Hazardous Medical Wastes-Ahmed Roushdy-educational Research

8/14/2019 Hazardous Medical Wastes-Ahmed Roushdy-educational Research

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MEDICAL WASTE

Definition: Medical waste is generally defined under state regulations. Medical waste is oftendescribed as any solid waste that is generated in the diagnosis, treatment, or immunization of

human beings or animals, in research pertaining thereto, or in the production or testing ofbiologicals, including but not limited to:

blood-soaked bandages

culture dishes and other glassware

discarded surgical gloves - after surgery

discarded surgical instruments - scalpels

needles - used to give shots or draw blood

cultures, stocks, swabs used to innoculate cultures

removed body organs - tonsils, appendices, limbs, etc.

lancets - the little blades the doctor pricks your finger with to get a

drop of blood

http://www.epa.gov/epaoswer/other/medical/

Types of Medical Waste

Human Blood and Blood Products

Human blood and blood products are classified and managed as medical waste because of thepossible presence of infectious agents that cause blood-borne disease. Wastes in this categoryinclude bulk blood and blood products as wellas smaller quantities of blood samples drawn for testing or research. Waste human blood must betreated by steam sterilization. After sterilization, the liquid portion may be safely poured off into asanitary sewer drain. Animal blood is not regulated as medical waste unless it has beenintentionally exposed to a human infectious agent and is capable of transmitting the disease backto humans.

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Cultures and Stocks of Infectious Agents

Cultures and stocks of human infectious agents, regardless of storage method, must be managedas medical waste. Cultures and stocks of zoonotic disease are not regulated as medical waste if

they have neither been intentionally exposed to ahuman infectious agent nor capable of transmitting that disease to humans.

Pathological Waste

Animal pathological wastes are considered to be medical waste only if the animal has beenintentionally exposed to a human infectious agent and it is capable of transmitting the diseaseback to a human. Animals that are accepted at the University that may be carriers of humaninfectious agents, e.g., rabies, are not regulated as medical waste. As long as the human diseaseagent was not deliberately introduced to the animal as part of a treatment or research regimen atthe University and the animal is not capable of transferring this disease back to humans it is notregulated as a medical waste.

Sharps

All hypodermic needles and syringes, intravenous needles and tubing, scalpel blades, lances,and other such devices are regulated as medical waste. Even if these materials are unused theyare still regulated. All sharps must be place in an approved sharps container. Sharps that havebeen exposed to human disease agents must be autoclaved prior to pickup by Safety andEnvironmental Health.

Glassware

Glassware exposed to a human infectious agent must be managed as a sharp until it has beenautoclaved. This includes pipettes, capillary tubes, test tubes, stir rods, and other laboratory

equipment. All glassware that has been exposed to human infectious agents must be autoclavedprior to disposal. After the glassware has been autoclaved it can be thrown in the trash.Glasswarethat has not been exposed to a human disease agent is not regulated as a sharp.

Broken glassware should be placed into a container designed for such materials and eitherrecycled or disposed. Currently, there is no locally available market for Pyrex glass so it should bedisposed of as solid waste. At a minimum, brokenglassware should be disposed of in small double lined cardboard boxes and clearly labeled asbroken glassware. Small double lined boxes minimize the potential for injury and excessiveaccumulation in the laboratory.

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Contaminated Equipment

This includes any equipment not mentioned above which may come into contact with humaninfectious agents. Equipment that has been contaminated with human disease agents must betreated as a medical waste and either autoclaved or shippedoff-site for treatment.

Sharps

Packaging

The sharps container must be red in color and display the International Biohazard Symbol or oneof the following phrases:

* Medical Waste* Infectious Infectious Waste Biohazardous

All sharps must be packaged in an approved sharps container. We are unable to accept sharps

that are in plastic milk containers, cardboard boxes or other types of unapproved containers. TheScientific Supply Store in Saunders Laboratoriescarries a selection of various size sharps containers and they are available from most generalscientific supply companies.

The generator must ensure that the container is properly sealed and labeled. If the container isnot properly sealed, or there is any doubt about the integrity of the sharps container it will not beaccepted for disposal. Sharps containers should not be used for the disposal of aluminum drinkcans, paper, gloves, laboratory glass, culture tubes, bodily fluids or any other similar types ofmaterials. Sharps containers shall not be used for the disposal of chemicals or radioactivematerials. Sharps containers should only be used for sharps. If the sharps have been exposed tohuman disease agents they must be autoclaved prior to being picked up by Safety andEnvironmental Health.

Sources

Hospitals are sources of many types of hazardous and solid wastes, and in small communitiesmay be the largest source of certain wastes. Specifically, there has been recent concern abouthospitals and hospital incinerators as sources of mercury in the environment. Many hospitalshave found that working to reduce specific wastes, such as mercury, or specific types of wastes,such as laboratory waste, has also resulted in significant cost savings. Information is included inthis sector on the reduction of hospital facility waste, lab waste, radiology (silver) and mercurywastes, and biohazardous waste, as well as wastes from hospital laundries, offices, andcafeterias. When hospitals expand to meet the needs of their communities, new constructionoffers opportunities for improved efficiency and the purchase of recycled and environmentallyfriendly products.

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Impact of Medical Wastes on Human Health.

1-Infectious wastes

Defining Infectious Waste

The words used to describe "infectious waste" are various. The terms usedinclude: biohazardous waste, biological waste, medical waste, hospital waste,medical hazardous waste, infective waste, microbiological waste, pathologicalwaste, and red bag waste. The industry also struggles with the acceptabledefinition of infectious waste. The regulatory agencies are not in completeagreement when defining medical waste but one can conclude from therecommendations that the following are classified as infectious waste:"human blood and blood products, cultures and stocks of infectious agents,pathological wastes, contaminated sharps, contaminated laboratory wastes,contaminated waste from patient care, discarded biologicals, contaminated

animal carcasses, body parts, and bedding, contaminated equipment andmiscellaneous infectious wastes" (34 Reinhardt). For our purpose, focus andattention will be made on contaminated sharps, blood and blood productsand pathological waste since these wastes are the higher percentage of themedical waste stream. "Contaminated sharps include hypodermic needs andsyringes, intravenous needles, scalpel blades, lances, disposable pipettes,capillary tubes, microscope slides and cover slips and broken glass. Humanblood and blood products include serum, plasma and other bloodcomponents. Pathological waste of human origin include tissues, organs, andbody parts removed during surgery or autopsy" (13 OTA). For all of the wastetypes, the regulatory agencies have recommendations for the best type of

treatment for the different types. One thing that will surprise those who arenot in the medical industry is the discharge of waste into the sanitary sewer.

The Environmental Protection Agency provides suggestions andrecommendations for treatment methods for each infectious waste type.Sharps represent a special hazard due to their ability to prick andcontaminate someone who is handling them. Blood and blood products aregenerally thought to be very hazardous since we identify the transmission ofthe HIV and HBV viruses with blood. Pathological waste must be transformedbefore it can be sent away to the landfill. God forbid the sanitation workerwake up to find someone's liver or heart in the dumpster. So, the EPAsuggests that all sharps be placed in rigid, puncture resistant container.

On a visit to the doctor's office to get an injection, you will notice that redlocked box used for this purpose. Once the sharps go in the container, it isnearly impossible for an unauthorized person to remove them. Sharps arecollected and then decontaminated by either incineration or steamsterilization. If they are steam sterilized, the sharps must be ground orcrushed.

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Surprisingly enough, the sanitary sewer provides a place to put the blood andblood products refused by our medical waste generators. "Reportedly, about23 percent of hospitals dispose of blood and body fluids to sewers and about14 percent grind solid infectious wastes and discharge them to sewers usinga grinder similar to that used for in-sink home garbage grinding" (62 OTA). Itis crucial that hospital have the proper plumbing to avoid clogging andoverflow (plumbers be beware). When doctors operate, body parts could endup in the waste stream. These body parts need special attention. The EPAdoes not allow for the discharge of body parts to landfills due to aestheticreasons. Therefore, body parts are incinerated or steam sterilized followingby shredding or grinding. As you can see, medical waste sometimes requiresmore than one type of treatment process to complete the job.

http://environmentalchemistry.com/yogi/environmental/medicalwaste.html

2-Medical Waste Incineration is a Major Source ofDioxins And Many Other Air Pollutants

The U.S. EPA identifies medical waste incineration as the third largest known source to theenvironment of highly toxic dioxin, a known carcinogen that has been linked to birth defects,immune system disorders and other harmful health effects. Incineration is also responsible forabout 10 percent of mercury emissions to the environment from human activities. Mercury is apotent neurotoxin that can cause developmental defects and harm the brain, kidneys and lungs.Other pollutants from incineration include furans, acid gases, heavy metals and particulates.

DioxinsDioxins are a family of complex, but related molecules with similar chemicalstructures. These highly toxic substances persistfor long periods in the environment, where they bioaccumulate in livingtissues. Nobody creates dioxins intentionallythey arewaste byproducts of industrial processes like combustion, chemical

manufacturing, and chlorine bleaching. While it appearsthat most dioxins are created by human activities, dioxins have been linkedto a few natural sources, like certain ball clays andvolcanoes.In humans, dioxins have the potential to cause cancer and to produce a broadspectrum of adverse effects, because they canalter the fundamental growth and development of cells. For example, dioxinscan weaken the immune system and interfere with

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the endocrine system, which is responsible for making hormones needed toregulate bodily functions including sexualdevelopment and fertility. According to U.S. EPA, dioxins exposures in thegeneral population are of great concern: Dioxins may be altering the biochemical processes in our bodies. (U.S. EPAdoes not know whether these changes

have adverse effects on human health.) Dioxins cancer risks could exceed 1 in 1,000 for the general population(actual risks are likely to be lower). Many clearly adverse effects (such as impacts on immune system functionand diabetes) may occur at concentrationsthat are less than 10 times the average dioxins exposure of the U.S.population.In the U.S., more than 90% of the dioxins released to the environment areemitted to the air. Due to their chemical properties, dioxins released tothe environment can travel far from their sourcesdioxins emitted inCalifornia can affect the Arctic! Deposition of dioxins emissions on fieldsand gardens brings dioxins into the human food chain.

U.S. EPA estimates that the typical U.S. resident receives about 95% ofhis or her dioxins exposure from consumption of animal fats. A 1995nationwide survey of the food supply using FDA estimates of foodconsumption in typical U.S. diets found that U.S. population dioxinsexposures exceed current World Health Organization dioxins consumptionguidelines. Happily, exposures are decreasing in response to governmentregulations and the decisions of dozens of businesses and institutions toeliminate dioxins-producing activitiesU.S. EPAs 1995 dioxins emissions inventory estimated that medical wasteincineration was the nations third largest dioxinssource, emitting 15% of all the dioxins on the national inventory. Theprevalence of chlorine-containing polyvinyl chloride (PVC)plastic products in medical waste is one contributor to dioxins formationstudies show that increasing the amount of chlorine orchlorine-containing PVC in a particular combustor (like a specific medicalwaste incinerator) increases its dioxins emissions.Diesel trucks hauling medical waste emit dioxins along the hauling routealong one for most of Northern Californias regulatedmedical waste, which is hauled to Salt Lake City, Utah for incineration.1Information in this section is from the U. S. EPA Exposure and Human Health Reassessment of2,3,7,8-Tetrachlorodibenzo-p-Dioxin (TCDD) and RelatedCompounds, draft September 2000 and Database of Sources of Environmental Releases ofDioxin-like Compounds in the United States, March 2001.

Dioxin-like chemicals in bivalvesDioxin-like chemicals were detected in all 18 bivalve samples collected

from freshwater, estuarine and marine locations covering the different

regions and various environments of Australia, and a summary of the results

is provided in Table 3.5 (refer to Table E1 for the analytical results). The

levels, expressed as TEQ, ranged from 0.0043 to 1.2 pg TEQFISH g-1 fm or

0.0068 to 3.4 pg TEQHUMANS g-1 fm. Note that the TEQFISH reflects toxicity to

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fish and bivalves, whereas the TEQHUMANS is relevant with respect to

human consumption and human body burden. Consistent with the sediment

results, the highest levels of dioxin-like chemicals were found in a bivalve

sample collected from Port Jackson. However, it should be noted that the

data are too few to evaluate clear trends with respect to regions or land-use.

The geographical distribution of the dioxin-like chemicals in bivalve

samples (TEFFISH).

http://environmentalchemistry.com/yogi/environmental/medicalwaste.html

Managing Regulated Medical Waste

Intr od ucti onThese guidelines are intended to help medical facilities comply with the Public Health Law whichgoverns the management of regulated medical waste. The criteria discussed in this document willprovide a basis for determining what waste generated by health care providers meets thedefinitions of regulated medical waste and could pose a risk of disease transmission if notmanaged properly. Implementing waste management procedures that are based upon thedefinitions found in Public Health Law and these guidelines should reduce the amount of

regulated medical waste. These guidelines may also be useful in physician, dental andveterinarian offices, as well as university settings where regulated medical waste is generated.

Some materials that have been associated with the delivery of health care and managed asregulated medical waste will no longer be considered as such. One notable example is I.V. bagsand associated tubing. Their inclusion into the broad definitions of regulated medical waste foundin the federal Medical Waste Tracking Act of 1988 was based solely upon the fact that they looked"medical". Not only does this reasoning run contrary to the basic tenets of disease transmission, italso reinforces misconceptions about the waste stream generated in health care facilities. Theseguidelines point out that I.V. bags and associated tubing are no longer considered as regulatedmedical waste under the Public Health Law .

It is also important to understand that the process being employed to implement the revisions of

Public Health Law 1389 aa - gg is different from that routinely used in introducing new laws.These interpretive guidelines are not intended to replace the process for promulgating revisionsto Part 70 of Title 10 of New York Code of Rules and Regulations (10 NYCRR Part 70). Rather,these guidelines were developed to explain the Department's position on managing regulatedmedical waste so that health care facilities can realize cost savings while the process forpromulgating the revisions proceeds. In addition, in order to enhance their utility, the guidelineswere developed with the assistance of health care providers and infection control practitioners.

Statute, Regulation and Guidelines

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Ed uc ati onEducating the public to the actual issues and risks associated with regulated medicalwaste, while not addressed in Public Health Law or the enabling legislation, still is an

important consideration. Often obscured in the public discussion and debate is the fact

that truly infectious waste (as defined by being the source of transmissible diseases) is aminuscule component of the state's overall solid waste stream and that this type of waste

is routinely handled every day inside and outside of health facilities all over the world

without causing disease

Univ er sa l P reca uti on s a nd Ma na gin g R egul at ed Medic alWasteAccording to the Centers for Disease Control and Prevention (CDC) and Occupational Safety andHealth Administration (OSHA), "universal precautions" refers to an infection control system which

assumes that any direct contact with a patient, particularly their body fluids, has the potential fortransmitting disease. This system resulted from the heightened awareness and concern over thepotential risk of transmitting Human Immunodeficiency Virus (HIV) and Hepatitis B (HBV) tohealth care providers. Therefore, universal precautions is a qualitative system designed to ensurethe safety of the individual health care provider. Contact with any body fluid, regardless of thequantity, is considered to be a potential source of infectious agents.

Conversely, the revisions of Public Health Law as it relates to the definitions of regulated medicalwaste described in the following categories and the methods used to treat and process medicalwaste provide a quantitative system for the overall handling of regulated medical waste. Therevisions discussed in these guidelines are intended to ensure the public's health and safety, aswell as those, within and outside health care facilities, who must manage medical waste. Thequantity, as well as quality of the waste must be considered in determining if it should be

designated as regulated medical waste.

At this point it is appropriate to clarify the application of universal precautions as it relates to thehandling and disposal of tubing used in patient care. The critical factor for determining if thetubing used in patient care should be considered as regulated medical waste are: (1) directcontact with any of the fluids identified by OSHA as being possible sources of transmission ofinfectious agents, and (2) the quantities of these fluids. OSHA1 has described semen, vaginalsecretions, pleural fluid, cerebrospinal fluid, synovial fluid, pericardial fluid, amniotic fluid, saliva indental procedures, and any other fluid visibly contaminated with blood. Conversely, feces, urineand vomitus are not included unless they contain visible blood. For tubing to be designated asregulated medical waste, it would have to have been in contact with those fluids listed by OSHA.For example, tubing used in gastrointestinal procedures which is visibly coated with body fluidsshould be discarded as regulated medical waste.

Int er pre tiv e G uideli nesEach section of the Public Health Law which was amended by Chapter 438 of the Laws of 1993will be discussed separately. Legislative intent as well as the Department's perspective will beincluded in the discussion and as appropriate, specific examples will be described to furtherclarify a point.

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Public Health Law 1389 - aa: Definitions

Chapter 180 of the Laws of 1989 broadened the state's regulated medical waste definitions to beconsistent with the Federal Medical Waste Tracking Act. In doing so it increased the number ofsubcategories of medical waste and included many items which did not pose a risk of diseasetransmission but simply looked "medical". The revised definitions resulting from Chapter 438 ofthe Laws of 1993 reduced the number of subcategories and in some instances, provided forfurther qualification of items in the subcategory. However, it is important to note that the revisedgeneral definitions of medical waste includes wastes resulting from diagnosis and treatment ofanimals, as well as that produced from health care research and development.

The general definitions states "Regulated medical waste shall mean any of the following wastewhich is generated in the diagnosis, treatment or immunization of human beings or animals, inresearch pertaining thereto, or in production and testing of biologicals, provided however, thatregulated medical waste shall not include hazardous waste identified or listed pursuant to Section27-0903 of the Environmental Conservation Law, or any household waste promulgated under thissection."Six subcategories exist within the general definitions of regulated medical waste. Thelast subcategory provides for the Commissioner of Health to designate specific items whichpreviously have not been considered as regulated medical waste. As no items have yet to be

added to this subcategory, the remaining five are considered to be part of the current workingdefinitions of regulated medical waste.

Subcategory 1: Cultures and Stocks. "This waste shall include cultures and stocks ofagents infectious to humans, and associated biologicals, cultures from medical or pathologicallaboratories, cultures and stocks of infectious agents from research and industrial laboratories,wastes from the production of biologicals, discarded live or attenuated vaccines, or culture dishesand devices used to transfer, inoculate or mix cultures."

The key to this subcategory is understanding what is meant by agents infectious to humans. Thedepartment has identified that such agents are currently described in Section 2.1 of the StateSanitary Code as those causing communicable diseases (Attachment 1). These guidelines also

recommend the inclusion within this subcategory of those agents designated as requiringbiosafety level II - IV in the CDC/NIH Manual for Biosafety in Microbiological and BiomedicalLaboratories (3rd edition, May, 1993).

In context of this subcategory, cultures and stocks refer to systems used to grow and maintaininfectious agents in vitro, including, but not limited to:

nutrient agars, gels, broths (including those utilizing human blood or blood products);human and primate cell lines; andimpure animal cell lines.

The term biologicals is intended to mean preparations made from living organisms and theirproducts which are used in diagnosing, immunizing, or treating human beings or animals,

including, but not limited to:serums;vaccines;antigens; andantitoxins.

Last, the phrase "culture dishes and devices used to transfer, inoculate or mix cultures" refers tothe use of items that have come in contact with high concentrations of infectious agents as in therecovery of such agents in culture from clinical specimens and includes:

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plastic or glass plates, flasks, vials, beakers, bottles, jars, and tubes;inoculation loops and wires;manual and mechanical stirring devices;rubber, plastic, and cotton stoppers and plugs;filtering devices made of natural and artificial substances; andmaterials used to clean and disinfect items indicated above after routine use or accident.

Subcategory 2 - Human Pathological Wastes."This waste shall include tissue, organs,and body parts (except teeth and the contiguous structures of bone and gum), body fluids thatare removed during surgery, autopsy, or other medical procedures, or specimens of body fluidsand their containers, and discarded material saturated with such body fluids other than urine,

provided that the Commissioner, by duly promulgated regulation, may exclude such discardedmaterial saturated with body fluids from this definitions if the Commissioner finds that it does not

pose a significant risk to public health. This waste shall not include urine or fecal materialssubmitted for other than diagnosis of infectious diseases."

It should be quite clear that organs, tissues and associated fluids removed as result of surgical orautopsy procedures are regulated medical waste. Some confusion however could exist regardingthe phrase "discarded materials saturated with such body fluids other than urine". The

determining factor for these materials to be regulated medical waste is if they are saturated to thepoint of dripping. This is consistent with OSHA's blood borne pathogen standard which definessaturated as referring to material that when squeezed produce free flowing fluid. The Departmentdoes not encourage individuals to squeeze any item to determine if it is saturated. Rather, thedepartment expects that health care professionals will use their experience and training to makethis determination. Examples of body fluids include, but are not limited to blood, cerebrospinalfluid and amniotic fluid and any body fluids which are visibly contaminated with blood.

One exception of particular interest in the definitions of this subcategory requires additionalclarification. Urine is not considered regulated medical waste unless it is submitted as a clinicalspecimen for laboratory tests. However, if a patient is found to have a disease which may betransmitted through urine, then the material containing this fluid (including diapers) must beconsidered regulated medical waste. Similarly, incontinence materials are not regulated medical

waste provided that the patient does not have an infectious disease transmissible by urine.Conversely, since feces always contain microorganisms and, since these microorganisms even ifpotentially pathogenic, cannot be transmitted from trash containers or disposal sites. Fecalcontaminated materials are not considered to be regulated medical waste.

Questions have also arisen regarding the appropriate disposal of organs and tissues which havebeen fixed for cytological and/or histological examination. Since the fixatives are considered to behazardous materials, organs and tissues discarded with these chemicals must be processed ashazardous waste, except for blocks of tissue in paraffin or similar embedding materials. The latterprevent the fixatives from leaching into the environment and the chemical fixatives destroy anypotential pathogens in the tissue block. Therefore, tissue blocks can be discarded as solid waste.Conversely, if organs and tissues are disposed of separately from the fixatives, then they shouldbe handled in accordance with Section 4215 of Article 42 of the Public Health Law. Specifically,

tissues, organs, recognizable body parts and cadavers which have been chemically preservedand can no longer be sources of transmissible disease should be disposed of by cremation orinterment. Section 4215 (1) allows the individual in possession of body parts removed bydissection from cadavers to retain the parts for scientific purposes. Similarly, organs orrecognizable body parts which have been removed during surgery can be retained by the patientfor religious purposes provided that the organs or body parts cannot serve as sources of diseasetransmission.

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Subcategory 3 - Human Blood and Blood Products. "This waste shall include: (I)discarded waste human blood, discarded blood components (e.g. serum and plasma), containerswith free flowing blood or blood components or discarded saturated material containing freeflowing blood or blood components; and (II) materials saturated with blood or blood products

provided that the commissioner, by duly promulgated regulation, may exclude such materialsaturated with blood or blood products from this definitions if the commissioner finds that it does

not pose a significant risk to public health."

Blood and its components, including stocks from transfusion or materials saturated with freeflowing blood, are viewed as regulated medical waste. Questions have been raised regarding theappropriate disposal of menses pads. OSHA has ruled that feminine hygiene products used toabsorb menstrual flow are not regulated medical waste. Waste containers into which these arediscarded should protect individuals from physical contact with these items.

Subcategory 4 - Sharps. "This waste shall include but not be limited to discarded unusedsharps and sharps used in animal or human patient care, medical research, or clinical or

pharmaceutical laboratories, hypodermic, intravenous, or other medical needles, hypodermic orintravenous syringes to which a needle or other sharp is still attached, Pasteur pipettes, scalpelblades, or blood vials. This waste shall include, but not be limited to, other types of broken or

unbroken glass (including slides and cover slips) in contact with infectious agents. This wasteshall not include those parts of syringes from which sharps are specifically designed to be easilyremoved and from which sharps have actually been removed, and which are intended forrecycling or other disposal, so long as such syringes have not come in contact with infectiousagents." The single most important aspect of sharps which gives rise to fear and apprehensionis their inherent ability to cause puncture wounds and/or lacerations which may create a portal ofentry for infectious agents. Although syringes with attached needles are the classic examples ofsharps, other items used in the delivery of health care or in research and which have come incontact with infectious agents, e.g., glass or rigid plastic culture tubes, flasks, beakers, etc., mustalso be considered as sharps and be disposed of accordingly. Therefore, even though many ofthe items identified in this subcategory do not exemplify the "classic sharp", they still can give riseto puncture or laceration wounds.

One point needs to be clarified. No attempt should be taken to remove the needle from thebarrel of the syringe. To do so would only increase the opportunity for needle stick injury. Thetotal unit should be placed in a sharps container and disposed of as regulated medical waste. Inthose instances, however, where only the barrel of the unit is utilized, as found for example ininfusion pump setups, then the barrel can be disposed of as solid waste provided it did not comeinto contact with infectious agents.

All syringes (barrel and needle) and those other sharps which have come into contact withinfectious agents must be contained in a rigid, puncture resistant container, secured to precludeloss of contents, and either, red in color or conspicuously labeled with either the universalbiohazard symbol or the word biohazard. In addition, all sharps after treatment must be destroyedto remove the risk of puncture wounds, before being disposed of as solid waste. Glass andplastic materials (other than syringes) which have not come in contact with infectious

materials need not be treated and destroyed but should be disposed of carefully as solidwaste, preferably in rigid containers. These containers are not required to be red in color orlabeled with the universal biohazard symbol nor the word biohazard.

Even though they are not considered to be regulated medical waste certain types of medicalequipment have found their way into sharps containers. The most common type of equipment tobe disposed of in this manner is endoscopes, perhaps due to the pincers found at the end of thetubing. Medical equipment should not be disposed of in this manner as it is costly and analternative decontamination (i.e. cold sterilization) would be more appropriate.

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Subcategory 5 - Animal Waste. "This waste shall mean discarded materials includingcarcasses, body parts, body fluids, blood, or bedding originating from animals known to becontaminated with infectious agents (i.e. zoonotic organisms) or from animals inoculated duringresearch, production of biologicals, or pharmaceutical testing with infectious agents."

Again, it is important to understand that exposure to a known infectious agent is necessary before

the waste should be considered as regulated medical waste. In certain instances, most notablyrabies, the ability to determine whether an animal has been exposed must await a specificlaboratory analysis. Given the nature of the suspected infectious agent in this case, it would beprudent to manage the waste generated in handling and preparing the carcass as regulatedmedical waste. Preserved animals used for educational purposes are not regulated medicalwaste and can be disposed of as solid waste if they are not considered hazardous waste due tothe fixative used to preserve the body.

Environmental Best Practices for Health CareFacilitiesJune 2003 JCAHO Environment of CareStandards 1.3, 2.3, 4.0

. Hospitals Lose Money Due to Regulated MedicalWaste Management CostsSimple management changes recoup 10% to 50% of costs (and reducepollution)About 90% of California hospitals currently manage essentially all of theirregulated medical waste off-site. Untilrecently, the majority of these wastes have been managed by incineration. Ifyour hospital is still incinerating itsregulated medical waste, now is a good time to rethink that decision because:

Incineration is expensive and prices are going upVendor consolidation and the December 2001

closure of Californias only commercial medical waste incinerator are greatlyincreasing costs forincinerating medical waste. Increased federal regulation, additionalincinerator closures, public pressureagainst incineration, and skyrocketing fuel costs will likely keep incinerationprices on the rise. Becauseof this, a 250-bad general acute care hospital now spends more than$100,000 per year to have anoutside vendor incinerate its regulated medical waste. Switching to analternative off-site treatment(for waste not legally requiring incineration) could immediately save ahospital 10-20%; switching to

an on-site autoclave saves 50%. Poor waste segregation = wasted moneyThrowing awaynon-contaminated waste into the regulatedmedical waste stream (red bags) may increase regulated medical wastevolumes by as much as 50%!Encouraging proper waste segregation and selecting products that dont windup in the trash can safelyreduce regulated medical waste volumes and save 40 to 70% on wastedisposal.

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Incinerators emit dioxins and mercuryMedical wasteincinerators are one of the nations leadingemissions sources of persistent, toxic, bioaccumulative pollutants like dioxinsand mercury. And thats not

allthe diesel trucks that haul regulated medical waste long distances toincinerators also emit toxicpollutants. Exposure to these pollutants threatens public health.

Better alternatives exist todayTo reduce costs, manyhospitals are now switching to alternative offsiteservices such as autoclaving (available statewide) and microwaving(available in SouthernCalifornia only). (Almost all California hospitals continue to send pathological,chemotherapy andpharmaceutical wastes off-site for incineration, which has until recently beenthe only legal option forthese 3 waste streams.) However, about 10% of California hospitals

currently manage most of theirregulated medical waste on-sitethey meet the same legalrequirements for managing medicalwaste at half the cost.

Q-Why are Municipalities Approaching HospitalsAbout Regulated Medical Waste Management?In 1999 and 2000, several San Francisco Bay Area municipalities and theExecutive Board of the Association of Bay AreaGovernments (ABAG) adopted resolutions calling for dioxins pollutionprevention and dioxins elimination. The resolutions were

motivated by concerns about the health and environmental effects of typicaldioxins exposures as well as by the additional risksexperienced by highly exposed Bay Area communities (such as neighbors of aregional medical waste incinerator). To meet thechallenge of the resolutionsthe elimination of dioxins formationthemunicipalities initiated the San Francisco Bay AreaDioxins Project under the auspices of ABAG.

The San Francisco Bay Area municipalities participating in the Bay AreaDioxins Project are asking hospitals to rethink the waythey manage their regulated medical waste because medical wasteincineration is one of the nations leading dioxins emissions..

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Eleven Recommendations for ImprovingMedical Waste Management

These basic recommendations are meant simply as guidelines to stimulate better and more specificplanning and action programs at the municipal government level and then at the level of individualhealth care facilities. They are based on observations made by Hollie Shaner, R.N. and GlennMcRae of CGH Environmental Strategies, Inc. of Burlington, Vermont, USA in their work both in theU.S. and their experiences in applying that work in other countries including India, New Zealandand Caribbean Island nations.

(1) CLEARLY DEFINE THE PROBLEM

Before any clear improvement can be made in medical waste management, consistent andscientifically based definitions must be established as to what is meant by medical waste and its

components, and what the goals are for how it is managed. If the primary goal of "managing" wastefrom medical facilities is to prevent the accidental spread of disease, then it must first beacknowledged that there is only a small percentage of the waste stream that is contaminated in amanner that renders it capable of transmitting disease, and that the only documented transmissionof disease from medical waste has been from contaminated sharps (syringes, etc.).

Chart 1:In the United States we differentiate the waste stream from medical facilities in three majorcategories:

A. Hospital Waste - all waste generated from a facility (including cafeteria, office, and

construction wastes)

B. Medical Waste (A subset of hospital waste) - waste generated as a result of patientdiagnosis, treatment, or immunization of human beings or animals--a subset of

hospital waste

C. Potentially Infectious Waste (A subset of medical waste) - that portion of medicalwaste that has the potential to transmit an infectious disease.

It is category "C" that a medical waste management scheme must address first. The AmericanHospital Association (Robert Fenwick, 5/91) indicates that this category of waste should not be anymore than 15% of the total hospital waste stream, and a number of U.S. hospitals who haveimplemented good segregation programs have reduced this portion of their waste stream to lessthan 8%.

Based on observations at a number of health care facilities in non-US countries we believe that theaverage hospital waste stream contains less than 10% of materials that could be considered"potentially infectious waste" if properly segregated.

We support the efforts of the governments and professional associations around the world to createclear definitions and standards in this area, and recommend the following resources as a base linein this effort:

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World Health Organization publication "Managing Medical Wastes in Developing

Countries" (WHO/PEP/RUD/94.1), edited by Dr. Adrian Coad.

Society for Hospital Epidemiology of America Position Paper on "Medical Waste"

by Drs. William A. Rutala (Division of Infectious Diseases, University of North

Carolina Hospitals, Chapel Hill) and C. Glen Mayhall (Division of InfectiousDiseases, University of Tennessee Medical Center, Memphis), published in "The

Journal of Infection Control and Hospital Epidemiology, 1992: 13:38-48.

Center for Disease Control, standards for management of infectious wastes, Atlanta,

GA.

Establishing a clear definition of the type of waste that is seen to be a problem will allow for thedevelopment of a sound solution. If we utilize the definition proposed and documented above thenthe volume of waste that is identified as a problem is only 10% of the wastes being generated atIndian hospitals and health care facilities. The solutions to look for must address the 10% first, andnot treat all waste generated at hospitals as the same.

(2) FOCUS ON SEGREGATION FIRST

The current waste management practice observed at many hospitals is that all wastes, potentiallyinfectious, office, general, food, construction debris, and hazardous chemical materials are allmixed together as they are generated, collected, transported and finally disposed of. As a result ofthis failure to establish and follow segregation protocols and infrastructure, the waste leavinghospitals, as a whole is both potentially infectious and potentially hazardous (chemical). At greatestrisk are the workers who handle the wastes (hospital workers, municipal workers and rag pickers).The risk to the general public is secondary and occurs in three ways: (1) accidental exposure fromcontact with wastes at municipal disposal bins; (2) exposure to chemical or biological contaminantsin water; (3) exposure to chemical pollutants (e.g., mercury, dioxin) from incineration of the wastes.

No matter what final strategy for treatment and disposal of wastes is selected, it is critical that

wastes are segregated (preferably at the point of generation) prior to treatment and disposal. Thismost important step must be taken to safeguard the occupational health of health care workers.Hospitals are currently burning wastes or dumping wastes in municipal bins which are transportedto unsecured dumps. The wastes contain mercury and other heavy metals, chemical solvents andpreservatives (e.g., formaldehyde) which are know carcinogens, and plastics (e.g., PVC) whichwhen combusted produce dioxins and other pollutants which pose serious human health risks notonly to workers but to the general public through food supplies.

Imposing segregation practices within hospitals to separate biological and chemical hazardouswastes (less than 10% of the waste stream) will result in a clean solid waste stream (90%) whichcan be easily, safely and cost-effectively managed through recycling, composting and landfilling theresidues. This resulting waste stream has a high proportion of organic wastes (food) and recyclablewastes (paper, plastic, metal) and actually very little that is truly disposable, especially given the

high percentage of reprocessing and reuse of materials which exists in many non-US health caresystems. Several hospitals in India have already set up segregation programs providing localexamples of what is possible. If proper segregation is achieved through training, clear standards,and tough enforcement, then resources can be turned to the management of the small portion ofthe waste stream needing special treatment. This is not to minimize the need for resources to beallocated to assisting with segregation. Training, proper containers, signs, and protective gear forworkers are all necessary components of this process to assure that segregation takes place and ismaintained.

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(3) INSTITUTE A SHARPS MANAGEMENT SYSTEM

Of the 10 percent or less portion of the waste stream that is potentially infectious or hazardous, themost immediate threat to human health (patients, workers, public) is the indiscriminate disposal ofsharps (needles, syringes, lancets, and other invasive tools). Proper segregation of these materials

in rigid, puncture proof containers which are then monitored for safe treatment and disposal is thehighest priority for any health care institution. If proper sharps management were instituted in allhealth care facilities most of the risk of disease transmission from medical waste would be solved.This would include proper equipment and containers distributed everywhere that sharps aregenerated (needle cutters and needle boxes), a secure accounting and collection system fortransporting the contaminated sharps for treatment and final disposal, and proper training of allhospital personnel on handling and management of sharps and personal protection.

(4) KEEP FOCUSED ON REDUCTION

Hospitals in the Third World generate significantly less volumes of waste than U.S. hospitals. In partthis is a result of a decision to maintain a system that relies on reprocessing and reuse of materials.Establishing clear guidelines for product purchasing that emphasized waste reduction will keepwaste management problems in focus. New emphasis needs to be put on waste reduction ofhazardous materials. For example, hospital waste management would benefit from a policy of aphase out of mercury-based products and technologies. Digital and electronic technology isavailable to replace mercury-based diagnostic tools. This is a purchasing and investment decision.Since there is no capacity in most countries to safely manage mercury wastes, this reduction policywill make a serious contribution to cleaning up the hospital waste stream. This is one example ofreduction strategies which could be identified and implemented in all countries. Practicing pollutionprevention is the most cost effective way of securing public health.

(5) ENSURE WORKER SAFETY THROUGH EDUCATION, TRAINING AND PROPERPERSONAL PROTECTIVE EQUIPMENT (PPE)

Workers who handle hospital wastes are at greatest risk from exposure to the potentially infectiouswastes and chemical hazardous wastes. This process starts with the clinical workers who generatethe wastes without proper knowledge of the exposure risks or access to necessary protective gear,and includes the workers who collect and transport the wastes through the hospital, the staff whooperates a hospital incinerator or who take the waste to municipal bins, the municipal workers whocollect wastes at the municipal bins and transport it to city dumping sites, and the rag pickers, whorepresent the informal waste management sector, but play an important role in reducing the amountof waste destined for ultimate disposal. Whether rag pickers are considered as part of the formalsystem or not, they are integrally involved in waste management and their unique role and personalsafety and health needs must be considered.

Proper education and training must be offered to all workers from doctors to ward boys, to laborersand rag pickers to ensure an understanding of the risks that wastes pose, how to protectthemselves, and how to manage wastes (especially how to properly segregate). Education andtraining programs must be developed which speak to each population in a way that will best meetthe needs and build understanding and change behavior in that population. There is no "one" wayto educate all workers.

(6) PROVIDE SECURE COLLECTION AND TRANSPORTATION

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If the benefits of segregation are to be realized then there must be secure internal and externalcollection and transportation systems for waste. If waste is segregated at the point of generationonly to be mixed together by laborers as they collect it, or if a hospital has segregated its waste andsecured it in separate containers for ultimate disposal only to have municipal workers mix ittogether upon a single collection, then the ultimate value is lost. While worker safety may have

been enhanced, the ultimate cost to the environment and the general public is still the same.

In addition the very real concern of hospital administrators and municipal officials to prevent thereuse of medical devices, containers and equipment after disposal should be taken into account inany management scheme. One has only to walk by street vendors selling used latex gloves, orusing cidex (a disinfectant regulated as a pesticide in the US) containers to hold water for makingtea, to understand the risk that unsecured waste disposal systems have.

In addition, the practice of cleaning and reselling, syringes, needles, medicine vials and bottles, isnot well documented but appears to have enough informal evidence to indicate that it is a seriousconcern. Items that could potentially be reused illegitimately must be either rendered unusable aftertheir use (cutting needles, puncturing IV bags, etc.) or secured for legitimate recycling by a vendoror system that can be monitored for compliance.

(7) REQUIRE PLANS AND POLICIES

To ensure continuity and clarity in these management practices, health care institutions shoulddevelop clear plans and policies for the proper management and disposal of wastes. They need tobe integrated into routine employee training, continuing education, and hospital managementevaluation processes for systems and personnel. In the U.S. the Joint Commission for theAccreditation of Health Care Organizations has been developing a set of standards on the"Environment of Care" which includes plans and policies for the proper management of hazardousmaterials and workers' safety, without which a hospital cannot be accredited. The USEPA's newMACT rule now requires that hospitals develop waste management plans, a requirement that manystates have had on the books for several years. Municipal governments or state governments inIndia could require waste management plans from all hospitals as a condition for operating.

(8) INVEST IN TRAINING AND EQUIPMENT FOR REPROCESSING OF SUPPLIES

The science of the reprocessing of equipment and materials for reuse in medical facilities is wellestablished in India and should be supported. Professional health care associations should beurged to firmly support judicious reuse of materials, and should begin to set standards forreprocessing. Maintenance of this effort within hospitals will provide quality products and thwartefforts to increase reliance on disposables. Disposables are costly, increase waste generation, anddo not necessarily provide for decreases in infection rates in hospitals. A reprocessing industrymust however be supported with investment in proper equipment and training so that it is carried onin a safe and efficient manner.

(9) INVEST IN ENVIRONMENTALLY SOUND & COST EFFECTIVE MEDICAL WASTE

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TREATMENT AND DISPOSAL TECHNOLOGIES

The rush to incinerate medical waste in countries around the world as an ultimate solution to aproblem without definition is doing a great injustice to the community, the public health of its people,and the environment. Of the eleven recommendations that we are making, it is no accident in giving

attention to treatment technologies as ninth. Without proper attention being paid to one througheight on this list, whatever decisions being made for treatment and disposal will be insufficient, if notcounter productive. The mass incineration of hospital waste given current practices of wastedisposal will not reduce risk to workers (this is where the greatest risk of disease transmission orchemical exposure exists) and will actually create a greater threat to the general public as mercuryand other heavy metals are spewed out into the general air of India's cities, or dioxins and furansare created from the combustion of plastics such as PVC which is growing in use in medicalpackaging in India. Additionally the ash generated from incineration of medical waste is also taintedwith heavy metals and other toxic residues. Lesser risks are associated with the treatment ofunsegregated wastes through other treatment technologies such as autoclaving, hydroclaving,microwaving and chemical disinfection, which affect workers more than the general public, andcontaminate water sources rather than air if improperly operated.

Choices of treatment technologies should be made in line with a clear knowledge of the wastestream to be managed and the goal to be achieved through treatment. If the technology is to beenvironmentally sound, the waste stream should be able to be treated (disinfected) without creatingother hazardous byproducts. Incineration may be an "overkill" technology. Its goal is sterilization,not disinfection. One has to ask the question as to whether sterilization is necessary, or if the goal issimply disinfection. Is achieving sterilization worth the cost of transferring the risk from a potentially"infectious" material to a clearly hazardous chemical one?

If the overall goal of waste management is to prevent disease transmission from waste products,then the emphasis should be placed on the "management" aspect of the process and not on the"technological fix" which time and again has proven to be an expensive diversion rather than aneffective solution. Technology should fit the situation and work in the management system toachieve the final goal as part of the overall system, not as a replacement for the system.

Technology choices will be made to meet local needs and conditions and cannot be uniformlyapplied throughout a state or country. National standards for operating acceptable treatmenttechnologies should be set, and there is no reason for any country to have standards any lessstringent than those being modeled in the U.S. or Europe.

(10) DEVELOP AN INFRASTRUCTURE FOR THESAFE DISPOSAL AND RECYCLING FOR HAZARDOUS MATERIALS

There was little or no observable capacity for the management, treatment, recycling or finaldisposal of hazardous wastes in most countries (e.g., chemicals, mercury, batteries). Hospitalsseeking to segregate hazardous wastes are left with little or no option for safe disposal. Thedevelopment of an industry which is capable of managing hazardous waste (chemicals) isessential. On-site reprocessing technology is available for hospitals for materials such as xylene or

formalin, and recovery technology for silver from developing solution. These technologies may becost prohibitive at this time. Pollution prevention and the choice of nonhazardous or less hazardousmaterial is the only real option left to hospitals, which should be followed regardless of theexistence of a hazardous waste industry.(SeeChart 2, "The Hazardous Waste Stream," below.)

As a result of a lack of waste segregation practices in most hospitals, many of these hazardousmaterials are flushed down a waste water drain that flows directly to an open sewer or river, aremixed into general solid waste for disposal in municipal bins or are mixed into wastes which are

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incinerated as potentially infectious waste. In either case they represent a serious health hazard toworkers and the public. At this time even if they were segregated the lack of real alternatives toproperly dispose of them would mean that they would be stockpiled, potentially creating yet anotherthreat.

(11) DEVELOP AN INFRASTRUCTURE FOR SAFEDISPOSAL FOR MUNICIPAL SOLID WASTE

Improper disposal of all wastes, municipal solid waste, hazardous wastes, industrial wastes, humanwastes, etc. poses a major health hazard. The development of sanitary landfills, sewage treatmentplants and other waste management facilities providing for the ultimate safe disposal of thosewastes which cannot be otherwise recycled, composted or reused is necessary to securing publichealth in the country. Studies of the municipal waste stream in many countries such as Haiti or Indiaconclude that approximately 50% of the wastes generated are organic and could be composted.Another large segment includes easily recyclable materials, leaving a relatively small portionrequiring actual disposal. Just as in the discussion of medical waste management, propersegregation and pollution prevention, combined with a clear definition of the problem and the goalwill provide the best, most environmentally safe and cost-effective solution to waste disposal. Also

again, proposals for large mass burn incinerators for the general mixed waste stream, not only donot address the real problem but are burdened with numerous "side effects" which render their realvalue as a negative.

Health care facilities need to be able to tie into a municipal system of proper waste management toensure that they are meeting their mission of providing for the public health. Until such aninfrastructure exists there are numerous decisions and actions that any hospital can make (listedabove) to begin the process of improving their waste management practices and ensuring publichealth and worker safety today.

Chart 2: The Hazardous Waste Stream

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Specific waste streams that any hospital or health care facility must examine in its assessment andplanning process include:

Hazardous

Material

Point of GenerationPoint of Use and

Disposal

Common Disposal

Chemotherapy and

antineoplastic

chemicals

* Prepared in central

clinic or pharmacy

* Patient Care areas

* Pharmacy

* Special Clinics

* Incineration as RMW

* Disposal as HW

Formaldehyde

* Pathology

* Autopsy

* Dialysis

* Nursing Units

* Pathology

* Autopsy

* Dialysis

* Nursing Units

* Diluted and flushed down

sanitary sewer

Photographic

chemicals

* Radiology

* Satellite clinics

offering radiology

services

* Radiology

* Clinics offering

radiology services

* Developer and fixer is often

flushed down sanitary sewer

* X-ray film is disposed of as

solid waste

Solvents

* Pathology

* Histology

* Engineering

* Laboratories

* Pathology

* Histology

* Engineering

* Laboratories

* Evaporation

* Discharged to sanitary sewer

Mercury

* Throughout all clinical

areas in thermometers,blood pressure cuffs,

cantor tubes, etc.

* Labs

* Clinical areas

* Labs

* Broken thermometers are

often disposed in sharpscontainers

* If no spill kits are available,

mercury is often disposed of as

RMW or SW

* Often incinerated

Anesthetic Gases

* Operating Theater * Operating Theater * Waste gases are often direct

vented by vacuum lines to the

outside

Ethylene Oxide

* Central Sterile

Reprocessing

* Respiratory Therapy

* Central Sterile

Reprocessing

* Respiratory Therapy

* Vent exhaust gas to the

outside

Radio nuclides

* Radiation Oncology * Radiation Oncology * Storage in secure area -

disposal by national atomic

energy commission

Disinfecting

Cleaning Solutions

* Hospital-wideEnvironmental Services

* Facilities Management* Operating Theater

* Diagnostic Areas* Operating Theater

* Facilities

Management

* Dilution, disposal in sewer

http://www.nihe.org/elevreng.html

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Methods of disposal and treatment

Managing the Regulated Medical Waste Stream

Beyond the revisions to several of the definitions found in the Public Health Law, Chapter 438 ofthe Laws of 1993 also revised two other sections that have an effect on the management ofregulated medical waste. One revision effects the labeling of red bags used to contain regulatedmedical waste and the other concerns disposal of treated regulated medical waste.

Public Health Law 1389 - cc: Storage and containment of regulated medical

waste. [Eff. July 1, 1995, as amended by L. 1993, c. 438] Containment of regulatedmedical waste shall be separate from other wastes. Containers used for the

containment of regulated medical waste shall be marked prominently on thecontainers with the universal warning sign or the word biohazard.

Prior to this provision's effective date of July 1, 1995, containers (bags and sharpscontainers) were required to be labeled prominently with either the word "infectious"

or the words "regulated medical waste" . Clearly, supplies of the outdated labeledbags and sharps containers held by health related facilities were not uniformly

depleted on July 1, 1995. The department will allow facilities to use up their currentstocks but when they reorder, they must acquire bags and containers which meet the

labeling requirements of the new statute.

Public Health Law 1389 - dd: Treatment and disposal of regulated medical

waste.

1. Treatment or disposal of regulated medical waste shall be by one of the followingmethods: (c) By decontamination by autoclaving, or by other technique approved bythe department, so as to render the waste noninfectious. Regulated medical wasteso treated shall be disposed of as solid waste provided it does not otherwise meet

the definitions of hazardous waste as defined in the regulations promulgated undersection 27-0903 of the environmental conservation law or the regulations

promulgated thereunder, and is accompanied by a certificate, in a form prescribedby the commissioner, which evidences such treatment.

2. Regulated medical waste shall not be disposed of by burial at a landfill disposal

facility, unless treated in accordance with subdivision one of this section. All sharpsmust be rendered unrecognizable prior to disposal.

This provision of the statute for the disposal of treated regulated medical waste assolid waste should result in decreased expenditure by health care facilities which

elect to treat on-site.

There are numerous alternative technologies which are currently available from over

forty manufactures within the United States and Europe. They vary in capacity fromthose designed for use in physician/dentist offices, capable of treating twenty-five to

one hundred pounds per cycle, to systems to be used in major medical centers or

regional treatment facilities, which are able to treat one ton or more of waste per

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cycle (generally a cycle is one to one and one/half hours in length). In manyinstances these alternative technologies simultaneously treat, destroy, and reduce

the volume of regulated medical waste through the use of pre- or post-treatmentgrinders/shredders or by use of extremely high temperatures (upwards of 15,000 o)

to reduce the waste to ash. They vary in cost from less than $2,000 per unit toapproximately $750,000 per system. The larger the capacity, the greater the waste

reduction and the more automated the technology, the higher the initial cost of theunit. However, regardless of the capacity, the extent of the automation, or overall

volume reduction, all alternative systems treat regulated medical waste using one ofthree methods; (a) heating the waste to a minimum of 210o F by means of

microwaves, radio waves, hot oil, hot water, steam or superheated gases; (b)exposing the waste to chemicals such as sodium hypochlorite (household bleach) or

chlorine dioxide; or (c) by subjecting the waste to heated chemicals.

As indicated in the above section, all alternative technologies must be approved bythe department prior to being offered for sale in New York State. The Regulated

Medical Waste Program (RMWP) is the unit within the Wadsworth Center which

evaluates all alternative treatment systems for the department. Each manufacturerseeking approval of an alternative treatment system for use in the State must test

the efficacy of the product in accordance with the recommendations contained in the"Technical Assistance Manual : State Regulatory Oversight of Medical Waste

Treatment Technologies". A list of such approved treatment technologies andinformation on the application procedures to obtain approval for alternative systems,

as well as questions related to efficacy test methods and results can be obtained bycalling the RMWP at (518) 485-5378.

It is important to understand that a form which evidences treatment by an approvedtechnology must accompany the treated waste to the solid waste facility. The

department has developed a form for this purpose which must be used by thosefacilities that treat on-site by incineration or autoclaving. The department does not

require the use of this specific form with waste treated by some alternative

treatment technologies. For specific information contact the RMWP. There is onecritical factor which must be pointed out. Sharps as defined in subcategory 4must be treated and destroyed (rendered unrecognizable) before they can

be disposed of in a landfill. Sharps which are only treated are still consideredregulated medical waste and, therefore, can not be disposed of in a landfill.

On-site Treatment and Disposal Strategies

As a result of the revisions in definitions of regulated medical waste and the ability to disposetreated regulated medical waste as solid waste, on-site treatment programs should be equally or

more cost effective than many commercial options. Two issues need to be clarified where on-sitetreatment involves the use of an autoclave. First is the importance of having an operational planprepared and submitted to the State health department for approval as required and described in10 NYCRR Part 70-3. Having an approved plan will be critical if the health care facility expects tohave their treated waste disposed of as solid waste. Clinical laboratory operational plansdeveloped to address the on-site treatment of regulated medical waste by autoclaves must besubmitted for review and approval to the Clinical Laboratory Evaluation Program, WadsworthCenter, New York State Department of Health, P.O. Box 509, Empire State Plaza, Albany, NewYork 12201-0509. Article 28 facilities must submit their operational plans developed to address

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the on-site treatment of regulated medical waste by autoclaves to the Bureau of OccupationalHealth, NYSDOH, Flanigan Square, 547 River Street, Troy, New York 12180-2216.

The second issue with respect to autoclaving regulated medical waste is the type of bag used tocollect and store the waste prior to treatment. The typical red bag currently employed in thecollection of regulated medical waste is not designed to withstand the high temperature and

pressure conditions created in an autoclave. However, there are specially designed bags whichare available to be used in autoclaving regulated medical waste. These bags not only remainintact, but also enhance the sterilization process by allowing easier passage of steam into thewaste. The department encourages those facilities which utilize autoclaves to treat regulatedmedical waste to use autoclavable bags as they do come in the color red with the appropriatelanguage imprinted on them.

Sharps Collection from Private Residences

In an effort to address the safe disposal of sharps generated in the private residence, Chapter438 of the Laws of 1993 requires hospitals and nursing homes to establish procedures wherebysuch household generated waste can be dropped off for proper disposal. This waste covered isspecific to that generated as a result of self maintenance programs involving the delivery of

injectable medication and includes sharps only . Sharps as described for purposes of thisprogram include needles, syringes and lancets, only. As originally adopted, this portion of thePublic Health Law was to become effective July 1, 1995. However, due to several factors a billwas signed into law by the Governor postponing the effective date of implementation to July 1,1996 .

Pilot projects that began prior to 1995 continue to exist and offer sharps disposal service to theprivate resident. In an effort to provide information to managers of the pilot projects and any thatmay come on line during the next year, the following guidelines have been developed. The intentof these guidelines is to provide a level of flexibility for all facilities so that local factors can bebrought into consideration in developing operational plans and procedures. When evaluating theorganization of such a program, facilities are encouraged to develop joint waste managementplans with other health care providers such as physicians, pharmacies, out patient clinics and

local municipalities.

A common concern identified in the Public Health Law is the nature of the container used by theprivate resident to store used sharps. Containers which do not provide protection against needlestick injuries can not be considered as adequate for the purposes of this program. Individuals whoare responsible within the health care facility for managing this program can not be exposed tothe risk of needle stick injury which would result from improperly packaged sharps. Therefore, it isimperative that an individual who wishes to participate in this program be made aware of what willbe acceptable by the health care facility.

At a minimum, the container adopted and / or accepted by the facility must be shatterproof, leak proof and puncture resistant. If this can not be assured by the generator, the healthfacility does not have to accept the sharps.

The primary elements which should be included in the household sharps disposal plan /procedure are:

Establish the location for delivery and hours of operation. Operational

hours, depending upon the locality, could range from daily to once a week.The sharps drop off point must have controlled access. Residential sharps will

not be considered as regulated medical waste until the health facility hasaccepted them according to their established procedure ;

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Identification of responsible staff. Individuals involved with managing the

household sharps program will need to be trained on the proper handling of

sharps and precautions necessary in handling sharps not disposed of in theappropriate containers or in the event spillage. Plans which detail the

responsibilities of these individuals should also provide specific information onhow staff will respond to spills;

Use of secondary containers. The facility's site for drop off of householdsharps must have secondary containers available so that sharps containersbrought in can be placed directly into the secured container. This will reduce

the likelihood of direct contact by hospital personnel with household sharps;

Public Information. The public will need information regarding the

procedure in order to participate in the program. This can take the form of

brochures, press releases or television or radio spots.

http://www.health.state.ny.us/nysdoh/environ/waste.htm

SAFE SYRINGE DISPOSAL GUIDE FOR

HOME GENERATED MEDICAL WASTE

Ifyou produce any medical waste athome, this Guide may apply to you.2005INTRODUCTIONHome generators of medical waste may account for the use of up to700,000sharps daily in New Jersey. The most common disease that requires

selfinjectionof insulin and lancets to monitor blood sugar levels at home isdiabetes.Data for 2000-2002 indicates that there are approximately 24,000individualsover the age of 18 who have been diagnosed as diabetic in the State ofNewJersey. (NJDHSS Center for Health Statistics) Further, it is estimated that anadditional134,000 individuals in the same age group have diabetes but have yetto bediagnosed. (NJDHSS Family Health Services)The proper disposal of home generated medical waste is an importantstep thatall home generators of medical waste can take to help ensure thehealth andsafety of all New Jerseyans.

Q-WHATHEALTH EFFECTS AREASSOCIATED WITH

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IMPROPER DISPOSAL OF HOME GENERATEDMEDICAL WASTE?The improper disposal of home generated medical waste poses apotentialhealth hazard to many, including family members, sanitation workers,

people inthe community, hotel housekeeping staffs and school personnel.Although rare,diseases as serious as Hepatitis B and AIDS can also result fromaccidentalneedle sticks. In addition, loose syringes thrown into your householdtrash canalso be misused if they fall into the wrong hands. Moreover, theseitems caninjure small children, pets and wildlife.

DOES THIS GUIDEAPPLYTO YOU?The Safe Syringe Disposal Guide (Guide) applies to New Jerseyansgenerating medical waste at home. These individuals are referred tothroughout this Guide as home generators of medical waste. ThisGuidealso applies to individuals visiting the State of New Jersey

Each day, up to 700,000syringes, needles andlancets are used by New Jerseyans

WHAT IS HOME GENERATEDMEDICAL WASTE?Home generated medical waste is created through the administrationofinjectable medications and other invasive or non-invasive procedures.It includes,but is not limited to, syringes, needles with attached tubing and othermaterials.

WHOARE HOME GENERATORSOF MEDICAL WASTE?Home generators of medical waste include any individual whoproduces waste asa result of medical care in the home (home self-care) through self-administrationpractices or by a family member or other person not receiving moneyfor their

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services.

ARE THERE LAWS GOVERNING THEDISPOSAL OF HOME GENERATED MEDICALWASTE IN NEWJERSEY?Yes. The improper disposal of syringes or reusable hypodermic needlesisregulated by State law (N.J.S.A. 2A:170-25.17). This Statute prohibitsany personfrom discarding disposable or reusable hypodermic needles orsyringes, inpublic or private places which are accessible to other persons(includingtrespassers) without first destroying the needle or syringe. This meansyou areresponsible for destroying your needles and syringes, even when youvisit otherpeople. Violators of this Statute can be fined up to $500.00 and/orimprisoned orboth. If visiting other states, check their laws to determine whetheryour medical waste is regulated and the proper disposal methods.

WHATABOUTMEDICAL WASTE GENERATEDBYMEDICAL CARE WORKERS IN YOUR HOME?Medical waste produced by health care workers (physicians, nurses,homehealth aides, etc.) as a result of providing medical care in the home isnothome

generated medical waste. It is Regulated Medical Waste (RMW) asdefined inthe N.J.A.C. 7:26-3A, and must be disposed of by a licensed RMWgenerator inaccordance with the New Jersey Department of EnvironmentalProtection(NJDEP) RMW regulations. The responsibility for the proper andsafedisposal of regulated medical waste rests with the health careprofessionalproviding services in the home.

HOWCAN YOU SAFELYDISPOSE OF YOUR SYRINGES?Several options are available to safely dispose of used syringesgenerated in thehome.

Safe Syringe Disposal Program- The New JerseyHospital

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Association together with local hospitals offer a program to safely andresponsibly dispose of syringes, needles and lancets generated in thehome.Participating hospitals offer rigid containers to dispose of these itemsfor a small

one time fee to individuals who are injection dependent. (This programdoes notrequire needles to be clipped prior to placing them in the container).Thecontainer must be returned to the hospital when full for proper disposaland willbe exchanged for a new empty container at that time. A list ofparticipatinghospitals is provided at the end of this brochure.Additional information about the Safe Syringe Disposal Program maybe obtained

by contacting:New Jersey Hospital Association760 Alexander RoadPrinceton, New Jersey 08543(609) 275-4058

See End for a List of Participating Hospitals.Physicians - Ask your physician if she/he will take your used syringesonce theyare properly placed in a container.Local Health Departments- Ask the Health Officer of your localhealthdepartment if there are any syringe disposal facilities in your area.(see http://nj.gov/health/lh/directory/lhdselectcounty.htm for a directoryof localand county NJ health departments and contact information.)

Household Waste- Follow these steps to safely dispose of yoursyringes in yourmunicipal trash. Your syringes must be placed in rigid containers thatwill protect people from needle sticks and use containers that areunlikely to break open on its way to the landfill.1. Rigid ContainerYou may use empty laundry detergent bottles or2-liter

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soda pop bottles or other rigid containers with screw-on caps todispose ofneedles and syringes. Check with a pharmacy. Ask if it sells commercialcontainers specially designed to hold sharps for disposal in yourhousehold trash.

2. Label/WarningPlace a large label with a warning on the emptycontainer. Example: SYRINGES - DO NOT RECYCLE3. Needle Clipper Clip the needle. You can buy an inexpensive handheld needle clipper from the pharmacy. Using anything other than aclipper tobreak a needle is not safe. After clipping the needle, carefully placeeach ofyour used needles and syringes into a plastic bottle with a screw-on lid.To theextent practicable, the individual receiving the medical treatmentshould clip the

needle and syringe and place them in the container. In cases wherethis cannotbe done due to the limitations of that individual, and a family caregiver orvolunteer must perform this activity, it is recommended that theindividualsphysician be consulted first.4. SealSeal the bottle tightly with its original lid and wrap duct tapeover the lidafter you fill the bottle with syringes.5. DisposalYou may now dispose of the tightly sealed full container of

syringes in your household garbage - NOT in your recycling bin.Remember,although you may feel healthy, your used syringes can transmit germs.Inaddition, loose syringes thrown in your trash can seriously hurt people.We allbenefit from the safe disposal of syringes. Please do your part to helpkeep our

environment clean and safe. Should a Hospital Treat itsRegulated Medical Waste On Site?Although on-site treatment of medical waste can greatly reduce medical

waste management costs, it is not for every hospital.On-site regulated medical waste treatment is a significant responsibility.Operating a treatment unit requires meaningfulmanagement oversight to ensure that wastes are safely managed incompliance with the Medical Waste Management Act, toprotect worker safety, and to be prepared to respond to accidents, shouldthey occur. Routine maintenance is essential to

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minimize downtimeas is a backup plan for autoclave down time. Thehospitals physical layout (considering possibleoperating noise and odorous emissions) and staffing must be able toaccommodate the operation. For hospitals willing to takeon this responsibility, the payoff includes cost savings, reduced accident risk(by eliminating off-site transport of untreated

regulated medical waste), and the ability to ensure direct compliance with allelements of the Medical Waste Management Act.Off-site medical waste treatment passes some responsibilities to a vendorbut at a price (about twice the cost of on-sitetreatment). The hospital has to count on an outside vendor to ensure thehospitals compliance with the Medical WasteManagement Act. Risks include accidents releasing the hospitals regulatedmedical waste, vendor service interruptions, andvendors improperly treating wastes. Any hospital relying on off-site wastemanagement services should routinely audit itsvendor to minimize these risks.

Pollution Prevention and Proper Segregation ofMedical Waste are The First StepsPrevention, recycling, and segregation are the first steps in wastemanagement. Prevention involves reducing the amount of waste you makeafter all,waste is lost resources and lost money. Recycling reuses unregulated wastes, to reduce resource use and keepwastes from polluting our environment. Segregation promotes compliance with medical waste managementrequirements, while keeping costly regulatedmedical waste to a minimumand ensures that hazardous materials aremanaged safely.

These simple measures can save you money. For example, Beth IsraelMedical Center in New York City reduced medicalwaste generation by a million pounds a year, saving the hospital $600,000per year in medical waste management costs. TheUniversity of Iowa Hospitals and Clinics reduced regulated medical wastevolumes by 60%, saving $400,000 per yearwhilereducing segregation violations by 80%. For hospitals considering on-sitetreatment of regulated medical waste, reducing wastevolumes means that less expensive on-site treatment equipment can bepurchased.

The main concepts in medical waste reduction are simple:1. Keep solid wastes out of the medical waste stream. This involves thoroughemployee training and thoughtfulplacement of regulated medical waste containers (red bags) so that theydont become trash bags.2. Eliminate waste sources. Look for re-usable products (like sharpscontainers) and recycling opportunities forcommonly mismanaged solid wastes (like blue wrap).Waste reduction is so important that in 1998, the American HospitalAssociation (AHA) signed a memorandum of understanding

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with U.S. EPA with the goal of reducing waste 33% in all hospitals by 2005and 50% by 2010. The resulting joint initiativeHospitals for a Healthy Environment (H2E)provides numerous resources forhospitals seeking to reduce regulated medicalwaste, mercury, and solid waste. (See Resources for Health Care PollutionPrevention for more information).

No matter which method is selected for treating regulated medical waste,proper segregation of hazardous and radioactivematerials is essential for worker and environmental safety. Not only are thesematerials dangerous for workers handling waste,every medical waste treatment method release hazardous and radioactivematerials to air, water, and land. For example,almost all of the mercury emitted from medical waste incinerators (which areone of the nations leading mercury emissionsources) is from improperly disposed materials. Improper solvent disposal is abig problem for autoclavessewer authoritiesfind spikes of solvents in autoclave discharges, due to incidents of impropersegregation by facility customers.

http://dioxin.abag.ca.gov/pilot_projs/MW_Background.pdf

http://www.state.nj.us/health/eoh/phss/syringe.pdf

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http://dioxin.abag.ca.gov/pilot_projs/MW_Background.pdfhttp://www.state.nj.us/health/eoh/phss/syringe.pdfhttp://dioxin.abag.ca.gov/pilot_projs/MW_Background.pdfhttp://www.state.nj.us/health/eoh/phss/syringe.pdf


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ALTERNATIVE MEDICAL WASTE DISPOSAL TECHNOLOGIES AUTHORIZED IN NEW JERSEY (AS OF 9/7/2005)

TECHNOLOGY PROCESS

Steam Treatment and

Shredding

Air is evacuated

from the treatmentchamber and steam

is injected into the

chamber. The

treated material is

shredded and

ground.

Chemical disinfection

and Mechanical

Shredding

A chemical

disinfectant is

mixed with the

waste and then the

material isshredded and

ground in a

mechanical grinder

or Hammermill

chamber.

Chemical

disinfectant &water mixed w/

RMW in grinding

chamber. Processed

waste rinsed w/

water and

solid/liquid waste

separated in

rinse/separatorchamber

NaOCL applied toRMW then

dropped intoshredder. After

shredding morechem. & water

applied, then solidand liquid

separated w/ film

remaining.

Microwave And Waste is shredded

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Shredding and moistened with

steam. The material

is then microwaved

in a treatment

chamber and

shredded, and

Ground in aparticulizer

Steam Treatment RMW is steamtreated. High

vacuum treatment

boils off and

condenses liquid.

RMW is dried andcooled to below

170oF (approved

for treatment only.

Processed medical

waste must still be

managed as RMW)

http://www.nj.gov/dep/dshw/rrtp/aamwdt.htm

HOUSEHOLD DISPOSAL OF UNUSED OREXPIRED MEDICATIONSJan2004There are two major concerns regarding household disposal of unused or expired medications.First, health threats may occur when other people, particularly children, mistakenly acquire the

prescription drugs if they are carelessly disposed. Secondly, some of these products cancause environmental damage if disposed into the sewer system because these materials arenot adequately destroyed by sewer treatment plants and can enter the water supply. T

Documents

Hazardous Medical Wastes-Ahmed Roushdy-educational Research