# Presentation: 214579

## Medical Waste Management in the Bioterrorism Era

- Lynne Sehulster, PhD, M(ASCP)
- Division of Healthcare Quality Promotion
- Centers for Disease Control and Prevention, Atlanta  GA

## Objectives

- After today’s “conversation,” listeners will:
-  Know the general categories of regulated medical waste;
-  Be aware of regulations in their state that address medical waste management;
-  See how the recent influenza A (H2N2) episode revealed weaknesses in current waste management strategies; and
- Understand the importance of on-site treatment in a bioterrorism era

## CDC Guidance on Regulated Medical Waste

- CDC Guidelines for Environmental Infection Control in Health-Care Facilities
- Full text version December 2003:  http://www.cdc.gov/ncidod/hip/enviro/guide.htm
- Topics include categories of medical waste, treatment, disposal, discharge of blood to sanitary sewers, CJD issues, and issues relating to on-site decontamination

## Epidemiology of Medical Waste

- Syringes on the beach and the AIDS era...
- No evidence that traditional medical waste treatment and management processes have contributed to increased levels of disease in the community and/or healthcare workers
- Occupational injuries sustained during care delivery (i.e., needlesticks) are excluded unless the item is already discarded

## General Categories of Medical Waste

- Identify wastes that represent a sufficient potential risk of infection during handling and disposal and for which some precautions appear prudent
- Microbiology laboratory waste; pathology and anatomy waste; blood, blood products, and other body substances; sharps
- States may designate additional categories (e.g., animal wastes)

## Basic Components of Medical Waste Management

- Discard at point-of-use
- Collection and consolidation within the facility
- (Containment and packaging)
- (Transport to treatment location)
- Treatment or decontamination
- Transport to disposal site
- Discharge to solid waste landfill

## Medical Waste Management is Heavily Regulated!

- Federal government agencies:
- OSHA
- DoT
- EPA
- CDC (guidance but not regulatory)
- State government agencies:
- Health department
- Environmental protection department

## State Medical Waste Regulations

-  State medical waste regulations address:
- Categories of medical waste
- Treatment or decontamination of these wastes
- Consolidation, packaging, and storage on-site
- Transport and disposal
- Treatment centers vs. on-site

## Where Can I Find My State’s Medical Waste Regulations?

- EPA has a link to all the state regulatory web pages:
- http://www.epa.gov/epaoswer/osw/stateweb.htm
- EPA also links to other Federal government agencies’ web pages:
- http://www.epa.gov/epaoswer/other/medical/#state

## Treatment of Medical Waste

- Method of treatment
- Traditional – autoclaving, incineration
- Chemical immersion
- Alternative treatment technologies
- Use conditions
- Treatment site
- On-site vs. off-site
- Off-site locations necessitate transport of untreated waste

## What Happened?!?

- Facilities outsourced medical waste management to third party waste management firms
- Regional medical waste treatment centers
- Decommissioned decontamination autoclaves
- Labs used disposable items and pre-sterilized supplies and reagents
- Incinerators deactivated – emissions

## Cluster of Mycobacterial Infections Associated with Medical Waste Treatment

- May – September 1997:  3 cases of TB among workers at a regional medical waste treatment facility in Washington state
- Grinding/shedding, “electrothermal deactivation” (radiofrequency oven)
- Workers who became infected worked with the waste prior to the electrothermal deactivation step

## Environmental/Occupational Investigation

- Safety flap in the in-feed chute missing: “blowback phenomenon”
- No decon procedures when leaving the processing area; confusion about use of protective clothing, inconsistent use
- No reporting of occupational injuries
- Airline respirators inadequate (NIOSH)
- No respiratory protection during spills

## Microbiological Aspects

- PFGE-matching of one worker’s TB isolate to that of a patient
- Lab did not decontaminate the TB culture before sending it off-site for medical waste processing

## Microbiological Aspects

- 45% of worker contacts of the 3 case-workers were skin-test positive; no household transmission, no community transmission
- 49% of WA laboratories ship viable MTB cultures to medical waste disposal facilities

## Decontamination of Amplified Cultures and Stocks

- Historically was done in the microbiological laboratory via steam autoclaving or on-site via incineration
- Phased out as other “clean” needs for autoclaving disappeared from the labs
- Release of “live” material from lab custody in these situations is not considered ethical
- Transport of “live” material on your highways

## Decontamination of Amplified Cultures and Stocks

- Inappropriate method for decontamination (e.g., never use an aerosol-generating method when airborne pathogens are present)
- Aerosol containment devices and procedures failed during operation at the WA facility
- First instance of infections due to medical waste handling

## Influenza A (H2N2) in 2005

- CDC advises hospitals to destroy virus via autoclaving or incineration
- Many hospitals attempt to use the clean autoclaves in central sterile prep. dept.
- Labs attempt chemical decontamination
- Incorrect assumptions at work:
- Pandemic strain must be more difficult to inactivate
- Any sterilizer is suitable to use

## Weaknesses in Medical Waste Management Processes

- Labs lack the capacity to do decon on-site
- Lack of awareness of key information:
- State regulatory process and recommended decon methods
- Transport and chain of custody issues
- EPA registered chemicals for medical waste treatment (List G) http://www.epa.gov/oppad001/chemregindex.htm
- Autoclave operations
- Infectious waste is not hazardous waste

## Disposal of Agents of Bioterrorism

- Prepare in anticipation that your lab will be asked to culture and identify a BT agent
- How will facilities that lack decon capacity now be able to treat / dispose BT agents?
- What is your state’s plan for management of discarded BT agent cultures, etc.?
- Laboratory Response Network (LRN)
- Release untreated materials to third party waste management?

## Restore the Capacity of In-Laboratory Decontamination of Stocks and Cultures

- AIA construction guideline, 2001 (7.12.G)
- CDC’s EIC guideline (Category II), 2003
- CDC’s Select Agent Rule, 2003
- ASM / American Academy of Microbiology endorsement, 2001
- Bioterrorism concerns
- Influenza A (H2N2) episode, 2005

## Thank You!