role and impact of plastics in the context of health products and their packaging: A scoping review

Supplemental material, sj-docx-1-shr-10.1177_20542704251409014 for Mapping the evidence on the role and impact of plastics in the context of health products and their packaging: A scoping review by Navisha Weerasinghe, Dana Hart, Andrea Bowra, Marilia D’Souza, Shugri Nour, Nicholas Chartres, Gillian Parker, Kelly Holloway, Fiona A. Miller, Mina Tadrous, Deirdre Dimancesco and Quinn Grundy in JRSM Open

Concept	Illustrative keywords
Health product
Medicines containers	Pharmaceutical, medication, medicine, or drug packages, sachets, bottles, blister packs, or vials
Drug administration devices	Pharmaceutical devices, canisters, spacers, inhalers, injectors, pens, ‘pre-filled,’ ‘single dose’
Clinical supplies	Syringes, tubing, mini bags, IV bags, catheters
Respiratory and anaesthesia devices	Oxygen or anaesthesia masks, devices, tubing
Medical devices	Health products, medical devices, ‘single-use’ or ‘disposable’
PPE	Gloves, gowns, face masks, procedure masks, surgical masks, face shields
Plastic
Plastic materials	Plastic, bioplastics, polymers, polyvinyl chloride, polyethylene, polypropylene, polystyrene, cyclic olefin
Outcomes
Environmental	Lifecycle assessment, greenhouse gas, climate change, carbon emission, carbon footprint, ozone depletion, fossil fuel, pollution
Health	Toxicity, leaching, exposure, infection control, safety
Utility/socioeconomic	Cost, durability, portability, affordability, convenience, equity, accessibility
Waste	Hazardous waste, medical waste, plastic waste, waste management, solid waste, toxic waste, waste reduction, waste minimization, waste diversion, waste audit, waste segregation, contamination, footprint, biohazardous waste, waste treatment

Study characteristic	N	%
Year of publication
2020s	364	63.6
2010s	74	12.9
2000s	61	10.7
1990s	46	8.0
1980s	18	3.2
1970s	8	1.4
1960s	1	0.2
	572	100
Author affiliation
Academia	254	44.4
Mixed (academic, public, non-profit, health system)	195	34.1
Industry collaboration	51	8.9
Health system	32	5.6
Government	20	3.5
Industry only	19	3.3
Unknown	1	0.2
	572	100
Industry affiliation
None	501	87.6
Pharmaceutical industry	24	4.2
Medical device industry	19	3.3
Consultancy	18	3.2
Manufacturing	7	1.2
Unknown	2	0.4
Fossil fuels industry	1	0.2
	572	100
Funder type
Government/not-for-profit	327	57.2
No info	120	21.0
For-profit	55	9.6
None	49	8.6
Mixed	21	3.7
	572	100
Conflicts of interest reported
None	369	64.5
No info	183	32.0
Yes	20	3.5
	572	100
Study location – region ^a
European Region	208	36.4
Western Pacific Region	154	26.9
Region of the Americas	132	23.1
South-East Asian Region	48	8.4
Eastern Mediterranean Region	23	4.0
African Region	5	0.9
Multi-region	2	0.4
	572	100
Study country – income status ^b
High-income	369	64.5
Upper-middle-income	146	25.5
Lower-middle-income	53	9.3
Low-income	3	0.5
Mixed income	1	0.2
	572	100
Health product(s) – type
Personal protective equipment	302	52.8
Medical device	221	38.6
	Vascular access catheters, dialysis supplies, intravenous infusion and transfusion bags and tubing	165	28.9%
Airway devices	16	2.8
Drainage and feeding devices	11	1.9
Wound care	5	0.9
Implantable devices	4	0.7
Durable equipment (incubator)	1	0.9
Packaging	28	4.9
Multiple	41	7.2
	572	100
Lifecycle stage focus
Use/storage	266	46.5
Disposal/recycling	146	25.5
Decomposition	103	18.0
Multi-stage	45	7.9
Sanitisation/reprocessing/sterilisation	11	1.9
Shipping/distribution	1	0.2
	572	100

Lifecycle	n (%)^a	Level of evidence	n (%)^b	Study design	Sample type	Outcome type	Outcomes	n (%)
Shipping	1 (0.2%)	Experimental	1 (100%)	Stability study	Drug	Utility	Product stability in different plastic containers	1 (100)
Use/storage	266 (46.5%)	Systematic review	1 (0.4%)	Systematic review of RCTs	Human	Health	Clinical complication rate comparing plastic and non-plastic devices	1 (0.4)
Experimental	205 (77.1%)	Migration/ leaching studies	Drugs, medical devices, and PPE	Health	Quantity and characteristics of plasticisers, heavy metals, and microplastics leached from plastic packaging, drug containers, or medical devices during storage or use	59 (22.2)
In vitro exposure studies	Simulants	Health	Quantifying exposure to leachates or microplastics released from simulated use of plastic health products	17 (6.4)
Cell cultures	Health	Cytotoxic effects of exposure to plastic health products used in clinical care or their leachates	12 (4.5)
In vivo exposure studies	Animals	Health	Toxic effects of exposure to plastic health products used in clinical care or their leachates; Quantifying exposure to leachates from health products used in clinical care; Clinical complications	6 (2.3)
Humans	Health	Quantifying exposure to leachates or microplastics released from use of plastic health products (blood, urine, air samples)	9 (3.4)
Prospective randomised controlled, crossover, and parallel group clinical trials	Humans	Health, Utility	Clinical complication rates; ease of use; procedure effectiveness/success comparing plastic medical device to alternative	26 (9.8)
Prospective non-randomised controlled, and crossover clinical trials	Humans	Health, Utility	Clinical complication rates; ease of use; procedure effectiveness/success comparing plastic medical device to alternative	3 (1.1)
Stability and adsorption studies	Drug	Utility	Drug stability; degree of drug adsorption; degree of light transmission; and plasticiser leaching in different plastic containers	35 (13.2)
Permeability studies	PPE	Utility	Permeability and breakthrough/failure rates of different PPE plastic materials	27 (10.2)
Durability studies	Catheters, airway masks, misc. medical devices and PPE	Utility	Durability; changes in surface properties; flammability; breakage rate of plastic devices and PPE when exposed to environmental stressors and use	9 (3.4)
Hemostasis study	Blood samples	Utility	Time to hemostasis in blood samples collected in different plastic containers	1 (0.4)
Analytic	9 (3.4%)	Chromatography/ mass spectrometry	Medical devices and PPE	Health	Presence and concentration of DEHP, phthalates, and other plasticisers in plastic health products	9 (3.4)
Observational/ descriptive	51 (19.2%)	Prospective observational studies	Humans and medical devices	Health, Utility	Quantifying exposure to leachates or microplastics released from use of plastic health products (blood, urine, air samples); Clinical complication rates for plastic versus alternative devices	23 (8.7)
Retrospective observational studies	Humans	Health, Utility	Frequency of clinical and technical (breakage) complications comparing a plastic and other medical device; Quantifying exposure to leachates or microplastics released from use of plastic health products (blood, urine, air samples)	17 (6.4)
Cross-sectional surveys	Humans and medical devices	Health, Utility	Frequency of clinical and technical (breakage) complications comparing a plastic and other medical device; presence and quantity of plasticisers	11 (4.1)
Sanitisation/sterilisation	11(1.9%)	Experimental	11 (100%)	Sterilisation and washing intervention studies	PVC infusion sets and face masks	Utility	Changes to plastic material properties; structural damage; strength/durability	8 (72.7)
PPE	Environmental	Release of microplastics; volatile organic compounds from plastic materials to environment	2 (18.2)
Infusion set	Health	Toxic effects of sterilisation exudates from treating plastic	1 (9.1)
Disposal	146 (25.5%)	Experimental	89 (61.0%)	Landfilling, upcycling/ recycling experiments (incl. pyrolysis, steam gasification, hydrocracking, incineration)	Waste PPE, packaging, medical devices and construction materials or composites containing waste health products	Utility	Performance (durability, strength, other mechanical properties) of material made with plastic health product waste; Mass loss/degradation of plastic health product waste; Quantity and characteristics of yields from plastic health product waste	87 (59.6)
In vitro exposure studies	Rats, bacteria	Health	Toxic effects of recycling process outputs from plastic health product waste	2 (1.4)
Observational/ descriptive	57 (39.0%)	Cross-sectional survey	PPE	Environmental	Quantity, composition, density, and distribution of PPE litter	38 (26.0)
Mixed health product waste	Environmental, Cost	Quantity and weight of mixed health product plastic waste AND cost of labour, wasted supplies or waste management	10 (6.9)
LCA (end-of-life)	Mixed health product waste	Environmental, Health	Environmental impacts of disposal methods of mixed health product waste (ReCiPe methodology; CML-IA baseline)	7 (4.8)
Mixed health product waste	Environmental, Utility, Cost, Social	Environmental impacts of disposal methods of mixed health product waste (ReCiPe methodology); energy recovery; degradation time; operational costs; social acceptability	1 (0.7)
Material flow analysis	Mixed health product waste	Environmental	Quantity and weight of mixed health product waste generated	1 (0.7)
Decomposition	103(18.0%)	Experimental	103 (100%)	In vivo exposure studies	Animals	Health	Toxic effects resulting from health product microplastic or leachate exposure	13 (12.6)
Cell cultures, soil samples	Health	Cytotoxic or toxic effects resulting from health product microplastic or leachate exposure	22 (21.4)
Simulated biofouling, weathering, sorption, and terminal velocity studies	PPE	Environmental	Characteristics and kinetics of microplastic release or leachates; sinking/floating rates; biodegradation and characteristics of microbial community (biofouling); sorption characteristics; degradation behaviours of decomposing PPE	52 (50.5)
In situ biofouling, weathering, sorption, and terminal velocity studies	PPE	Environmental	Characteristics and kinetics of microplastic release or leachates; sinking/floating rates; biodegradation and characteristics of microbial community (biofouling); sorption characteristics; degradation behaviours of decomposing PPE	16 (15.5)
Multi-stage	45 (7.9%)	Experimental/ observational	9 (20.0%)	Mixed experimental (in vivo, in vitro, in situ) and observational (environmental surveys)	PPE, medical devices, animal, human, cell cultures	Environmental	Measures of quantity and characteristics of waste, decomposition, and environmental toxicity	9 (20.0)
Observational/ descriptive	36 (80.0%)	LCA	Medical devices and PPE	Environmental	Environmental and human health-related impacts (using LCA methodologies)	30 (66.7)
LCA, lifecycle costing and Material Flow Analysis	Medical devices and PPE	Environmental, Health, Cost	Environmental and human health-related impacts (using LCA methodologies); lifecycle costing; social impacts	6 (13.3)

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for this work provided by the University of Toronto Collaborative Centre for Climate, Health and Sustainable Care, the Institute for Inclusive Wellbeing at University of Toronto Scarborough, and the University of Toronto Institute of Health Emergencies and Pandemics.

Ethical approval

This study is a review of publicly available literature and does not involve direct interaction with human participants or access to identifiable patient data. Therefore, ethical approval and consent were not required for this review.

Guarantor

Quinn Grundy serves as guarantor for the study, accepting full responsibility for the work and/or the conduct of the study. Dr. Grundy had full access to the data and controlled the decision to publish.

Author contributorship

QG and DD conceived the study; QG, GP, MT, and KH acquired funding; QG, NC, GP, FM, MT, and DD designed the study and methodology; QG, NW, DH, AB, MD, and SN conducted study screening and data abstraction. QG, NW, DH, and AB conducted data analyses; QG, NW, DH, and AB drafted the manuscript; all authors contributed to data interpretation, and critical review and editing of the manuscript. All authors approved the final manuscript.

Provenance

Not commissioned: peer reviewed by Julie Morris and Anthony David Dayan.

ORCID iDs

Navisha Weerasinghe

Dana Hart

Andrea Bowra

Marilia D’Souza

Shugri Nour

Nicholas Chartres

Gillian Parker

Kelly Holloway

Fiona A. Miller

Mina Tadrous

Deirdre Dimancesco

Quinn Grundy

Supplemental material

Supplemental material for this article is available online.

References

United Nations Environment Programme. UNEA resolution 5/14 entitled “End plastic pollution: Towards an international legally binding instrument.” https://wedocs.unep.org/bitstream/handle/20.500.11822/39812/OEWG_PP_1_INF_1_UNEA%20resolution.pdf (2022).

Intergovernmental Negotiating Committee. INC: Media | UNEP - UN Environment Programme. United Nations Environment Assemblyhttps://www.unep.org/inc-plastic-pollution/media (2024, accessed 5 February 2025).

Intergovernmental Negotiating Committee. Chair’s text: Intergovernmental negotiating committee to develop an international legally binding instrument on plastic pollution, including in the marine environment. United Nations Environment Assembly; 2024. https://wedocs.unep.org/bitstream/handle/20.500.11822/46710/Chairs_Text.pdf

Anderson

. UN plastic pollution treaty derailed as fossil fuel nations block production limits - health policy watch. Health Policy Watch. https://healthpolicy-watch.news/global-plastics-treaty-talks-derailed-as-fossil-fuel-nations-block-production-limits/ (2024, accessed 5 February 2025).

Smith

Singh

Sherman

. Infection prevention, planetary health, and single-use plastics. J Am Med Assoc 2023;330(20):1947–1948.

Street

Stringer

Mangesho

Ralston

Greene

. Why medical products must not be excluded from the Global Plastics Treaty. Lancet 2024;404(10464):1708–1710.

World Health Organization. Ensuring the integration of health aspects within the international legally binding instrument on plastic pollution, including in the marine environment. World Health Organization; 2024. https://cdn.who.int/media/docs/default-source/chemical-safety/plastics/who-inf-paper-for-inc5.pdf?sfvrsn=6ebbe6b6_3(2024)doi:10.5334/aogh.4459.5

MacNeill

Hopf

Khanuja

, et al. Transforming the medical device industry: road map to a circular economy. Health Aff (Millwood) 2020;39(12):2088–2097.

Sherman

Thiel

MacNeill

, et al. The green print: advancement of environmental sustainability in healthcare. Resour Conserv Recycl 2020;161:1–11.

10.

UN Environment Programme. Chemicals in plastics – A technical report. United Nations Environment Programme. https://www.unep.org/resources/report/chemicals-plastics-technical-report (2023, accessed 25 June 2025).

11.

World Health Organization. Global analysis of health care waste in the context of COVID-19. World Health Organization. https://www.who.int/publications/i/item/9789240039612 (2022, accessed 29 May 2025).

12.

International Federation of Pharmaceutical Manufacturers & Associations. Comprehensive approach for a treaty to end plastics pollution: Perspectives from the biopharmaceutical and consumer health industries. https://www.ifpma.org/news/comprehensive-approach-for-a-treaty-to-end-plastics-pollution-perspectives-from-the-biopharmaceutical-and-consumer-health-indusries/ (2024, accessed 19 November 2024).

13.

Chartres

Aung

Norris

, et al. Development of the navigation guide evidence-to-decision framework for environmental health: version 1.0. Environ Sci Technol 2025;59(9):4230–4244.

14.

Page

McKenzie

Bossuyt

, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Br Med J 2021;372:1–9. doi:10.1136/bmj.n71

15.

Garritty

Hamel

Trivella

, et al. Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness. Br Med J 2024;384:1–13. doi:10.1136/bmj-2023-076335

16.

Pollock

Peters

MDJ

Khalil

, et al. Recommendations for the extraction, analysis, and presentation of results in scoping reviews. JBI Evid Synth 2023;21(3):520.

17.

Covidence. The World’s #1 Systematic Review Tool. https://www.covidence.org/ (2024)

18.

Zotero. https://zbib.org/ (2025, accessed 25 June 2025).

19.

Google. Google Translate. https://translate.google.ca/?sl=en&tl=el&op=translate (2024, accessed 6 November 2024).

20.

Greene

Skolnik

Merritt

. How medicine becomes trash: disposability in health care. Lancet 2022;400(10360):1298–1299.

21.

Rizan

Mortimer

Stancliffe

Bhutta

. Plastics in healthcare: time for a re-evaluation. J R Soc Med 2020;113(2):49–53.

22.

World Health Organization. WHO Health dialogue: Plastics in health care. https://www.who.int/news-room/events/detail/2023/11/08/default-calendar/who-health-dialogue–plastics-in-health-care (2023, accessed 22 January 2024).

23.

Veidis

LaBeaud

Phillips

Barry

. Tackling the ubiquity of plastic waste for human and planetary health. Am J Trop Med Hyg 2022;106(1):12–14.

24.

World Health Organization. Impacts of chemicals, waste, and pollution on human health. https://apps.who.int/gb/ebwha/pdf_files/EB154/B154_24-en.pdf (2023).

25.

Deeney

Yates

Banner

Kadiyala

. Ending pollution and health harms from plastics. Br Med J 2025;388:r71.

26.

European Union. Directive 2007/47/EC of the European Parliament and of the Council of 5 September 2007. 2007. doi:10.1007/978-1-137-54482-7_24

27.

Bernard

Décaudin

Lecoeur

, et al. Analytical methods for the determination of DEHP plasticizer alternatives present in medical devices: a review. Talanta 2014;129:39–54.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.03 MB