Medical Waste

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Medical Waste

Introduction

Medical waste, also termed health-care waste, is garbage and effluent (liquid waste) produced by hospitals, clinics, research facilities, laboratories, and veterinary facilities. Most health-care waste (up to 85%) is similar to ordinary non-hazardous household trash, but about 10% consists of potentially infectious biological materials and 5% of hazardous wastes (chemical, radioactive, and pharmaceutical substances). Sometimes, the term medical waste is restricted to the infectious/hazardous component of health-care waste. In the United States, medical waste is governed by the Medical Waste Tracking Act of 1988, which required the U.S. Environmental Protection Agency (EPA) to establish a medical-waste tracking program.

Historical Background and Scientific Foundations

Medical waste first became a major political issue in the United States in 1987 and 1988, when large amounts of medical waste and other trash washed up on New Jersey beaches. The waste included disposable syringes (injection needles), so the event came to be known as the Syringe Tide. Hearing about the repulsive and possibly dangerous pollution, thousands of tourists stayed away from the Jersey shore, usually a prime tourist destination, costing the state almost one billion dollars in lost business revenue. New Jersey blamed New York City for the waste, and indeed, it was eventually traced to New York’s Fresh Kills Landfill on Staten Island. In late 1987, a federal judge approved an agreement in which New York City accepted partial responsibility for the medical and other trash washing up on New Jersey beaches, and agreed to pay one New Jersey town, Woodbridge, $1 million in compensation and to pay for cleanup of the town’s shoreline. The suit actually long predated the Syringe Tide, being brought by the town in 1979. Regular collection of floating trash by New York City and the U.S. Army Corps of Engineers has kept closings of beaches due to washed-up trash much lower since 1989.

Publicity over the medical waste washing up on New Jersey beaches led to hundreds of pieces of legislation (according to the EPA) originating from town and city governments up to Congress. The most far-reaching law pertaining to medical waste to come from the Syringe Tide incident was the Medical Waste Tracking Act of 1988. This laid out a federal definition of what constitutes medical waste and mandated a cradle-to-grave tracking system for June 1989 to June 1991 under which hospitals would have to keep track of their medical waste so that its proper disposal, usually by incineration, would be verifiable. Penalties for mismanagement of medical waste were established. The tracking system was applied only in New York, New Jersey, Connecticut, Rhode Island, and Puerto Rico and expired in 1999.

What Is Medical Waste?

The hazardous fraction of medical waste can be broken down into a number of sub-categories. Different expert sources use somewhat different categories, but the World Health Organization of the United Nations recognizes the following:

Infectious waste: includes used bandages and dressings; swabs, sponges, tubes, and other disposable products used in surgery; infectious cultures from laboratories; all wastes from infectious-disease wards.
Pathological waste: tissue samples, body parts removed during surgery or autopsy, blood and blood products, dead infected laboratory animals, body fluids, etc.
Sharps: all items that can cut or puncture the skin: most commonly needles, used surgical tools, and broken glass.
Pharmaceutical waste: unused drugs of all kinds.
Genotoxic waste: waste containing substances that interfere with the functioning of DNA, whether by causing cancer, interfering with fetal development, or causing mutations. The main substances in this category are cytotoxic (cell-toxic) drugs, widely used in chemotherapy for cancer to interfere with the replication of cancer cells.
Chemical waste: waste containing chemical substances such as disinfectants, solvents, cleansers, preservatives (e.g., formaldehyde), photographic chemicals, oils, pesticides, acids, or the like.
Heavy metals: wastes containing a high heavy-metal content. The most common toxic heavy metals are lead and mercury, which are found in batteries, old thermometers, and wall-mounted sphygmomanometers (blood-pressure gauges), and other wastes.
Pressurized containers: all containers containing gas under pressure, such as handheld aerosol cans and oxygen tanks.
Radioactive waste: all radioactive materials, including sealed sources of radiation from radiotherapy machines and substances used in nuclear medicine.

WORDS TO KNOW

RADIOACTIVITY: The property possessed by some elements of spontaneously emitting energy in the form of particles or waves by disintegration of their atomic nuclei.

SHARPS WOUNDS: Wounds caused by discarded medical instruments including hypodermic needles and, scalpels (knives) and other sharp objects potentially contaminated by human contact.

TOXIC: Something that is poisonous and that can cause illness or death.

Impacts and Issues

The type of hazard posed by medical waste depends on what type, or mixture of types, of waste it contains. It may contain infectious agents (viruses or bacteria that can cause disease), genotoxic agents, toxic chemicals, radioactivity, or sharps that can cause wounds and transmit infections (e.g., of HIV, the virus that causes AIDS). Persons working in health-care facilities are most exposed to these hazards; the next most exposed category includes people who handle waste directly from such facilities, such as garbage collectors.

Injury by sharps is the most common form of harmful encounter with medical waste. For example, from 46,000 to 70,000 nurses are injured by used sharps every year in the United States; from 500 to 7,300 waste handlers are injured. Cases of disease transmission by hospital waste have been documented: most of these involve hospital workers handling sharps. For example, by June 1996, the U.S. Centers for Disease Control and Prevention (CDC) had identified 51 cases of HIV infection due to occupational exposure. Most of the cases were from sharps wounds; four involved contact with infected blood. Data from Japan show that puncture by a used hypodermic needle in medical waste conveys a 0.3% chance of contracting HIV, a 3% chance of contracting viral hepatitis B, and a 3 to 5% chance of contracting viral hepatitis C.

The EPA, after the two years when it tracked medical waste in part of the United States, concluded that the potential of medical waste to cause disease is greatest when it is newly generated. At that point it contains the most living disease organisms and its chemicals are most concentrated. Risk from exposure to medical waste decreases as the waste ages.

Few data are available on the risks to health workers and the public of chemical, genotoxic, radioactive, and other sub-categories of medical waste. However, these are among the most potentially harmful types of medical waste, likely to cause much more disease over time than infectious agents. Of particular concern are heavy metals. According to the EPA, over 90% of potentially infectious medical waste is disposed of by incineration. Incineration is not appropriate for heavy metals, since they are dispersed more widely by burning and not destroyed. Medical waste incinerators (most of which are located at hospitals) were once a major source of mercury pollution: In 1990, they were responsible for 25% of U.S. mercury emissions. The EPA states that its regulations governing emissions from medical-waste incinerators, promulgated in 1997, have reduced mercury emissions from medical-waste incineration by 94%.

One well-documented case illustrates the importance of containing radioactive medical wastes. In the Brazilian town of Goiano, a radiotherapy institute was closed in 1985. (Radiotherapy is the selective use of radiation to kill cancer cells.) A machine containing a large quantity of the radioactive nuclide 137Cesium, whose radiation was once used to treat cancer, was abandoned in the facility. Local people, scavenging gear from the site, obtained the lead-encased source and broke it open, revealing its blue contents. Having no idea what it was, they gave the sticky radioactive powder to children to play with, who painted their skin with it, and otherwise

spread it widely. Four people died from radiation exposure and hundreds more were exposed, causing long-term health consequences that have not been tracked by the Brazilian government.

Medical waste is also generated by home use of pharmaceuticals, home dialysis, and other products. In early 2008, a five-month investigation by the Associated Press revealed that a wide variety of prescription drug metabolites (drugs requiring a doctor’s order) are found in most U.S. drinking water: these drugs include mood stabilizers, anti-epileptics, sex hormones, and antibiotics. The likely source of these drugs was not only health-care facilities, but also home consumers of the drugs, who pass the unmetabolized drug out of their bodies in urine and dump unused drugs into the toilet. Flushed drugs enter the municipal wastewater streams and spread out into the environment. Whether any of the drugs exist in amounts large enough to be harmful is debated by epidemiologists (scientists who study the causes of disease in populations). Since February, 2007, the U.S. government has advised persons who are disposing of unused drugs not to flush them down the toilet, but mix them with some repellent material such as coffee grounds (to insure that they will not be retrieved from the garbage and eaten by children) and to put them out with the regular trash for eventual landfill burial.

Primary Source Connection

In response to the pollution of beaches by medical waste, Congress enacted the Medical Waste Tracking Act of 1988 (MWTA), an excerpt of which follows, as an amendment to the Solid Waste Disposal Act. The MWTA established a two-year program that studied the disposal of medical wastes in several states on the East Coast as well as states adjacent to the Great Lakes. The program had four major goals. The first was to develop clear definitions of medical waste. The second was to develop a tracking system for medical waste from the point of origin through the final disposal point. The program also developed standardized measures for packing, labeling, and storing medical waste. Finally it established penalties for not adhering to the medical waste tracking system.

The formal outcome of the Medical Waste Tracking Act of 1988 was a set of recommendations called Standards for the Tracking and Management of Medical Waste. Although the Standards were only in place for two years, the MWTA resulted in stricter laws and regulations for the disposal of medical wastes in state and local governments. A multi-billion dollar industry developed in response to these requirements. Facilities that are properly equipped to autoclave, incinerate, microwave, chemically disinfect, or thermally inactivate medical wastes have become an important part of the medical waste disposal stream. Businesses that contract with hospitals, doctors and dentists offices, veterinarians, and research laboratories are required to obtain permits and to adhere to strict performance standards.

MEDICAL WASTE TRACKING ACT OF 1988

TITLE 42, CHAPTER 82, SUBCHAPTER X

Sec. 6992. Scope of demonstration program for medical waste

(a) Covered States

The States within the demonstration program established under this subchapter for tracking medical wastes shall be New York, New Jersey, Connecticut, the States contiguous to the Great Lakes and any State included in the program through the petition procedure described in subsection (c) of this section, except for any of such States in which the Governor notifies the Administrator under subsection (b) of this section that such State shall not be covered by the program.

(b) Opt out

If the Governor of any State covered under subsection (a) of this section which is not contiguous to the Atlantic Ocean notifies the Administrator that such State elects not to participate in the demonstration program, the Administrator shall remove such State from the program.
If the Governor of any other State covered under subsection (a) of this section notifies the Administrator that such State has implemented a medical waste tracking program that is no less stringent than the demonstration program under this subchapter and that such State elects not to participate in the demonstration program, the Administrator shall, if the Administrator determines that such State program is no less stringent than the demonstration program under this subchapter, remove such State from the demonstration program.
Notifications under paragraphs (1) or (2) shall be submitted to the Administrator no later than 30 days after the promulgation of regulations implementing the demonstration program under this subchapter.

The Governor of any State may petition the Administrator to be included in the demonstration program and the Administrator may, in his discretion, include any such State. Such petition may not be made later than 30 days after promulgation of regulations establishing the demonstration program under this subchapter, and the Administrator shall determine whether to include the State within 30 days after receipt of the State’s petition.

(d) Expiration of demonstration program

The demonstration program shall expire on the date 24 months after the effective date of the regulations under this subchapter.

Sec. 6992a. Listing of medical wastes

(a) List

Not later than 6 months after November 1, 1988, the Administrator shall promulgate regulations listing the types of medical waste to be tracked under the demonstration program. Except as provided in subsection (b) of this section, such list shall include, but need not be limited to, each of the following types of solid waste:

Cultures and stocks of infectious agents and associated biologicals, including cultures from medical and pathological laboratories, cultures and stocks of infectious agents from research and industrial laboratories, wastes from the production of biologicals, discarded live and attenuated vaccines, and culture dishes and devices used to transfer, inoculate, and mix cultures.
Pathological wastes, including tissues, organs, and body parts that are removed during surgery or autopsy.
Waste human blood and products of blood, including serum, plasma, and other blood components.
Sharps that have been used in patient care or in medical, research, or industrial laboratories, including hypodermic needles, syringes, pasteur pipettes, broken glass, and scalpel blades.
Contaminated animal carcasses, body parts, and bedding of animals that were exposed to infectious agents during research, production of biologicals, or testing of pharmaceuticals.
Wastes from surgery or autopsy that were in contact with infectious agents, including soiled dressings, sponges, drapes, lavage tubes, drainage sets, underpads, and surgical gloves.
Laboratory wastes from medical, pathological, pharmaceutical, or other research, commercial, or industrial laboratories that were in contact with infectious agents, including slides and cover slips, disposable gloves, laboratory coats, and aprons.
Dialysis wastes that were in contact with the blood of patients undergoing hemodialysis, including contaminated disposable equipment and supplies such as tubing, filters, disposable sheets, towels, gloves, aprons, and laboratory coats.
Discarded medical equipment and parts that were in contact with infectious agents.
Biological waste and discarded materials contaminated with blood, excretion, excudates [1] or secretion from human beings or animals who are isolated to protect others from communicable diseases.
Such other waste material that results from the administration of medical care to a patient by a health care provider and is found by the Administrator to pose a threat to human health or the environment.

(b) Exclusions from list

The Administrator may exclude from the list under this section any categories or items described in paragraphs (6) through (10) of subsection (a) of this section which he determines do not pose a substantial present or potential hazard to human health or the environment when improperly treated, stored, transported, disposed of, or otherwise managed

Sec. 6992b. Tracking of medical waste

(a) Demonstration program

Not later than 6 months after November 1, 1988, the Administrator shall promulgate regulations establishing a program for the tracking of the medical waste listed in section 6992a of this title which is generated in a State subject to the demonstration program. The program shall:

provide for tracking of the transportation of the waste from the generator to the disposal facility, except that waste that is incinerated need not be tracked after incineration,
include a system for providing the generator of the waste with assurance that the waste is received by the disposal facility,
use a uniform form for tracking in each of the demonstration States, and

include the following requirements:
A requirement for segregation of the waste at the point of generation where practicable.
A requirement for placement of the waste in containers that will protect waste handlers and the public from exposure.
A requirement for appropriate labeling of containers of the waste.

(b) Small quantities

In the program under subsection (a) of this section, the Administrator may establish an exemption for generators of small quantities of medical waste listed under section 6992a of this title, except that the Administrator may not exempt from the program any person who, or facility that, generates 50 pounds or more of such waste in any calendar month.

Concurrently with the promulgation of regulations under subsection (a) of this section, the Administrator shall promulgate a recordkeeping and reporting requirement for any generator in a demonstration State of medical waste listed in section 6992a of this title that:

(1) incinerates medical waste listed in section 6992a of this title on site and
(2) does not track such waste under the regulations promulgated under subsection (a) of this section. Such requirement shall require the generator to report to the Administrator on the volume and types of medical waste listed in section 6992a of this title that the generator incinerated on site during the 6 months following the effective date of the requirements of this subsection.

(d) Type of medical waste and types of generators

For each of the requirements of this section, the regulations may vary for different types of medical waste and for different types of medical waste generators

U.S. Congress

U.S. CODE. “MEDICAL WASTE TRACKING ACT OF 1988. AN AMENDMENT TO THE SOLID WASTE DISPOSAL ACT.”TITLE 42, CHAPTER 82, SUBCHAPTER X, SECTIONS 6992, 6992A AND 6992B.

See Also Toxic Waste

BIBLIOGRAPHY

Books

Dutta, Subijoy. Environmental Treatment Technologies for Hazardous and Medical Wastes: Remedial Scopand Efficacy. New York: McGraw-Hill, 2007.

Periodicals

Narvaez, Alfonso. “New York City to Pay Jersey Town $1 Million Over Shore Pollution.” New York Times (December 8, 1987).

Web Sites

CNN.com“Prescription Drugs Found in Drinking Water Across U.S.” March 10, 2008. http://www.cnn.com/2008/HEALTH/03/10/pharma.waterl.ap/ (accessed May 10, 2008).

U.S. Environmental Protection Agency. “Medical Waste.” http://www.epa.gov/epaoswer/other/medical/ (accessed May 10, 2008)

U.S. Environmental Protection Agency. “Medical Waste Tracking Act (1988).” http://www.epa.gov/epaoswer/other/medical/mwpdfs/mwta.pdf (accessed May 10, 2008).

World Health Organization. “Medical Waste.” http://www.who.int/topics/medical_waste/en/ (accessed May 10, 2008).

World Health Organization. “Safe Management of Wastes from Health-Care Activities.” http://www.healthcarewaste.org/en/documents.html?id=1 (accessed May 10, 2008).

Larry Gilman

Environmental Science: In Context