US APPROACH TOWARD MEDICAL WASTE MANAGEMENT

BYKRISTINA MESON, OSWER

CHEN H. WEN, OPPTSUS Environmental Protection Agency

Overview of Presentation

n US Regulatory Frameworkn Healthcare Waste Generationn Management of Medical Wasten Treatment and Disposal Optionsn Source Reduction as an Option for

Waste Treatment and Disposal

Major Environmental Regulations Affecting Healthcare Sector

n Clean Air Act n Clean Water Actn Comprehensive

Emergency Response Compensation and Liability Act

n Federal Insecticide, Fungicide, and Rodenticide Act

n Resource Conservation and Recovery Act

n Solid Waste Disposal Act

Many Other Federal Agencies Also Regulate Healthcare Industry

n Dept. of Health and Human Services– Centers for Disease Control– Drug Enforcement Agency– Food and Drug Administration– National Institutes of Health– Occupational Safety and Health

Administration

n Department of Transportationn Nuclear Regulatory Administration

Healthcare Waste Generation

n Healthcare Waste consists of multiple waste streams:– Infectious/Medical Waste– Pharmaceutical Waste– Pesticides– Cleaners– Cafeteria and other municipal solid waste

n 8 - 45 lbs. of waste per bed per day– Infectious waste is 15% or less of total

Waste Audits

n An analysis of a facilities waste stream has many benefits:– Identify sources of waste, their

compositions, and rates of generation;– Provide information on:

n waste minimization and handling practicesn segregation efficiencyn regulatory compliancen costs

Waste Handling

n Getting infectious waste safely to proper treatment and disposal is critical:– For worker safety – To minimize environmental releases

n Waste handling procedures should include:– Good segregation practices– Appropriate containment to protect workers– Clear labeling– Safe Storage– Solid chain of custody

Categories of Medical Waste

n 1. Cultures and stocks of infectious substances

n 2. Human Pathological wasten 3. Used Sharpsn 4. Contaminated animal wastesn 5. Isolation wastesn 6. Blood and blood productsn 7. Unused, discarded sharps

Treatment OptionsInfectious/Medical Waste

n Incinerationn Non-incineration technologies

– Thermaln autoclaven microwave

– Chemical/Mechanical– Irradiation

n Medical waste treated by one of these methods can be safely landfilled

US Trends for Medical Waste Incinerators

n Medical Waste Incinerator Rule promulgated in 1997

n In September 1997:– ~1800 MWI, 80 of which were commercial

n In May 2003: – 110 MWI, 22 of which are commercial

n Air emissions reduced by 95-99%

Size and Capacity

n On-site small MWIs generally are:– dual chamber– batch feed; manual handling– 200 - 1,000 lbs./hr; often not operated 24/7

n Off-site Commercial MWIs generally are:– dual chamber– continuous feed; manual handling– 1,950 lbs./hr– can operate 24/7

Considerations

n Suitable for most waste typesn Renders waste unrecognizablen Significant reduction of volume and weightn May be some worker exposure to bioaerosols

during loading without proper protection n Proper incinerator operation critical to

pathogen destructionn Need for continuous operations to achieve

efficiency (burn everything)n Costs

Thermal Destruction Autoclave/Steam Sterilization

n Thermal inactivation of microbes using:– Moisture– Heat– Pressure

Size and Capacity

n Small bench top (e.g., dental office), size of small microwave

n Mid-size lab and on-site hospital, holds several trays of culture plates to several “red bags”

n Large commercial, 8’ diameter x 30’ length; 96 tpd

Considerations

n Generally achieves sterilizationn Appropriate for most waste types except

large pathological wasten Able to change time duration of treatment to

accommodate load characteristics n Few residualsn Does not render waste unrecognizablen No significant reduction of volume or weightn Costs ($200,000 - $400,000)

Microwave

n Steam-based, low heat thermal technology

n Use waves in radio-frequency range to denature proteins within the microbial cell

n Waste is shredded prior to heating

Size and Capacity

n Batch or semi-continuousn 550 - 900 lbs/hrn Approximately 22’L x 18’H x 10’W

Considerations

n Substantial microbial inactivationn Appropriate for most waste types except

large pathological waste, metal objects, chemotherapy waste

n Few residualsn Renders waste unrecognizablen Significant reduction of volumen Costs ($500,000 - $600,000)

Pyrolysis

n High temperature non-combustion treatment

n Forms glassy aggregate as residualn Requires energy to operaten Relatively new technology - requires

careful consideration

Considerations

n May achieve sterilizationn Appropriate for most waste types n Lower emissions than incineration (still

dioxins)n Renders waste unrecognizable (glassy

aggregate)n Significant reduction of volume or weightn Large sizen High costs ($750,00 - $3.3 million)

Chemical/Mechanical

n Mechanically shred and mix waste to increase exposure to chemical

n Use disinfectants to kill microbesn Most common disinfectant used is

sodium hypochloriten Others include: peroxyacetic acid,

glutaraldehyde, sodium hydroxide, ozone gas, and calcium oxide

n Range in size in capacity

Considerations

n Substantial reduction in microbial loadn Appropriate for most waste types except

pathological waste*, large metal objects, chemotherapy waste

n Potential chemical hazards/worker safety issues

n Renders waste unrecognizablen Significant reduction of volumen Costs

Irradiation

n Electron beam interacts with cells at DNA level

n Examples are Cobalt 60, UV-Cn Technology has been around for

decades; application for medical waste still in development stage

Summary:Factors to Consider

n Throughputn Types of waste treatedn Microbial inactivation efficacyn Environmental emissions and waste

residuesn Occupational safety and health waste

reductionn Noise and odor

Factors to Consider

n Regulatory acceptancen Space requirementsn Automation, reliabilityn Level of commercializationn Background of technology manufacturer

or vendorn Costn Community and staff acceptance

But Destruction Isn’t Always the Best…..

n The healthcare sector generates a lot of waste! – Medical waste incinerators identified as 4th

large source of mercury release into the air (1990 Report to Congress);

– Healthcare sector generates approx. 1,000,000 pounds of waste per day.

n Economically or environmentally, there are alternatives to destruction.

Hospitals for a Healthy EnvironmentGoing Beyond Disposal

n There are roughly 7000 hospitals in U.S. n Voluntary program between EPA,

American Hospital Association, and other institutional partners– Currently attracted 780 hospital “Partners”– Major goals of program include:

n Virtual elimination of mercury n Significant reduction of overall waste volume

H2E’s Approaches Toward Mercury Elimination and Waste Reduction

n Show the impact of mercury and waste on patient and staff health;

n Show the expense in not eliminating mercury, and not reducing waste;

n Promote design and sale of better products with manufacturers;

n Promote better training of healthcare workers to waste reduction and proper disposal.

H2E Provides Its Partners…..

n Web page - updated bi-weekly with latest technical information;

n Listserv of healthcare professionals for peer-to-peer advise;

n Monthly teleconference training calls; n Awards and recognition for outstanding

Partners.

Examples of Partner Acheivements

n 66 Partners have eliminated mercury-containing products altogether;

n Beth Israel Hospital in New York saved $500,000 a year from waste segregation and reduction;

n University of Michigan Hospital:– Recovered 2000 pounds of Hg– Saved 8 million gallons of water – Saved 8 million kilowatts of energy

Benefits of Segregation, Source Reduction & Recycling

n Minimizes the amount of infectious waste that needs to be treated;

n Minimizes costs for handling hazardous waste;

n Reduce natural resources consumption; n Create healthier environment for

patients and staff.

On-line Resources

n www.epa.gov/epaoswer/other/medical/EPA’s webpage on medical waste, with links to EPA and state regulations

n www.epa.gov/ttn/atwEPA’s rule for medical waste incinerators, related fact sheets

n www.noharm.org“Non-Incineration Medical Waste Treatment Technologies” August 2001

On-line Resources, cont.

n www.h2e-online.orgHospitals for a Healthy Environment’s website, with numerous documents and links

n www.uml.edu/centers/lcsp/hospitalsClearinghouse on “cleaner” healthcare supplies

n http://www.cdc.gov/ncidod/hip/enviro/Enviro_guide_03.pdfCDC Guideline for Environmental Infection Control in Heath-Care Facilities