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Report of the Council on Scientific Affairs
Biohazardous Waste Management: What the Physician Needs to Know
Linda Cocchiarella, MD, MSc;
Scott D. Deitchman, MD, MPH;
Donald C. Young, MD;
for the Council on Scientific Affairs, American Medical Association
Arch Fam Med. 2000;9:26-29.
ABSTRACT
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Sources of biohazardous waste include not only large hospitals and laboratories, but also physicians' offices, dental offices, clinics, research facilities, surgery centers, veterinary offices, funeral homes, and a growing number of settings where home health care is delivered. State and local municipality definitions and regulations on biohazardous waste vary widely. Most regulations exempt home health care settings, but include physicians' offices. Although the infectious public health risk posed by medical waste is exceedingly low, this fact is not well understood by the general public. Physicians should develop biohazardous waste management programs that fulfill their county, state, and municipal regulations and that consider the difference between health risks to employees and risks to the general public. Physicians can considerably reduce the amount and costs of biohazardous waste disposal by proper identification and segregation of waste in a manner that meets their state's criteria. Using products that can be recycled may reduce the amount and costs of disposal of biohazardous waste. Processing costs also may be reduced by cooperative arrangements among medical groups or health care facilities to negotiate group disposal rates with vendors.
INTRODUCTION
The American Medical Association (AMA), Chicago, Ill, Council on Scientific Affairs reviewed the issue of proper disposal of infectious medical waste in its 1988 report,1 noting that if existing federal and state guidelines were adhered to and properly enforced, the public and environment would not be endangered by biohazardous medical waste.
Federal legislation, titled the Medical Waste Tracking Act (MWTA), was signed into law on November 1, 1988, in response to medical waste washing up along beaches.2 Although the news media identified the beach waste as mainly medical in origin, only 1% to 10% actually was medically related.3-4 Most of the syringes came from sources not covered by medical waste regulations, such as from homes or illegal use.4-5 Nevertheless, the public perceived medical facilities, particularly hospitals, as irresponsibly dumping biohazardous waste.
The MWTA was designed to monitor the disposal of biohazardous waste from medical facilities, hospitals, and physicians' offices and thereby prevent future mishaps. The MWTA required the Environmental Protection Agency (EPA), Washington, DC, to publish an interim rule for a 2-year demonstration medical waste management and tracking program. The act established a "cradle-to-grave" medical waste tracking program for 2 years that was implemented in 4 states and 1 US territory.2, 6 The program expired in June 1991, without being reauthorized by congress and is unlikely to be reinstituted. Despite its discontinuation, the EPA and other organizations evaluated this program. Since there was no federal definition or guidelines, 49 states developed their own definitions and programs to define, manage, and prevent health problems from biohazardous waste, based on the MWTA and program evaluations.2, 5-9
DEFINITIONS OF BIOHAZARDOUS WASTE
Although no federal mandate has been developed to define biohazardous waste, several federal agencies, including the EPA and the Centers for Disease Control and Prevention in Atlanta, Ga, have developed categories of biohazardous waste.2, 6, 10 Biohazardous waste has been referred to as medical waste, infectious waste, red bag waste, biomedical waste, and regulated medical waste. Most agencies and states assume that biohazardous waste is waste capable of transmitting infectious disease, and therefore includes materials sufficiently contaminated with blood or body fluids to transmit disease. In a physician's office, this would include supplies or disposable materials saturated with blood or body fluids. Physicians must contact the EPA in the state in which they practice to determine how their state defines biohazardous waste.
PRODUCTION OF BIOHAZARDOUS WASTE
Biohazardous waste is produced from a wide array of settings: hospitals and laboratories, physician offices, dental offices, clinics, research facilities, surgery centers, nursing homes, veterinary offices, funeral homes, and settings where home health care is delivered. Although some states have regulations pertaining to handling biohazardous waste from home health care settings, most biohazardous waste is disposed of with the setting's household trash. Biohazardous waste generated from home health care settings is regulated in some states at the municipal level.6-7
Definitions vary from state to state as to what qualifies as a small biohazardous waste producer. According to the EPA's hazardous waste rule developed from the MWTA, facilities that produce less than 50 lb/mo of regulated medical waste were not required to participate in the tracking or full transporter standards but were required to maintain records of waste generation and handling. Facilities generating more than 50 lb/mo were subject to full tracking and management standards.5, 11-12 State and local municipality definitions often vary considerably as to which settings qualify for exemptions. Most regulations exempt home health care settings but include physicians' offices.
Physicians are responsible for identifying their state's definition of biohazardous waste and required management policies. This information can usually be obtained from the state EPA office or the state medical society. The state EPA office can be reached by telephone (see local directories) or on the Internet (http://www.epa.gov/epahome/locate2.htm). State and county medical societies can be located on the Internet at http://www.ama-assn.org/mem-data/directry/statemed/statemed.htm. Once physicians determine how their state classifies biohazardous waste, they can estimate the number of pounds of biohazardous waste generated per month in their office and use this estimate to determine whether they are subject to state tracking regulations.
HEALTH IMPLICATIONS OF BIOHAZARDOUS WASTE
Evaluation of the health implications of biohazardous waste includes examination of the health risks of several different and overlapping populations, eg, health care employees, waste handling and treatment workers, and the general population. Occupational biohazards associated with patient care are regulated by the Occupational Health and Safety Administration, Washington, DC, through standards such as the Occupational Exposure to Bloodborne Pathogens Standard.2, 5 Health risks to health care workers during biohazardous waste management also may be minimized through adherence to universal precautions and the Bloodborne Pathogen Standard.13
Biohazardous waste poses an exceedingly low risk to the general public according to scientific reviews conducted by the Agency for Toxic Substances and Disease Registry, Atlanta, Ga, the Society for Healthcare Epidemiology of America, Mt Royal, NJ, the Centers for Disease Control and Prevention, and the Council on Scientific Affairs.1, 4-5,10, 14-15 The risk is low because of the unlikelihood of survival of the infectious agent in refuse environments and the low probability of a portal of entry for infectious organisms in a susceptible host.14, 16 In multiple studies, household waste has been found to contain more microorganisms with pathogenic potential for humans on average than medical waste.3, 6 There also is no evidence that a member of the public or a waste industry worker has ever acquired an infection from medical waste, although injuries have been reported.3, 15 The only medical waste that has been associated with infectious disease transmission is contaminated sharps (needles, scalpels, or lancets).3, 15
MANAGEMENT OF BIOHAZARDOUS WASTE
The EPA recommends, and many states require, that each site that produces medical waste establish an infectious waste management plan.6 Table 1 lists components of a biohazardous waste management protocol that physicians may develop for their practices.2, 6 Physicians also may prepare an educational information sheet for their patients on the safe disposal of syringes or biohazardous waste. Physicians in group practices may benefit by contacting the materials management division of their affiliated hospital for protocols on biohazardous waste management for larger organizations.
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Components of a Biohazardous Waste Management Protocol*
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Medical waste can be effectively treated by many chemical, physical, or biological modalities. Commonly used methods include autoclaving, incineration, chemical or microwave inactivation, and sanitary sewage treatment.2, 6, 9
COST ESTIMATES AND SAVINGS
Total solid waste generated per person per day in hospital facilities has been estimated to range from 10 to 24 lb.17 Of this amount, approximately 10% would be classified as infectious under EPA guidelines. The American Hospital Association, Chicago, Ill, has stated that costs for a comprehensive tracking program as proposed by the EPA are much greater than the EPA's estimate of an additional $0.08 per pound, ranging instead from $0.28 to $0.58 per pound.5 Cost estimates using the MWTA definition of biohazardous waste are estimated to be prohibitive3 since every item tinged with blood could be classified as biohazardous waste.
Hospitals have achieved considerable cost savings by implementing a comprehensive management plan, taught to all employees.15, 18-19 In an office setting, physicians need to educate their staff about—and document—a uniform definition of what constitutes biohazardous waste and appropriate segregation so that not all medical waste is considered biohazardous.
Physicians can ensure that only biohazardous waste is classified as such through appropriate segregation practices in their office. This requires separate waste segregation for sharps, a solid waste container in each examination room to capture waste not saturated with blood or contaminated with suspected infectious agents (eg, paper towels, packaging, tongue depressors), and a small container for biohazardous waste saturated with blood or other body fluids or from patients with infectious diseases. Using products that can be recycled may also decrease disposal costs.
Although not biohazardous waste, segregation and proper disposal of waste containing mercury (in sphygmomanometers and thermometers) or cadmium (from batteries) also prevents environmental contamination.
In surgical settings, recycling and converting from disposable medical supplies to reusable equivalents for items such as linens has produced cost savings.18 The EPA has compiled information sheets for the public for disposing of biohazardous waste in home health care settings.2, 6
One cost-effective strategy is for physicians in ambulatory settings to discuss the policy for biohazardous waste management with hospital personnel where they hold privileges and consider the possibility of joint processing. Physicians may be able to make an arrangement with their admitting hospital to accept a limited amount of biohazardous waste, such as needles and other medical sharps. Physicians need to have a biohazardous waste management plan as they may be held accountable if the waste is discovered any place where the public could be endangered.12 Although the cost of waste management cannot be directly billed for, the costs associated with proper waste management may in many cases be incorporated into business overhead.
CONCLUSIONS
The general public perceives that biohazardous waste from medical facilities poses a considerable risk to public and environmental health, despite the lack of evidence of notable public health problems.16 The problem of potentially biohazardous waste contaminating the environment is not mainly from hospitals but primarily due to improper disposal from homes and illegal settings.3, 16 Unless biohazardous waste control from these sources is achieved, future incidents will occur, and public outrage will continue. Medical personnel and institutions are likely to be held accountable. Physicians need to educate their staff, patients, and the public about the origins, attributable risks, and handling of biohazardous waste. By exemplary management of their own biohazardous waste, physicians can set an example for the public. The expense of biohazardous waste management can be reduced by ensuring that only regulated biohazardous waste is processed as such, and by forming alliances with other medical groups or health care facilities to negotiate group disposal rates with vendors.
RECOMMENDATIONS
The following statements, recommended by the Council on Scientific Affairs, were adopted as AMA policy in December 1997. (1) The AMA encourages the EPA to explore the feasibility of establishing a national definition of biohazardous waste, emphasizing the origins and relative importance of waste that can plausibly transmit infection compared with waste that cannot. (2) The AMA encourages the EPA to monitor the sources of medical waste in environmental settings and develop guidelines applicable to all waste generators, including home health care sites, to reduce these sources of environmental pollution. (3) The AMA will work with appropriate governmental agencies and medical societies to educate physicians about the management of biohazardous waste and advocates that these groups work collectively to attain cost savings in biohazardous waste management. (4) The AMA urges practicing physicians to develop a biohazardous waste management program that fulfills their county, state, and municipal regulations, and that considers the different health risks to employees and the general public.
AUTHOR INFORMATION
Accepted for publication May 5, 1999.
Reprints: Barry D. Dickinson, PhD, Secretary to the Council on Scientific Affairs, American Medical Association, 515 N State St, Chicago, IL 60610 (e-mail: barry_dickinson{at}ama-assn.org).
Council on Scientific Affairs
Members and staff of the Council on Scientific Affairs (CSA) at the time this report was prepared: Ronald M. Davis, MD, Detroit, Mich (CSA Chair); Joseph A. Riggs, MD, Haddon Field, NJ (CSA Chair-Elect); Roy D. Altman, MD, Miami, Fla; Hunter C. Champion, New Orleans, La; Scott D. Deitchman, MD, MPH, Decatur, Ga; Myron Genel, MD, New Haven, Conn; John P. Howe III, MD, San Antonio, Tex; Mitchell S. Karlan, MD, Los Angeles, Calif; Mohamed Khaleem Khan, MD, PhD, Boston, Mass; Nancy H. Nielsen, MD, PhD, Buffalo, NY; Michael A. Williams, MD, Baltimore, Md; Donald C. Young, MD, Iowa City, Iowa. Staff: Linda Cocchiarella, MD; Linda B. Bresolin, PhD (CSA Secretary); Barry D. Dickinson, PhD (CSA Assistant Secretary), Chicago, Ill.
A complete list of the members and staff of the Council on Scientific Affairs at the time this report was prepared appears below.
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