West Virginia Department of West Virginia Department of Health and Human ResourcesHealth and Human Resources

Bureau for Public HealthBureau for Public HealthOffice of Environmental Health Office of Environmental Health

ServicesServices

Infectious Medical Waste Infectious Medical Waste ProgramProgram

Presents:Presents:

Infectious Medical WasteInfectious Medical WasteInformationInformation

Guidance on Segregation of Guidance on Segregation of WastesWastes

and Waste Reductionand Waste Reduction

Why Infectious Waste is Why Infectious Waste is RegulatedRegulated

To minimize the potential for the spread To minimize the potential for the spread of disease from a medical setting to the of disease from a medical setting to the general public; andgeneral public; and

To reduce the overall amount of infectious To reduce the overall amount of infectious medical waste produced in West Virginia.medical waste produced in West Virginia.– helps to protect the environment, and reduces helps to protect the environment, and reduces

medical facilities’ treatment expendituresmedical facilities’ treatment expenditures

Diseases Caused by Diseases Caused by Bloodborne PathogensBloodborne Pathogens

MalariaMalaria RabiesRabies SyphilisSyphilis TularemiaTularemia Viral Hemorrhagic Viral Hemorrhagic

FeversFevers

Arboviral Arboviral infectionsinfections

BrucellosisBrucellosis Creutzfeldt-Jakob Creutzfeldt-Jakob

DiseaseDisease Hepatitis CHepatitis C LeptospirosisLeptospirosis

HIV / AIDSHIV / AIDS Hepatitis BHepatitis B

What is Infectious Medical What is Infectious Medical WasteWaste

Infectious Medical Waste is defined as medical Infectious Medical Waste is defined as medical waste capable of producing an infectious waste capable of producing an infectious disease. disease.

Waste is considered Infectious when it is:Waste is considered Infectious when it is: Contaminated by an organism that is Contaminated by an organism that is

pathogenic to healthy humans;pathogenic to healthy humans; The organism is not routinely available in the The organism is not routinely available in the

environment; andenvironment; and The organism is in significant quantity and The organism is in significant quantity and

virulence to transmit disease.virulence to transmit disease.

Infectious Wastes Specifically Infectious Wastes Specifically AreAre

Blood and blood Blood and blood products in a free products in a free flowing, unabsorbed flowing, unabsorbed state;state;

Contaminated sharps,Contaminated sharps, Isolation Wastes,Isolation Wastes, Laboratory wastes, andLaboratory wastes, and Unfixed pathological Unfixed pathological

tissuestissues

Infectious Laboratory Infectious Laboratory WastesWastes

CulturesCultures Etiological agentsEtiological agents SpecimensSpecimens StocksStocks Related Related

contaminated contaminated wasteswastes

Vaccine vialsVaccine vials

Pathological WastesPathological Wastes Fixed Pathological Fixed Pathological

wastes are not wastes are not Infectious Medical WasteInfectious Medical Waste

Unfixed Pathological Unfixed Pathological wastes must be wastes must be incineratedincinerated– wastes containing wastes containing

pathological items must pathological items must be appropriately be appropriately labeled to ensure they labeled to ensure they are incineratedare incinerated

Infectious Isolation WastesInfectious Isolation Wastes Wastes generated from the care of a patient Wastes generated from the care of a patient

who has or is suspected of having a disease who has or is suspected of having a disease caused by a CDC Class 4 agent, listed belowcaused by a CDC Class 4 agent, listed below

CLASS 4 VIRAL AGENTSCLASS 4 VIRAL AGENTS: : Alastrim, Smallpox, Monkey pox, and White pox.Alastrim, Smallpox, Monkey pox, and White pox. Hemorrhagic fever agents, including Crimean hemorrhagic fever Hemorrhagic fever agents, including Crimean hemorrhagic fever

(Congo), Junin, and Machupo viruses(Congo), Junin, and Machupo viruses Herpes virus simiae (Monkey B virus)Herpes virus simiae (Monkey B virus) Lassa virusLassa virus Marburg virusMarburg virus Tick-borne encephalitis virus complex, including Russian spring-Tick-borne encephalitis virus complex, including Russian spring-

summer encephalitis, Kyasanur forest disease, Omsk hemorrhagic summer encephalitis, Kyasanur forest disease, Omsk hemorrhagic fever, and Central European encephalitis virusesfever, and Central European encephalitis viruses

Venezuelan equine encephalitis virusVenezuelan equine encephalitis virus Yellow fever virusYellow fever virus

Disposal of Isolation WastesDisposal of Isolation Wastes Isolation wastes that do not meet the Isolation wastes that do not meet the

definition of infectious medical waste should definition of infectious medical waste should be separated and disposed in the general be separated and disposed in the general waste stream waste stream

disposable gownsdisposable gowns face masksface masks shoe coversshoe covers

All waste from an isolation room should be All waste from an isolation room should be treated with caution and the appropriate treated with caution and the appropriate Personal Protective Equipment (PPE) must be Personal Protective Equipment (PPE) must be worn during handling and disposal.worn during handling and disposal.

What about OSHAWhat about OSHA Ensure that all employees can safely perform Ensure that all employees can safely perform

their normal duties without undue health riskstheir normal duties without undue health risks Bloodborne Pathogen (BBP) Standard developed Bloodborne Pathogen (BBP) Standard developed

to protect employees with occupational to protect employees with occupational exposure to bloodborne pathogensexposure to bloodborne pathogens– HIVHIV– HbVHbV

Employers required to evaluate engineering Employers required to evaluate engineering controls to reduce or eliminate employee controls to reduce or eliminate employee exposure risksexposure risks– adoption of a needleless systemadoption of a needleless system

Bloodborne Pathogen Bloodborne Pathogen StandardStandardEmployers must:Employers must:

Ensure that Universal Precautions are observedEnsure that Universal Precautions are observed Provide free Hepatitis-B vaccination seriesProvide free Hepatitis-B vaccination series Provide all necessary PPE and ensure that is it usedProvide all necessary PPE and ensure that is it used Provide BBP training at hire, and annually thereafterProvide BBP training at hire, and annually thereafter Maintain records of all trainingMaintain records of all training Maintain an Exposure Control Plan, update annuallyMaintain an Exposure Control Plan, update annually Record exposure incidents and follow-up activitiesRecord exposure incidents and follow-up activities

Bloodborne Pathogen Bloodborne Pathogen StandardStandard

Defines Infectious Medical Waste as:Defines Infectious Medical Waste as: Liquid or semi-liquid blood or other potentially Liquid or semi-liquid blood or other potentially

infectious materials (OPIM),infectious materials (OPIM), Contaminated items that would release blood or Contaminated items that would release blood or

OPIM in a liquid or semi-liquid state if OPIM in a liquid or semi-liquid state if compressed,compressed,

Items caked with dried blood or OPIM that would Items caked with dried blood or OPIM that would dislodge during handling,dislodge during handling,

Contaminated sharps, andContaminated sharps, and Pathological and microbial wastes containing Pathological and microbial wastes containing

blood or OPIMblood or OPIM

Other Potentially Infectious Other Potentially Infectious MaterialMaterial

OPIMOPIM Any body fluid with visible bloodAny body fluid with visible blood Amniotic fluidAmniotic fluid Cerebrospinal fluidCerebrospinal fluid Pericardial fluidPericardial fluid Peritoneal fluidPeritoneal fluid Pleural fluidPleural fluid Saliva in dental proceduresSaliva in dental procedures Semen/vaginal secretionsSemen/vaginal secretions Synovial fluidSynovial fluid Anywhere body fluids are indistinguishableAnywhere body fluids are indistinguishable

Infectious Waste Is NotInfectious Waste Is Not Used personal hygiene productsUsed personal hygiene products

– tissuestissues– feminine productsfeminine products– diapersdiapers

Gauze and dressings containing small amounts Gauze and dressings containing small amounts of blood,of blood,

Fixed pathological tissues,Fixed pathological tissues, Uncontaminated medical tubing and devicesUncontaminated medical tubing and devices

Tubing with any visible fluid blood must be Tubing with any visible fluid blood must be disposed in the biohazard wastedisposed in the biohazard waste

Infectious Wastes Do Not Infectious Wastes Do Not IncludeInclude

Human remains and body parts being Human remains and body parts being used for medical purposes, under the used for medical purposes, under the control of a licensed doctor or dentistcontrol of a licensed doctor or dentist

Human remains lawfully interred in a Human remains lawfully interred in a cemetery or in preparation for intermentcemetery or in preparation for interment

Hair, nails, and extracted teethHair, nails, and extracted teeth

Preventing Disease Preventing Disease TransmissionTransmission

The single most effective measure to The single most effective measure to control the transmission of Bloodborne control the transmission of Bloodborne

Pathogens is:Pathogens is:

Universal PrecautionsUniversal Precautions Treat all human blood and other Treat all human blood and other

potentially infectious materials like they potentially infectious materials like they are infectious for Hepatitis B and HIVare infectious for Hepatitis B and HIV

Blood and Fluid Borne Blood and Fluid Borne Pathogen ExposuresPathogen Exposures

Exposures to blood and fluid borne pathogens in Exposures to blood and fluid borne pathogens in the medical setting typically occur by one of the the medical setting typically occur by one of the following ways:following ways:

Puncture from contaminated needles, broken Puncture from contaminated needles, broken glass, or other sharpsglass, or other sharps

Contact between non-intact (cut, abraded, acne, Contact between non-intact (cut, abraded, acne, or sunburned) skin and infectious body fluidsor sunburned) skin and infectious body fluids

Direct contact between mucous membranes and Direct contact between mucous membranes and infectious body fluidsinfectious body fluids

Example: A splash in the eyes, nose, or mouthExample: A splash in the eyes, nose, or mouth

Transmission of Blood and Transmission of Blood and Fluid Borne PathogensFluid Borne Pathogens

An exposure incident does not guarantee disease An exposure incident does not guarantee disease transmission. Several factors affect transmission. Several factors affect transmission:transmission:

Infected Source – the disease stage of the sourceInfected Source – the disease stage of the source Means of Entry - severity or depth of the: Means of Entry - severity or depth of the:

puncture wound, broken skin, or direct contact puncture wound, broken skin, or direct contact with mucus membranewith mucus membrane

Infective Dose - the amount and type of fluid, as Infective Dose - the amount and type of fluid, as well as the amount of infectious agent in the well as the amount of infectious agent in the fluid Blood is the fluid of greatest concernfluid Blood is the fluid of greatest concern

Susceptible Host - immunocompromisedSusceptible Host - immunocompromised

Prevention of ExposurePrevention of ExposureGuidelines to reduce the risk of exposure:Guidelines to reduce the risk of exposure:

Frequent hand washingFrequent hand washing Use of standard barrier precautionsUse of standard barrier precautions Regular cleaning and decontamination of Regular cleaning and decontamination of

work surfaces with a cleaning agent work surfaces with a cleaning agent labeled as effective against labeled as effective against Mycobacterium/TBMycobacterium/TB

Vaccination against Hepatitis-BVaccination against Hepatitis-B Proper infectious waste disposalProper infectious waste disposal

Exposure Incident ResponseExposure Incident Response Wash exposed area with soap and waterWash exposed area with soap and water Flush splashes to nose, mouth or skin Flush splashes to nose, mouth or skin

with waterwith water Irrigate eyes with water or salineIrrigate eyes with water or saline Report the exposure to supervisorReport the exposure to supervisor Follow your facility’s exposure response Follow your facility’s exposure response

planplan Report all exposures, regardless of Report all exposures, regardless of

severity, for your safetyseverity, for your safety

Collection of Infectious Collection of Infectious WasteWaste

Infectious medical wastes must Infectious medical wastes must be collected at the point of be collected at the point of generation in the appropriate generation in the appropriate color coded bags color coded bags

Orange bags for autoclaved Orange bags for autoclaved waste, Red bags for all other waste, Red bags for all other treatment methodstreatment methods

Biohazard bags must be labeled Biohazard bags must be labeled with the international biohazard with the international biohazard symbol and appropriate wording; symbol and appropriate wording; “biohazard,” “biomedical waste,” “biohazard,” “biomedical waste,” “infectious medical waste,” or “infectious medical waste,” or “regulated medical waste”“regulated medical waste”

SharpsSharps Must be collected at the point of generation, in

a leak-proof and puncture-resistant container Containers must bear the international

biohazard symbol and appropriate wording Containers should

never be completely filled, nor filled above the full line indicated on box.

Liquid Infectious Medical Liquid Infectious Medical WastesWastes

Placed directly in the Placed directly in the Biohazardous waste, Biohazardous waste,

Poured down a Poured down a sanitary sewer,sanitary sewer,

Solidified using an Solidified using an approved disinfectant approved disinfectant solidifier and solidifier and discarded in the solid discarded in the solid wastewaste

Liquid Infectious Medical Waste, i.e., the Liquid Infectious Medical Waste, i.e., the contents of suction canisters, may be disposed contents of suction canisters, may be disposed of in several ways:of in several ways:

Packaging and StoragePackaging and Storage Wastes shall be collected in a lined, cardboard

box or reusable plastic container that is labeled with the biohazard symbol and appropriate wording.

Once the box or container is full, the bag lining it must be sealed and the container then sealed shut

Boxes must be labeled with facility name, address, phone and fax numbers, and the date

A full, sealed container can be stored on site for no more than 30 days

Shipping and ManifestsShipping and Manifests Every load of waste shipped off-site for Every load of waste shipped off-site for

destruction is tracked using a manifest systemdestruction is tracked using a manifest system The manifest is a multiple copy document that The manifest is a multiple copy document that

accompanies the waste to the treatment facilityaccompanies the waste to the treatment facility Every individual who takes possession of the Every individual who takes possession of the

waste, including someone from your facility, waste, including someone from your facility, must sign the manifestmust sign the manifest

As the waste generator, your facility is As the waste generator, your facility is responsible for the waste until you receive the responsible for the waste until you receive the proof-of-destruction copy of the manifestproof-of-destruction copy of the manifest

Generator’sGenerator’sSectionSection

Transporter’sTransporter’sSectionSection

TreatmentTreatmentFacility’sFacility’sSectionSection

Tracking Waste Through Tracking Waste Through DestructionDestruction

The proof-of-destruction copy of the The proof-of-destruction copy of the manifest must be returned to your manifest must be returned to your facility within 50 days from the date that facility within 50 days from the date that the load of waste was picked up.the load of waste was picked up.

WV Infectious Waste Program must be WV Infectious Waste Program must be notified of any load that has not been notified of any load that has not been accounted for within 50 days.accounted for within 50 days.

All proof-of-destruction manifests must All proof-of-destruction manifests must be kept on file at your facility for 3 years.be kept on file at your facility for 3 years.

This manifest has been signed by the treatment facility, certifying that this load has been destroyed and is no longer infectious.

Bloodborne Pathogen Spill Bloodborne Pathogen Spill KitKit

All medical facilities must have a spill kit. All employees All medical facilities must have a spill kit. All employees should know where the spill kit is located. should know where the spill kit is located.

It must contain the following items: It must contain the following items: Absorbent material to manage ten gallons of fluidAbsorbent material to manage ten gallons of fluid One gallon hospital grade disinfectant and a spray bottleOne gallon hospital grade disinfectant and a spray bottle Many large biohazard bagsMany large biohazard bags 2 sets of disposable coveralls, boots, caps2 sets of disposable coveralls, boots, caps 2 pair of heavy neoprene gloves2 pair of heavy neoprene gloves 2 pair of eye and respiratory protection devices2 pair of eye and respiratory protection devices 100 yards of boundary marking tape, 1 roll of packing 100 yards of boundary marking tape, 1 roll of packing

tapetape First aid kit (facilities with an emergency room exempt)First aid kit (facilities with an emergency room exempt)

Over ClassificationOver Classification The improper disposal of solid wastes that The improper disposal of solid wastes that

do not meet the definition of infectious do not meet the definition of infectious medical waste, as if they were infectiousmedical waste, as if they were infectious

It is the most commonly cited violation, It is the most commonly cited violation, with 98% of permitted facilities being with 98% of permitted facilities being markedmarked

It increases the financial burden on It increases the financial burden on patients and taxpayers in the form of patients and taxpayers in the form of increased disposal costs for health care increased disposal costs for health care facilitiesfacilities

Problems with Over Problems with Over ClassificationClassification

When large volumes of When large volumes of plastics, common in plastics, common in medical waste, are medical waste, are incinerated there is an incinerated there is an increased potential for increased potential for atmospheric release of atmospheric release of carcinogenic agentscarcinogenic agents

Increased medical waste generation Increased medical waste generation increases the risk of costly accidents and increases the risk of costly accidents and spills due to the increased number of trucks spills due to the increased number of trucks required to haul the wasterequired to haul the waste

Why Bother Segregate Why Bother Segregate Wastes?Wastes?

Costs for waste disposal:Costs for waste disposal:

About $0.01 per pound to haul regular waste to a About $0.01 per pound to haul regular waste to a landfill.landfill.

From $0.28, and From $0.28, and increases to over increases to over $4.00 per pound to $4.00 per pound to haul and treat as haul and treat as infectious waste.infectious waste.

A Real Life ExampleA Real Life Example During an inspection of one southern West During an inspection of one southern West

Virginia facility it was noted that the ER, ICU, Virginia facility it was noted that the ER, ICU, Lab, OB, and OR departments were not Lab, OB, and OR departments were not segregating any waste. segregating any waste.

All waste was being disposed of as infectious. All waste was being disposed of as infectious. Management said the staff was too busy to Management said the staff was too busy to

segregate garbage.segregate garbage. In 1996 this facility generated 245,060 lbs. of In 1996 this facility generated 245,060 lbs. of

infectious waste.infectious waste. They paid $0.29 cents per pound to have their They paid $0.29 cents per pound to have their

infectious waste hauled away and treated.infectious waste hauled away and treated.

The Cost of Over The Cost of Over ClassificationClassification

The inspection The inspection revealed 90 - 95% revealed 90 - 95% over classification.over classification.

The total cost for The total cost for disposal of infectious disposal of infectious waste for 1996 was waste for 1996 was $71,067.40$71,067.40

Cost savings potential Cost savings potential of $64,000 to $68,000of $64,000 to $68,000

Teamwork Made it PossibleTeamwork Made it PossibleThis same facility two years later:This same facility two years later:

In 1998 they generated 114,000 pounds. In 1998 they generated 114,000 pounds. A reduction of about 50%.A reduction of about 50%. In 2001 they generated 58,838 pounds. In 2001 they generated 58,838 pounds. A total reduction of more than 76%A total reduction of more than 76% This facility realized a $54,004 cost This facility realized a $54,004 cost

savingssavings

Source Separation is the Source Separation is the Key!Key!

Everyone needs to consider which waste Everyone needs to consider which waste stream an item goes in every time wastes stream an item goes in every time wastes are disposedare disposed

We realize that you are busy, but it only We realize that you are busy, but it only takes a few seconds to separate waste takes a few seconds to separate waste items into the proper waste streamitems into the proper waste stream

By properly segregating medical wastes, By properly segregating medical wastes, the weight of infectious waste can be the weight of infectious waste can be drastically reduced in every facilitydrastically reduced in every facility

Routinely Over Classified Routinely Over Classified ItemsItems

Diapers (adult and baby)Diapers (adult and baby) Paper towelsPaper towels Unsaturated dressings and chucksUnsaturated dressings and chucks Wrappers and packagingWrappers and packaging IV bags and oxygen tubingIV bags and oxygen tubing Gloves with no visible Gloves with no visible

contaminationcontamination Urine catheters and bagsUrine catheters and bags Paper, newspapers, and food Paper, newspapers, and food

containerscontainers Urine cups and specimen Urine cups and specimen

containers with no visible bloodcontainers with no visible blood Empty Medication vials and Empty Medication vials and

broken glassbroken glass

Penalties for ViolationsPenalties for Violations West Virginia does not fine for over West Virginia does not fine for over

classification. Facilities are fining classification. Facilities are fining themselves by paying extra for infectious themselves by paying extra for infectious waste treatment.waste treatment.

There ARE penalties for putting infectious There ARE penalties for putting infectious materials into the regular solid waste materials into the regular solid waste stream.stream.

Fines are assessed based on the severity Fines are assessed based on the severity of the instance and negligence. of the instance and negligence.

Fines can be up to $25,000 per day. Fines can be up to $25,000 per day.

When you mix infectious waste When you mix infectious waste and regular solid waste and regular solid waste together, you are not permitted together, you are not permitted to separate themto separate them

Once Once combined, the combined, the entire contents entire contents are considered are considered infectious infectious waste!waste!

A Little History, Where We A Little History, Where We StartedStarted

1996 was the year of peak infectious 1996 was the year of peak infectious medical waste production in WV, with medical waste production in WV, with nearly 10 million pounds generatednearly 10 million pounds generated

In 1998, infectious medical waste In 1998, infectious medical waste generation was down 3 million pounds, generation was down 3 million pounds, to roughly 6 million total poundsto roughly 6 million total pounds

A statewide reduction of 33%!A statewide reduction of 33%!

There’s Still More Work To There’s Still More Work To DoDo

From 1998 to 2005, the annual IMW From 1998 to 2005, the annual IMW generated in WV has remained around generated in WV has remained around 6 million pounds6 million pounds

Estimated reduction potential of 30%Estimated reduction potential of 30% West Virginia health care facilities West Virginia health care facilities

could save an estimated $1,000,000 a could save an estimated $1,000,000 a yearyear

IMW Program WebsiteIMW Program Websitehttp://www.wvdhhr.org/wvimwhttp://www.wvdhhr.org/wvimw

Alternative Waste Treatment InformationAlternative Waste Treatment Information Applications: Major Change, Incinerator Applications: Major Change, Incinerator

Operator Registration, Permit Renewal, etc.Operator Registration, Permit Renewal, etc. Approved Waste Haulers ListApproved Waste Haulers List Forms: Annual Report, Quarterly Report, etc.Forms: Annual Report, Quarterly Report, etc. Links to Federal Agencies & IMW InformationLinks to Federal Agencies & IMW Information Presentations: this presentation, Small Quantity Presentations: this presentation, Small Quantity

Generators, Disposal of Household SharpsGenerators, Disposal of Household Sharps Question and Answer ForumQuestion and Answer Forum

Contact InformationContact InformationDavid Thornton, R.S., Program Manager David Thornton, R.S., Program Manager Jaclyn Boylan, Inspector Jaclyn Boylan, Inspector

Phone (Jaclyn’s): Phone (Jaclyn’s): (304) 558-6725 (304) 558-6725 Phone (David’s): Phone (David’s): (304) 558-6783 (304) 558-6783 Fax : Fax : (304) 558-1071 (304) 558-1071

Email : Email : dthornton@wvdhhr.orgdthornton@wvdhhr.org, , jaclynboylan@wvdhhr.orgjaclynboylan@wvdhhr.org

Mailing Address :Mailing Address : Office of Environmental Health ServicesOffice of Environmental Health Services

Capitol and Washington StreetsCapitol and Washington Streets1 Davis Square, Suite 2001 Davis Square, Suite 200Charleston, WV 25301-1798Charleston, WV 25301-1798