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Medical Waste

Medical Waste


Medical wastes are generated as a result of patient diagnosis and/or treatment or the immunization of human beings or animals. The subset of medical waste that potentially could transmit an infectious disease is termed infectious waste. The Centers for Disease Control (CDC), the U.S. Environmental Protection Agency (EPA), and the World Health Organization (WHO) concur that the following wastes should be classified as infectious waste: sharps (needles, scalpels, etc.), laboratory cultures and stocks, blood and blood products, pathological wastes, and wastes generated from patients in isolation because they are known to have an infectious disease. Medical wastes can also include chemicals and other hazardous materials used in patient diagnosis and treatment. In some cases this subset of medical waste is classified as hazardous waste. Hospitals, clinics, research facilities, diagnostic labs, and other facilities produce medical waste. The bulk of the wastes generated by most health care facilities, however, is municipal solid waste (MSW), or trash. MSW includes large quantities of paper, cardboard and plastics, metals, glass, food waste, and wood. Medical waste, though a smaller portion of the total health care waste stream, is of special concern because of the potential hazards from pathogens that may be present, or from hazardous chemicals.


Risk and Health Care Waste

In the late 1980s there were a series of syringe wash ups on beaches along the East Coast of the United States, which were mistakenly attributed to health care facilities. The federal Medical Waste Tracking Act (MWTA) was passed and the EPA attempted to set standards for managing the infectious waste component of medical waste that they renamed regulated medical waste. Few states adopted its stringent guidelines. The MWTA expired in the early 1990s, making each state responsible for establishing its own classification and management guidelines for medical waste.

There are very few documented cases of disease transmission from contact with medical waste. The notable exception is needle stick, or "sharps" injuries. Paralleling the concern over beach wash ups of medical waste, was a growing awareness of the increase in HIV-AIDS and other cases of infectious diseases being diagnosed and treated in health care settings. This, along with a series of events, led to the Occupational Safety and Health Administration (OSHA), which established rules designed to protect health care workers (OSHA blood-borne pathogen standards and universal precautions) by stipulating the need for such personnel to wear protective clothing and equipment, and to take special precautions when handling or disposing of sharps. The interpretation of rules surrounding worker safety regulations led to some confusion over waste classification, thus causing a greater amount of wastes to be considered as potentially infectious. (For example, under the OSHA universal precautions guidelines, a worker handling a bandage with a single drop of blood on it should wear gloves, but the waste itself would most likely not be classified as infectious.)

Noting that there are multiple risks inherent in medical waste including toxic chemicals and radioactive materials, the WHO has chosen to use the term health care risk waste instead of medical waste.

Regulation

Many regulations govern the labeling, handling, treatment, transport, storage, and disposal of medical waste, including: Department of Transportation (DOT) rules for the packaging and transportation of wastes; OSHA guidelines for worker safety, waste labeling and handling; the Resource Conservation and Recovery Act (RCRA), which governs the management of hazardous materials and wastes, including hazardous pharmaceutical wastes; Nuclear Regulatory Commission (NRC) radioactive waste management practices, Drug Enforcement Agency (DEA) regulations for handling and disposing of controlled substances such as narcotics; the Clean Air Act, which regulates emissions from incinerators; the Clean Water Act, which defines what may be disposed of down the drain; state environmental and health rules that define certain types of waste and determine the specifics of waste treatment, as well as requirements for storage, labeling, handling, and segregation. Most other countries have similar multitiered regulatory regimes, such as Australia, where a national standard defines clinical waste (what is termed medical waste in the United States). However, the particulars of regulation are left to the discretion of individual Australian states.


Proper Management, Treatment, and Disposal

There is general consensus among professional health care organizations, the waste management industry, and regulators that proper management starts with the identification of wastes requiring special handling and treatment because of their hazardous nature (biological, chemical, or radioactive). Waste identification is necessary for proper segregation, so that only those wastes needing special treatment and handling are treated. Proper management of all waste streams enhances worker safety, protects the environment, and can reduce costs.

Wastes that are deemed potentially infectious may be treated prior to disposal by a number of different technologies that either disinfect or sterilize them. These technologies include incineration, steam sterilization, dry heat thermal treatment, chemical disinfection, irradiation, and enzymatic (biological) processes among others. In 2002 there were more than one hundred specific technologies in use. In order for treatment systems to work properly, distinctive protocols for the classification and segregation of wastes must be in place. Most treatment technologies for infectious wastes cannot process chemical or radioactive waste. Misclassification and inappropriate treatment of infectious wastes can result in significant harm to the environment and human health; for example, residual chemotherapeutic agents are should not be treated in autoclaves, but rather should be set aside and treated by either incineration (hazardous waste incinerators) or chemically neutralized where feasible.

The EPA has cited medical waste incinerators as among the top sources of mercury and dioxin pollution. New regulations governing the operation of, and emissions from, medical waste incinerators in the late 1990s have resulted in the closure of most such incinerators in the United States. Other countries such as the Philippines have completely banned incineration because of its adverse environmental impacts.

The health care industry is rapidly changing in ways that continue to have significant impact on the volume and characteristics of wastes produced.

  • New (e.g., laproscopic and laser) surgical techniques result in procedures that produce very little blood-contaminated waste.
  • Advances in cancer treatment have produced many drugs used in chemotherapy that are highly toxic in small quantities, producing more hazardous chemical wastes.
  • Patient residence time in hospitals has declined. Procedures that previously required an extended stay now commonly occur on an outpatient basis without necessitating an overnight stay.
  • Home care continues to grow, shifting the location of service delivery. Dialysis, chemotherapy, and hospice care are but a few examples of health care that often take place in a home setting, the result being that many wastes regulated as infectious or hazardous waste in a hospital are being disposed of as ordinary trash at curbside. (Household waste is exempt from many regulations.)
  • As hospitals close their incinerators, biohazardous and sometimes (inadvertently) hazardous wastes are being hauled significant distances to centralized facilities for treatment and disposal.
  • All of these changes represent new challenges in continuing efforts to properly define, classify, regulate and manage medical wastes.

see also Dioxin; Endocrine Disruption; Hazardous Waste; Incineration; Infectious Waste; Mercury; Occupational Safety and Health Administration (OSHA); Resource Conservation and Recovery Act.

the hazardous waste stream
hazardous material point of generation point of use and disposal common disposal
chemomtherapy and antineoplastic chemicals prepared in central clinic or pharmacy patient care areas incineration as rmw
    pharmacy disposal as hw
    special clinics  
formaldehyde pathology pathology diluted and flushed down sanitary sewer
  autopsy autopsy  
  dialysis dialysis  
  nursing units nursing units  
photographic chemicals radiology radiology developer and fixer is often flushed down sanitary sewer
  satellite clinics offering radiology services clinics offering radiology services  
      x-ray film is disposed of as solid waste
solvents pathology pathology evaporation
  histology histology discharged to sanitary sewer
  engineering engineering  
  laboratories laboratories  
mercury throughout all clinical areas in thermometers, blood pressure cuffs, cantor tubes, etc. clinical areas broken thermometers are often disposed in sharps containers
    labs  
      if no spill kits are available, mercury is often disposed of as rmw or sw
  labs    
      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 central sterile reprocessing vent exhaust gas to the outside
  respiratory therapy respiratory therapy  
radio nuclides radiation oncology radiation oncology storage in secure areadisposal by national atomic energy commission
disinfecting cleaning solutions hospital-wide environmental services diagnostic areas dilution, disposal in sewer
    operating theater  
  facilities management facilities management  
  operating theater    
maintenance: maintenance maintenance solid waste
waste oil     sewer
cleaning solvents      
leftover paints      
spent florescent lamps      
degreasers      
paint thinner      
gasoline      



Bibliography

bisson, connie leach; mcrae, glenn; and gusky shaner, hollie. (1993). an ounce of prevention: waste reduction strategies for health care facilities. chicago: american hospital association.

health care without harm. (2001). "non-incineration medical waste treatment technologies." washington, d.c.

mcrae, glenn, and gusky shaner, hollie. (1996). guidebook for hospital waste reduction planning and program implementation. chicago: american hospital association.

pruss, a.; giroult, e.; and rushbrook, p. (1999). safe management of wastes from health-care activities. geneva: world health organization.

rutala, william a., and mayhall, c. glen. (1992). "medical waste: the society for hospital epidemiology of america position paper." infection control and hospital epidemiology 13:3848.

internet resources

centers for disease control web site. available from http://www.cdc.org.

u.s. environmental protection agency web site. available from http://www.epa.gov.

Hollie Shaner and Glenn McRae

PHARMACEUTICAL WASTE

Pharmaceutical wastes are diverse and in some cases trace amounts can be discarded as medical waste. Certain pharmaceuticals are hazardous wastes when disposed, and some common ones are "acute" hazardous wastes under RCRA regulations (e.g., Epinephrine, Nitroglycerin, Warfarin (>0.3%)).

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Medical Waste

MEDICAL WASTE

Medical waste is generally defined as any solid waste generated during the medical diagnosis or treatment of humans or animals, in related research, or in the production of biologicals used in clinical activities. Concern about medical waste streams has been growing. Syringes washing up on New Jersey beaches in the 1980s following massive illegal dumping of medical wastes into New York harbor threw a spotlight on the issue. Similar beach problems have occurred in Britain and have been suggested to be a cause of hepatitis B among users of recreational waters.

A number of factors make management of medical wastes more difficult than other waste streams. Standard landfill disposal is complicated by the potential for infection of workers and of the general public. On-site incineration of hospital wastes, a common practice that effectively destroys infective organisms, is of increasing concern as a source of dioxins due to the high chlorine content of many of the disposable plastics in common medical use. Local opposition has made it more difficult to site and plan hospital incinerators. Mercury from amalgam fillings discarded in dental offices has been suggested to be a cause of mercury discharge into surface water from publicly owned water-treatment works.

While there are federal guidelines concerning medical wastes, including a 1989 Medical Waste Tracking Act administered by the U.S. Environmental Protection Agency (EPA), the major regulatory control is by state and local authorities. The increased cost of safe disposal of medical waste has led to efforts to reduce the size of the waste stream, including consideration of a return to reusable syringes, endoscopy tubes, and other medical devices. This requires a careful assessment of the tradeoff with simplicity of use, certainty of sterility, and lower costs provided by the disposable items. There is also a tradeoff between increased medical-waste disposal costs and the likelihood of illegal dumping. Clinically useful plastics formulated without chlorine are also being actively sought to decrease the risk of dioxins from incineration.

Not all medical waste comes from obvious point sources such as hospitals, doctors' offices, clinical laboratories, and research facilities. Over a million syringes are used at home by diabetics and others on a daily basis. This has led to community-based approaches to collect and safely dispose of these syringes and needles. Similarly, the trend toward shorter hospital stays means postoperative patients are more frequently discharged to their homes with surgical dressings and other potentially contaminated medical paraphernalia. Chronic infectious diseases are also now more likely to be treated at home than in a hospital. Patients, families, and visiting nurses should be instructed in the proper handling of these wastes. Landfilling of medical wastes is a particular problem in many developing countries, where scavenging of landfills is an organized activity among the poor. In addition to exposure to infectious agents, there have been instances where discarded radioactivity sources, such as cobalt used in the treatment of cancer, have been recycled into the community with devastating effects.

Bernard D. Goldstein

(see also: Environmental Protection Agency; Municipal Solid Waste; Ocean Dumping; Sewage System )

Bibliography

Phillip, R.; Pond, K.; and Rees, G. (1997). "Research and the Problems of Litter and Medical Wastes on the U.K. Coastline." British Journal of Clinical Practice 51(3):164168.

Phillips, G. (1999). "Microbial Aspects of Clinical Waste." Journal of Hospital Infection 41:16.

Thomas, C. S. (1977). "Management of Infectious Waste in the Home Care Setting." Journal of Intravenous Nursing 20(4):188192.

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