Hospitals, clinics, nursing homes, laboratories, doctors' and veterinarians' offices, private households-and many other places-have to dispose of materials that have been used in medical care or treatment. Some of this material is infectious-that is, it has the potential to cause some kind of infection and/or disease. Examples of medical wastes are used "sharps"-hypodermic needles and syringes, IV needles, scalpel blades, and glass items; items containing or soaked with blood or certain other body fluids; human or animal organs or body parts; lab cultures that may contain disease-causing agents; and things like gloves, bedding, dressings, sponges, and other items that have been used in surgery, autopsy, or treatment of patients with certain contagious diseases.
It is possible for medical waste to cause infection and/or disease if it enters the body through broken skin or puncture wounds; if it splashes into the eyes, nose, or mouth; if it is inhaled; or if it is swallowed.
Medical waste may be dangerous for other reasons besides the risk of disease-for example, sharps can cause cuts. Some of the material disposed of by hospitals and other health care facilities may be hazardous for other reasons. It may contain hazardous chemicals, or low-level radioactive wastes. If the medical waste contains hazardous waste or radioactive waste, it cannot go to solid waste landfills.
On the other hand, not all waste created at such facilities is dangerous. Hospitals contain offices and cafeterias that create waste that is not dangerous, and much of the waste generated by patient care poses no threat at all to landfill workers. Even materials that have been classified as medical waste will not always cause disease-they merely pose a risk that must always be considered in handling, storage, transportation and disposal.
This information will outline current practices for disposing medical waste, partially summarize the regulations covering medical waste disposal, explain the specific and general risks that medical waste may pose to you in your job, and suggest ways you can protect yourself from those risks.
The required disposal methods for medical waste depend on the type of waste and on the nature of the facility that created it.
Medical waste disposal by health care facilities and households is subject to regulation at the state level by the Louisiana Department of Health and Hospitals (DHH) and the Louisiana Department of Environmental Quality (DEQ). In addition, all employers except state and local governments are required to dispose medical wastes according to regulations of the federal government's Occupational Safety and Health Administration (OSHA). These agencies' rules (which are summarized in more detail later) are similar. They require that "sharps" (needles and syringes, scalpel blades, etc.) should be placed in closed, leakproof containers (though these do not have to be puncture-resistant). This type of container must be labeled or color-coded as containing medical waste.
Red or orange are the colors used on containers to indicate that they contain medical waste. Typically, hospitals use hard red plastic containers for "sharps," and red trash bags for other medical waste, however, other colors could be used and it is important to look at the labeling or identification on the container. Another indicator of the presence of medical waste, which may be used instead of or in addition to the red or orange color code, is the "BIOHAZARD" symbol.
Medical waste from health care facilities must be treated in a way that destroys its potential for causing disease, prior to disposing it in a landfill. Acceptable treatment methods may include incineration, steam sterilization (or autoclaving), and chemical disinfection. Waste that has been treated, but that is still recognizable as medical waste (for example, waste that has been autoclaved which is still in a red bag or sharps container), must be labeled with the name of the facility that generated it, the type of treatment method used, and the name or initials of the person in charge of treatment.
Many landfills in Louisiana do not accept medical waste from health care facilities unless it has been incinerated. Incinerated waste would not be recognized as medical waste. Therefore, as a general rule, if you encounter any red bags, red sharps containers, or packaging marked with the biohazard symbol, in waste that is sent to your landfill, you should notify your supervisor before handling them in any way.
Not all medical wastes are covered by regulations that require this kind of labeling and treatment. The most obvious example is waste generated by private households. Many diabetics, allergy suffers, dialysis patients, and other people who receive medical care at home (not to mention users of illegal intravenous drugs) have to dispose needles and syringes and other medical wastes. Rules promulgated by the Louisiana Department of Health and Hospitals require households to package their medical wastes in tightly closed, wrapped containers before discarding them in household garbage. However, these regulations frequently violated. Therefore, medical wastes will be mixed with ordinary trash, and you may encounter it in connection with your work.
In Louisiana, there are three (3) sources of regulations for medical wastes: OSHA, the Louisiana Department of Health and Hospitals, and the Louisiana Department of Environmental Quality.
Summary of OSHA Regulations
The following is a partial summary of OSHA regulations regarding occupational exposure to bloodborne pathogens, 29 C.F.R. Part 1910.1030. If your employer is covered by OSHA, it must make a copy of the complete regulations and an explanation of their contents accessible to you. In Louisiana, these regulation apply to all private employers and to federal civilian employers. If the employer has any employees who can be reasonably anticipated to be exposed to infectious material, it must follow these OSHA regulations. According to OSHA's written enforcement procedures (OSHA Instruction CPL 2-2.44C, March 6, 1992), employees who handle medical waste are considered to have occupational exposure. In general, the rules require employers to develop exposure control plans, to adopt engineering controls and work practices that minimize exposures, to provide handwashing facilities and personal protective equipment, to provide training to workers, to provide hepatitis B vaccines free of charge, to provide medical evaluation and follow-up to exposed workers, and to keep medical and training records.
Under the OSHA rule, exposure means skin, eye, mucous membrane (mouth and nasal) contact with blood or other potentially infectious materials. Blood means human blood, blood products, or blood components. Other potentially infectious materials include all body fluids in situations where it is difficult or impossible to differentiate between body fluids.
Exposure Control Plan Covered employers must prepare an "Exposure Control Plan." This plan must contain separate lists of job classifications where some or all of the employees may be exposed and a list of job tasks and procedures in which exposure may occur (whether or not personal protective equipment is used). The Exposure Control Plan must also contain a timetable for implementing various provisions of the regulations and a description of the procedure that will be followed if an exposure occurs. The plan must be made accessible to all employees.
Methods of Compliance Section (d) of 1910.1030 specifies the procedures that must be followed by all employers to comply with the regulation. "Universal precautions," an approach to infection control that assumes that all blood and certain body fluids are infectious for HIV (Human Immunodeficiency Virus which leads to AIDS), HBV (Hepatitis B Virus), and other bloodborne pathogens, must be followed. If the circumstances are such that different body fluids cannot be distinguished from each other, all should be treated as potentially infectious.
Employers are required to employ "engineering and workplace controls" wherever possible to minimize or eliminate employee exposure. Engineering controls either remove the hazard or isolate the worker from exposure. An example of an engineering control is the use of a ventilated cab on earth-moving equipment to protect workers from dust and aerosols. Workplace controls alter the manner in which tasks are performed to reduce exposure-for example, always cleaning equipment with implements or with high-pressure hoses, rather than by hand. Employers are required to examine, maintain, and replace engineering controls on a regular basis to insure their effectiveness.
Personal Protective Equipment Appropriate personal protective equipment must be used to reduce risk of worker exposure. Employers must make readily available at no cost to employees appropriate specialized clothing or equipment to protect against exposure to blood and other potentially infectious materials. Personal protective equipment must prevent such materials from passing through to an employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time that the equipment is in use.
Personal protective equipment consists of, but is not limited to, gloves, face shields, masks, and eye protection, gowns, aprons, and similar items. Employers must ensure that appropriate personal protective equipment is used and used correctly. Employers must also see to it that personal protective equipment is properly cleaned, laundered, repaired, replaced, or disposed as needed, at no cost to the employee.
The employer must ensure that employees observe precautions for handling and using personal protective equipment, including:
Handwashing and Hygiene Employers must provide handwashing facilities that are readily accessible to all employees. When this is not feasible, they must provide antiseptic towelettes. Employers must ensure that employees wash their hands as soon as possible after removing gloves and other personal protective equipment, or after contact with potentially infectious material.
Disposal Methods for Medical Waste at Health Care Facilities The rules provide requirements for handling contaminated sharps, including a requirement that they be placed in a closed, puncture-resistant, leakproof, color-coded (or biohazard-labeled) containers prior to disposal. If the container can leak, it must be placed in a second closed, leakproof container.
Blood and other potentially infectious material (other than sharps) must be placed in leakproof, color-coded (or biohazard-labeled) container before it leaves the facility. If outside contamination occurs, or if the container is punctured, it must be placed in another leakproof, labeled or color-coded container.
Disposal of medical wastes must be in accordance with all applicable federal, state, and local regulations.
Training All persons with a potential for exposure must be provided with adequate training and information including general explanation of the modes of transmission, symptoms, epidemiology, warning signals relating to possible exposure, and procedures to follow if exposure occurs.
Hepatitis B Vaccine Covered employers must make available, free of charge, and at a reasonable time and place, the hepatitis B vaccine and vaccination series to all employees who are at risk of occupational exposure. Employees may decline either antibody pre-screening or vaccination; if they decline vaccination, they must sign a declination form.
If an Exposure Incident Occurs Employees should immediately report exposure incidents. The employer is responsible for establishing the procedure for evaluating exposure incidents.
Recordkeeping The employer must keep medical records and records of training sessions. Medical records must be kept confidential (though an employee and his or her representative may see and copy his own record on request) and must be maintained for thirty (30) years after employment has ended.
Training records, including the dates, content, names and qualifications of trainers, and names and job titles of trainees, must be kept for three (3) years.
Summary of Louisiana Department of Health and Hospitals Regulations
This agency has regulations governing the packaging, labeling, storage, transportation, and treatment of medical waste, contained in the Louisiana Sanitary Code, Part XXVII.
Definitions and Exclusions - The regulations define several categories-medical waste, infectious biomedical waste, and potentially infectious biomedical waste. The latter is used most extensively throughout the regulations, and is defined, in pertinent part, as follows:
"...waste considered likely to be infectious by virtue of what it is or how it may have been generated in the context of health care or health care like activities."
"Potentially Infectious Biomedical Waste" includes, but is not limited to the following:
Eating utensils, animal carcasses and bedding, and "very small quantities" (less than 250 grams or 1/2 pound) of human or animal tissue, clean dressings, and clean surgical wastes from persons or animals not known to be infected, are excluded from the definition of potentially infectious biomedical waste. The last two categories of material must be disposed in tightly closed plastic bags or other impervious containers.
Animal carcasses and tissues and wastes from large animals must be disposed either as potentially infectious biomedical waste, or according to regulations of the Livestock Sanitary Board. Carcasses, tissue, and wastes of pets may be buried, rendered [cooked at a minimum temperature of 250 degrees Fahrenheit for at least thirty (30) minutes], incinerated, or disposed either in accordance with these regulations or on the order of a licensed veterinarian.
Packaging and Labeling - Potentially infectious biomedical waste (i.e., medical waste) must be packaged in a manner that prevents exposure to the material. Liquids must be in a sturdy, leak-resistant container. Sharps must be in a closed, rigid, break-resistant, puncture-resistant container. Plastic bags and other containers must be clearly labeled, impervious to moisture, strong enough to prevent tearing or bursting under normal conditions, and closed prior to transport. A second level of containment is necessary if the material is to be stored prior to transport.
All containers of potentially infectious biomedical waste must be labeled "Potentially Infectious Biomedical Waste," "Medical Waste," or "Infectious Waste." Untreated waste must bear the name and address of the generator or transporter when it leaves the generator's premises. Treated waste that is still recognizable must carry a supplemental label to specify the treatment method used, the date of treatment, and the name or initials of the person responsible for treatment. All labels must be clearly visible and legible, and must be water resistant. Note: There are no requirements in the DHH Regulations that state that the bags, boxes, containers, etc., be a certain color.
Storage and Transport - Potentially infectious medical wastes must be stored in a secure manner. Compactors shall not be used for storage. Except for small quantities (defined as a single package containing less than 11 pounds of waste other than sharps or less than 2.2 pounds of sharps), wastes can be transported off the site where they were generated only by transporters permitted by the State Health Officer.
Small quantity generators, including doctors', dentists', and veterinarians' offices and private households, may transport small quantities of properly packaged and labeled wastes to approved large quantity generators, permitted storage facilities, or permitted treatment facilities without meeting the requirements for transport and treatment that large quantity generators must meet.
Transportation of potentially infectious waste (except by small quantity generators, as described above) is governed by Part XXVII.Chapter 7 of the regulations. This section contains provisions for transporter permits; written contracts between generators and transporters; vehicles used in transportation; transporter operation plans (including worker safety and decontamination provisions), and delivery of potentially infectious biomedical waste only to properly permitted facilities.
Special Rules Applicable to Households and Other Small-quantity, Non-healthcare Facilities - Households and other small-quantity, non-healthcare facilities may dispose their waste in the ordinary trash. The waste must be packaged to assure that there will be no leakage, even if the original package is violated (generally, this means double bagging, or placing sharps containers in a second rigid disposal container). Sharps must either be encased in plaster or in another substance as approved by the State Health Officer, or placed in a sharps container of standard manufacture or other similar container of a type approved by the State Health Officer. This sharps container should then be placed in another bag or other rigid container containing a greater volume of non-infectious waste. Note: No labels or symbols are required on these containers.
Treatment and Disposal - Acceptable treatment methods for potentially infectious biomedical waste are set forth in Part XXVII.Chapter 11 of the regulations. These include incineration; steam sterilization [generally, autoclaving at least 248 degrees Fahrenheit (120 degrees C.) and a minimum pressure of 15 psi for a minimum of 30 minutes, or longer if necessary]; disposal of liquids into a sanitary sewer system that meets the requirements of Part XIII of the Sanitary Code; thermal inactivation [dry heat of at least 320 degrees F. (160 C.) at atmospheric pressure for at least 2 hours, excluding lag time]; chemical disinfection (use of chemical agents that have been approved by the State Health Officer); and irradiation (only with the written approval of the State Health Officer).
Sharps must be incinerated, encased in plaster or other approved substances in a tightly closed container, or treated in some other manner that renders them unrecognizable as medical sharps and practically precludes the release of recognizable needles and syringes if compacted.
Once treated, potentially infectious biomedical waste may be disposed in a permitted sanitary landfill in accordance with the Solid Waste Regulations of the Department of Environmental Quality. As noted above, treated and still recognizable medical waste must carry a supplemental label specifying the treatment method and date, and the name or initials of the person responsible for treatment.
On-site Storage and Treatment - Generators may store and treat their own potentially infectious biomedical wastes, if they obtain a proper permit and comply with substantive provisions of the regulations as to packaging, labeling, storage, transportation, and treatment.
Enforcement - These regulations are enforced by the Office of Public Health.
Summary of Louisiana Department of Environmental Quality Regulations
Currently, the Solid Waste Regulations, Louisiana Administrative Code Title 33, Part VII, Chapter 7, paragraph 711.D.1.e, deals with medical wastes. The regulation states that infectious waste from hospitals or clinics may be deposited in Type I or II landfills if it has been properly packaged and identified and is treated by a method approved by the Department of Health and Hospitals. Infectious waste is defined as follows:
"waste that contains pathogens of sufficient virulence and quantity that exposure to it could result in an infectious disease in a susceptible host."
The La. R.S. 30:2180 D., authorizes the Department of Environmental Quality to promulgate rules and regulations for the transportation, incineration, and disposal of medical waste.
The concern created by medical waste is that it can cause infection and/or disease. In order for this to happen, several things must occur. First, infectious agents (for example, viruses) must be present in the waste. It is important to keep in mind that certain types of materials are classified as medical waste because they might cause disease. Blood, for example, is considered infectious because it might contain viruses. Any given sample of blood or blood-soaked material may, in fact, be harmless.
Not only must infectious agents be present in the waste for it to cause disease-they must also survive in the waste in large enough quantities to be able to cause infection if an exposure occurs. The hepatitis B virus (or "HBV"), for example, is usually present in the blood of persons infected with hepatitis B in higher quantities than the AIDS virus (or "HIV") is in persons infected with HIV. For this reason, it is much easier to contract hepatitis than AIDS from exposure to infected blood. Further, HIV normally does not survive for very long outside a living organism. Therefore, the chance of contracting AIDS from contact with medical waste outside a health care setting is considered to be remote by the Agency for Toxic Substance and Disease Registry of the Public Health Service.
Second, an exposure has to occur in a manner that will be effective in transmitting the disease. There are four basic ways that a person can be exposed to infections: through the skin; through mucous membranes in the eyes, nose, and mouth; by inhaling infectious agents; and by swallowing them. Not all of these "routes" of infection will actually transmit a given disease. For example, AIDS can only be transmitted by sexual contact; by contact with the blood of an infected person on mucous membranes, broken skin, or through needle sticks; or from a pregnant woman to her fetus. It cannot be transmitted by inhalation or by touching an infected person.
Finally, in order for the exposure to cause disease, enough of the infectious agent must be transmitted to the person who is exposed so that his immune system cannot effectively protect him or her from the disease. Even if the waste does contain a large enough concentration of a disease-causing agent, and exposure does occur in a way that could transmit the disease, disease may or may not develop. For example, AIDS can be transmitted through being stuck by a needle that contains the blood of an HIV-infected person. However, the chance of contracting AIDS from a single needle stick, even if the needle does contain HIV-infected blood, has been estimated by the Centers for Disease Control to be only approximately 0.4%, or 1 in 250. The chances of becoming infected with hepatitis B from a single needle-stick, even if the needle contains blood of an infected person, is between 6 and 30 percent. A person's chances of not contracting the disease from an exposure are usually better if he or she receives prompt medical attention.
The risk to landfill workers from medical waste that has caused the most public health concern is that of contracting hepatitis B or AIDS from needle-sticks or from infected blood or blood-containing fluids being splashed or rubbed into open wounds, non-intact skin, or mucous membranes.
Some of the other diseases that could be transmitted through both medical waste and ordinary household waste include the common cold, "pink-eye" (bacterial conjunctivitis), chicken pox, and flu-all of which can be transmitted by mucous membrane exposure, inhalation of airborne particles from soiled articles, or inadvertent swallowing of particles after handling soiled articles. Bacterial infections are less common communicable diseases that can potentially be transmitted through cuts or abraded skin, following handling of contaminated articles.
Drawing together information from a variety of sources, the Agency for Toxic Substances and Disease Registry (a division of the United States Public Health Service, or ATSDR), has attempted to quantify the risk of disease caused by medical waste to workers. One of the categories of workers for which these risks were examined was "refuse workers"-workers involved in waste collection and disposal. This category includes landfill operators. The only diseases for which enough data were available were hepatitis B and AIDS.
AIDS can be transmitted in three ways-through exposure to infected blood or blood products (for example, through a needle stick injury), through sexual contact, or from a pregnant woman to her fetus. At writing, there have been no documented cases of transmission of AIDS through contact with contaminated surfaces or dried blood. The virus that causes AIDS dies rapidly in normal environmental conditions outside a living host, making transmission outside the health care setting unlikely. As of the date of the ATSDR study, there had been no cases of HIV infection from medical waste reported in the scientific literature.
Contaminated sharps, like used hypodermic needles, create the greatest concern for AIDS transmission. However, the ATSDR study estimated that, out of approximately 200,000 refuse workers in the U. S., less than 1 case of HIV infection per year is expected to result from injury from discarded sharps.
Hepatitis B is a viral infection that causes acute and chronic hepatitis, cirrhosis, and liver cancer. Symptoms include combinations of anorexia, nausea, vomiting, abdominal pain, and jaundice.
Hepatitis B virus (HBV) is transmissible in the same ways as the AIDS virus. As with AIDS, the greatest risk is from being cut or stuck by a contaminated sharp. However, since HBV is much more concentrated in infected blood than the AIDS virus (HIV) is, and since it is able to survive in the environment for a longer period of time (up to 7 days at 77 degrees Fahrenheit and 42% relative humidity)-HBV is more likely than the AIDS virus to be transmitted by medical waste. The ATSDR still concludes, however, that transmission of HBV outside a health care setting is a remote possibility.
In another study, dealing with a health care setting, the federal Centers for Disease Control has estimated that 12,000 health care workers whose jobs entail exposure to blood become infected with hepatitis B each year, that 500-600 of them are hospitalized as a result of that infection, and that 700-1,200 of those infected become carriers. Of the health care workers infected with hepatitis, about 250 can be expected to die of hepatitis, cirrhosis of the liver, or liver cancer.
However, landfill workers as a group face much lower risks of becoming infected than health care workers do. The ATSDR study estimated that in the 200,000 refuse workers nationwide, medical waste injuries from discarded sharps can be expected to cause only between 1 and 15 cases of hepatitis B infection per year.
Your risk of being infected by medical waste can be reduced to a very low level if you obtain proper preventative medical care, follow safe work practices, report any exposures promptly, and obtain medical care and counseling if exposure does occur.
Preventative Medical Care
A safe and effective vaccine is available for hepatitis B. According to the federal Centers for Disease Control, the vaccine provides 80-95% protection against hepatitis B. (It can also help prevent infection if it is administered immediately after exposure to the HBV virus.) It consists of a series of three (3) injections, usually in the arm, the second given one (1) month from the first, and the third given six (6) months after the initial dose. All employers covered by OSHA regulations must make this vaccine available free of charge to workers who have occupational exposure to blood or other potentially infectious material. In Louisiana, state and local government employees are not covered by OSHA; however, your employer may provide this as a service to employees. Other immunizations that may be appropriate are the tetanus vaccine and immune globulin ("gamma globulin"). You should consult a physician about whether or not to have these immunizations.
Safe Work Practices
Report All Exposures Immediately
If you are exposed to infectious waste-including any time that you are stabbed by a hypodermic needle or other sharp, or any time that blood or other body fluid in waste comes into contact with a place where you have an open wound; non-intact skin, or mucous membrane (eyes, nose, or mouth)-report the exposure to your supervisor immediately, and try to make sure that the incident is recorded. Wash the exposed area thoroughly with soap and water, and apply a disinfectant such as alcohol or hydrogen peroxide. Your employer may be able to trace the waste, which may make it possible to determine how likely it is that the waste came from an infected individual (if your employer is covered by OSHA, he must attempt to locate the source individual, and attempt to obtain his or her consent to an HBV and HIV test). Further, receiving prompt medical attention following exposure can be very important for your own health.
Medical Care and Counseling after Exposure
You should receive prompt, confidential medical attention following an exposure. If your employer is covered by OSHA, this follow-up care and all necessary tests must be provided to you free of charge.
With proper preventative care, safe work practices, prompt reporting of exposures, and post-exposure medical attention and follow-up, there is little likelihood that medical waste will harm you on the job.