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Medical Waste THE GROWINGISSUES OF MANAGEMENT AND DISPOSAL
Margaret F. Fay, RN; William C. Beck, MD; James Michael Fay; Mary Kay Kessinger, RN
he management and disposal of regulated, hazardous, or infectious waste is America’s primary environmental problem.’ Although medical waste as an environmental hazard has only recently captured public attention, the overall problem of waste management and control has resulted from decades of negligence and a lack of foresight by the public, medical community, regulatory bodies, and industry. Clearly, these groups cannot shoulder the entire blame. As a society, Americans must share some of the responsibility because of their preference for disposable products. Americans throw away 1.6 billion disposable pens, 2 billion disposable razors, and 16billion disposablediapers each year.2 Individually, each person generates 3.5 pounds of garbage per day (Table 1).
Margaret F. Fay, RN,PhD, is a medical affairs consultant, Eden Prairie, Minn She received a nursing diploma from St Catherine’s Hospital, Creighton University, Omaha; a bachelor of arts degree in business administrationfrom Columbia University, New York City; a master’s degree in clinical psychology from Columbia University Pacgic, San Francisco; and a doctorate in psychology from the University of Minnesota at Minneapolis. William C. Beck, MD, FACS, FIES, is the president emeritus of the Guthrie Foundation for Medical Research, Sayre, Penn. He received his medical degree from Northwestern University
Growing Dependence on Disposable Items
isposable products and toxic chemicals have become deeply embedded in the infrastructure of our economy. As a nation, we have become highly dependent upon toxic chemicals, especially in the medical field. We cannot prep and drape patients, sterilize equipment, power emergency vehicles, or print medical books without generating large amounts of potentially toxic waste. Technology has developed faster than our understanding of it. Although the public lacks interest in the underlying nature of technical changes, it continues to dewnd new materials and products. Anything technically feasible is tried,
Medical School Evanston, 111 James Michael Fay, BIS is an independent medical marketing and research consultant, Eden Prairie, Minn. He has a bachelor of individualized studies degree in psychology and business from the University of Minnesota at Minneapolis. Mary Kay Kessinger, RN,MHA, is the manager of medical affairs for Advanced Marketing Concepts International, Eden Prairie, Minn. She received a bachelor of science degree in nursing from Loyola Universityof Chicago and a master’s degree in hospital and health care administration from the Universityoj Minnesota at Minneapolis. 1493
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and nowhere has that trend been more pronounced than in the field of medicine. Since the 19OOs, morbidity and mortality have been greatly reduced. Disposable instruments, implants, suture materials,and drapes are delivered prepackaged, presterilized, and ready to use. Antibiotics, while saving lives, have created strains of resistant bacteria. Improvements in nutrition, surgery, and other health care interventions have extended the life cycle. As a society, we have driven the health care field toward a technologically advanced market that is now highly dependent on disposable products. Even the composition of medical waste has undergone a dramatic change in the last few decades, reflecting the evolution of medical practice as well as industry’s response to those advances. Our growing use of disposables has caused the amount of medical waste to grow at an alarming rate, and more alarming still, that most medical waste is designated as regulated, infectious, hazardous, or toxic. No one knows exactly how much medical waste 1494
is produced in the United States,but the government estimates it is more than three million metric tons per year (Fig 1): One study conducted at the University of North Carolina estimated that waste from North Carolina hospitals increased 15%from 1980 to 1988. The study estimated the annual cost of medical waste disposal at $3.7 billion4
Problem of Medical Waste
pproximately 20% of all medical waste falls into the “red bag” or infectious waste category. Another 5% consists of toxic, corrosive, flammable, reactive, or radioactive materials and is classified as regulated waste. Chemotherapeutic waste (ie, materials that have come into contact with cytotoxic or antineoplastic drugs) is a relatively new type of waste. Because these drugs are considered to be carcinogenic, they pose special handling problems and require separate waste management controls. The remaining 70%to 75% of hospital waste usually is less contaminated than household waste.
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Fig 1. Waste dump site containing medical and municipal waste. Few studies have been conducted to determine the microbial composition of waste; however, assays have found similar types and numbers of pathogens in municipal and hospital waste streams, according to Pamela Sulmer, an environmental science investigator with the office of the Minnesota Attorney General. One might ask, why is medical waste a crisis now? Until the summer of 1987, the handling, management, and disposal of medical waste were not professional concerns. Health care workers simply picked waste up and threw it out. Medical waste was a problem for the waste hauler. All that changed, however, with daily reports of medical wastes being found on the shores of the Atlantic and along the Great Lakes. Beaches in New Jersey were closed as needles, used syringes, and blood vials washed ashore. These events quickly made medical waste a public concern. Public concern was based largely on a fear that the human immunodeficiency virus (HIV) could be contracted through accidental exposure to infectious waste. Fear also emanated from
potential exposure to the hepatitis B virus (HBV). Little documented evidence exists that housekeepers, health care professionals, or waste haulersby virtue of their professions-are more susceptible to disease from medical waste. The fear of potential contamination, however, has led unions, legislators, and the public to demand governmental control of medical waste.
Federal and State Regulations
he federal government has been involved in efforts to clean up the environment since Congress established the Clean Air Act in 1963. On Nov 1, 1988, the Medical Waste Tracking Act was signed into law as P. L. 100582 (Table 2). The Act requires the Environmental Protection Agency (EPA) to establish a two-year tracking program and to report its findings to Congress. For enforcement purposes the law is known as 40 CFR Part 259. It specifically adds Subtitle J to the 1976 Resource Conservation and Recovery Act (RCRA). 1495
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AORN J O U R N A L
Historical Background: Federal Regulations Affecting Hazardous Medical Waste Management 1963 Clean Air Act
1965 Solid Waste Disposal Act
Resource Recovery Act
Occupational Safety and Health Act
1974 Transportation Safety Act
1975 Hazardous Materials Transportation Act
Resource Conservation and Recovery Act
u Clean Water Act
1980 Superfund Law Comprehensive Environmental Response, Compensation and Liability Act (CERCLA) 1986 Community Right to Know Act and other amendments to Superfund Law
(Reprinted with permission from Margaret E Fay, copyright 1990) 1496
1989 EPA Standards for the Tracking and Management of Medical Waste Interim Rule and Request for Comments
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The Act, consisting of 11 sections, describes the scope of the program, designates the general classes or types of waste that must be tracked, and defines tracking requirements. The intent of the Act was to prevent public exposure to medical waste through illegal dumping and improper labeling or packaging and to protect the environment by controlling waste disposal practices. Biomedical wastes are generated by a wide range of facilities including clinics, nursing homes, physician and dental offices, blood banks, laboratories, and mortuaries. Hospitals, however, are the major producers of medical waste. They generate large quantities of sharps, microbiological cultures and stocks of infectious agents, pathological or anatomical waste, human blood and blood products, animal wastes, isolation materials, body parts and tissues, bandages, casts, catheters, and other items used in the diagnosis and/or treatment of patients. Medical waste differs in its potential to transmit diseases. Unfortunately,there is no clear definition of what constitutes infectious waste, nor is there an acceptable method of treatment for various waste products. To add to the confusion, only Puerto Rico and four states currently participate in the federal EPA program-New York, New Jersey, Connecticut, and Rhode Island. In addition, these states adopted their own health and environmental standards. All other states, while meeting the minimum federal regulation, have developed their own requirements for handling, packaging, transporting, and disposing waste. With no firm guidelines in place, hospitals are left to determine which wastes constitute a biological hazard.
Hospital Management of Medical Waste
o establish a waste management program, the program must include four elements that minimize worker risk from the potential hazards of infectious or hazardous waste. Health professionals must be able to distinguish waste that poses a significant infection hazard from other biomedical
waste that poses no greater hazard than general municipal waste. Infectious waste must be clearly defined to include all waste that poses a genuine hazard of infection. A waste management team must be assembled with administrative support and with the authority to readily implement an internal program that meets the EPA requirements. The program must include an effective enforcement system that segregates waste that has been defined as infectious to keep it out of the general waste stream. The Centers for Disease Control (CDC), Atlanta, has recognized that certain body fluids present a potential threat of disease transmission.5 According to the CDC, body fluids that pose a threat of disease from agents such as HBV and HIV include blood, vaginal secretions, synovial fluid, cerebrospinalfluid, and amniotic fluid. Other body fluids, nasal secretions, sweat, tears, urine, and vomitus, pose little risk of transmission of HBV and HIV unless they are contaminated with blood. Bulk body fluids (ie, vomitus or fluids collected in suction canisters during surgery) usually do not enter the solid waste stream, but like blood, they are generally disposed of via the sewer. The diseases that are potentially transmissible by infectious waste include hepatitis B, non-A nonB hepatitis, acquired immunodeficiency syndrome (AIDS), malaria, syphilis, enteric diseases, and tuberculosis. Disease can be transmitted through a percutaneous route such as needle sticks, sharp punctures, cuts with glassware; through inhalation of aerosols, dust, and spills; or through ingestion of contaminants via contaminated hands. Of these modes, the percutaneous route poses the greatest risk. Because of the risk of disease transmission via medical waste, precautions should be taken by waste generators and waste handlers. To ensure safe handling of infectious waste, a program should effectively incorporate segregation, packing, storage, and transportation techniques that limit exposure to the waste. Because the bulk of potentially infectious waste
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is generated by the OR, the focus of any control program must start with the OR. All people directly involved in managing infectious wastes should receive adequate training in the safe handling and disposal of waste. Although there are little data available on the composition of hospital waste, characteristically it is heterogenous in nature. It is a mixture of materials that includes general trash such as office paper, dietary waste, and noninfectious patient waste; infectious waste such as human blood and blood products, and contaminated sharps, isolation waste, pathological waste, anatomical waste; and radioactive wastes and hazardous wastes such as cytotoxic or antineoplastic materials, mercury or other heavy metals, or waste pharmaceuticals. Determining which portion of this waste constitutes a probable threat to workers is key to worker protection, injury prevention, and waste reduction.
Defining Infectious Waste
n 1987, William Rutala, University of North Carolina School of Medicine and director of the state infection control program, noted that no objective tests existed to identify infectious waste! This led the CDC, EPA, and state and federal agencies to develop a working definition to identify and define infectious waste by waste category and characteristics. The EPA defines infectious waste as “waste capable of producing an infectious disease.”7 The agency notes that for waste to be infectious, “it must contain pathogens with sufficient virulence and quantity so that exposure to the waste by a susceptible host could result in an infectious disease.”8 In August 1987, the CDC published universal precautions as a guide to reducing health care worker exposure to HIV and HBV in the work setting. Essentially, universal precautions designate blood and body fluids as potentially infectious. According to CDC guidelines, “all patients are considered potentially infected with HIV and/or other blood-borne pathogens and workers must, therefore, adhere rigorously to infection control precaution^."^ 1500
The CDC precautions are intended to protect health care workers from risk. They are not intended to address waste management practices or to define infectious waste. Unfortunately,many hospitals have misinterpreted the guidelines to categorize all patient contact items as infectious waste. The potential impact of such a trend on hospital waste management could be disastrous because it increases the cost of waste disposal and strains existing capacity for managing truly infectious waste. Hospitals must work with the EPA definition in establishing hospital-wide waste segregation and control policies. Working with a compliance assessment checklist (Table 3), a hospital committee is able to determine facility compliance levels. The checklist serves as a guide to both program and policy development. Other critical factors are the composition of the waste stream and analysis of methods used to minimize, control, contain, and segregate medical waste. A waste stream survey will generally provide sufficient data to begin a waste reduction program.
Segregation of Infectious WasteA Method of Waste Reduction
he first step in segregation is to define wastes that present a potential threat of infection (Table 4). Waste that poses no risk includes supplies from the central supply room such as external wrappers, packaging materials, glove wrappers, prepping materials and solutions not contaminated with blood or body fluids, and noncontact patient items. Noninfectious waste may be disposed of in the general waste stream. Wastes presenting a potential risk may include patient drapes, bloody sponges and laps, gowns and gloves, bloody body fluids, and anatomic or pathologic tissue. These items should be segregated from the general waste stream. The OR may elect to use red bags to visually segregate potentially infectious waste from general waste. This serves the dual function of initiating the general waste treatment process while restricting and minimizing the volume of the waste stream that must undergo treatment. Waste segregation eliminatcs the added
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Compliance Assessment Checklist This checklist was developed to assist the health care facility in determining the level of compliance with the standards of the Medical Waste Tracking Act of 1988. (40 CFR part 259)
1. Does the facility have a policy which describes the waste classified as regulated
as defined by the Act: (40 CFR 259.30) A. Cultures and stocks of infectious agents i. vaccine ii. culture dishes iii. transfer devices B. Pathological waste i. tissues ii. organs iii. body parts iv. body fluids a. cerebrospinal b. synovial c. pleural d. peritoneal e. pericardial f. semen g. vaginal secretion v. specimens of body fluids and their containers C. Human blood and blood products i. liquid waste (human blood) ii. products of blood iii. items saturated and/or dripping with human blood iv. items that were saturated or dripping with human blood v. serum, plasma, other blood components D. Sharps i. hypodermic needles, syringes ii. Pasteur pipettes iii. scalpel blades iv. blood vials v. needles with attached tubing vi. culture dishes vii. broken glassware in contact with infectious agents viii. unbroken glassware in contact with infectious agents ix. slides and cover slips E. Animal waste i. contaminated animal carcasses ii. bedding F. Isolation waste i. biological waste contaminated with blood, excretion, exudates, a secretion from humans who are isolated to protect others from certain highly communicable diseases
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Yes ii. animal waste from animals known to be infected with highly communicable diseases G. Unused sharps i. discarded sharps ii. hypodermic needles iii. suture needles iv. syringes v. scalpel blades 2. Segregation requirements (40 CFR 259.40) is regulated waste intended for off-site transport segregated from all other waste prior to placement in transport containers. 3. Packaging requirements (40 CFR 259.41) A. Is regulated medical waste placed in containers that are: i. rigid ii. leak resistant iii. impervious to moisture iv. strong to prevent tearing or busting v. sealed to prevent leakage B. Sharps and sharps with residual fluid is placed in puncture resistant containers C. Fluid in quantities greater than 20 cc are placed in packaging that is: i. break resistant ii. tightly lidded or stoppered 4. Storage of regulated material (40CFR 259.42). All regulated medical waste is stored: A. in a manner that maintains integrity of packaging B. in a location that provided protection from i. water ii. wind iii. rain iv. animals and insects C. in a manner that maintains the waste in a nonputrescent state D. in manner that prevents unauthorized access 5. Decontamination (40 CFR 259.43) A. All nonrigid packaging and inner liners are not reused B. Containers showing signs of contamination are decontaminated C. Containers that cannot be decontaminated are marked and disposed of as medical waste 6. Labeling requirements (40 CFR 259.44) Each package of regulated medical waste is labeled as follows: A. The words medical waste or infectious waste B. Displays the universal biohazard symbol 7. Marking requirements (40 CFR 259.45) A. Each package of regulated medical waste has: i. water resistant tag containing generator name generator state permit number (if no state permit number, the address 1502
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appears on the tag) transporter name transporter state permit number (if no state permit number, the address appears on the tag) date of shipment identification of contents as medical waste B. Each inner container is marked with generator’s name and state permit number (if no state permit number, the generator address appears) 8. Transporter acceptance (40 CFR 259.7 1) A. All waste accepted by transporter is properly labeled. B. Tracking form completed. C. The transporter ensures: i. container contains transporter name and permit number ii. date of receipt 9. Vehicle requirement (40 CFR 259.73) A. The transporter vehicles are: i. fully enclosed ii. leak resistant B. Waste is not subject to mechanical stress or compaction C. Cargo carrying body is in good sanitary condition D. Cargo carrying body is secured when left unattended E. Outside of the cargo carrying body is identified on two sides and back with i. transporter name ii. transporter state permit iii. the words medical waste iv. the letters are a minimum of 3 inches in height 10. Tracking form (40 CFR 259.74) A. Transporter does not accept waste unless it is accompanied by tracking form. B. Transporter assures: i. tracking form accurately reflects the number and total weight of packages to be transported ii. returns signed copy of tracking form to generator C. Transporter ensures tracking form accompanies shipment D. Upon delivery, the tracking form shall be completed: i. date of delivery ii. signature of transporter iii. name of facility where waste is delivered 11. Recordkeeping (40 CFR 259.77) A. Transporter keeps copy of tracking form B. All records maintained for three years by i. generator ii. transporter (Reprinted with permission from Margaret E Fay, copyright 1990) 1503
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AORN J O U R N A L
Handling Sequence for Infectious Material Separate medical waste at site of generation
Special packaging for sharps, liquid, or solid
G Routine packaging
Discard in general waste stream
Discard in general waste stream
Store for on-site incineration
Affix labels and complete paperwork
I On-site incinerator; collect ash and dispose of as hazardous waste
Waste hauler pickup; ensure tracking forms accompany trash to disposal site
(Reprinted with permksion from Margaret E Fay, copyright 1990) 1504
Within 45 days, receive signed tracking forms or notify state and EPA
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costs of special handling, treatment, and disposal of infectious waste.
tightly are required for containers that have fluids in excess of 20 mL.
Storage of Infectious Waste
Packaging and Labeling
ne of the primary methods of preventing disease is to break the chain of transmission. The chain of transmission has six elements or links: an adequate dose of an infectious agent, a viable source of infectious agents, a mode of escape for the agent, a mode of transmission, an entry route, and a susceptible host.1° Breaking the chain of transmission at any point will help ensure worker protection. Proper packaging and containment of infectious waste is one method of breaking the chain.” If infectious waste is properly contained, organisms cannot escape from their reservoir, nor can they inoculate a susceptible host and induce disease. The Medical Waste Tracking Act requires waste generators to select packaging materials that maintain integrity throughout the handling and disposal process. The Act also requires that contents be labeled to enable visual identification. According to EPA requirements (40 CFR 259.40 and 259.41), all waste generators must segregate and package waste. Hospitals are required to segregate waste into categories of sharps, fluids (greater than 20 mL), and other medical waste. In some states, such as New Jersey, disposal of fluid in general sewage is restricted; use suitable containers for various wastes that are rigid, leak resistant, impervious to moisture, have sufficient strength to prevent rupture or tearing under normal conditions, and are sealed to prevent leakage during transport; use puncture-resistant containers for sharps and sharps with residual fluids. These containers also must meet general container criteria listed above; and use packagmg that is break resistant, leak resistant, impervious to moisture, and have sufFcient strength to prevent tearing or rupture. Packagmg must be sealed to prevent leakage during transportation. Lids or stoppers that fit
he EPA has stated that hospitals that store regulated medical waste before treatment or disposal must comply with prescribed storage requirements.’*These include storage of waste in a manner and location that maintains the integrity of the packaging and provides protection from water, rain, and wind; transporter’s name, address, and state identification number; and date of waste pickup and the identification of the package’s contents and destination. External labels must be water resistant, and in some states must contain “floater labels” (ie, waterproof labels attached to waste that can float if medical waste is dumped in the ocean, lakes, or rivers). For the states participatingin the federal program, the EPA requires hospitals to hire a transporter who has notified the EPA of intent to operate in the state as a regulated medical waste transporter. To determine whether a transporter is on the EPA list, parties should contact the EPA RCRA/Superfund hot line at (800) 424-9346 or the state environmental department. The waste generator is responsible for instituting a tracking form that accompanies the waste shipment at all times. A copy of the form must be returned to the hospital within 45 days. If the signed forms are not returned, the hospital must notify both the EPA and the state of the waste hauler’s infraction. For hospitals that incinerate on-site, an operating log of load frequencies, amounts, and incinerator start-ups must be maintained. This log must be made available to the EPA, according to Michael Petruska, Office of Solid Waste, EPA, Washington, DC.
ome facilities autoclave waste before disposal to eliminate microbial contamination; however, this activity is not permitted 1505
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Requirements for Handling Medical Waste
in the states participating in the federal program. To be exempt from federal regulations, hospitals must both treat (eg, autoclave) and destroy (eg, grind) waste, reducing the end waste product to half an inch in size. Even with treatment and destruction, the hospitals must still comply with record keeping and disposal requirements. Although waste is rendered noninfectious and nonrecognizable, it still must be hauled away. As fewer landfills accept medical waste, even after sterilization, hospitals are left with an unagreeable environmental problem. Many have turned to on-site incineration as a solution. Most of the noninfectious, unregulated medical waste is placed in landfills, while most infectious waste from hospitals is incinerated. A 1983 American Hospital Association survey reported that approximately 67% of US hospitals use on1506
site incinerators, 16% use autoclave systems and landfills, and approximately 15% use off-site treatment facilities.13 Historically, incineration was the only treatment method generally accepted by regulators for infectious waste. It offers total destruction of the waste, which not only provides an aesthetic benefit, but due to the volume reduction, reduces the generator’s solid waste disposal cost. When properly outfitted with heat recovery capability, an incinerator can reduce the generator’s energy cost by using heat from the incinerator to fire boilers, and thus reduce natural gas consumption. It also is considered the one method of waste disposal suitable for treating infectious materials. Despite the potential benefits, hospitals are not choosing off-site disposal alternatives because of the existing regulations. As more states begin to
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Fig 2. Six pieces to the waste management puzzle-all
must work together.
regulate infectious waste or amend existing regulations, incineration requirements are becoming more stringent (Table 5). As states impose stricter guidelines on stack emissions, hospitals are unwilling to risk large capital outlays to bring incineratorsinto compliance with new regulations. Unfortunately, many hospital incinerators are so old, obsolete, or improperly operated that they are unable to meet the stringent emission controls without considerable expenditures to bring them into compliance. For most hospitals, refurbishing the incinerator is not a viable solution. Construction costs can run as high as $30,000 for retrofitting, $1.5 million for a new incinerator with scrubbers, and $500 million for a regional hospital waste disposal system.14 A 1989 study by the Congressional Office of Technology Assessment evaluated hospital incinerators and examined stack gas emissions, including hydrochloric acid, dioxins, furans, and other toxic substance^.^^ With the likelihood that the EPA will press further in its evaluation and with legislators’ interest in strengthening the Clean
Air Act, hospitals simply do not want the added liabilities associated with incinerator operation. Right or wrong, hospital incinerators have caused a “not in my backyard” attitude in the public sector. As a result, many hospitals have been forced to suspend their permit process or have had their permits denied solely on the basis of public pressure. On-site incineration evolved during the 1970 energy crisis because hospital administrators believed that the steam and electricity produced by such as system could offset utility costs while reducing trash volume by 70%to 80%.Today, the energy produced by small incinerator units is not cost competitive and the toxic air pollutants, including dioxins that some incinerators release, make incinerators a poor option.
hen addressing the impact of medical waste management and regulatory controls on the health care industry, 1507
it is important to remember that as long as modern medicine continues to maintain and sustain its current quality of life and wellness standards, industry will continue to generate various byproducts that have adverse effects on both people and the environment. It is important, therefore, to carefully evaluate the impact of societal demands. Unless government, industry, environmental groups, and health care providers abandon their current adversarial relationships and work together to solve shared problems, there will be no improvement in the growing problem of medical waste. The long-term solutions to today’s growing waste problems depend to a great extent on human factors and the willingness of industry, medical community, and governmentalbodies to cooperate with each other, recognizing the cause-effect relationship of a continued demand for disposable products. There are many pieces to the waste management puzzle (Fig 2). Obviously, surgeons cannot perform surgery without exposure to blood, tissue or body fluids, and nurses cannot maintain asepsis without sterile products. Because the health care team cannot totally eliminate the source of medical waste, they must learn to more effectively manage and control it. Health care professionals must encourage industry and government to work together to develop standards for products and materials used as barriers and use more biodegradable materials. Health care facilities must learn to minimize the amount of medical waste designated as regulated or infectious. Segregating potentially infectious material from clean waste at the point of generation may reduce both volume and cost. While modern technology and products must be used for worker protection, the temptation to define and solve the growing problems of medical waste in purely technological or product terms is simplistic. The ultimate solution to medical waste management problems will depend on both technical and nontechnical solutions, and even more importantly, on the changing attitudes of society toward the world around it. 0 1508
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Notes 1. “Infectious waste disposal crisis coming to a head,” Znfectious WasteNews (March 10, 1988) 3. 2. S Begley, P King, “Buried alive,”Newsweek (Nov 27, 1989) 66-76. 3. W Rutala, R L Odette, G P Samsa, “Management of infectious waste by US hospitals,” Journal of American Medical Association 262 (Sept 22/29, 1989) 1635-1640. 4. Zbzii! 5. US Department of Health and Human Services, Centers for Disease Control, “Recommendations for prevention of HIV transmission in healthcare settings,” Morbriiifv and Mortalifv Weekly Report 36 (2s) (Aug 21, 1987) 3s-16s. 6. N Slavik, Report presented on the proceedings of the EPA infectious waste management meeting, Washington, DC, Nov 12, 1987; L Doucet, “Hospital infectious-wasteincinerationdilemmas,”Hospitals (July 5, 1989) 80. 7. Guide for Znfectious Waste Management, publ no 530-SW-86-014 (Washington,DC US Environmental Protection Agency, May 1986). 8. Oflice of Solid Waste and Emergency Response, Municipal Waste Combustion Study, Report to Congress, publ no. NTWPB87-206074 (Washington, DC US Environmental Protection Agency, June 1987). 9. US Department of Health and Human Services, Centers for Disease Control, “Recommendations for prevention of HIV transmission in health-care settings,” 3s-16s. 10. Infectious Diseases: A Modern Treatise of Znfectious Processes, P D Hoeprich, ed (Philadelphia: Harper & Row, 1983) 714-727. 11. 49 CFR 172.401 (1988) 12. Zbbid; Rutala, Odette, Samsa, “Management of infectious waste by US hospitals,” 1635-1640. 13. Rutala, Odette, Samsa, “Management of infectious waste by US hospitals,” 1635-1640. 14. Begley, King, “Buried alive,” 71. 15. “CHS to build infectious waste incinerator,”
Hospital Material Management 14 (June 1989) 4; Rutala, Odette, Samsa, “Management of infectious waste by US hospitals,” 1635-1640. Suggested reading Freeman, H M. Standard Handbook of Hazardous Waste Treatment and Disposal. New York: McCraw-Hill Publishing Co, 1989.