Finding the Rx for Managing Medical Wastes

October 1990

OTA-O-459

NTIS order #PB91-106203
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Finding the Rx for Managing Medical

Wastes, OTA-O-459 (Washington, DC: U.S. Government Printing Office, September 1990).

For sale by the Superintendent of Documents

U.S. Government Printing Office, Washington, DC 20402-9325

(Order form can be found in the back of this report.)
Foreword

The adequate management of medical wastes first became a major focus of public

attention when medical wastes with other debris washed ashore on the East Coast in the

summer of 1988. In October of that year, as part of OTA’s assessment of municipal solid waste

management, OTA issued a background paper entitled Issues in Medical Waste Management.

That study provided an overview of medical waste disposal practices and potential risks

associated with them, and discussed the need for further Federal involvement in managing

medical wastes.

Also in October of 1988, Congress passed the Medical Waste Tracking Act, establishing

a 2-year demonstration tracking program for medical waste management and directing the

Environmental Protection Agency and the Agency for Toxic Substances and Disease Registry

to complete several studies to evaluate management issues and potential risks related to

medical waste disposal.

Some studies by these and other government agencies, and by private-sector interests,

have been completed since that time on various aspects of medical waste management issues.

The focus of concern has shifted primarily to the adequacy of handling, treatment, and disposal

practices for medical wastes. Public concern remains high and much of the confusion and

inconsistency associated with medical waste policy persists.

This OTA report was requested by the House Committee on Science, Space, and

Technology, the House Subcommittee on Transportation and Hazardous Materials, Committee on Energy and Commerce, and the House Subcommittee on Regulation, Business

Opportunities and Energy, Committee on Small Business. The report evaluates medical waste

issues in the broader context of a waste management policy for the Nation. Waste reduction

and recycling options for medical waste management, as well as incineration and

non-incineration treatment alternatives are examined.

Applying a more comprehensive waste management approach to medical wastes, such

as has evolved for municipal solid waste and hazardous waste, could help ensure

environmentally sound and economically feasible waste practices. At a minimum, we realize

that (as with most waste problems) there is no one management scenario to “solve” our

medical waste problems; rather the most important task is to devise policies that will facilitate

adoption of individually optimal solutions to specific problems.

OTA benefited from the assistance received from many organizations and individuals

during the course of this study. We express our gratitude and thanks to the review panel and

the many other reviewers for their input which greatly facilitated the preparation of the report.

OTA, however, is solely responsible for the contents of this report.
Review Panel and Medical Waste Workshop Participants for

Finding the Rx for Managing Medical Waste

Barry Rabe, Chairman

School of Public Health

University of Michigan

Richard Bernstein

General Medical Corp.

Leland Cooley

Radiation Safety/Biosafety Office

University of Maryland at Baltimore

Frank Cross

Cross/Tessitore & Associates, P.A.

John Cusack

Asea, Brown & Boveri

Janet Emmerman

Waste Management, Inc., Medical Services

Roger Etter

John Zink Co.

Martin S. Favero

Centers for Disease Control

Randell Forshey

San-i-pak Pacific, Inc.

Barbara Fry

State of California

Air Resources Board

Allen Hershkowitz

Natural Resources Defense Council

Ode Keil

Joint Commission on Accreditation

of Healthcare Organizations

Janis Kurth

Metropolitan Hospital

Jenny Lezak

Health Organization to Protect Our Environment

Daniel Liberman

Massachusetts Institute of Technology

Thomas J. Murphy

Thomas J. Murphy Associates

Edward Norman

State of North Carolina Health Department

Claude D. Rounds

Albany Medical Center

James Sharp

Stericycle

Robert Spurgin, OTA Contractor

Spurgin & Associates

Martha Trusler

Methodist Health Systems

Wayne Turnberg

Department of Ecology

State of Washington

Michelle Wilson

U.S. Environmental Protection Agency

NOTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the workshop participants,

advisory panel members, and reviewers. These participants do not, however, necessarily approve, disapprove, or endorse this

special report. OTA assumes full responsibility for the special report and the accuracy of its contents.

iv
OTA Medical Waste Management

John Andelin, Assistant Director,

Project Staff

OTA

Science, Information, and Natural Resources Division

Robert Niblock, Oceans and Environment Program Manager

Kathryn Wagner, Project Director

Contractors

Robert Guttman, Esq.

Robert Spurgin, Spurgin & Associates

Administrative Staff

Kathleen Beil Sally Van Aller
Reviewers and Contributors

Robert Ashworth

Browning-Ferris Industries

Charlotte Baker

University of California

Robert G. Barton

Energy & Environmental Research Corp.

John N. Basic, Sr.

Basic Environmental Engineering

William F. Bina

Naval Medical Command

Jack D. Brady

Anderson 2000, Inc.

Theodore G. Brna

U.S. Environmental Protection Agency

Joy Buck

City Hospital, Inc.

Robert E. Campbell

Johnson & Johnson

Sherry Clay

Texas Department of Health

Peter S. Daley

Chemical Waste Management, Inc.

Milton Dezube

American Hospital Association

Henry L. Diamond, Esq.

Beveridge & Diamond, P.C.

Lawrence Doucet

Doucet & Mainka

Dennis Downing

Cornell University

Al Dozier

Advanced Concepts, Inc.

Kenneth L. DuFour

Medical Disposal Systems

George Estel

New York State Department of Health

Jacquelyn Flora

Browning-Ferris Industries

Robin Gillespie

Service Employees International Union

Martin E. Gilligan, Jr.

Donlee Technologies, Inc.

Mary Greene

U.S. Environmental Protection Agency

Roger Greene

State of Rhode Island

Dieter Groschel

University of Virginia Medical Center

Robert Guttman, Esq.

Shari Haley

American Hospital Association

John Hall

San-i-pak Pacific, Inc.

Susan Harwood

U.S. Department of Labor

Steven A. Hickerson

EMCOTEK

Travis Honeycutt

Isolyser

Wally Jordan

Waste Tech

Edwina Juillet

Martha Jefferson Hospital

Larry King

Poly-Flex

Jonathan Kiser

National Solid Waste Management Association

Carolyn Konheim

Konheim & Ketcham

Judy Kowalski

New Mexico Energy, Minerals

and Natural Resources Department

Jack Lauber

New York State Department of

Environmental Conservation

Cc. Lee

U.S. Environmental Protection Agency

Howard Levenson

Office of Technology Assessment

Maureen Litchveld

Agency for Toxic Substances and Disease Registry

Edward Londres

New Jersey Department of Environmental

Protection

Hugo Lopez

Rebecca Goldberg Beth Israel Hospital

Environmental Defense Fund

vi
Robert Lord

Nassau-Suffolk Hospital Council, Inc.

Rodney W. Lowman

The Council for Solid Waste Solutions

Donald C. Malins

Pacific Northwest Research Foundation

Ted Malloy

Stanford University

John Manuel

Ontario Ministry of the Environment

Gretchen McCabe

Human Affairs Research Center

Battelle

Jean-Ann McGrane

New York City Health & Hospitals Corp.

Jim McLainey

American Hospital Association

Allan McLean

The University of Chicago Medical Center

John McVicar

Centers for Disease Control

Tom Merski

University of Pittsburgh

Thomas W. Moody

State of Florida Department

Environmental Regulation

Pat Moore

U.S. General Accounting Office

Sue Moreland

University of Tennessee

Phil Morris

South Carolina Department of

Health and Environmental Control

Regina Morns

New York Department of Sanitation

Liisa Nenonen

The RACOURSE Network

Jerry Ness

Northwestern Memorial Hospital

Ross Patten

BFI Waste Systems

Jacqueline Polder

Centers for Disease Control

Sven E. Rodenbeck

Agency for Toxic Substances and Disease Registry

Claude Rounds

Albany Medical Center

William Rutala

University of North Carolina

School of Medicine

Jacqueline W. Sales

Hazmed

W. Thomas Schipper

Kaiser Permanence

Steve Schuler

Joy Energy

Harvy Schultz

NY City Department of

Environmental Protection

Robert Sheehan

Medi-Gen

Robert Spurgin

Spurgin & Associates

Jeffrey Steiner

Mayo Clinic

Tom Stewart

State University of New York

Christopher B. Strasser

The Allentown Hospital—

Lehigh Valley Hospital Center

Pam Sulmer

State of Minnesota

Attorney General’s Office

Kevin Tonat

National Institutes of Health

Jim Tripodes

University of California

Jacqueline Warren

Natural Resources Defense Council

Joe Wilson

Medical Safetec

Robert Peters

National Solid Waste Management Association

vii
Contents

Page

Introduction, Major Findings, and Policy Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4

POLICY ISSUES FOR FEDERAL ACTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Chapter 1. Characterizing Medical Wasteland Applying a Comprehensive Management Strategy. 9

MEDICAL WASTE IN A COMPREHENSIVE WASTE MANAGEMENT STRATEGY . . . . . . . . . . 9

WASTE CHARACTERISTICS AND TYPES-TREATMENT IMPLICATIONS . . . . . . . . . . . . . . . . 11

Chemical Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Biological Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Physical Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Chapter 2. Before Treatment: Waste Reduction and Recycling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

BEFORE-TREATMENT APPROACHES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

WASTE REDUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

RECYCLING AND SOURCE SEPARATION PRACTICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Chapter 3. Non-incineration Treatment Technologies and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

AUTOCLAVING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Capacity and Siting Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Suitability for Different Medical Wastes and Associated Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Costs and Volume Reduction Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

AUTOCLAVING AND COMPACTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

MECHANICAL/CHEMICAL DISINFECTION. , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

MICROWAVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

IRRADIATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

OTHER POTENTIAL TREATMENT TECHNOLOGIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Chapter 4. Incineration Treatment Issues and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

REGULATORY TRENDS AND MEDICAL WASTE INCINERATION . . . . . . . . . . . . . . . . . . . . . . . . . 42

CAPACITY, COSTS, AND RISKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

TRENDS IN AIR POLLUTION CONTROL SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

OPERATOR TRAINING.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

OFF-SITE INCINERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Off-Site v. On-Site Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Co-Incineration or Co-Firing of Wastes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Regional Incineration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Chapter 5. Special Treatment Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

SHARPS MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Manufacturing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Mechanical/Chemical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Encapsulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Mail Shipment for Disposal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

SMALL GENERATOR MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

OTHER TREATMENT TECHNIQUES: SEWER USE AND SHREDDING . . . . . . . . . . . . . . . . . . . . . 62

Sewer Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Shredding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Chapter 6. Comparisons of Treatment Alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

CAPABILITIES AND RISKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

COSTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Appendix A. The Medical Waste Tracking Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Contents—Continued

Boxes

Box Page

A. Management of Medical Low-Level Radioactive Waste (LLW) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

B. Disposables: Infection Control and Waste Management Implications . . . . . . . .......... . . . . . 20

C. California and Its Dioxin Control Measure: A Case Study of One State’s Approach to

Figures

Figure Page

l. Schematic of One Hospital’s Proposed Segregation Categories and Comprehensive

Medical Waste Management Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... 23

3. Typical Sterilization Destruction Curve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 30

5. Mechanical/Chemical Disinfection Unit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

6. Mobile Microwave Medical Waste Disinfection Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 37

8. Controlled Air Incinerator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............ . 45

9. Comparison of PCDD/PCDF Concentration in Medical and Municipal Wastes. . . . . . . . . . . . . . . . . . . 49

IO. Comparison of PCDD/PCDF Emissions From a Variety of Icinerators . . . . . . . . . . . . . . . . . . . . . . . . . 49

11. Comparisons of Cadmium Emissions From a Variety of Incinerator s..... . . . . . . . . . . . . . . . . . . . . . . 50

Tables

Table Page

l. Major Federal Agencies Addressing Medical Waste Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2. Types of Wastes Designated as Infectious by Various Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

3. Percentages of Waste Types Produced at Different Medical/Health-Care Facilities in the

State of Washington . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... 14

4. Characteristics of Medical Waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

5. Comparison of the Composition of Medical and Municipal Waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

6. Emissions of Dioxins and Cadmium From Medical Waste Incinerators in California . . . . . . . . . . . . . . . 48

7. Performance Data of Medical Waste Incinerators With Pollution Control Equipment . . . . . . . . . . . . . . 52

8. Comparison of Treatment Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Introduction, Major Findings, and Policy Issues

Two years after the beach washups of medical

wastes in a hot summer,l preliminary results from

investigations by Federal agencies into medical

waste management issues are being reported.2 At the

same time, many State and local governments (107,

139,110) and several private groups (77) have

undertaken efforts to better address the management

of medical wastes. Certainly, more is known about

current medical waste management practices than

prior to the passage of the Medical Waste Tracking

Act (MWTA) in October 19883 (see app. A). Yet,

much of the confusion and inconsistency associated with medical waste policy persist. Basic

information as well as consensus on some fundamental management issues remain absent from the

efforts to formulate a adequate national medical

waste policy.

As current governmental studies and efforts are

completed, it is clear that critical aspects of medical

waste issues need to be addressed further:

Consensus on the definition of regulated medical wastes must develop, based on the potential

health risks posed by these wastes (e.g., the

ability of a particular type of medical waste to

pose a risk of infectious disease transmission

beyond that associated with municipal solid

waste).

Basic, more precise information on the generation (amounts and disposal methods) of medical wastes, particularly by non hospital sources,

is needed.

Potential waste reduction and recycling opportunities to improve medical waste management

need to be investigated, including consideration of product redesign to produce reusable

and recyclable medical products where appropriate, or to avoid use of problematic (e.g.,

cadmium and lead) components in products.

Appropriate workplace practices for occupational groups in frequent contact with medical

wastes (e.g., health-care workers, refuse workers) need to be developed by relevant govern-

●

●

●

mental agencies and adopted by employers to

minimize the occupational hazards posed by

these wastes.

Information on treatment technologies, inparticular nonincineration alternatives, needs to be

more readily available to State and local

regulators, to generators, and to the general

public.

Air emission standards for medical waste

incinerators, expected to be completed in a

couple of years by the Environmental Protection Agency (EPA), are needed to create a more

certain regulatory climate. Procedures to establish the safety and efficacy of new treatment

technologies are needed.

Management options for small generators of

medical waste (including households) must be

developed and information on their availability

should be more readily available.

Before a comprehensive approach to medical

waste management can be pursued, gaps in informaion and research that limit resolution of these issues

must be better addressed. Some of the necessary

studies, particularly those that better characterize the

nature of health risks posed by medical wastes, will

require significant commitments of time and funding, e.g., for epidemiologic and longitudinal studies.

The Office of Technology Assessment (OTA), in

a background paper released in October 1988, Issues

in Medical Waste Management, briefly examined

the adequacy of current medical waste disposal

practices, the potential risks from such practices, and

the need for further Federal requirements for the

handling, treatment, storage, and disposal of medical

wastes. The focus of this OTA report is: 1) to place

medical waste problems in a broader waste reduction

and materials management perspective, as is evolving for municipal solid waste (MSW) and hazardous

waste; and 2) to address a number of outstanding

issues on incineration and other medical waste

treatment technologies.

l~e causes and impacts of the beach washups of medical waste are discussed in a sep~ate effofi (11s).

~amely, the studies of medical waste issues mandated by the Medical Waste Tracking Act to be completed by the Environmental Protection Agency

and the Agency for Toxic Substances and Disease Registry, as discussed below.

3~e Me~~ Wwte T~a&@ Act is mended ~ new subti~e J to tie so~d waste Dispos~ Act and tie Resource Conservation and Recovery Act

(Public Law 89-272; 42 U.S.C. 6901 et seq.).

– l-
2 ● Finding the Rx for Managing Medical Wastes

Medical wastes are defined to include all the types

of wastes produced by hospitals, clinics, doctors’

offices, and other medical and research facilities.4

These wastes include infectious, hazardous, radioactive, and other general wastes from these healthcare and medical facilities. Infectious wastes are a

relatively small portion of medical wastes, although

a high level of concern regarding their management

exists. 6 For purposes of this report, regulated

medical wastes are those infectious, potentially

infectious, and special wastes designated by EPA as

such under MWTA (see app. A). Throughout this

report, the regulated medical waste stream is the

primary focus and is usually referred to as such

unless another type of medical waste (e.g., low-level

radioactive, hazardous, etc.) is being discussed.

All medical wastes represent a small portion of

MSW. Estimates for medical waste, exclusive of that

generated from home health-care (for which reliable

national estimates do not exist), range from 0.3 to 2

percent of the total municipal solid waste stream

(130, 114).7 The amount of infectious waste generated by medical facilities as a percentage of their

total waste stream varies widely depending on the

type of health-care facility, the definition of infectious waste used, and the standard operating procedures specified by it for designating and separating

waste types. Most hospitals, however, designate

about 15 percent of their waste as infectious (95).

EPA reports that autoclaving (i.e., steam sterilization) is utilized nationally to treat most infectious

medical waste (141, 49, 139). However, medical

waste incinerators continue to be a source of public

concern, particularly because there are no national

emission control standards for them (because their

small size exempts them from current standards).

EPA is in the process of developing new source

performance standards (NSPS) for medical waste

incinerators, which are expected to be proposed in

1992 (41; see ch. 4). Meanwhile, many States have

developed new regulations to control these sources

(107). To date, even less regulatory development has

Photo credit: R. Guttman

Infectious wastes, although a relatively small portion of all

types of medical wastes, are the principal focus of

regulatory concern.

occurred for autoclaves or other nonincineration

treatment alternatives (see ch. 3).

Nearly 70 percent of the Nation’s hospitals use

on-site incinerators. There is, however, great variation in the type, nature, and use of these incinerators.

Some are used only for pathological waste disposal;

others are used for disposal of infectious and

noninfectious medical wastes.

Only a few States have reliable information on the

number, types, and conditions of treatment units

operating in their States. The State of Washington,

for example, in its recent survey of medical waste

practices, found that somewhere between 48 and 87

percent of the incinerators operating in the State

were doing so without emission control equipment

(139). The State of California reports that most of its

146 operating medical waste incinerators are small,

uncontrolled units; 94 percent are on-site units

(107). Recently, data has been reported that indicates

that the rates of toxic emissions from medical waste

incinerators (without emission controls) exceed

those from modern MSW incinerators (106). Interestingly, the State of California also reports that a

maximum of 60 percent of the waste burned in these

4Medic~ w~tes from households are generally considered to be part of the municipal solid waste stream. AS noted throughout this repo~ however,

certain items such as syringes, which can be generated in significant quantities by households, may warrant separate and special management practices.

Further, wastes similar to those identified as medicaI wastes may be generated by such facilities as police crime investigation units, mortuaries, veterinary

clinics, etc.

51t sho~d be noted mat ~ ~s context “&mdous” is a leg~ desi~tio~ not necess~y a m~sure of tie ac~ -d C)f a pMdCUkU WaSk

61t i5 fipo~t t. emp~~e tit not all medical waste is infectious. As EPA noted in 16 gui&nce document, defining infectious WMe aS W&Xt3

capable of producing an infectious disease requires consideration of factors necessay for induction of disease. These factors include: presence of a

pathogen of sufficient virulence, dose, portal of entry, and resistance of the host (122).

7J3pA es~ates that 2 to 3 million tons of infectious hospital waste is generated annually.
Introduction, Major Findings, and Policy Issues ● 3

incinerators is regulated medical waste, the remaining 40 percent being municipal waste (107).

EPA, the Centers for Disease Control (CDC), the

Occupational Safety and Health Administration

(OSHA), and other Federal agencies have issued

different, general guidelines for infectious and

medical waste management (see table 1). Differences of opinion exist over the importance and

impact of variations between the definitions and

recommendations of these government agencies.

Any remaining confusion over government positions on these matters could be eliminated if

Congress designated a lead agency to coordinate and

clarify the Federal Government positions on medical

waste issues. As noted in OTA’s previous background paper on medical waste, EPA is the agency

with the most comprehensive authority to provide

Federal leadership on the management of medical

wastes (114).

OTA’s statement in that background paper still

applies: “Currently, no Federal regulations exist

that comprehensively address the handling, transportation, treatment, and disposal of medical waste”

(emphasis added; 114). This means that variation

exists among the requirements that States and

localities have devised for medical waste management. In recent years, such variations have led

observers to suggest that the Federal Government

needs to establish some baseline, uniform standards

and guidelines for medical waste management. To

date, the Federal Government has been reluctant to

act without greater information on a number of

issues related to medical waste management (114).

Some of this information may come from studies

that both the EPA and the Agency for Toxic

Substances and Disease Registry (ATSDR) are

required to conduct under MWTA (sees. 11008 and

11009). MWTA (sec. l1008(a)) requires EPA to

evaluate and include in reports to Congress: generator information (types, number, and size); on-site

and off-site management practices, including sewer

use; types and amounts of medical wastes; costs

associated with the improper management of medical waste and those from compliance with the

regulatory requirements of MWTA demonstration

program; available and potential reduction, reuse,

and management methods; implications of regulatory exemptions of household and small quantity

generators; guidelines for the management of medical waste from households and small-quantity generators; existing State and local controls; and the

appropriateness of applying Subtitle C requirements

Table l—Major Federal Agencies Addressing Medical Waste Issues

Agency Authority Activity

U.S. Environmental Protection

Agency (EPA)

Occupational Safety and Health

Administration, U.S. Department

of Labor (OSHA)

Centers for Disease Control, U.S.

Department of Health and Human

Services (CDC)

Agency for Toxic Substances and

Disease Registry, Public Health

Service, U.S. Department of

Health and Human Services

(ATSDR)

Guidance and Regulatory aIssued Guide for Infectious Waste Management; issued

regulations to establish the Medical Waste Tracking

Program; establishing new source performance standards for medical waste incinerators; completing studies requested by the Medical Waste Tracking Act;

authority under the Resource Conservation and Recovery Act to regulate the handling, storage, and transportation of medical wastes.

Guidance and Regulatory b

Issues advisory notices and workplace standards focusing

on occupational exposure to infectious materials and

wastes.

Guidance and Recommendations c

Issues notices and advisories, sometimes jointly with

OSHA, focusing on infection and control issues.

Study and Reviev c Completing study required by the Medical Waste Tracking

Act, focusing on evaluating health effects associated

with medical wastes.

aEpA’$ comprehensive autlmfity to regulate medical waste management is granted under the Resource Conservation and Recovery Act. The Agency also

has special regulatory authority to administer a demonstration medical waste tracking program and is required to complete a number of studies related to

medical waste management under the Medical Waste Tracking Act (42 U.S.C. 6901 et seq.).

b@J+A~$ Pnmwy a~honty is granted under the ~upationa[ safety and Health Act (29 IJ.S.C. 651 et seq.). Guidelines or regulations only appiy tO priVd43

facilities, unless a State extends cmverage to employees of public facilities as well.

CDCMM not have the authority to issue regulations.

SOURCE: Office of Technology Assessment, 1990.
4 ● Finding the Rx for Managing Medical Wastes

(i.e., the hazardous waste provisions) of the Resource Conservation and Recovery Act (RCRA) to

medical wastes.

EPA has concentrated its implementation efforts

thus far on promulgating and implementing the

requirements for the MWTA demonstration program. The regulations were promulgated ahead of

schedule in March 1989 and became effective in

June 1989 (Federal Register, Mar. 22, 1989). The

Agency and its contractor convened a meeting in

November 1988 with health-care and waste industry, environmental, and various State and Federal

Government representatives to discuss ways to

collect information on medical waste generation and

management practices as part of this effort (123).

EPA’s first of three required reports to Congress

under the law, highlighting the efforts to address the

issues under study, was delayed by more than a year.

This delay was due, at least in part, to inaction by the

Office of Management and Budget (OMB) in its

review of the report. The first report is expected to

review what EPA plans to study and focus on the

proposed approach for a health hazard assessment

(89).

ATSDR is required to report on such health

effects of medical waste as: estimates of the number

of people annually infected or injured by medical

wastes (including sharps), including descriptions of

the nature and seriousness of those incidents; and

estimates of the number of cases traceable to medical

waste of diseases that could be spread by improper

management of such wastes (in particular, hepatitis

B virus (HBV), and immunodeficiency virus (HIV),

or AIDS). Its report to Congress on the public health

implications of medical waste is expected to be

released on schedule on November 1, 1990.8

The EPA and ATSDR studies are limited

because existing information and data are inadequate (134). Still needed are research, surveys

and studies that generate new information and

address existing data gaps.

To address these research needs is beyond the

scope of this report, which is intended to provide a

framework for considering medical waste management issues and to assess in a preliminary way the

potential of various reduction and treatment methods for medical waste.9 The report is divided into six

chapters: 1) applying a comprehensive waste management strategy to medical waste and a brief review

of Federal efforts undertaken to date; 2) exploring

pretreatment approaches (e.g., waste reductions and

recycling options); 3) exploring nonincineration

medical waste treatment technologies and emerging

treatment technologies; 4) examining current issues

regarding incineration of medical wastes; 5) discussing special treatment issues, such as sharps (e.g.,

needles, glass, etc.) management and small generator issues; and 6) comparing various management

treatment alternatives.

SUMMARY OF FINDINGS

Two of the critical findings of this study are

consistent with a comprehensive waste reduction

and materials management approach to waste

management. First, treatment technologies will

continue to be needed for waste management, but

they can be preceded and complemented by

prevention and pretreatment efforts (i.e., reduction and recycling). Second, while there is no one

preferred treatment method, source separation

practices (i.e., separating wastes based on the

physical, chemical, and infectious characteristics) are key to targeting particular materials/

wastes for the most appropriate treatment method.

Other findings of this report include:

. The commercial viability of nonincineration

treatment alternatives has increased in recent years due to the increased cost of

incineration, the difficulty associated with

permitting incinerators, and the perceived

desirability of reducing dependence on incinerators given concern over their emissions.

Alternative treatment technologies such as

autoclaving (steam sterilization) with compaction, microwaving, and mechanical/chemical disinfection are likely to be less capital

intensive and have fewer emission concerns

than incineration processes. Yet, further investigation of treatment alternatives (e.g., health

8~e~e fi&g~, h~wever, ~ be ~ted by the Mme of the e,xisfig &M base ~d litera~e fiom Wtich & findings are drawn. The number Of

unreported occupational injury cases, the baseline health status of workers, and the significance of potential exposure routes not yet studied (e.g.,

aerosolization of substances during treatmen~ etc.) are crucial unknowns which could strongly impact risk determinations of VfiOUS @aWent

technologies.

%eatrnent methods throughout this report refer broadly to any management technique and processes intended to render the wastes suitable for

disposal. Treatment of medical wastes is intended both to render wastes noninfectious and to lead to environmentally sound disposal.
Introduction, Major Findings, and Policy Issues ● 5

Photo credit: Extrufix, OrIando, Florida

The diversity of the medical waste stream indicates that

source separation practices can help target particular

materials/wastes to the most appropriate management

method, based on the physical, chemical, and infectious

●

characteristics of that waste.

risks) and determination of appropriate performance standards is warranted, as well as

consideration of research and development

funding to encourage innovative technologies.

Current regulatory activity at all levels of

government tends to encourage incineration

either by focusing most of its activity on

incineration and/or by identifying it as a

preferred treatment method in regulations or

guidelines with minimal attention to alternatives. Congress may alleviate concerns over

the difficulties associated with introducing

alternative treatment technologies by directing EPA to specify approval or certification

processes for treatment alternatives capable

of rendering infectious medical wastes noninfectious. A program taking these factors into

account might help stimulate the development

of innovative and improved treatment processes.

Incineration remains and is likely to continue to remain a primary treatment method

for medical wastes for the foreseeable future.

Advanced pollution control equipment is becoming a standard part of many new incinerators. An important concern is the impact

Federal regulation of air emissions from medical waste incinerators will have when they are

finalized in 1991, since stringent regulations

have been already enacted by some States.

New incinerators for a variety of reasons (as

noted above) are tending to be larger facilities that operate on a more continual basis

than facilities in the past. A number of

regional incinerators, either nonprofit/generator or commercial ones, are being planned.

Yet some medical waste generators prefer to

continue managing their own waste in an effort

to maintain greater control over their costs and

liability. A number of factors weigh in favor of

or in opposition to on-site and off-site management, leaving the particular circumstances of

the medical waste generator and the host

community to be the main determinants for the

type of treatment selected.

A fundamental policy issue of importance

that the Federal Government could address

is the extent to which medical wastes are to

be regulated on the basis of their potential

threat to public health (i.e., infectious nature) and their aesthetic characteristics (i.e.,

recognizability as a medically related item).

That is, Congress could clarify whether the

nonrecognizability criteria of MWTA should

remain a part of future regulations by addressing this issue either as part of the current

Resource Conservation and Recovery Act (RCRA)

reauthorization or as part of the evaluation of

MWTA upon its expiration in 1991.

A need exists for further education about the

nature of the risks posed by medical wastes

and methods for their proper handling and

management for health-care workers, other

workers at risk, and the general public.

These efforts could be undertaken by either or

both the health-care community and the government. Such efforts could include instruction

for health-care workers and housekeeping staff

exposed to medical wastes and incinerator
6 ● Finding the Rx for Managing Medical Wastes

operating training for workers responsible for

medical waste management.

This brief study discusses what is known regarding

various medical waste treatment technologies and

related management issues. Possible directions for

Federal policy and areas where further information

to facilitate policy development and improved

management are suggested by the study’s findings.

POLICY ISSUES FOR

FEDERAL ACTION

The reauthorization process for RCRA provides an opportunity to revisit the medical waste

issues first addressed by Congress in 1988. In

1991, the completion of the MWTA demonstration

program will provide further opportunity to incorporate what is learned from the program and from the

mandated studies by EPA and ATSDR into the

decision making process for any further Federal

action on medical wastes management.

One possible option regarding medical waste

issues for Congress to choose is to do nothing in this

area once the MWTA demonstration program and

agency studies are completed. EPA will set air

emission standards for medical waste incinerators

and Congress could defer to the Agency, as it has in

the past, for any further policy action as considered

necessary. Given the general concern over EPA’s

past reluctance to act on medical waste issues and

current efforts at improving waste management

practices in the country coupled with concern over

State variations in the regulation of medical wastes,

this appears to bean unlikely course for Congress.

More likely, Congress will address at least some

issues regarding medical waste management as part

of the RCRA reauthorization, whatever action may

or may not be taken once MWTA expires. 10 Congress could move beyond the current approach to

medical waste management and define a more

comprehensive approach. A comprehensive approach might incorporate medical waste into the

type of waste reduction and materials management

approach suggested by OTA (1 16) for MSW. Such

an approach could, for example, include determinations on the definition of regulated medical

wastes; address waste reduction and recycling

goals/objectives; encourage the development and

adoption of baseline, uniform standards for each

type of treatment method; establish a protocol for

approving or certifying new treatment alternatives; and include medical wastes in State waste

management plans. In these plans, States could be

required to consider waste reduction options, recycling opportunities, capacity needs for treatment,

and similar planning issues for medical waste, as

they would be required to do for MSW.

Within this more comprehensive approach to

medical waste management, or independent of it, a

number of other policy issues can be addressed.

These include the following:

●

●

●

●

A

Reduction and recycling issues-Greater attention to opportunities for toxicity and volume

reduction and recycling of medical wastes

would complement the efforts suggested and

being adopted throughout the country for MSW.

Dissemination of information through the EPA

clearinghouse and possibly research and development (R&D) funding, could bring attention

to these opportunities.

Non-incineration treatment technologies—

Further investigation of treatment alternatives

is warranted, e.g., health risks; need for performance standards (e.g., waste loadings, temperatures); operator and maintenance procedures, etc.

Incineration treatment issues—Monitoring and

operating requirements for medical waste incinerators and operator training and certification

requirements could be specified; standards for

air emissions and ash management could be

established.

Small generator management-Information and

assistance for households and other nonhospital sources of medical wastes could be made

available through the clearinghouse for solid

waste, which RCRA already directs EPA to

establish and the Agency is currently developing.

number of these issues will need to be

addressed by nongovernmental entities, such as

hospitals and other generators of medical wastes,

the manufacturers of medical supplies, and the

waste management industry. In particular, a hospital or medical facility itself can best identify

standard operating procedures that affect waste

IONote tit ~ ~mber of b~S on “fi~uS ~Sp=~ of medic~ ~aSte m~agement ~ve been fi~oduced ~ con~ess, @ he focus Of activity iS ~ely

to center on how medical waste issues are addressed in the reauthorization of RCRA.
Introduction, Major Findings, and Policy Issues ● 7

Photo credit: R. Guttman

Careful planning and a comprehensive approach to waste

management, which may include recycling efforts, are

likely to reap cost savings to a medical facility, as well as

environmental benefits for its community.

segregation practices, safe handling of waste materials, and adoption of waste reduction, reuse, or

recycling practices.

Medical waste management is a small part of a

health-care facility’s function, but careful planning and a comprehensive approach to waste

management are likely to reap cost savings to the

facility, as well as environmental benefits for its

community. This type of planning would involve

consideration of purchasing practices, use of different types of products, methods of waste segregation,

and selection of treatment option(s) based on consideration of the full range of available alternatives. The

benefits of such efforts may include cost savings to

the facility as well as a reduction in the amount of

waste requiring management.

Education efforts regarding the nature of the

risks posed by medical wastes and methods for

their proper handling and management can also

be effectively undertaken by health-care providersfor health-care workers, other workers at risk,

and the general public. These efforts can include

incinerator operating training and personal protective equipment and instruction for housekeeping

staff exposed to medical wastes. The government,

waste generators and others involved in medical

waste management also can undertake such efforts

(see ch. 4).

For example, the American Diabetes Association

helps educate diabetic patients on the safe disposal

of their syringes (4). The government also could

make information and assistance for households and

other nonhospital generators of medical wastes more

readily available. One possibility is to include such

a focus in the clearinghouse for solid waste being

established by EPA, as currently required by RCRA.

The resources spent on various education efforts

would improve understanding of how medical

wastes can properly be managed, their associated

risks, and would facilitate adoption of improved

management practices.

Other more specific issues for which policy

clarification by Congress will be useful are whether

the nonrecognizability criteria of MWTA will remain a part of future regulations; whether shredding

requirements should or will be adopted; and also

some specific packaging, transportation, and mailing issues.1l Of these issues, a fundamental one of

critical importance that the Federal Government

could address is the extent to which medical

wastes are to be regulated on the basis of their

1 IFOreX~ple, two bilk (s. 2393 and H.R. 3386) currently before Congress address the transportation of medical waSteS as it is Part of the bac@*g

of waste. The legislation seeks to require the use of dedicated vehicles for some substances, such as medical wastes, to avoid the transportation of food

in vehicles used to haul such wastes. The Department of Transportation, however, does not want the authority to regulate backhauling (as the proposed

law would grant them) and instead believes the EPA, Department of Agriculture, and the Food and Drug Administration could better take the lead in

determining the necessary standards.
8 ● Finding the Rx for Managing Medical Wastes

potential threat to public health and their aesthetic characteristics.

Considerable expense can be associated with

managing wastes (e.g., certain IV tubing) that pose

little public health threat but are recognizable as

medical items. A health-care organization official

recently mused something to the effect that medical

waste is probably as much in need of an image

consultant as it is in need of regulation. The adoption

of regulations that treat wastes purely for aesthetic

reasons reinforces a “bad image” for medical

wastes, or at least the notion that more of this waste

poses hazards than may be true. It may be that the

most appropriate treatment criterion with respect to

medical waste is the ability of a treatment system to

render wastes noninfectious.

Clarifying the definition of regulated medical

wastes to include only the waste types considered

infectious based on objective criteria may facilitate

special management of those wastes that pose the

greatest risk to human health without risking" overregulation” (e.g., special management of wastes for

primarily aesthetic reasons). Concerns over such

‘‘needless and expensive’ requirements are particularly heard from public officials and generators of

medical wastes in rural areas or areas where medical

wastes have not been as much of a public concern as

they have in the Northeast and other coastal and

more densely populated areas. The potential implications of national legislation on areas of the country

primarily concerned with the infectious potential

(and not appearance per se) of medical wastes need

to be carefully considered and balanced against the

needs of coastal areas and more densely populated

areas. In these areas, the medical waste beach

washups and other waste related problems in recent

years create entirely different waste management

circumstances.

Another important issue centers on addressing

whether a “level playing field” exists for all the

available treatment alternatives. Congress might

facilitate the introduction of new treatment technologies through specification of certification or approval processes for treatment alternatives capable

of rendering infectious medical wastes noninfectious. The same testing will not be appropriate for all

treatment technologies and determining potential

risks and identifying any necessary control measures

will also vary depending on the nature of the

treatment technology.

A protocol to evaluate new technologies by

identifying appropriate tests, establishing standards

to demonstrate effective microbial kill, establishing

operating parameters and evaluating potential risks

could be adopted. Veterans hospitals or other

Federal medical laboratories and facilities might

also be possible pilot/test sites for new treatment

technologies. Funding for the research, development, and testing of alternatives would also encourage innovation and improvement in medical waste

management.

It will be an important part of any program

regarding the management of medical wastes to

include a provision addressing how the adequacy of

various treatment alternatives (which in fact might

evolve in response to the regulatory program) will be

considered. As noted, such a program could provide

interim approval or certification status and/or funding for a pilot/test facility to facilitate gathering the

information necessary to determine whether routine

adoption of the technology would be acceptable.

Such a program might help stimulate the development of improved treatment processes.
Chapter 1

Characterizing Medical Wastes and Applying a

Comprehensive Management Strategy

The Medical Waste Tracking Act (MWTA) of

1988 represents an attempt by Congress to address

the problems of beach washups and illegal disposal

of medical wastes.

1 A more comprehensive approach to medical waste management, one consistent with the broader waste management strategy

evolving nationally, could be formally established if

the issue of medical wastes remains part of the

current RCRA reauthorization effort. Medical

wastes need to be put into a broader frame of

reference along with other wastes (e.g., municipal

and industrial hazardous and nonhazardous wastes)

if we are to establish appropriate levels of protection

for humans and the environment. The relative risks

posed by all these types of wastes must be considered when determining appropriate management

methods for them.

This chapter consists of a brief discussion of the

context within which the current Federal approach to

waste management for other hazardous and nonhazardous wastes evolved and consideration of the

implications of a broader, more comprehensive

waste management strategy for medical waste.

Appendix A to this report provides a short review of

MSVTA, the first major Federal effort to address

medical wastes.

MEDICAL WASTE IN A

COMPREHENSIVE WASTE

MANAGEMENT STRATEGY

The Resource Conservation and Recovery Act

(RCRA),2 passed by Congress in 1976, is the major

Federal statute addressing management of the Nation’s wastes—hazardous, municipal, industrial, and

other types of solid waste, including medical waste.3

EPA has authority under RCRA to regulate the

handling, storage, treatment, transportation, and

disposal of all of these wastes. Before passage of

MWTA, EPA’s activity regarding medical waste

issues was mostly limited to distribution of its

guidance document for the management of infectious wastes. Other medical wastes were considered

to be like any other solid waste and subject to

relevant RCRA Subtitle D regulations (114).

OTA finds four key challenges which need to be

resolved for medical waste management:

1.

2.

3.

4.

The

better defining/identifying infectious and other

medical wastes, to facilitate more consistent

and adequate handling and treatment of

wastes;

better addressing the diversity of generators

(e.g., home health care, small doctors’ offices,

clinics, etc.) to minimize contradictory requirements and inequities they pose;

improving the segregation of wastes for their

proper treatment; and

identifying appropriate treatment alternatives.

very nature of these issues indicates that a

comprehensive, flexible, yet cost-conscious approach is needed for medical waste management.

These challenges can be met by a broader approach

to medical waste management that emphasizes

waste prevention efforts and management of different portions of the medical waste stream based on

their physical, chemical, and biological (i.e., infectious) properties. Such a comprehensive approach to

waste management is beginning to be applied to

hazardous waste and more recently to municipal

solid waste (MSW).

ICongress alSO amended the Marine Protection Research and Sanctuaries Act (also known as the Ocean Dumping Act) h 1988 to fif=ase the

penalties for illegal disposal of medical wastes by public vessels (33 U.S.C. 1401 et seq.). See app. A and (115) for discussion of MWTA.

Zwbhc bW 94-580 (1976); 42 U.S.C. 6901 et seq. The Solid Waste Disposal Act of 1965 (Public Law 89-272; as amended by the Resource Recovery

Act of 1970, Public Law 91-512) was the law by which Congress first established a F~eral role in solid waste management. The most recent major

revision of RCRA was by the Hazardous and Solid Waste Amendments of 1984 (Public Law 98-616), which did not address medical waste issues in

any detail. RCRA is currently in the process of further revision and reauthorization.

30m (1 15) recenfly completed its assessment of municipal solid waste, of which the 1988 background paper on medical wastes was a Part. CurrenflY,

OTA is completing a background paper on industrial solid (Subtitle D, RCRA) waste issues (expected to be rdeased in early 1991). Hazardous waste

issues have been addressed by several OTA reports (e.g., 112, 113).

It should be noted that the following discussion is based in part on ref. 137.

-9-
10 ● Finding the Rx for Managing Medical Wastes

Photo credit: L. Swanson

Beach washups containing medical debris, such as

syringes, helped prompt passage of the MWTA.

Subsequent studies indicate the sources of most washups

to be related more directly to sewage treatment systems

operation than illicit waste management practices.

There is some consensus that at least portions of

the medical waste stream can be treated like other

MSW. Indeed, in practice this appears to occur. The

California Air Resources Board reports, as noted

above, that typically 40 percent or more of the waste

burned by medical waste incinerators in their State

is waste, comparable to MSW in nature (106, 108,

29).4 Available evidence also seems to indicate that

most medical waste poses no more public health or

environmental hazard when properly handled than

does MSW (109, 56, 107, 139). Yet, when medical

waste is incinerated (or treated by some other means)

its emissions may be hazardous if not properly

controlled (as is the case with any other waste).

Thus, basic policy determinations regarding management approaches, and weighing risks and costs,

etc., are common to any waste problem.

It is instructive to consider the current trends in

hazardous waste and MSW treatment in which there

is a movement away from treatment methods that

manage indiscriminately mixed wastes and toward

source separation programs that encourage management based on the properties of the materials in the

wastes (e.g., recyclability, ability to destroy or

neutralize, etc.). OTA’s assessment of the MSW

issue found that environmentally sound waste management requires focusing on how the Nation uses

materials from manufacturing through subsequent

distribution and disposal (116). On this basis, OTA

concluded that,

A clear national policy on MSW that addresses

the use of materials is essential for providing a

broader context in which specific MSW programs

can be developed and implemented. Waste prevention and materials management should be the

foundation of this policy.

The basic steps are: 1) characterizing the waste

stream in light of categories used for different

alternative treatment options; 2) segregating wastes

at the point of origin to facilitate management based

on their characteristics; and 3) examining the

production of the waste, i.e., looking upstream to

consider possible opportunities for waste reduction

(in either volume or toxicity) that may include use of

different products which are reusable or recyclable

or contain less problematic substances for waste

treatment.

For example, government agencies and/or the

health-care industry could examine prospects for

waste reduction in health-care settings (see ch. 2).

Although the growth in the volume of medical

wastes is not well documented, there is general

acknowledgment that the use of disposable in

health care has increased significantly in the last two

decades. Clearly, in some cases the use of disposable is important for infection control. Yet, those

uses driven primarily by economies may need to be

reassessed (see ch. 2).

From a management perspective, the presumption

held by some regulators and members of interest

groups that incineration is the “preferred’ treatment

option for medical wastes warrants closer examination. Most of the recent regulatory activity for

medical waste management at all levels of government tends to focus on incineration and does not

usually include specific procedures for the regulatory approval of nonincineration alternatives.

For example, the “treat and destroy or track”

requirement of MWTA does not include a process with specific criteria for how the standard can

4B~~~d on ~~ me of ~omation, ~~~~ion data from medic~ and MSW facilities can be compar~, as long as the &pe and size of incinerator Or

other technology and the mix of wastes is taken into account (see ch. 5).
Chapter 1-Characterizing Medical Wastes and Applying a Comprehensive Management Strategy ● 11

be met by various treatment alternatives, and

does not specify how new non-incineration treatment alternatives can be introduced. A number of

such alternatives (e.g., several types of disinfection

units) are commercially viable and warrant consideration (see ch. 3).

Further, a number of unanswered questions remain regarding incineration, e.g., the nature of

emissions and proper controls, the nature and

adequate treatment of ash residues, and the cost

compared with alternative management methods

(see ch. 4). Information on operating parameters,

risks, and costs for various alternative treatment

methods is also needed. As with the hazardous and

solid waste streams, a combination of management

options may prove optimal for managing medical

waste once the material composition of its components is considered.

That is, landfilling, incineration, and other

treatment alternatives, as well as recycling and

waste reduction all may be viable management

options for medical waste—when it is considered

on a waste component basis. Ultimately, this may

help to control costs and minimize any hazards

associated with medical waste management. This is

one way, given the experience gained in regulating

other waste streams, that programs to manage

medical wastes can be devised wisely and efficiently

in order to alleviate public concern, protect workers,

and provide environmental protection.

WASTE CHARACTERISTICS AND

TYPES—TREATMENT

IMPLICATIONS

Examining various treatment options underscores

the importance of considering the properties of

different types of medical waste and matching them

to the capabilities of the treatment technologies.

Although the medical waste stream is heterogeneous, the focus of concern is on the portion of the

waste stream termed ‘‘infectious, ’ and how these

wastes are classified (e.g., solid, hazardous, or

special) and regulated. The regulated waste stream,

i.e., the medical wastes covered by MWTA, includes

infectious, potentially infectious, and some wastes

identified as requiring special handling. Most estimates are that 10 to 15 percent of medical wastes

generated by hospitals are infectious, although this

figure can range as high as 80 percent depending on

the generator’s definition. Determining which portion of medical waste is infectious remains at the

heart of definitional issues. How infectious waste is

defined can greatly affect the cost of waste management, and ultimately the choice of disposal options

(114).5

Currently, both aesthetic considerations and

health risks posed by medical wastes can lead to the

classification of a medical waste as infectious and/or

regulated and requiring special management. The

State of Washington has defined infectious waste

based on risk criteria, particularly the determination

of “infectious disease causation potential’ (139). A

consensus on which medical waste warrants

special regulation and management might be

forged if the definition of regulated medical waste

is based on the potential health risks associated

with the waste (i.e., the ability of a particular

medical waste-given organism concentration,

ability of the waste to penetrate skin, etc.—to

pose a risk beyond that associated with MSW to

transmit infectious disease).

As noted, no consensus exists on the types of

medical wastes that should be designated as infectious or that require special handling, although

several categories of wastes are included in most

lists (114; also see table 2). Under MWTA (see

below), EPA has listed seven types of medical waste

(commonly and hereafter refer-red to as “regulated

waste types’ to be tracked in the demonstration

program. These are:

1. microbiological wastes (cultures and stocks of

infectious wastes and associated biological

that can cause disease in humans);

2. human blood and blood products (including

serum, plasma, and other blood components);

Ssome confusion was created over the Centers for Disease Control (cDC) universal precautions guidance issued in August 1987, tit suggestti tit

all patients be considered potentially infected with human immunodeficiency virus (HIV) (i.e., the virus which causes acquired immunodeficiency

syndrome, AIDS) and/or other blood-borne pathogens and that workers should adhere to rigorous infection-control procedures. In October 1987, CDC

issued a joint advisory notice with the Department of Labor further addressing protection against occupational exposure to Hepatitis B (HBV) and HIV.

After these advisories led to a great inflation of the amount of waste designated as infectious, the CDC issued a cltilcation in August 1988, indicating

to which types of secretions and circumstances its recommendations applied and that CDC did not intend for generators to alter waste mamgement

procedures, but only meant to protect health-care workers. In May 1989, the Occupational Safety and Health Administration (OSHA) of the U.S.

Department of Labor issued a proposed job health standard for protecting health-care workers from blood-borne diseases.
Table 2—Types of Wastes Designated as Infectious by Various Entities

EPA/ Percentage

Waste category MWTA EPAa CDC MA CA IL NY SC WI of hospitals

Microbiological c . . . . . . . . . . . . . . . . . . . . Yes Yes Yes Yes Yes Yes Yes Yes Yes 99.0

Human blood and blood products . . . . . Yes Yes Yes Yes Nod Yes Yes Yes Yes 93.7

Isolation wastes . . . . . . . . . . . . . . . . . . . . Yes Yes Optional e Yes Yes Yes Yesf Yes No 94.4

Pathological wastes g 

. . . . . . . . . . . . . . . . Yes Yes Yes Yes Yes Yes Yes Yes Yes 95.6

Contaminated sharps h . . . . . . . . . . . . . . Yes Yes Yes Yes Yes Yes Yes Yes Yes 98.6

Contaminated animal carcasses,

body and bedding . . . . . . . . . . . . . . . . Yes Yes No Yes Yes Yes Yes Yes Yes 90.1

Uncontaminated sharps. . . . . . . . . . . . . . Yes No No Yes No No Yes No No N/A

Other contaminated wastes:

Miscellaneous laboratory wastes . . . . . . Optiona l

i N o Yes Yes Yes Yesf No Yes 88.8

Surgery and autopsy wastes . . . . . . . . . Optiona l

i N o Yes Yes Yes Yesf No Yes 83.2 &91 .9,

respectively

Dialysis unit wastes . . . . . . . . . . . . . . . . Optiona l

i N o Yes Yes No Yesf No Yes 83.4

Equipment . . . . . . . . . . . . . . . . . . . . . . . . . Optiona l

i N o Yes Yes Yes Yesf No Yes N/A

Any other infectious waste . . . . . . . . . . . No No Yes Yes Yes Yes Yes Yes Varying

percentages

aB=~ on r=ommen~tions in EpA Gu&nce D~ument (U.S. En~ronmentai prot~tion Agency, Gujde for /nfectious Waste ~anagement, EPA/!X30-SW-86-01 4 (Washington, DC: May 1986);

see discussion in U.S. Congress, Office of Technology Assessment, /ssues in Medica/ Waste Marragernent-/3ackground Paper, OTA-BP-O-49 (Washington, DC: U.S. Government Printing Office,

October 1988).

bpercentage of hoSp~als&@n~ting thiS~aste ~ategory, according t. a survey completed for the Amefican Hospital Association. w, Rutala, W.W. Odette, and G. %fTW, “Management Of Infectious

Waste by U.S. Hospitals,” Journal of American Medicai Association 262:1635-1640, 1989.

csuch as-cultures and stocks of infectious agents.

dHumm blo~ and blo~ pr~u~s that are proven to ~ntain pathogens arae subject to California’s inf~tious waste law and rWJJh3tiOM.

ecDC r~ommencls that this waste be treated according to hospital policy.

fThe New York State Commissioner of Environmental Conservation may exclude this category.

9Such as human body parts, tissues, fluids, and organs.

hsuch ss syringes, needles, scalpel blades, and 91a=.

iEpAJs 1 g86 gu~ance stat = that the decision to handle these wastes as infectious should be made by a responsible, authorized person or committee at the individual faCility.

SOURCE: Office of Technology Assessment, 1990; based on U.S. General Accounting Office, Medicaf Waste Regulation: Health and Environmental Risks Need To Be Fully Assessed,

GAO/RCED-90-86 (Washington, DC: March 1990).
Chapter l--Characterizing Medical Wastes and Applying a Comprehensive Management Strategy ● 13

3.

4.

5.

6.

7.

pathological wastes of human origin (including tissues, organs, and body parts removed

during surgery or autopsy);

contaminated animal wastes (i.e., animal carcasses, body parts, and bedding exposed to

infectious agents during medical research,

pharmaceutical testing, or production of biologicals);

isolation wastes (wastes associated with animals or humans known to be infected with

highly communicable diseases);

contaminated sharps (includes hypodermic

needles, scalpels, broken glass); and

uncontaminated sharps.6

Other waste categories that EPA had to consider for

inclusion in MWTA demonstration program are:

wastes from surgery or autopsy that were in contact

with infectious agents (e.g., sponges, soiled dressings, drapes, surgical gloves, drainage sets); dialysis

wastes that were in contact with blood; discarded

medical equipment and parts that were in contact

with infectious agents; and laboratory wastes that

were in contact with infectious agents (e.g., laboratory coats, slides and cover slips). EPA determined

that potentially infectious items from these waste

categories are covered by the other seven regulated

waste types. It is interesting to note that according to

a recent survey sponsored by the American Hospital

Association, the vast majority of the 441 randomly

selected hospitals designated six of the seven

categories above as infectious (the exception being

unused sharps) (95).

Wastes within each of these regulated waste type

categories can have different chemical (hazardous,

radioactive, or nonhazardous) and physical (liquid,

gas, or solid) characteristics that are important to

consider in selection of the most appropriate treatment method. Clearly, different types of medical

practices by physicians, types of hospitals, and

different departments within a hospital generate

different types and quantities of the regulated waste

types (123, 29) (see table 3). Therefore, it is

reasonable to assume that just as hospital type and

size and occupancy rate are important determinants

of generation rates of medical wastes, they are also

key factors affecting the chemical and physical

make-up of the wastes. That is, general medical and

surgical hospitals will generate a different quantity

and mix of wastes than psychiatric or other specialty

hospitals (e.g., chronic disease, orthopedic, and

eye/ear/nose/throat hospitals).

Chemical Characteristics

Hazardous Constituents

Waste from a medical facility may contain

cytotoxic chemicals, laboratory solvents, toxic metals, low-level radioactive waste, or waste contaminated with human pathogenic microorganisms. Cytotoxic chemicals are hazardous pharmaceuticals

used in chemotherapy, and seven such compounds

are on the RCRA ‘‘U’ list of hazardous waste.7 This

means that they cannot be disposed of in bulk

quantities in medical waste incinerators without a

RCRA hazardous waste incinerator permit. It is also

true that these RCRA hazardous wastes could not be

treated by most nonincineration treatment methods.

Yet, given that these substances are usually encountered as “trace” contaminants, rather than “bulk

wastes, ” they are not managed as RCRA hazardous

wastes, and can legally be disposed of with other

medical wastes.

Laboratory solvents and other types of hazardous

chemicals are commonly found in medical wastes,

and many of these are also listed as hazardous wastes

under RCRA.8 Although these wastes should be

managed separately from other medical wastes as

RCRA hazardous wastes, like cytotoxic compounds,

sometimes they are so intimately mixed with medi6c&e GAO (134) for ~ more complete discussion of tie EPA’s determinations for inclusion and Specification of the different wa.~tc tYPcs.

7~e~e ~e: c~o~bucil, cyclophosp~ide, duanarnyc~, melpha]~, mitomycm, stretozotocin, and uracil mustard. nesc CYtotoxic compounds

are a small fraction of all cytotoxic agents. The total amount of cytotoxic compounds incinerated is not known and little is known of the potential threat

from cytotoxic emissions.

Indeed, data for cytotoxic emissions is lacking and conditions necessary to destroy cytotoxic compounds arc not known. A conservative assumption

is that 1,800 ‘F (1,260 K) would ensure complete destruction of cytotoxic compounds, although destruction is also dependent on rcsidcncc time and

mixing (12, 41). As part of its testing program (at two incinerators) for developing standards for ncw medical waste incinerators, EPA is conducting tests

to determine the destruction efficiency of the two test medical waste incinerators of hcxochlorobcn7zne as a surrogate for cytotoxic chemicals (the tests

will be conducted at a secondary chamber temperature of 2,000 OF) (41).

8Hudous solven~ ~ic~]y fo~d in medic~ w~tc ~cludc: acetone, 2.butane], bu~l atcohol, Cyclohexane, dietiyl cticf, ethyl acetate, Cthyl

alcohol, formaldehyde, heptane, hexane, methyl alcohol, methyl cellosolve, pentane, petroleum ether, 2-propanol, scc-butyl alcohol, tert-butyl alcohol,

tetrahydrofurau and xylene (12). Many of the chemicals used as laboratory solvents and all but the seven chcmotherapeutics listed as ha7adous waste

can be disposed of legally through the sewer system (141).
Table 3—Percentages of Waste Types Produced at Different Medical/Health-Care Facilities in the State of Washington

Type of facility

Surgery

All cases Total Funeral Nursing Vet Lab centers Hospital Clinic Dental Research Medical

Wastes produced (*) ... , . . . . . . . . . . . 100% 1 00% 100 ”/0 1 00% 1 00% 100”/0 100”/0 100% 100% 10070 10070

(350) (32) (43) (49) (25) (8) (51) (60) (32) (17) (33)

Wastes with excretions/secretions , ., 75 91 84 64 63 96 70

Microbiological , ., . . . . . . . , . . . . . . . . . 42 0 16 41 44 25 92 57 3 65 42

Human blood and blood products . . . . 56 88 23 2 88 38 96 63 44 53 64

Animal blood and blood products . . . . 15 0 0 69 12 0 10 0 0 59 3

Pathological . . . . . . . . . . . , ., ., . . . . . . 44 28 5 86 32 50 88 32 31 24 30

Sharps . . . . . . . . . . . . . . . . . . . . . . . . . . 94 94 98 96 92 100 98 87 91 88 100

Wastes from surgery . . . . . . . . . . . . . . 64 69 16 92 8 88 98 67 78 12 76

Dialysis unit wastes ., . . . . . . . . . . . . . 7 19 0 0 0 0 25 5 0 6 3

Contaminated animal carcasses/

bedding . . . . . . . . . . . . ., . . . . . . . . . 14 3 0 76 0 0 4 0 0 47 0

Isolation patients’ wastes ., . . . . . . . . . 32 47 77 37 8 0 78 5 0 0 6

Radioactive wastes ... , ., ., . . . . . . . . 15 0 0 0 40 0 49 10 0 53 9

Chemotherapy wastes . . . . . . . . . . . . . 18 9 2 10 12 13 69 15 0 0 18

None of the above ., . . . . . . . . . . . . . . 3 3 0 0 8 0 2 10 3 6 0

(*) percentages may not add to 100 percent because of multiple responses.

SOURCE: Washington State Department of Ecology, Solid and Hazardous Waste Program, “Report to the Legislature: Washington State Infectious Waste Project and Attachments” (Olympia, WA:

Dec. 30, 1989).
Chapter 1-Characterizing Medical Wastes and Applying a Comprehensive Management Strategy ● 15

cal wastes that separation is impractical.9 When

hazardous materials are mixed with infectious

wastes in this way, the hazardous portion needs to be

the component that is given primary consideration

for proper treatment. Some generators prefer a

treatment method (e.g., incineration) that is practical

for both hazardous and infectious materials so that

only one treatment form is required. Alternatively,

the infectious nature can sometimes by addressed

through thorough disinfection before being sent for

hazardous treatment to avoid exposure to infectious

agents during the handling process (43).

These substances may be precursors in the formation of dioxins (dibenzo-p-dioxin, PCDD) and

furans (dibenzofuran, PCDF), suspected carcinogens, when chlorine is present during incineration

(12). Metals that can be toxic, such as lead,

cadmium, chromium and mercury, are present in

medical waste. One study completed by the University of California at Davis concluded that plastics in

the waste contributed most of the lead and cadmium

(12). Although lead was found in many materials,

plastics were the primary source. Both cadmium and

lead are components in common pigments and are

used as thermo- and photo-stabilizers in plastics,

such as may be used to color red bags used for

infectious waste (12).

Low-Level Radioactive Wastes

Low-level radioactive wastes (LLW) are produced in health-care settings from administering

radiopharmaceuticals and performing nuclear medicine procedures and radio-immunology procedures.

In fact, medical and research facilities produce less

than 5 percent of the total volume of LLW generated

in the United States (1 17). It should be noted that

unlike radioactive materials used in powerplants or

the production of weapons, medically useful radioactive tracers, which are extremely valuable in

diagnostic procedures and medical research (e.g.,

testing new drugs), usually have a very short

half-life (1 17). That is, typically, half of the material

decays to a nonradioactive form in hours to days.

Hospitals usually do not store LLW with isotopes

with half-lives greater than 8 days given the significant amount of storage space this would involve

(117, 73). Currently, there are only three disposal

sites for storage of LLW in the United States.10 The

temporary closure of two of these sites in 1979 set in

motion Federal efforts to encourage States to establish more sites and spurred medical and health-care

facilities to devise a variety of new reduction and

management strategies for LLW (see box A).ll

Biological Characteristics

Pathogens in Wastes

Pathogens in medical wastes include a wide range

of bacteria, viruses, and other microorganisms (e.g.,

mycobacteria, yeasts, fungi, parasites, and rickettsia) that are sufficiently virulent to infect a human

body if they are given an exposure route (e.g., a

puncture or an open wound) (12,3).12 Clearly,

pathogens are also present in MSW (e.g., contributed by disposable diapers, sanitary napkins, tissues,

etc.), although the likely higher concentrations of

pathogens in medical waste and the level of pathogenicity of organisms found in health-care institutions and their increased resistance to antibiotics

may make them a greater threat for those who handle

the material and may also introduce the possibility

of public health concerns (43).

The important issue is the viability of the pathogens during treatment and disposal and their potential to transmit disease. Some degree of pathogen

survival in an MSW landfill is expected, for

example, but the likelihood of pathogens migrating

from a properly operated landfill is considered

extremely low, based on available research (110,

138, 116). Even so, there have been few scientifically designed experiments to measure for pathogens, e.g., in leachate or waters downstream from a

landfill (41).13

What is, radioactive tracers which are commonly used for diagnostic purposes arc commonly mixed with solvents during the extmctive procedures

and should be handled as hazardous waste, according to EPA (141).

l~~cse arc in Washington State, Nevada, and South Grolina. Not surprisingly, Lhesc States object to being the Nation’s o~y disposal sites.

1 lcongres~ pass~ the ~w.~ve] Radloactivc Waste Pollcy Act in 1980 (later amended in 1985), which -es each State responsible for providing

disposal capacity for its own LLW and encourages States to form compacts (which can exclude wastes from nonmembership States) to provide disposal

capacity. Too little waste is generated to justify a need for a LLW disposal site in every State (see 117).

12M~i~~l ~z~tc~ and Msw can Contain such organisms as: staphylococcus aurcus, candida albica~, pseudomonas, clostidiurn perfringem,

staphylococcus cpidermidis, and respiratory streptococci (12).

}~For Cx:lmplc, microorganisms such as Salmonella and Hepati~s VifUS can& carricd in water, and Can SUXWiVt3 Well (43).
16 ● Finding the Rx for Managing Medical Wastes

Box A—Management of Medical Low-Level Radioactive Waste (LLW)

Medical LLW is treated in several ways, depending on the physical form of the waste (e.g., liquid or solid) and

the type and quantity of its radioactivity. The medical LLW with short-lived radionuclides (i.e., less than 8 days)

in low concentrations is typically stored until its radioactivity is below detectable levels. The waste can then be

disposed of as nonradioactive waste. Certain liquid medical LLW that meets limits established by the U.S. Nuclear

Regulatory Commission (NRC) for radioactivity concentration and volubility in water can be disposed of through

the sewer. Certain solid medical LLW (e.g., liquid scintillation counting media and biological) can be disposed

of without regard to its radioactivity, where the radiological hazard is considered small, but the nonradiological

hazards warrant special handling and disposal. 1 The NRC considers controlled incineration of low-activity medical

LLW to be adequate treatment because any radioactivity released during the burning is well below accepted

environmental levels. Medical LLW, which cannot be stored for decay, disposed to the sewer, or incinerated, is

typically land disposed.2

The NRC distinguishes four classes of LLW: Class A Waste (contains low levels of radiation and requires no

shielding to protect workers; decays in less than 100 years and represents about 97 percent of LLW); and Class B,

Class C, and Greater Than Class C (all three of which require shielding and can remain harmful for 300 or more

years). In addition, LLW that is mixed with hazardous waste is referred to as ‘‘mixed waste” (e.g., organic liquids,

such as scintillation fluids used in diagnostic tests, comprise the largest volume of mixed LLW). Mixed LLW is

regulated by both the NRC and the EPA; at this time there are no licensed facilities to accept mixed LLW (117).3

Since 1980, total LLW volumes have been reduced by 55 percent, and estimates for reducing medical LLW

could be 70 percent or higher ( 117, 140, 136). This reduction is due to efforts by generators to reduce volume, costs,

and risks associated with LLW management. The waste min imization techniques include improved management

(i.e., segregation of nonradioactive from radioactive waste), substitution of nonradioactive materials, and

operational practices to prevent materials from becoming contaminated (1 17, 24).4 Although volume reduction to

date has already reduced the amount of LLW requiring disposal, the NRC and Agreement States have considered

reclassifying some LLW to a category for which no special handling or management would be required. Previously,

public concern over potential health risks associated with any such reclassification has worked against adoption of

any national proposal to reclassify LLW in this way. Recently, however, the NRC announced a controversial new

policy that deregulates certain low-level radioactive wastes considered nonhazardous. This so-called “below

regulatory concern” (BRC) waste would include such items as trace amounts of radioactive material and mildly

contaminated bodies of laboratory animals, which health-care and medical research laboratories could dispose of

with municipal solid waste (135).

ITM IS, such waste woutd be managed as a hazardous waste if other components of the waste are hazardous or as medical waste if tie

waste is non-hazardous (1 17, 70, 24)

2Es~tes are that two lo-foot-deep trenches, each about the sue of a footbalt field, are required to meet the amount Of LLW from medi~

and health-care settings annualty in the United States. However, the exact amount of medlcat LLW is not known (l). (See ref. 117 for a detailed

discussion of these site requirements, the efforts to date to form compacts, and other issues regarding LLW management.)

3A excepuon of M5 Sutement is scmti~tion fluids. For the most part, these substances can be treated (e.g., ~c~erated) b~ause tie

concentration of radionuclides in them falls below limits set in the XRC’s Blome&cat Rule (10 CFR, Part 20.306). Other higher concentrated

medicat mixed wastes, however, are left with no treatment or disposal ophons.

d~teres~gly, medical LLW is one M= Of waste management for which the medicat profession has been encouraging governmental

action to ensure the availability of disposat sites, and thereby the continued use of radioactwe isotopes. For example, the American College of

Nuclear Physicians has ‘‘stIongly’ encouraged officials of all levels of government to aciue~e a timely resolution of the VW issues], stressing

public safety, economy, and preservation of all the benefits society enjoys that depend on radioactive isotopes” (19).

A risk evaluation completed in King County, escapes of gases containing pathogens during loadWashington (Seattle area), concluded that reduction

in the risks posed by medical waste will best be

achieved by eliminating modes of transmission

between humans and the pathogens in the wastes

(111). Pathogens are easily destroyed when exposed

to the mean gas temperature and residence times

encountered in incineration. The main potential

routes of exposure of concern, then, are through

ing, and pathogen survival in the ash or air emissions

due to poor operating conditions (see discussion in

134). To date few test results have been published

documenting pathogen survival after incineration,

and further study has been recommended (1 34). EPA

is planning to address the issue of potential pathogen

survival in the incineration cycle in its current study

of medical waste incineration (33). The results of
Chapter l--Characterizing Medical Wastes and Applying a Comprehensive Management Strategy ● 17

Table 4-Characteristics of Medical Waste

Bulk density as fired Moisture content as fired Heating value as fired

Waste component (Ib/cu.ft.) (weight percent) (Btu/lb)

Human anatomical ... , . . . . . . . . . . . . . . . . . . . . . . . . . 50-75 70-90 800-3,600

Plastics , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-144 0-1 13,860-20,000

Swabs, absorbents ., ., . . . . . . . . . . . . . . . . . . . . . . . . . 5-62 0-30 5,600-12,000

Alcohol, disinfectants . . . . . . . . . . . . . . . . . . . . . . . . . . . 48-62 0-0.2 10,980-14,000

Infected animals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-80 60-90 900-6,400

Glass ... , .., , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175-225 0 0

Bedding, shavings, paper, fecal matter . . . . . . . . . . . . . 20-46 10-50 4,000-8,100

Gauze, pads, swabs, garments, paper, cellulose . . . . 5-62 0-30 5,600-12,000

Sharps, needles ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450-500 0-1 0-60

Fluids, residuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62-63 80-100 0-2,000

KEY: 1 Ib/cu.ft. = 16.03 kg/m3

1 Btu/lb = 2.324 J/g

SOURCE: T. Milburn, “Biomedical Waste Incineration BACT Application Considerations, ” Proceedings of the Third National Symposium on Infectious Waste

Management, Chicago, IL, April 1989, as cited in R. Barton, G. Hassel, W. Lanier, and W. Seeker, State of the Art Assessment of Medical Waste

Thermal Treatment EPA Contract 68-03-3365 and ARB Contract A832-155 (Irvine, CA: Energy & Environmental Research Corp., 1989).

this effort will be reported in the Agency’s final

report to Congress, although EPA anticipates that

further studies on the issue beyond this effort maybe

warranted (14 1).

Disinfection rates for nonincineration treatment

alternatives can also be high, if the treatment system

is properly designed and operated. A source of

general concern and confusion is the extent to which

various treatment alternatives ‘‘disinfect’ medical

wastes. The efficacy of a treatment method should

be demonstrated by development of an appropriate

biological testing program. It appears reasonable

that the degree of disinfection not be required to

exceed microbial and virulence levels that may

generally be found in MSW (111).

Physical Characteristics

The basic physical forms of medical wastes (solid,

liquid, and gas) should be taken into account for their

handling and management. Segregation of wastes by

health-care facilities into types based on these

physical states is likely to occur, e.g., liquid wastes,

non-sharp/solid wastes, sharp wastes (see tables 4

and 5).

Both physical characteristics (e.g., heat value and

moisture content) of waste components and the

biological make-up and chemical (elemental) composition of the waste are important determinants of the

most appropriate treatment technology and have

important impacts for that treatment. Despite the fact

that medical waste is heterogeneous in its physical

and chemical nature, the waste is rarely managed

initially as a mixture of all the wastes from the

facility. That is, it is likely that a medical facility will

Table 5-Comparison of the Composition of

Medical and Municipal Waste

Amount in waste,

percent by weight

Medical Municipal Hazardous

Waste component waste waste wastea

Dry cellulosic solids . . . . . . . . . 45.1 54.2 0

Wet cellulosic solids . . . . . . . . 18.0 12.2 0

Plastics . . . . . . . . . . . . . . . . . . 14.2 7.4 12

Rubber . . . . . . . . . . . . . . . . . . 0.7

Solvents . . . . . . . . . . . . . . . . . . 58

Noncombustibles . . . . . . . . . . 20.4 26.2

Pathological . . . . . . . . . . . . . . . 1.6

Heating value (Btu/lb) . . . . . . . 6,000 4,335 6,030

aFOr a typICaI comrneraal incinerator accepting a broad range Of wastes.

1 Btu/lb = 2.324 J/g

SOURCE: D. Campbell, “Hospital Waste Management in Canada,” Pro-

~wadings of the Nat]onal Workshops on Hospital Waste incineration and Hospital Sterilization, U.S. Environmental Protection

Agency, San Franciscx, CA, May 19843, as cited in R. Barton, G.

Hassel, W, Lanler, and W. Seeker, State of the Arf Assessment

of Medical Waste Thermal Treatment, EPA Contract 68-03-

3365 and ARB Contract A832-155 (Irvine, CA: Energy &

Environmental Research Corp., 1989).

collect wastes from various departments separately

(i.e., computer printouts are collected from the

accounting department; kitchen waste, patient waste,

etc. are collected separately), although they may be

mixed for treatment (e.g., incineration) (12, 139).

Given the important impact chemical characteristics of wastes can have on the effectiveness of

various treatment technologies to safely manage

medical waste, it appears sensible to keep wastes

separate based on their physical and chemical

properties, at least as carefully as possible into

hazardous, solid, and regulated medical/infectious

waste categories, to ensure the wastes receive

appropriate treatment/management. This will be true

whether incineration or nonincineration treatment
18 ● Finding the Rx for Managing Medical Wastes

technologies are used. It will also facilitate efforts to

recycle wastes when feasible and identify opportunities for waste reduction.

EPA adopted as part of its regulations under

MWTA (40 CFR Part 259) segregation requirements

to control and reduce costs for waste disposal and

minimize worker exposure to certain medical

wastes. The Agency reports, however, that facilities

in MWTA demonstration program base their segregation policies primarily on the basis of convenience

and barriers associated with reeducating their staff to

change management practices (141). A recent study

commissioned by the New York City Health &

Hospitals Corp. and conducted by Waste Tech, finds

that facilities required to comply with MWTA could

reduce the cost and volume of their waste management through more careful segregation and reduction practices (62, 63). Waste management companies also report that segregation at the point of

generation is key to containing handling and treatment costs, as well as assisting in appropriate

recycling opportunities (43) (see ch. 4).
Chapter 2

Before Treatment: Waste Reduction and Recycling

Waste management concerns now confronting the

medical waste generator are largely reflective of the

general movement toward minimizing the quantity

of waste warranting disposal. Effective management

of medical waste incorporates a waste reduction and

recycling component where appropriate. These activities should be fostered via policy incentives.

This chapter explores the implications of applying

a waste prevention and materials management approach (ch. 1) to medical wastes by considering

“before treatment” approaches to controlling medical wastes. This exploration includes a discussion of

careful on-site planning, and waste reduction and

recycling opportunities in health-care facilities.

BEFORE-TREATMENT

APPROACHES

Lessons from the management of other waste

streams, notably hazardous waste and MSW, indicate that (as noted in ch. 1) a sound control strategy

for waste management follows the basic steps of

characterizing the waste stream in light of different

treatment alternatives, segregating some wastes to

facilitate management based on these characteristics, and looking “upstream” to discover any

opportunities to reduce the volume and/or toxicity of

waste. Achieving this strategy requires some form of

planning to garner the necessary information for

reduction and management decisions.

The value of on-site management plans or strategies appears to be gaining recognition as mor e

medical and health-care facilities grapple with how

to respond to increasingly complicated regulations

for waste management (94). Waste audits of some

form are becoming more common in hospitals

and other medical institutions. The advantages of

these waste audits or more comprehensive plans for

a facility include using the information they provide

not only to devise a strategy for compliance with

environmental requirements, but also to determine

the most cost-effective means to meet requirements

without compromising the quality of patient care

and to identify waste reduction, reuse, and recycling

activities as well as other management options that

could be adopted.

Every facility must tailor its own strategy based

on its characteristics, but several areas should be

addressed in any attempt to analyze waste options.

First, the definition and segregation of wastes

should be examined because facility standard operating procedures (SOPS) for waste segregation have

a direct impact on type and cost of medical waste

treatment. For example, sometimes when a facility

designates “surgery waste” as infectious waste all

waste from that department is managed as infectious

waste, some of which could be managed as noninfectious (e.g., paper from the administrative area).

Second, the types of products and packaging

(e.g., for wastes) used in the facility and their impact

on the waste stream can be considered, without

compromising infection control goals. For example,

woven linens may be substituted for some applications of disposal linens with little risk of increased

infection potential; and, based on preliminary data

from the New York City Medical Waste Study,

considerable reduction in the volume of waste and

significant cost savings (see box B) (62, 63, 94).

Careful purchasing might help reduce the level of

toxic emissions from an incinerator. Finally, the

types of on-site versus off-site disposal options

available to a facility need to be considered from

handling and management perspectives and their

costs and risks compared.

WASTE REDUCTION

Source reduction, or prevention, of waste is

defined by OTA as “activities that reduce the

toxicity or quantity of discarded products before the

products are purchased, used, and discarded” (1 16).1

Source reduction can be achieved by: 1) manufacturers considering waste issues in designs of current

and planned medical and health-care products and

their packaging; and 2) consumers of medical and

health-care products (e.g., hospitals) directing their

purchasing decisions, product use, and the discarding of products toward waste reduction goals. The

two fundamental characteristics of wastes that are

the focus of reduction efforts are: toxicity, i.e.,

eliminating or finding benign substitutes for substances that pose risks when they are discarded; and

IA basic distinction is made between prevention and management, the latter occurring after Waste is generated.

–19–
20 ● Finding the R X for Managing Medical Wastes

Box B—Disposables: Infection Control and Waste Management Implications

It appears that the use of disposable can be carefully tailored, from an infection control perspective, to those

procedures where disposable have the greatest benefit (e.g., isolation situations). Based on a literature search of

research to date, OTA found that handwashing is widely considered to be the most important barrier to transmission

of infections (119, 53, 59, 61). A clear understanding of modes of infection transmission and the factors that affect

it can ensure that the most effective infection control practices are undertaken (53, 59,98, 105). Measures to control

infections include handwashing, the use of sterile disposable items, and other measures (e.g., closed urinary

drainage, intravenous catheter care, nontouch dressing techniques, and proper care of respiratory equipment and

perioperative chemoprophylaxis) (119, 120, 53).

In some cases, the benefits of isolation (in which typically disposable, nonwoven polypropylene gowns and

nonsterile latex gloves are used) have been demonstrated for reducing the incidence of nosocomial bacterial and

fungal infection, particularly in cases of prolonged (more than one week) intensive care for a patient (64). Yet, often

the sources of infections in hospitals are discovered to be related to misuse of medical equipment and

person-to-person transmissions. In one London hospital, the investigation of a number of incidents of

cross-infection with an antibiotic resistant infection (Klebsiella aerogenes) led to the conclusion that, ‘While many

units practise [sic] almost ritual cleansing of selected equipment, and rely heavily on disposable, there are often

circumstances when the misuse of simple ward equipment [in this case, contamination of portable suction apparatus]

becomes an accepted routine with inevitable consequences” (37a).

Some infection control measures are proven and standard practices for every hospital, while others are

supported by less extensive studies, and some proposed measures are not supported by study data (e.g., floor

disinfection). A disposable item maybe in any one of these categories regarding its value as an effective infection

control measure depending on the particular item and its use. Studies have found, for example, that nonwoven

disposable gown and drape fabrics were no better barriers to infection than reusable, woven, cotton gowns and

drapes; and, in point of fact, the protective value as well as the transmission potential of gowns, shoe covers, and

even masks has been questioned (50, 16, 59).1 Potential volume reduction of disposable linens and medical

apparatus could be considerable, perhaps between 30 to 60 percent depending on the specific health-care facility

(63).

With other disposable items, e.g., some catheters and syringes (by diabetics), reuse is not a simple yes-or-no

issue. Studies to date indicate that morbidity associated with reuse of cardiac catheters, for example, is low (46, 37,

60). With regard to the reuse of disposable syringes, it appears both safe and practical for diabetics to use disposable

syringes and needles for more than one injection (4, 52, 23, 90, 46).2

Nonetheless, the practicality of reuse, given liability concerns and standard operating procedures for a

particular health-care facility, may preclude reuse of particular medical items at an institutional level.3 Certain

disposable items though are advantageous over reusable items for various reasons including controlling infection,

saving labor costs for processing, and minimizing exposure to hazardous chemicals used in chemical sterilization

processes. The use (and reuse) of disposable can be considered on an item by item basis, in light of how they will

be used, including consideration of infection risks and other factors associated with those risks. Some institutions

are beginning to examine the opportunities for use of fewer disposable and other waste reduction options (see

below).

lb my ~~e, one s~dy reports that linen poses a higher infection risk to laundry workers tin to patients (Zla).

21t should be noted that these studies focused on the reuse by the same patient, i.e., a diabetic, using the Same S@nge. Dhbetic pati~ts

who used the same plastic disposable syringe (up to 7 days) were not found to develop infection at the site and little or no contamma “ tion of the

syringes was found (23, 90).

The American Diabetes Association (ADA) in its Position Statement on Insulin Administration states that although manufacturers of

disposable syringes recommend that they be used only once, most insulin preparations have bactenostatic additives to inhibit growth of bacteria

commonly found on the sic@ and generally “it appears both safe and practical for the syringe to be reused if the patient so desires” (4). The

syringes must be discarded when the needle is dull or if it becomes contaminated in some way. The ADA statement also discusses the importance

of such practices as good personal hygiene and proper handling of syringes (i.e., procedures to recap a syringe safely) by patients.

3The potential for ~cr~sed Habfity of a he~th-cme facility using nondisposables v. disposable for different medical apptiCatiOm ~

been raised. OTA asked only one insurance company about this concern and was told that insurance companies insure for negligence and

distinguish between real and perceived risk in such a way that the use of disposable v. nondisposables would not usually matter horn a liability

perspective. It was also noted that insurance companies do attempt to ensure that proper procedures are followed to help keep risks as low as

possible (15).
Chapter 2-Before Treatment: Waste Reduction and Recycling ● 21

quantity, i.e., changing the design or use of products

to minimize the amount of waste generated when

they are discarded.

For waste reduction, reuse, or recycling to occur

within a medical facility, a waste audit that emphasizes characterization of the waste stream and

development of a plan delineating necessary segregation techniques and education/training of the

approach to be taken to the employees of the

health-care facility is necessary. Currently, most

health-care facilities resist waste segregation because of its perceived inconvenience and the difficulty of ensuring staff compliance. The increased

costs associated with new regulatory requirements,

however, are creating an economic incentive for

greater waste segregation by health-care facilities.

From both volume and toxicity perspectives, the

use of plastics in society is a focus of waste

management concern. EPA’s recent report on plastics in MSW found that plastics production has had

an average annual growth of 10 percent for the last

30 years (132). The report also noted that “source

reduction and recycling are the best way to reduce

potential environmental impacts from plastic

wastes” and discusses a number of activities EPA

will undertake toward these ends. A higher percentage of plastics is contained in medical wastes than in

MSW, approximately 20 percent (by weight) in

medical wastes (and perhaps higher)2 and slightly

under 10 percent (by weight) in MSW (1 14, 116).3

The medical community is projected to consume 2.4

billion pounds annually by 1994 (13).

As in general public use, plastics are utilized for

both products and packaging. While single-use

disposal plastic items are often preferable from an

infection control perspective, other forces have

stimulated the use of these products. For instance, to

facilitate pricing patient procedures individually,

disposable products are individually wrapped to

make bookkeeping easier both internally and for

third-party reimbursement. Certain internal practices within health-care institutions reduce waste

even if they were not initially developed for this

purpose. For instance, inventory programs that keep

packaging and corrugated cardboard boxes out of the

health-care facility, and often times discourage

single-item packaging, can have a positive effect.

Photo credit: R. Guttman

Corrugated cardboard-including that used to specially

package regulated medical waste s-can comprise a

significant portion of a hospital’s waste stream. Some

hospitals have purchased balers to facilitate handling

and marketing of reclaimed cardboard.

Procedural trays that are prepackaged by distributors

reduce individual packaging and put all necessary

products for a procedure within a single container.

The type of plastic used and its impact on waste

treatment is one example of how waste reduction

efforts focused on reducing certain emissions can

link pretreatment and treatment management efforts.

The higher concentrations of hydrogen chloride

(HCl) in emissions, on average, from medical waste

incinerators compared with MSW incinerators may

be due to the higher levels of polyvinyl chloride

(PVC) plastics in medical wastes. Almost all of the

chlorine in these wastes is converted to HCl during

the combustion process (assuming a high combustion efficiency). In this way, chlorinated plastics

may contribute to the high emission rates of HCl and

%%e recent survey of New York City hospitaIs found 26 percent of medical waste to be plastics (63).

3Ye. @ven tit ~edic~ waste is a ~m~ percen~ge of MSW, it is likely ~t me fofu/ rele~e of HC1 from m~ic~ wrote incineration is comparably

lower (despite the higher concentration). In a local are% however, it could be a signillcant source of such emissions.
22 ● Finding the Rx for Managing Medical Wastes

possibly the formation of dioxins (particularly if

combustion efficiency is low) (114).

PVC plastics were reported to account for 9.4

percent of the weight of infectious wastes in one

study of two Houston hospitals (cited in 139).4

Concerns over hydrogen chloride generation

through on-site incineration, as well as off-site, have

begun to put pressure on the producers of plastic

medical products to switch from polyvinyl chloride

plastic to one that does not carry the same type of

environmental concerns, such as polyethylene (51,

43). Unfortunately, because of certain physical

characteristics, the PVC plastic is more desirable in

certain products. Increased efforts to find alternate

materials for products such as intravenous tubing

should be encouraged. For other products, such as

slide holders, trays, and garbage bags, manufacturers

may be able to easily substitute materials (139, 43).

Sometimes there can be a direct tradeoff between

the potential environmental harm caused by one

management practice versus another. For example,

the issue of whether using disposable or reusable

items is “better” can be difficult to determine. It

will depend on which particular goal (e.g., infection control, convenience/labor savings, cost savings, safe waste management) is deemed most

important regarding the product’s use. One

example of where such a determination has to be

made regards the use of products and equipment

generating chlorofluorocarbon (CFC) emissions,

which are used by the medical and health-care

industry to sterilize reusable items for patient

procedures.

The medical and health-care industry is responsible for less than 4 percent of the total amount of

CFCs released to the atmosphere. Given the concerns over the association of CFCs with ozone

depletion and possible global warming effects, the

American Hospital Association has recommended

that hospitals reduce consumption of all CFC-based

products and chemicals used for sterilization purposes.

5 This reduction can be achieved through the

use of disposable, but any significant growth in the

use of plastics containing CFCs might negate overall

CFC reduction. It maybe that other solutions would

avoid greater contributions to the medical and solid

waste streams, e.g., the greater use of steam sterilization or other substitutions for CFC-dependent sterilization systems, or use of non-CFC, recyclable

plastics (76, 129).

The increased use of disposable in health-care

settings is widely acknowledged, if not well documented. Battelle recently has undertaken a project,

Medpak, to study the consumption, use, and disposal

of medical products and packaging by health-care

facilities in order to assist health-care product

companies to develop products, packages, and

process concepts that would reduce the volume and

cost of managing medical wastes by hospitals and

other medical facilities (13).

The growth in the use of disposable in healthcare settings is attributable to a number of converging factors in recent decades. These include:

1.

2.

3.

4.

One

increased concern over infection control;

decreased available nursing staff (and a need to

provide more expedient treatment and more

convenient clinical practices);

increased cost of health-care labor (and concern over the time needed to handle and

sterilize reusable items); and

consideration of disposable as part of the

general solid waste stream of the health-care

facility (with, in the past, resultant low cost for

handling and disposal) (94, 17).

widely held presumption is that the use of

disposable is important from the perspective of

infection control. Nosocomial (hospital-acquired)

infections are a serious concern in U.S. hospitals,

with 2 to 15 percent of all in-patients acquiring them

and millions of dollars spent to control them (37).

Yet, infection control studies do not indicate a

constant and consistent reduction in nosocomial

infections where disposable replace reusable

products. Other factors also come into play (see

box B). Competing concerns over the cost, and

more recently the waste implications, of using

large quantities of disposable in health-care

facilities are now being raised, particularly for

products that do not have a direct effect on

infection control and patient care (e.g., disposable telephones).

4~es of plastics in products ordered by hospitals include: polyvinyl chloride, polyethylene, polypropylene, polystyrene, and polyurethane (139).

SH~th fisks t. employ=s proc.~sfig ~~pment via ethylene Ofide ~te~~tion also prompt~ con~ms. Often equipment sterilized by thiS IIMMIM,

however, cannot be steam sterilized because damage to the equipment would result.
Chapter 2-Before Treatment: Waste Reduction and Recycling . 23

RECYCLING AND SOURCE

SEPARATION PRACTICES

In addition to reduction efforts, source separation

practices (i.e., segregation of materials as they are

discarded based on their characteristics) that target

particular materials/wastes for recycling and the

most appropriate treatment method can lead to more

environmentally sound medical waste management.

Source separation before incineration or any other

type of treatment has been shown to improve the

operation of MSW incinerators, and the same may

be true for medical waste treatment as well (1 16).

Most health-care facilities segregate infectious and

noninfectious waste streams, but separation of other

items for recycling may also facilitate management

efforts. Yet, any recycling efforts must also consider

and address the potential of increased exposure to

wastes to health-care workers and waste handlers

from such management efforts.

A number of hospitals are adopting recycling

programs as part of their waste management programs, although in the past little recycling has

occurred by hospitals. A recent reported survey

sponsored by the Greater Boston Chamber of

Commerce found that hospitals were discarding tons

of waste that could be reused or sold and were paying

more than other businesses to dispose of noninfectious, commercial solid waste. Hospitals in this

metropolitan area, including Massachusetts General

Hospital and Beverly Hospital, however, have begun

paper recycling programs (9).

Some health-care facilities are planning and

developing comprehensive waste management programs, of which recycling is an integral part. For

example, Bayfront Medical Center(a518-bed acutecare community hospital) in St. Petersburg, Florida,

has proposed a recycle-and-reclaim project in conjunction with its proposed waste-to-energy system

(see figure 1). This system represents a comprehensive waste strategy designed to recycle materials as

possible, effectively render infectious medical waste

noninfectious, reduce the amount of waste going to

a landfill, generate energy to power the hospital’s

laundry, and reduce some of the risks and costs

associated with waste management (14).

Figure l—Schematic of One Hospital’s Proposed

Segregation Categories and Comprehensive Medical

Waste Management Approach

Pharmacy &

Patient care

Food Off Ice

laboratory Housekeeping

&

services supplies medical

supplies supplies

I

Hospita l

1

[

Off Ice paper Aluminum cans Green bar Regulated Cardboard

Selected plastics Batteries medical &

Selected glass

computer waste food waste

paper

I I

SOURCE: Bayfront Medical Center, St. Petersburg, FL.

Cardboard, food, and other general wastes can

comprise as much as 85 to 90 percent of a hospital’s

waste stream, with pathological and infectious

wastes comprising the rest (29, 12).6 Some hospitals

are beginning to focus on the nonpatient sources of

wastes in their facility and target materials for

recycling. For example, corrugated cardboard, computer paper, cans and bottles, and other items (which

can contribute metals, particulate, and volatiles to

flue gas emissions from incinerators) can be segregated for recycling. Batteries and other noncombustible items that can contribute air emissions

of cadmium and lead from incinerators, or if

state-of-the-art air pollution control equipment is in

place can affect the ash, can also be segregated for

more appropriate management efforts.

A Department of Energy study of three MSW

incinerators found that presorting not only reduced

uncontrolled emissions significantly, but also led to

~s estimate is based on hospital survey information reported by Cross (30), see also Cross data cited in (12).
24 ● Finding the Rx for Managing Medical Wastes

better ash burnout and thereby cut ash volume by

half and reduced its toxicity as well. Boiler efficiencies and increased disposal capacities also resulted

(heat value increased by 25 percent with presorting)

(109).7

The New York City Health & Hospitals Corp., as

part of the regional planning effort for medical waste

(see ch. 4), has undertaken waste audits of area

health-care facilities; when the results are compiled

they will set a target goal for reduction and recycling

efforts. These types of activities may become more

typically associated with efforts to establish treatment facilities.8 It appears that the emphasis will be

on recycling cardboard and other nonpatient wastes

in these New York hospitals (71, 67). Recycling of

corrugated and high-grade papers may achieve up to

20 percent waste reduction (62, 63). Yet, some items

in the entrained regulated medical waste stream may

become targets for reduction and recycling efforts as

well. For example, based on the preliminary evaluation of the waste audits, disposable linens were a

major component of this waste category (62, 63).9

An interesting finding is that the red bags and the

shipping boxes themselves comprise the largest

single component of the regulated waste stream

(perhaps as much as 16 percent) (62, 63). Alternative

forms of packaging that will reduce the volume and

weight of the waste stream, as well as potentially

some toxic components, may be considered provided they will ensure safe and adequate handling.

For example, some reusable, versus disposable,

sharp containers are available (62, 63).

The preliminary results of the New York City

medical waste study indicate that the amount of

regulated medical waste escaping the MWTA system may be as high as the amount actually captured

by it. Further, the amount of nonregulated medical

waste entrained in the regulated waste stream maybe

about 50 percent of the total captured medical waste

(63). Importantly, weight, volume, and cost reductions are predicted to be achievable through better

segregation, management, and accounting practices

at the department levels of hospitals (51). Education

is important to achieve the cooperation necessary to

ensure successful changes in such practices.

Improved waste segregation can reduce the amount

of regulated medical waste requiring disposal by 30

percent (43). Enlightened management practices can

also dramatically affect the volume of waste requiring treatment-and influence the cost associated

with managing that waste. For example, the true cost

to dispose of medical wastes from different departments can be included in costs charged on a patient

basis and become reimbursable under Medicare (see

ch. 6). Other management controls that can improve

options for waste reduction and recycling include

internal controls over unused products and materials, bulk purchasing, and adoption where feasible of

reusable products (e.g., food service items) (62, 63).

Beth Israel Hospital (a 1,000-bed major metropolitan hospital) in New York City is one of the frost

hospitals in that area to recently institute a recycling

program.

l0 The initial program involved recycling

corrugated cardboard and office paper (including

computer printouts and computer tab cards). The

program will be extended to include newspapers,

magazines, bottles, and cans. The hospital expects to

recover approximately 13 tons of computer printout

paper and computer cards and 300 tons of corrugated

cardboard per year (28).11

Beth Israel purchased a baler to improve the

ability to market the corrugated cardboard. It was

expected to quickly pay for itself, given the anticipated savings in waste disposal costs of over

$100,000 a year (based on avoided disposal costs)

(28). Colorful collection folders given to workers for

their desks, collection bins placed near photocopying machines and related work stations, and posters

and flyers explaining the goals and logistics of the

recycling program are all part of the educational and

TMedic~ waste incin~ato~ burn a higher Btu value waste than municipal solid waste incinerators (10,000 Btu V. 5,000 Btu). Mtic~ waste itse~

has been presorted and does not contain the material that one sees in solid waste that lowers Btu value, increases toxicity, etc. (43). Ag~ the importance

of good segregation practices is underscored.

8Effo~s such as ~ese could si@ficanfly r~uce tie Volwe of tic mea’s waste s~cam and will need to be taken into consideration when sizing an

incinerator (or alternative treatment method) for the region.

sos~fidicates fiat its proposed stand~d prohibits the use of reusable sh~s containers, but it nlay amend this provision if CommelMS on the

proposal and evidence indicate that no added occupational hazard is associated with the use of reusable containers (55).

IOO~er hospi~ls ~ tie New York Ciw mea also have adopt~ recycling proms, These inc]ude: ~nox fiu Hospital, Lutheran Medical Center,

Metropolitan Hospital Center, and Doctors’ Hospital (28).

1 l~e p~cipat~g ~eas of fie Hospi~l me: mamgement info~ation center, matel-ials m~gement, SUpply room for pathology, receiving for

pathology, centrat supplies, pharmacy, housekeeping, storeroom.
Chapter 2-Before Treatment: Waste Reduction and Recycling . 25

Photo credit: R. Guttman

Increasingly hospitals are adopting recycling programs to help reduce the volume of waste requiring disposal.

publicity efforts associated with the Beth Israel

Recycling Program (67).

The Iroquois Healthcare Consortium, located in

northeastern New York, has implemented an aggressive effort to educate its 56 member facilities

and assist them in developing and implementing

comprehensive recycling programs. The region’s

success stories include the Albany Medical Center,

which currently recycles over 350,000 pounds of

cardboard, paper, glass, aluminum cans, and plastic

annually. The region has also developed successful

programs working closely with local government. In

Otsego County, New York, the A.O. Fox Hospital

and Mary Imogene Bassett Hospital are two community hospitals that have worked closely with county

officials to develop and implement an effective

program now being used as a model in the development of the region’s recycling program (94).

In several areas of the country, commercial wastes

from institutions such as health-care facilities are

included in community recycling programs. In these

situations, the special nature of the medical waste

stream should be taken into account by local

planners (e.g., the lower percentage of paper content

in hospital wastes than in wastes from some other

commercial facilities). Again, health-care facilities

will need to ensure proper worker education and

training, necessary so that separation practices for

recycling will not pose increased hazards to workers.

Recycling efforts by hospitals have been inhibited in some cases by the lack of available markets

and in some cases by discrimination against discarded medical materials. For example, in New York

State glass intravenous (IV) bottles are not a

category of regulated medical wastes, but hospitals

report they are unable to successfully market the

glass for recycling because it is perceived to be

infectious/medical waste (94).

This underscores the need for greater education

efforts and better understanding of the nature and

actual public health risks posed by the various

components of the medical waste stream. In part to

address this need, the Iroquois Healthcare Consortium held a meeting sponsored by hospitals at the

Albany Medical Center in June 1990 to discuss

opportunities and existing programs for recycling

certain materials from the medical waste stream

(94).
26 ● Finding the Rx for Managing Medical Wastes

Obviously, some items (e.g., most sharps) in

health-care settings are not likely candidates for

recycling or reuse, but a surprising volume of

materials in health-care settings have reduction,

recycling, and reuse potential. For example, a new

company (a joint venture of Standard Textile Co.

and Marriott Food & Service Management) was

recently announced that will offer hospitals recyclable, protective, sterile surgical linen packs. The

company claims the specially designed barrier fabric

products (e.g., surgical drapes and gowns) will be

highly protective and safely recycled at a cost lower

than disposable (69).

The importance of product packaging on the total

waste stream can also be significant and a focus of

waste reduction efforts. Health-care facilities can

hold medical product manufacturers accountable for

reductions in packaging and for constructing products that use recycled materials and/or that are

reusable or recyclable (65).

Some organizations encourage the recovery of

medical items that would otherwise be discarded.

For example, sometimes more than one disposable

kit is opened in order to use just a part of it for a

procedure, or items are opened and then not used.

Rather than being discarded, sometimes these items

are stored, desterilized (if necessary), and then sent

overseas for use there. Outmoded medical equipment that can still be used in other countries is also

sometimes sent (139, 84). (It should be noted that no

governmental guidelines exist currently to ensure

the safety of these practices.)

An organization in Texas, the Medical Benevolence Foundation Presbyterian Medical Mission

Fund, is one such organization that collects equipment from medical facilities in the United States to

send to developing countries where it will be used

(139). A network of surgical nurses supporting this

type of ‘recycling” is being organized in Oakland,

California (84). The group, called RACORSE Network (Recycling, Allocation, and Conservation of

Operating Room Supplies & Equipment), hopes to

facilitate efforts to direct needed medical supplies

overseas that would otherwise be discarded here.12

12~g~ ~pliatiom of ~S ~ctivi~ ~d its s~e~ me being reviewed by the group. The goal of RACORSE is to help tie tie practice Safer by

establishing recommended protocols (84).
Chapter 3

Non-incineration Treatment Technologies and Trends

Of the still unresolved issues regarding medical

waste management, one of the most critical is which

technologies and controls are most appropriate for

treatment. 1 Clearly, the answer depends on the

particular circumstances of the medical waste generator and the host community for the treatment

facility. Factors such as the nature (quantity and

types) of the medical waste, the availability of

permitted landfill space, local air quality conditions,

and other demographic and geographic factors (e.g.,

urban v. rural locations) need to be considered when

selecting the most appropriate management strategy.

Safety, reliability, and costs of alternative treatment

methods and the regulatory certainty associated with

their use also affect selection of treatment alternatives. Knowledge of various incineration and nonincineration alternatives can also facilitate adoption

of medical waste policies at all levels of government.

While some States and localities actively encourage incineration as a preferred method of treatment,

others have enacted moratoriums on incinerators to

suspend permitting until further information on the

safety of the option is available or new regulations

governing it are completed. Thus, incompleteness

and uncertainty characterize regulatory activity for

medical waste management.

The dilemma now facing New York State facilities, for example, can occur elsewhere depending

upon how a State adopts regulations. Facilities there

must make management decisions regarding whether

to upgrade existing on-site incinerators no later than

the fall of 1990 in order to be able to meet New York

State’s new air quality standards by January 1, 1992.

At present many facilities are seeking treatment

technologies alternative to incineration; however, to

date the State Health Department has not developed

and implemented standards for the approval of

treatment alternatives. As a result, the State government is limiting the available treatment technologies

to the previously approved methods of incineration

and autoclaving. This delay in the evaluation and

approval of alternative technologies may prevent

many New York State facilities from using them,

including technology already approved in other

States and/or technology which could be more

attractive from both financial and environmental

perspectives (94).

This chapter, based on available information,

addresses the variety of available and emerging

non-incineration treatment alternatives, their technical capabilities, and their risks and costs. First,

treatment of medical wastes by autoclaving (i.e., a

process of steam sterilization), the most frequently

employed alternative to incineration, is discussed.

Then, a number of other alternative treatments are

examined: steam disinfection and compaction; mechanical/chemical disinfection; microwaving; irradiation;

and other emerging treatment technologies. 2 Chapter 4 discusses various incineration options, including co-incineration and regional incineration, and

pollution control issues, as well as risk and cost

implications. A comparison of non-incineration and

incineration treatment alternatives is included in

chapter 6.

Increasingly, questions are raised about the availability and performance of non-incineration treatment alternatives for medical wastes. While the

majority of medical waste is autoclave or incinerated, some medical waste (treated or untreated) is

landfilled, including some categories of infectious

wastes. The State of Washington found in its survey

of medical facilities that some infectious wastes are

about as frequently treated by autoclaving as by

incineration (139). In addition, other treatment

methods, including disposal into the sewer system,

are not rare. It should be noted again that most

treatment alternatives some form of solid waste

disposal, usually either incineration or landfilling,

will be necessary.

IIt sho~d be not~ tit ~~tment in this repofl refers to a process to render wastes noninfectious, unless otherwise indicated, sucb as ~atment to

reduce toxicity of wastes, or treatment to render wastes nonrecognizable.

z~s ~~pter relies on tie Om con~act repo~ ‘‘Medical Waste Treatment Tw~ologies,’ completed by Robert Spurg@ Spurgin & Associates,

March 1990. See alSO (30) and (73). It should be noted tht mention of a specific company or treatment technology does not constitute endorsement

of it by OTA. OTA tloes not endorse any specific application of the various incineration and nonincineration treatment alternatives.

–27-
28 ● Finding the Rx for Managing Medical Wastes

The viability of alternative technologies has

increased in recent years due to the increased cost

of incineration, the difficulty associated with

permitting incinerators, and the perceived desirability of reducing dependence on incinerators

given concerns over their emissions. A number of

States (e.g., New Jersey, California, Washington)

are attempting to encourage adoption of alternative

technologies for such reasons. EPA is conducting

several research projects to evaluate various waste

treatment technologies as required by MWTA (92).

The extent of detail contained in these EPA

studies is not known, but the Agency does report that

‘‘most of the treatment technologies are as effective

[as incineration] in rendering medical waste noninfectious” (141). In addition to the usually higher

capital, maintenance, and operating costs of incineration, EPA cites the public perception problems and

uncertain regulatory climate associated with incineration as disadvantages of incineration compared to

alternative treatment technologies (141). Landfill

availability and other factors, however, will also

influence a medical or health-care facility’s choice

of treatment technology.

Alternative treatment technologies are less capital

intensive and have fewer emission concerns than

incineration processes. Although it is important to

recognize that oftentimes more than one treatment

technology may be needed to manage all components of the waste stream (e.g., incineration of

pathological wastes that cannot be autoclave).

Further, the nature of emissions and efficacy of new

treatment technologies must be demonstrated.

AUTOCLAVING

Historically, autoclaving or steam sterilization

has been used as a treatment method in laboratory

settings to sterilize microbiological laboratory cultures (104).3 The first commercial steam sterilization

process for medical infectious waste was introduced

in California in 1978. As incineration requirements

were tightening in California, it became clear that

insufficient off-site capacity existed to replace

closed on-site incinerators, which would not meet

the State air emission standards (see ch. 5).

Autoclaving is a process by which wastes are

either sterilized or disinfected prior to disposal in a

landfill (114) (see figure 2).4 Autoclaving can be a

sterilization process if all microorganisms are exposed to the steam for a sufficient temperature/pressure/

time period to assure their destruction. The routine

achievement of sterilization can be monitored by

placing Bacillus stear other mophilus spores into the

center of a load to be autoclave. If the spores

survive, then the conditions for sterilization have not

been achieved; if the spores are destroyed (i.e., fail

to grow in microbiological media after steam

sterilization), then the conditions for sterilization

have been achieved (given the practical limitations

of this routine test).

If the spores have not been destroyed during steam

sterilization, then sterilization has not occurred.

However, some level of disinfection of the waste

would likely have resulted. Unfortunately, the level

of disinfection cannot be routinely or practically

measured. Sterilization of infectious waste is generally regarded as “overkill” for most waste disposal

situations. Disinfection of infectious waste is probably a more reasonable goal for most infectious

wastes, though some appropriate and measurable

disinfection goal should be established (1 11).

Most steam sterilizers in use for treating infectious wastes are of the high-vacuum type (92). In the

autoclaving process, bags of infectious waste are

placed in a chamber and steam is introduced for a

determin ed period of time (usually about 15 to 30

minutes) and pressure. The use of pressure helps

reduce the required time for disinfection of medical

wastes, yet the amount of time required will still vary

depending on the type and volume of waste (141).

Steam temperatures are usually maintained at 250‘F

or slightly higher (to disinfect the waste more

quickly and allow for shorter cycle times).

Autoclaving parameters, e.g., temperature and

residence/cycle time, are determinedby the factors

influencing the penetration of steam to the entire

sEthylene oxide and other gas sterikation processes are typically used to sterilize processes for medical equipmen~ but are dSO SOmebes used to

treat wastes. EPA, however, does not recommend ethylene oxide for treating infectious wastes because of its toxicity and given that other treatment

options are available (122).

4st~~ation i5 a Pmwss tit des~oys ~ ~cmorg~5m5 (e.g., Pathogem). Disinfection is a process intended to reduce the number o f

microorganisms or pathogens as low a level as possible, at least below the level at which exposure to a susceptible host could not result in an infectious

disease. Actual sterilization is not likely to be maintained once wastes leave the autoclave, m is true of incineration ash residue (see studies cited in 134);

thus, disinfection is a more accurate term.
Chapter 3-Non-incineration Treatment Technologies and Trends ● 29

Figure 2—Autoclave

SOURCE: AMSCO, Erie, PA.

load and consequently the extent of pathogen

destruction (114, 30) (see figure 3).5 Generally,

complete pathogen destruction should occur if

sterilization is the goal of treatment (92; see

discussion in 114).

A major advantage of autoclaving is its ability to

scale to various on-site and off-site treatment

requirements, including the possibility of multiple

units that can be located close to the areas where

wastes are generated. Most health-care facilities do

not use the largest available autoclaves and some

companies are beginning to market smaller, tabletop

units for use by doctors’ offices and other small

generators (141). Autoclaving is considered appropriate for treating most regulated medical wastes,

except pathological wastes (see below). Commercial

spore indicator kits provide easy and reliable quality

control capabilities for autoclave systems if sterilization is the goal of treatment (141, 92).6

Capacity and Siting Issues

Browning-Ferris Industries (BFI), the largest

off-site waste management company for medical

wastes, has employed autoclaving since 1976. Other

large waste management companies and regional

waste management firms use autoclaves as well

(104). Indeed, one large waste management firm

ssee C)W’S back~o~d paper (1 14) on medic~ waste for a more complete description of the autoclaving process md Operadng P~eters.

blf dis~ection is the goal of treatment, spore strip testing would not have a use.
30 ● Finding the Rx for Managing Medical Wastes

Figure 3—Typical Sterilization Destruction Curve

‘F ‘C

250(1 27)

240(1 16)

220(104)

200(93]

180(82

160(71)-

140(60)-

120(49)

100(38)

Temperature

O 5 lb microbiological wastes

● 15 lb microbiological wastes

10 20 30 40 50 60 70 80 90

Time (rein)

SOURCE: William Rutala et al., “Decontamination of Microbiological Waste

by Steam Sterilization,” Applied Environment/ Microbiology,

vol. 33, 1982.

reports that it is currently siting more autoclaves

than incinerators. Meanwhile, some hospitals continue to use on-site autoclaves for treating their own

medical waste. The demand for autoclaving appears

to be increasing across the Nation, as the rest of the

country begins to experience the shift from heavy

reliance on incineration and the increased need for

off-site medical waste treatment that emerged in

California in the late 1970s.

A major advantage of autoclaving is the capacity

a single unit can provide without the spatial requirements associated with incineration systems. The

capacity of an autoclave is a function of its size and

throughput. 7 For example, an autoclave capable of

disinfecting 4,000 pounds per hour of medical waste

measures 8 feet in diameter by 24 feet in length,

which means it occupies about as much space as a

500-pound-per-hour incinerator (104).

Autoclaving maybe limited in some applications

because wastes that are only autoclave are still

recognizable-unless they are then shredded or

compacted (see below).8 EPA points out that the

‘‘recognizability’ of medical wastes is only an issue

in States covered by MWTA and that most States

have not found it necessary or practical to adopt such

a requirement (141). The potentially high costs of

requiring the nonrecognizability of treated wastes

have led some to question the wisdom of a requirement to address solely an aesthetic concern.

In the past, landfill refusals of autoclave medical

wastes frequently occurred. A variety of reasons

account for these refusals, but usually they happened

because landfill operators could not easily identify

whether waste had been treated and disinfected.

Efforts to use bags that change in some visible way

in response to autoclaving (e.g., that melt in the

autoclaving process or have a strip that changes

color) apparently have met with mixed results (104).

A nonrecognizability requirement is one solution to

this problem, albeit a potentially costly one.

Another solution is for commercial users to have

their own private, permitted landfills for disposal.

Informal discussions by OTA with a number of

hospital officials across the country indicate, however, that few refusals occur if a hospital works

closely with landfill operators to explain their waste

procedures. The State of Washington reports from

its 1989 survey that 86 percent of the hospitals

responding to the survey have not had a waste

collector or landfill refuse to accept its waste

because of its potentially infectious nature (139).

For States under the MWTA program, wastes

must be treated and destroyed or rendered nonrecognizable to be exempt from the tracking program.

This would necessitate that some form of shredding

7~e ~~e of tie autoclave loading hopper and the cycle time needed for disinfection% however, affect and limit autoclave ~ou@Put (63).

8Histofic~ly, proble~tic operation has also been a factor leading some hospitals to abandon autoclavfig (1 14). Appmently, re~nt ~Provements

in the technology have minimiz ed some of these concerns. Proper operatio% however, is key to the effective functioning of any treatment technology.
Chapter 3--Non-incineration Treatment Technologies and Trends ● 31

be employed before shipping the autoclave waste

off-site; otherwise use of the manifest form would be

required to meet the tracking requirements. An

option for Congress is to amend MWTA (or

related follow-ens) to allow verified autoclaved

wastes to be exempt from manifesting. This

essentially means modifying the nonrecognizable

criteria of the regulatory program.

Suitability for Different Medical Wastes and

Associated Risks

Some wastes are not suitable for autoclaving.

‘‘ Suitability,’ however, is determined by both

technical and nontechnical factors. For example,

particular pathological wastes are sometimes considered unsuitable for autoclaving (principally for

aesthetic reasons, i.e., they will not be rendered

nonrecognizable). 9 In any case, approximately 90

percent of the regulated medical wastes generated

are suitable for autoclaving (104). Autoclaving is

considered particularly appropriate for microbiological wastes (e.g., laboratory cultures). In contrast,

autoclaves are not suitable for cytotoxic and other

toxic chemical wastes because of the hazardous

nature of these wastes. In addition, contaminated

animal bedding is not autoclave.

To the extent that autoclaving is used for only a

portion of medical wastes, then it can be used as a

supplement, more than a substitute for incinerating

medical wastes. Yet, if wastes are segregated for

treatment based on their chemical and physical

characteristics, it is likely that a smaller fraction of

waste will require incineration. Additional segregation of the items requiring incineration (or other

treatment) is not usually necessary since these

wastes are generated and/or managed separately .10

Documented health impacts from autoclaving do

not exist. It is of critical importance that certain

wastes, due to their either hazardous or pathological

nature, not be autoclave. For example, autoclaving

hazardous materials such as antineoplastic agents,

radioisotopes, solvents, or other toxic wastes could

lead to chemicals being volatilized by the steam and

could result in possible worker exposure between

process cycles. If autoclaves are of a gravitydisplacement type, steam “escapes” through an

outlet vent, most of which is condensed and drained

into the sanitary sewer.11

Potentially, if the waste itself contains trace

elements of formalin or other carcinogenic compounds, workers could be exposed to the aerosolized

compounds if they come in contact with the venting

steam (104). Once again, the importance of separating waste materials for diversion to the most

appropriate treatment method is evident (e.g., in this

case, hazardous materials to a hazardous waste

treatment option). Further study of emissions from

autoclaves is warranted based on the fact that

infectious wastes may contain significant levels of

cytotoxic compounds or low level radioactive

wastes and concerns that the presence of such

substances could lead to emission problems.

A noticeable odor in the steam discharge, described by one knowledgeable observer as ‘‘much

like styrofoam cups tossed in a campfire,” is not

known to be harmful (104). Odor-controlling tablets

that can be added to each autoclave load are

available. 12 The potential for problems with landfill

leachate associated with autoclave waste is not

known, but in general the survival of viruses in solid

waste leachate does not seem to occur.13

Costs and Volume Reduction Issues

Autoclave units are generally not as costly as

on-site or off-site incineration alternatives. An

autoclave unit will cost between $30,000 and

$100,000 installed (depending on the size of the

unit), with annual operating costs at about $0.05 to

0.07 per pound plus labor, with an expected equipme phrase “pathological wastes” throughout this report refers to wastes of human origin (e.g., tissues, organs, body parts). Pathogens and

pathogenetic wastes should be distinguished from pathological wastes (of human origin). Pathogens and pathogenetic wastes are components of the

microbiological waste type (see ch. 1).

~~or exmple, in most hospitis all tissue samples are transferred to pathology for amlysis before disposal and can be collected separately here for

incineration.

ll~ese disch~ges t. he s~tw sewer system should be fiocuous ~ their impact although ~~dus~~ waste water discharge pefit may be

required by the local sewage distict authority (see ch. 5).

]@TA&d not dete~e Whether these table~ m~kthe odor orac~ly c~gethe chefis~, orwhether their effect makes a differencefrom a h~~

health perspective.

13 See litera~e review ~d discussion by ~nberg (1 10), from w~ch the au~or concludes tit reseach hS not esmblished a relationship between

landfill leachate and solid waste and disease, and that obtaining evidence of such a relationship is difficult and further research is necessary. Also see

refs. 138, 103, 44.
32 ● Finding the Rx for Managing Medical Wastes

ment lifetime of 10 to 15 years. Landfill costs must

also be taken into account, but overall this treatment

option appears less expensive than incineration and

management of its ash residue (if it has to be sent to

a hazardous waste landfill). The State of California

concluded from its preliminary cost data that autoclaving and other non-incineration alternatives may

be more economical for some small medical facilities than retrofitting existing incinerators to meet

their newly proposed air emission control measure

(108).

If autoclave waste is not subsequently compacted or shredded, there is no significant volume

reduction. Yet, given that medical waste represents

such a small percentage of the solid waste stream, it

does not pose a significant contribution to landfill

capacity problems experienced in some areas of the

country (and landfill waste cost is usually charged

on a weight rather than a volume basis). For

example, California reports that if all on-site incinerators are abandoned for alternative treatment

methods, the medical waste requiring landfilling

would only represent 0.03 percent of the waste

currently handled at MSW landfills in the State

(108).

AUTOCLAVING AND

COMPACTION

High-vacuum steam sterilization combined with

the compaction of treated waste began in California

in 1978 and is increasingly being used in the

Northeast and Mid-Atlantic areas of the country. As

of May 1990, over 100 units are in operation. This

treatment process combines an autoclave with a

stationary compaction unit intended to handle the

regulated medical waste as well as the solid waste

from a health-care facility (see figure 4). The system

is designed to be used as an on-site treatment

alternative (104, 48, 30).14

The high-vacuum autoclave removes air, which

acts as a steam displacement barrier, and thereby

shortens the time for the steam to achieve the

necessary operating temperature (approximately 284

°F) and permeate the entire waste load. This means

that exposure to the waste is faster and the cycle time

is reduced, which is estimated to be between 40 and

50 minutes from loading to loading (104).

The disinfected waste is then hydraulically fed

into the solid waste hopper, where it is compacted

with general refuse from the facility and automatically fed into the refuse bin or trailer for hauling to

a solid waste facility. Operators are not exposed to

the treated medical wastes, reducing the risk of

exposure to sharps, fluids, or other waste items. As

with most autoclaves, no separate fuel source is

usually needed since live steam from existing boilers

in the facility’s physical plant can usually power the

system (104). The compaction process achieves a 60

percent reduction of volume of the waste, and higher

levels of up to 80 can be achieved if corrugated

cardboard and other recyclable materials are separated from the waste to be compacted and landfilled.

The system is increasingly being adopted on the

east coast, even in States covered by MWTA (where

the autoclaved/compacted waste must be tracked).

In New York State, however, the two restrictions

associated with compacted, autoclave waste have

limited the application and acceptance of this

alternative. First, the New York State Department of

Health is requiring that the sharps treated in autoclave/

compaction units, such as the San-i-pak units, must

be in compaction-resistant containers to prevent

spillage and/or exposure to sharps when the compacted waste is placed in the landfill. Second, the

‘‘recognizability’ of the compacted waste has

resulted in refusal by many local landfills to accept

the waste (94). As noted above, however, in other

areas of the country such refusals appear less

difficult to overcome with explanation and demonstration of the process to landfill operators.

The capital costs are approximately $115,000 to

$130,000 for equipment suitable for a 400 bed

hospital, with estimates of $35,000 to $60,000 for

site preparation (including utilities, slab, drainage,

etc.) (48, 94). Operating costs, according to the sole

manufacturer, San-i-pak, range from $0.03 per

pound when the solid waste disposal costs are $300

per pull (haul) to $0.10 per pound when pull costs

run as high as $1,600. Fuel costs are stated to be

$0.003 per pound of steam used (47). The operating

cost estimate includes this steam and electricity cost,

as well as repairs and maintenance, the capitalized

cost of the equipment, labor, and bags (48). The

systems have an expected lifetime of 15 years

(similar to that of most incinerators). The operating

laFour sizes of the autoclave and compaction unit are available which will accommodate 1,3,7, or 16 autoclave bags, m=s~appm~ately 38x44

inches each in a given cycle. Some limitti attemp~ have been made for a commercial off-site use of the technology; such use, however, does not appear

as practical as the on-site application for which the unit was designed (104).
Chapter 3-Non-incineration Treatment Technologies and Trends ● 33

Figure 4—Autoclave and Compaction Unit

Sterilizer

load door

(for medical

wastes)

Compactor

load door

(for other

solid

wastes)

(roll-off)

interface

Time and

Compactor

temperature

control

chart recorder

panel /

Sterilizer

/

control

panel

Ratchet I

jack “eye” Gauges

connector

SOURCE: San-i-pak Pacific, Inc., Tracy, CA.

cost includes hauling costs for infectious and general

wastes, and specially hauled wastes, i.e., chemotherapeutic, radioactive, and pathological wastes (estimated to be less than 1 percent of a facility’s total

waste).

MECHANICAL/CHEMICAL

DISINFECTION

Chemical agents such as chlorine have been used

as disinfectants for medical products for some time,

although the application to large volumes of infectious wastes generated by hospitals and laboratories

is more recent (104). This type of technology, which

has been available since the mid- 1980s, is referred to

as “mechanical/chemical’ because of mechanical

maceration and chemical disinfection (a result of

forcing a reaction that occurs to volatilize waste

material and expose all of the pathogens to a

chemical disinfectant in a controlled environment);

the residue is discharged to the sewer system.15

Chemical disinfection processes, according to

EPA, are most appropriate for liquid wastes, although they can be used to treat solid wastes (122).

The appropriateness of the process for pathological

wastes is not clear (92). A number of factors should

be considered regarding the effective use of chemical disinfection, including: the types and biology of

microorganisms in the wastes; degree of contamination; type of disinfectant used (usually sodium

hypochlorite, commonly known as chlorine bleach)

and its concentration and quantity; the contact time;

mixing requirements; etc. (122). As with other

treatment alternatives, efficacy of the method needs

to be demonstrated through the development of a

biological testing program and monitoring on a

periodic basis using appropriate indicators in order

for the system to be adopted and used on a routine

ls~s me of system is also sometimes referred to as “hydropulptig” (see 30).
34 Ž Finding the Rx for Managing Medical Wastes

basis. Test results reported to date find the process,

using chlorine bleach, to be an effective disinfectant

for medical wastes contaminated with vegetabl e

bacteria and viruses, but less effective against

spore-formin g bacteria (92).16 No standard protocol

has been developed to evaluate the efficacy of the

system and to assist in developing standard operating procedures for it (92).

Maceration of the medical waste, involving highspeed hammermill blades and/or shredders, requires

use of copious amounts of water. To keep the unit

from overheating as well as to disinfect the waste,

water is introduced along with the disinfectant

(usually chlorine-based) during the maceration phase.

The simultaneous volatilization and introduction of

the disinfectant is designed to render the wastes

noninfectious. The introduction of water creates a

liquid waste, which is discharged to the sewer.17

This means an industrial waste water discharge

permit from the local sewage district may be

required.

According to Research Triangle Institute’s (RTI)

contractor report to EPA, “Once the proper operating parameters such as the flow rates for water and

chlorine solutions are established the device is

simple to operate and requires little training” (92).

The nonrecognizable nature of the byproduct of the

mechanical/chemical treatment process and its ability to treat liquid medical waste before discharging

it to the sewer system are important factors accounting for the favorable market response to this

treatment alternative. The waste treated by the

process is rendered nonrecognizable by the shredding and pulverizing phases, which are primarily for

treatment efficiency but act to destroy the waste as

well (104).18 This means that the waste meets the

nonrecognizability criteria of MWTA and would not

have to be tracked under its manifest system.

Increased concern over the practice of discharging

untreated liquids (e.g., blood and other body fluids)

into the sewer system also makes the mechanical/

chemical process with its discharge of treated

liquids an attractive alternative. Yet, it is not clear

that this system would reduce any risks that might

exist as a result of direct discharges in a facility of

blood and body fluids into the sewer system (see ch.

5). Further, the sewage system contains countless

human pathogens from the vast quantity of human

body waste. Liquid medical waste comprises only a

minor fraction of this overall waste flow. Microbiologically, there is little difference between blood

waste and fecal/urine waste (except that fecal wastes

would be expected to have a far greater number of

human pathogens) (11 1).

The process is designed for on-site use with

possible applications to a variety of medical and

health-care settings (see figure 5). The frost company

to manufacture such a system (Medical SafeTec.,

Inc.) currently offers three machines, one for larger

applications and the other two for laboratory settings. A similar system was designed by a company

for application in the funeral industry. This company

also has a clinical machine for sharps and plans to

offer over 200 separate machines for a wide variety

of health-care applications. While the one company

is offering a system that would require a large

facility to purchase one unit, the other company is

marketing smaller machines for use throughout the

hospital (104).

States such as California and New Jersey, which

are open to innovative technology for medical waste

generally, are a responsive market for this alternative. Some large generators converted to this system,

rather than replacing or retrofitting existing incinerators (104). Currently, about 40 of the smaller

units are in use, primarily for sharps management.

These systems can treat pathological waste (e.g.,

formalin-fixed tissue samples) and most other medical wastes. 19 The system is powered electrically with

standard electrical requirements. Sewer connection

is mandatory, and, as noted, a local discharge permit

may be necessary. Concern has been raised over the

level of metals, organics, and other contaminants

that may be in the sewage discharge (5).

IGHward and ocwpation~ risk from tie handling, storage, and use of chlorine have been suggested as a potential disadvantage of ~s tec~olog’y

(94).

17Repofiedly, systems that shred and disinfect medical wastes that will not require use of copious amounts of water or a sewer dkchge are being

developed (63). One such process will combine conventional shredding technology with the use of special red bags. These red bags have a small seam

that envelops a few grams of formulated powder (a water-activated disinfectant). Treated material is “only slightly moist, no longer

recognizable. . disinfected and volume-rcxiuced” (78).

18A pres~~~g system which is part of the large hammermill, breaks up the waste materials before the ha.mmermill pulverims hem.

lg~e EPA s~tes, however, that these units are not normally recommended for patiOIOgicd waste ~es (141).
Chapter 3-Non-incineration Treatment Technologies and Trends .35

Figure 5-Mechanical/Chemical Disinfection Unit

Negative pressure

Mepa filter system blower

1

SOURCE: Medical SafeTec, Inc., Indianapolis, IN.

The percentage of dissolved solids in the discharge into the sewer is high (up to 10,000 ppm v.

300 ppm for residential users), but the manufacturer

states that changes necessary to reduce the level to

that of other points of discharges are now feasible

(104). Even so, the liquid effluent contains high

concentrations of substances, e.g., chlorine, that may

require pretreatment before being discharged to the

municipal sewer system. It would appear that local

permit levels for sewage discharges would have to

be met.20

Solid

waste

collection

cart

\

designed to control emissions and force air through

a series of prefilters and a chlorine-resistant falter

before discharging it to the atmosphere (141, 5). The

use of chlorine and the potential impact on sewage

discharges is also raised as a concern with the

chemical disinfection process. Further study of these

issues is needed, possibly as part of EPA’s current

research on alternative treatment methods.

There are no air quality regulations that are

relevant. Although it is not clear there is a need for

any air regulations, given that no known air emissions problems have been encountered, little has

been reported about the nature of the emissions.

There is some concern over the potential for

producing volatile chemicals and/or microbes during the shredding process, although the system is

The mechanical nature of the equipment, with so

many moving parts, means it could require a high

level of maintenance. This also means there is more

potential occupational exposure. The manufacturers

note that no injuries involving equipment repair or

maintenance have been reported.21 As with an

autoclave unit, the space needed for a mechanical/

chemical unit is not large and the capacity is then

mainly a factor of the throughput rate for the unit.

The smaller units require an area approximately 10

20R~ (92) ~Wo~ tit~a~te ~eatment effluent from the Medical S~eT& tit has been tested according to the specitlcations published under the

Clean Water Act for pollutant analysis (40 CFR, Part 136).

21Ye~ ~S ~th o~er ~eatment ~ternatives, it is not clear how fr~uently a~idents are reported (given mncerns OVer pOteIl~ hpiiCtS 011 kMIKZIIICe

pre miums, etc.).
36 ● Finding the &for Managing Medical Wastes

feet by 9 feet and the units with additional capacity

would require areas of 11 feet by 10 feet.

Capital costs are approximately between $40,000

and $50,000 (equipment and installation) for the

smaller units and approximately $350,000 for the

larger sized unit. Operating costs are reported to be

$0.06 per pound of waste per hour of treatment

(104).

MICROWAVE

The application of microwave technology to

disinfect medical waste was introduced in Europe

several years ago. The technology is from West

Germany and just recently is being marketed in the

United States (34). The units can be on-site or

mobile facilities. The first on-site installation was in

North Carolina in March 1990. A second commercial system began operation shortly after this in

California as a supplemental technology to an

existing regional incinerator (104, 34).

Powered by electricity, the unit shreds the waste

in a controlled environment; the waste then enters

the chamber for exposure to the microwaves (see

figure 6). The disinfection process takes place

through microwave heating, which occurs inside the

waste material (unlike other thermal treatment

methods which heat wastes externally) and wetting

and shredding the waste to facilitate heating and

steam penetration of the waste. The material is

discharged to a storage bin for ultimate disposal.

Computerized controls, as with most other treatment technologies, are used to ensure the minimum

parameters for disinfection and proper function of

the equipment. Fire and temperature conditions

necessary for waste sterilization are the same as

those for autoclaving (92). Studies conducted in

Germany by the Institute of Hygiene, University of

Gottingen concluded that the process treated material to a lower level of bacteria content than

ordinary household wastes (as reported by ref. 35).

Performance tests at a unit operating in the United

States, using a Bacillus subtilis microbiological

spore test indicator, found the wastes to be treated

under conditions to render it sterilized (35). Research Triangle Institute reports that although the

method is essentially a steam sterilization method, it

is necessary to confirm that conditions required for

steam sterilization exist in the microwave process

(92).

Photo credit: Vetco Sanitec Corp.,

Combustion Engineering, Stamford, CT

Microwave units can be installed on-site or be used as

mobile units. Mobile units could facilitate collection of

regulated medical wastes from home health-care settings,

doctor offices, and other small generators of medical

wastes. This type of mobile microwave unit has been used

in Berlin, West Germany for several years.

As with autoclaving, approximately 90 percent of

medical wastes can be treated by this method (it is

not recommended for pathological wastes). The use

of electricity averages about $0.02 per pound.

Energy use is reportedly lower than that of an

incinerator (35). The shredding process results in a

volume reduction of 80 percent prior to disposal.

Treated wastes are suitable for disposal in a solid

waste landfill. Given that the process is used in

Europe with no reported emission problems, its

acceptance is anticipated in the United States (35,

104).

The microwave system is designed to be operated

by unskilled labor. All adjustments in wastes levels

and time are preprogrammed into the system (92).

Operating and maintenance costs are reported to be

approximately $0.10 or $0.07 per hour, depending

on whether the system is operated 8 hours or 10

hours a day, respectively. Capital costs are about

$500,000 for a unit (35). It appears that health risks

associated with the unit would primarily be associated with the maintenance of the shredder component of the system. Potential operator exposure to

volatized chemicals during loading or cleaning/

maintenance should be examined,however .

IRRADIATION

A common practice is to treat medical products

with radiation for sterilization purposes (104). The

high cost of cobalt used in the process and high

operating costs have discouraged commercial ventures from using the technology for medical waste

management. In February 1990, however, the first
Chapter 3-Non-incineration Treatment Technologies and Trends ● 37

Figure 6—Mobile Microwave Medical Waste Disinfection Unit

\

u

12

o11

I

I

1

‘%31 0)

- 13o

1.

2.

3.

4.

5.

6.

7.

8.

9.

Process scheme of a mobile microwave-disinfection unit

Feeding hopper

Feeding crank

Shredder

Connecting hopper

with inspection window

Level sensors

Main conveyor auger

Microwave generators

Temperature holding section

Discharge conveyor auger

SOURCE: Vetco Sanitec Corp., Combustion Engineering, Stamford, CT.

commercial medical waste irradiation facility was

opened in Arkansas, and additional facilities are

planned in California and New Jersey. Questions

have been raised about the actual process of radiating the material and achieving adequate disinfection

(104) (see figure 7). Garoma radiation sterilizes

infectious waste by penetrating the waste and

inactivating microbial contaminants. The ionizin g

radiation hydrolyzes the water molecules within the

10.

11.

12.

13.

14.

15.

16.

17.

Temperature sensors

Filter system, 2-stage

Water tank with pump

and spraying connection

Steam generator

Steam connection

Hydraulic aggregate

Room heater

Container

micro organisms and these intermediate hydrolysis

products interact with the gamma radiation and

biological compounds, are broken down and are

rendered noninfectious. The company pursuing this

treatment technology emphasizes that the waste will

not be disposed of as solid waste. Rather, it is

shredded, rendering it nonrecognizable, and is

shipped to a cement kiln where it is burned as fuel

(104).22 Eventually, one such operator of a system

~t should be noted that concerns have also been raised about the practice of burning wastes in cement kilns, which typically are not subject to air

emission standards (other than the new source performance standard (NSPS) for particulate matter emissions). The assumption is that these kilns operate

at such high temperatures that wastes used as fuels are destroyed without producing harmful emissions. This is an unsettled regulatory issue. It is true,

however, that any cement kiln burning MSW would be subject to air emissions standards for MSW incinerators as proposed by EPA in December 1989.
38 ● Finding the Rx for Managing Medical Wastes

Figure 7—irradiation Unit

Cobalt 60 radiation chamber

Infectious waste

SOURCE: Technology Process, Inc.

plans to separate the plastic waste and sell the treated

plastic residues for recycling (92, 101).

The process is highly predictable, according to

RTI’s analysis (92). Verification of the conditions

for disinfection involves using Bacillus pumilis as a

test indicator organism. According to RTI, no

studies specifically addressing the efficacy of gamma

irradiation of medical waste for disinfection (92). In

addition, film is placed between every few boxes to

quantify the amount of radiation each box receives

(104).

Again, this treatment method is not recommended

by EPA for pathological wastes. The capacity of

these units is a factor of the throughput rate. The

units are an off-site alternative and can manage all

types of waste, except pathological wastes. The

approximate operating cost could be $0.15 per

Treated waste

pound. Potential risks of this alternative treatment

technology are primarily associated with the possibility of radiation exposure to workers.23

OTHER POTENTIAL

TREATMENT TECHNOLOGIES

Other technologies with potential application to

medical waste management are in a conceptual or

experimental stage in their development. Several are

mentioned here to illustrate the variety of attempts

to develop treatment alternatives for medical wastes.

One technology that has recently been announced

as available and capable of thermally destroying

biomedical wastes uses an electric molten glass

furnace. At least with other waste types, the wastes

are fed into the furnace and are subjected to intense

heat (2,300 ‘F) and air and water vapor. The result

~Worker~ ~pma@ ~ese systems ~~~d ~ve to be @ained according to tie IfJ ~ ‘‘S~nd~ds for Protection Ag&t Radiation” re@tiOIIS.

Operators would need to be highly trained to ensure the efficient and safe operation of the process.
Chapter 3--IVon-incineration Treatment Technologies and Trends ● 39

is the vaporization or oxidation of some wastes and

a inert stable glass residue (87).

Electrohydraulic disinfection and pulse-power

technology were created as disinfection systems for

contaminated liquids. Their uses are not widespread,

although the concept of applying the technology to

medical waste disinfection has been suggested. It

appears that the perceived high cost of this technology is a major reason it has not yet been developed.

The process involves the use of pulsed plasma of

electrical discharges in water, using ultraviolet

radiation, hydrogen, hydroxil, ozone and shock

waves to act as disinfectants. One application of

pulse power technology does not require the use of

radioisotopes (104).

Future application of plasma torch technology to

medical wastes (and other hazardous wastes) has

been suggested (42, 39, 31). A “pyroxidize,” a

small pyrolysis on-site laboratory waste disposal

unit, is being developed (92). Another recently

announced potential treatment technology is an

electrocatalytic oxidation system (38).

Adaptations of existing technologies have been

suggested, for example, a sterilization/dry grinding

method (30). This system would combine an autoclave system with dry grinding/shredding in a

hammermill to achieve both volume reduction and

nonrecognizability of the wastes. Projected costs for

this hypothetical alternative treatment are $0.08 per

pound (30). It is not clear whether the increased

maintenance cost usually associated with shredders

is taken into consideration in these calculations. One

reason frequently given for the limited application to

date of shredders is that they require a high level of

maintenance. Thermal inactivation or dry heat

sterilization, reportedly sometimes used for both

solid and liquid medical wastes, also could possibly

be used in conjunction with a shredder or compactor

(although it is not considered as efficient as steam

disinfection) (73).

SUMMARY

Several non-incineration alternative treatment

technologies for medical wastes are commercially

available, others are at a conceptual or developmental stage. Autoclaves, autoclave/compaction units,

mechanical/chemical units, and most recently microwaving and irradiation treatment alternatives are

in use in medical facilities across the Nation. Most

of these units are on-site treatment alternatives and

most appear less costly than incineration. Many of

the alternatives will achieve significant volume

reduction (of 60 percent or more) of the medical

waste and all can render wastes nonrecognizable (if

a compactor or shredder is added). Weight reduction

may or may not occur, particularly if water is added

during the treatment process. In fact, some of these

treatment alternatives can add to the weight of

waste, given their use of water. These alternatives

appear to have fewer emissions concerns (although

these warrant further study) than incinerators. Most

of these alternatives do not appear appropriate for

pathological wastes.

Health risks associated with these technologies

have not been thoroughly investigated. Further

examination of potential health risks is warranted

(particularly for the newest applications, e.g., microwave and irradiation). When any waste treatment

alternative is considered, any new or additional

employee exposures that could result from utilizing the new method should be identified and

evaluated.

Before adopting a medical waste management

strategy, medical waste generators must first know

the applicable regulatory requirements and then

assess the capabilities, costs, and associated health

and environmental risks of various treatment technologies as applied to their facility in order to adopt

the most appropriate technology for their needs. It is

likely that the emergence of these non-incineration

alternative treatment methods will reduce but not

eliminate the current level of dependence on incineration for medical wastes. Many of these alternatives

can be viewed as supplementing the use of incineration for treating medical wastes. Pathological wastes

are the one type of regulated medical wastes for

which incineration remains the preferred treatment

alternative (122, 92).

It appears most prudent for any regulatory program for medical waste to avoid directly or indirectly encouraging a particular type or application of

treatment technologies. Rather, flexibility for the

generators to meet their management needs and

comply with regulatory requirements will allow for

adoption of the most appropriate treatment options

and help ensure safe management of medical wastes.

Government agencies, particularly EPA, could

facilitate the evaluation and adoption of new

treatment alternatives by developing a program

for demonstrating the efficacy of a treatment
40 ● Finding the Rx for Managing Medical Wastes

method. A general protocol for the certification of

approval of any type of waste treatment technology

(e.g., hazardous, solid, medical) could be established

with adjustments made for developing appropriate

testing programs (e.g., biological testing of medical

treatment methods).

Interim approval status might be given while test

protocols and results are developed and/or pilot

projects, perhaps at veterans’ hospitals or other

government facilities could be used. Monitoring

new facilities on aperiodic basis, perhaps with some

supporting funding, could facilitate developing appropriate operating parameters and specifications. A

program similar to the Superfund Innovative Technology Evaluation Program has been suggested as a

model for a program evaluating new medical waste

technologies (31, 124).

Such efforts could help ensure that government

regulatory activity does not create barriers for

evaluation and adoption of new technologies. An

important task for State and Federal regulators then

is to rid the current regulatory system of inconsistencies and ambiguities and enable the “market” to

move ahead with optimum management solutions.
Chapter 4

Incineration Treatment Issues and Trends

Incineration of medical wastes remains a prevalent treatment method in the United States.l It is also

the treatment technology most often used for medical wastes in other Western countries (57, 58). The

advantages of incinerating medical wastes, are those

associated with the incineration of any type of waste:

significant volume reduction (by about 90 percent),

assured destruction, sterilization, weight reduction,

and the ability to manage most types of wastes with

little processing before treatment.2 The disadvantages include potential pollution risks associated

with incineration processes and increased costs

associated with controlling pollution emissions (114,

116). 3

In some European countries it appears that

regional off-site incineration facilities have been

encouraged to optimize the economical application

of advanced pollution control technologies (57). In

the United States, incineration continues to occur

on-site in smaller units, most of which have few or

no pollution controls. As some States adopt more

stringent air standards for medical waste incinerators, 90 percent or more of these existing units can

be expected to retire when these new standards go

into effect within the next several years (e.g., New

York State, California) (12). New on-site as well as

off-site units can be designed to meet stringent

emission control standards, and some older, on-site

facilities can be retrofitted with air emission controls

(if sufficient space and the economics make this

practical). Retrofitting can include modifying the

incinerator, adding or changing pollution control

devices, or both.

While new regional facilities are being established and other new on-site facilities are operating

in the United States, it is also likely that incineration

will be supplemented by other treatment technologies. Nearly 80 percent of the hospitals in California

use alternatives to on-site incineration (49). Several

interrelated factors account for the likely decreased

dependence on incineration:

1.

2.

3.

4.

the increased cost of incineration due to

increased equipment needs to meet new emission standards and permit requirements;

siting and permitting difficulties associated

with locating new incineration facilities;

regulatory uncertainty associated with incineration requirements at the local, State, and

national levels of government; and

the increasing availability of nonincineration

alternatives for treatment of medical wastes.

In fact, increasing concern over incineration in

general and particularly for medical waste has

resulted, in some States, in indirect regulatory

encouragement for developing alternative treatment

technologies.

More specifically, the regulatory emphasis by

States has been on operation requirements for

increasing temperature, residence times, and combustion efficiency to foster destruction of toxic

compounds in the combustion process in order to

preclude their release to the atmosphere. The required temperatures are tending to be set increasingly higher than necessary to destroy pathogens.

According to EPA, the incinerator conditions needed

to destroy gas stream pathogens emitted from the

medical wastes are a function of temperature,

residence time, and good mixing to preclude ‘pockets’ of gases (which do not reach the required

temperature). Based on limited available data, at

typical residence times, temperatures (for the secondary chamber) necessary for pathogen destruction

are 1,600 ‘F or more. Most existing regulations

usually require temperatures of 1,800 or 2,000 ‘F,

higher than the temperature probably needed for

pathogen destruction, but considered necessary to

control other emissions such as volatile organics

(e.g., chemotherapy agents) (41).

Incineration technology continues to evolve, and

more sophisticated pollution control equipment is

becoming available. Another source of concern,

IMost of ~ese~c~erators are of tie controlled-air type (see below and 114). This type of incinerator is popub.rfor medicd wastes because it mica.llY

is more fuel-efficient and has lower particulate emissions than other smaller, modular combustion systems and its solid hearth can vapor-combust liquid

wastes and ensure that needles are rendered noninfectious.

2A]tiough separation of noncombustibles and items with problematic constituents improves maintenance and possibly air emissio~.

30nce other ~mtment me~ods (e.g., ~utoclaving) me more ~oroughly s~died, however, ~creased coscs to ensure tieir enviromnenti safety may

also occur. Nonetheless, most nonincineration altermtives are less capital-intensive than incineration.

-41 –
42 ● Findingh the Rx for Managing Medical Wastes

however, is the potentially hazardous nature of

incinerator ash. As air pollution control equipment

becomes increasingly effective in removing particulate matter and toxic substances from flue gases, the

potential toxicity of fly ash collected from the

equipment is likely to increase.4 Effective destruction of toxic substances during combustion (i.e., of

some organic chemicals, as opposed to metals)

would minimize the presence of those substances in

flue gases; this would reduce the amount requiring

removal by pollution control equipment and thereby

reduce subsequent concentrations in fly ash residues

collected from the equipment. The toxic materials

captured in the fly ash are usually disposed of in a

landfill. 5 Limited data available on the constituent

nature of medical waste incinerator ash indicates it

can contain a number of hazardous substances (e.g.,

heavy metals; and dioxins and furans in fly ash) (as

reported in 114) (54a).

The presence of a toxic substance in ash does not

necessarily mean it presents an environmental hazard. This depends, for example, on its volubility and

how it is managed (e.g., whether conditions will

allow leaching or gaseous emissions that lead to

inhalation or ingestion of the substance) (116). In

this light, the nature and management of ash from

medical waste incinerators requires careful consideration. To date, little information is available about

its nature and potential hazards.6 EPA, as part of its

NSPS test program, will be collecting and analyzing

both bottom ash and fly ash samples for dioxins and

heavy metals.

This chapter reviews: 1) the regulatory trends

driving the market and development of incineration

options; 2) capacity, cost, and risk issues associated

with incineration; 3) current trends in the selection

of air pollution control systems; and 4) prospects for

co-firing medical waste with other waste types and

for regional incineration.

REGULATORY TRENDS AND

MEDICAL WASTE

INCINERATION

Currently, trends in medical waste management

are primarily being driven by State regulation,

particularly of air emissions, of medical waste

incinerators. At the Federal level, the Clean Air Act,

which is being re-authorized, is a source of concern

to the medical waste incineration industry.7 Less

attention has been paid to the regulation of incinerator ash from medical waste incinerators. Increased

State and/or Federal regulation of ash disposal could

increase insurance (due to potential RCRA and

“Superfund” liabilities if it is considered hazardous) and other operating costs for managing the ash

(presumably off-site at a specially controlled

landfill). s

The Waste Combustion Equipment Institute (WCEI)

testified before the Senate Committee on the Environment and Public Works that the proposed Clean

Air bill would inappropriately apply standards for

large MSW incinerators to incinerators of different

types and for different wastes, such as medical

wastes (45). At the same time, EPA is in the process

of formulating its new source performance standards

(NSPS) for medical waste incinerators under its

existing authority in the Clean Air Act. They are

expected to be proposed in 1992. Some NSPS and

other types of Federal standards have been established for MSW.9 The Agency initially considered

4F1Y ash is comp~s~ of fight p~icles that me either carried off the grate by turbulence, or that condense ~d fOrm ~ tie flue gas ~ the bofler sYstem.

Bottom ashis the residue from combustion (ash) that accumulates on or falls through the grate of the incinerator. Most volatile metals (e.g., lead, mercury,

cadmium) are concentrated in fly as& whereas other types of less volatile metals (e.g., al uminu chromium iron) are concentrated in bottom ash (1 16).

sc~en~y, ~ the sate rewlates an ash tes~g pro-, the material should be tested, and if it is h~dous it sho~d be sent to a ~ardous waste

facility. See OTA (1 16) for a discussion of the current unresolved state of ash regulation at the national level.

GAItiou~ Wrote wmgaen~rnc. indicates that its testing of medical waste incinerator ash det ermined that the quality of the ash is similar to MSW

incinerator ash (43). See OTA (1 16) for a discussion of the nature and management of MSW incinerator ash. Quberand DrUIU (66) report that EP toxicily

tests at one facility with advanced pollution control equipment have tested the ash and found it to be nonhazardous.

~SCA 7401 et seq.

8See OTA, 1989 (1 16) for a more de~led ~scussion of MSW ~c~emtor ash ~d possible m~gement ad r@atory scendos. presumably,

medical waste incinerator ash, which has been found to be more hazardous than MSW ash in some cases, would be regulated in a similar way as MSW

incinerator ash (54a).

9CWenfly, at me Federal 1evel, NSPS for p~ic~ate matter and opaci~ ~ssions ~set for MSW ~ctierators. MSW incinerators dSO must meet

the mercury standard which is regulated as a hazardous air pollutant and the national ambient air quality standards [set for such pollutants as nitrogen

oxides and carbon monoxide (1 16)]. The revised NSPS for MSW incinerators, proposed by EPA on Dec. 20, 1989, would cover acid gases,

dioxins/furans, nitrogen oxides, carbon monoxide, and metal emissions and revises the particulate matter and opacity standards to more stringent levels

(41). In additio~ emission guidelines for existing MSW incinerators were also proposed in the Federal Register on Dec. 20, 1989.
Chapter Incineration Treatment Issues and Trends ● 43

including medical waste incinerators in their proposed air emission standards for all incinerators

burning more than 50 percent MSW on November

30, 1989. Those proposed standards would have

applied to most medical waste incinerators and

required a 90 percent reduction in air emissions

through emissions limits, operating standards, and

some source separation and recycling requirements.

Apparently, at this time EPA is considering a lower

size cutoff for the MSW NSPS standard, which

would essentially exclude medical waste incinerating. Instead, a specific NSPS for medical waste

incinerators would be adopted (41).

At the State level, over half the States have

changed their requirements for medical waste management within the last 2 years (107). Most of this

regulatory activity focuses on setting stricter air

emission standards for medical waste incinerators.

Currently, the standard-setting process for air emissions from medical waste incinerators in California

is attracting considerable attention (see box C). The

California Air Resources Board (CARB) is proposing regulations for medical waste incinerators that

would require reducing emissions of dioxins by 99

percent or to 10 nanograms per kilogram. There is no

cadmium requirement, but local air districts are

recommended to evaluate the need for such standards on a case-by-case basis.

Originally, the proposal required the use of a dry

scrubber/baghouse combination for air pollution

control equipment, as the best available control

technology (BACT), to achieve the desired removal

rates. Any other technology that could document the

necessary reductions in dioxins could also be

Box California and Its Dioxin Control Measure: A Case Study of One State’s Approach

to Regulation of Air Toxics and Medical Waste Incinerators

On July 12, 1990, a proposed “air toxic control measure” (ATCM) requiring a 99 percent reduction in dioxins

or control to a level no greater than 10 rig/kg of medical waste burned was adopted by the State of California.1 It

is the culmination of an effort begun when the California Air Resources Board (CARB) identified dioxins as toxic

air contaminants in July 1986.2 CARB is required to evaluate the need for and the appropriate degree of control for

a compound that is identified as a toxic air contaminant (106, 108).

Through a formal risk management process, medical waste incinerators were found to have the greatest

individual risk potential of all dioxins sources the State identified. This, combined with the facts that most of the

incinerators are uncontrolled and located in residential areas and that emission test results from eight test facilities

found that they were also sources of other pollutants (e.g., cadmium, benzene, polycyclic aromatic hydrocarbons,

lead, mercury, nitrogen oxides, sulfur dioxide, particulate matter, and hydrochloric acid), led CARB to give medical

waste incinerators the highest priority for the dioxin ATCM (106, 108).

CARB identified 146 facilities that incinerate medical wastes in the State of California. Of these, 137 are

on-site facilities incinerating 28 percent of the total amount of medical waste incinerated, and 9 are off-site, regional

facilities incinerating the remaining 72 percent of the medical waste incinerated. The on-site incinerators are

typically located at a medical facility and mainly incinerate general solid waste (70 to 95 percent by weight of the

total amount of waste incinerated), similar to MSW, with infectious and pathological waste (5 to 30 percent by

weight of the waste incinerated). The incinerator may generate steam and hot water, but the only current air emission

regulation is a particulate matter emission standard set by the local air pollution control district (49, 106, 108).

Regional incinerators in California are located to serve many medical facilities and incinerate only pathological

and infectious wastes. These facilities have particulate matter and HCl emissions regulated by the local air pollution

control districts and the Department of Health Services (49, 106, 108). These regional facilities manage nearly 75

percent of the infectious waste incinerated in the State (8,700 tons per year of the 12,105 tons per year of infectious

l~ter tie a&ptiOn of the CARB control measure, local air pollution control districts have 120 days to propose ad 6 monti to adopt

a regulation at least as stringent as that adopted by CARB (106, 108).

2~cordfig to Califofia law, a tOXiC fi conti~t “an air pollutant which may cause or contribute to an increase in mortality or

an increase in serious illness, or which may pose a present or potential hazard to human health’ (California Health and Safety Code Section

39655).

Continued on next page
44 ● Finding the Rx for Managing Medical Wastes

wastes incinerated). The amount medical waste currently incinerated represents about 0.05 percent of the total

general waste produced in California annually (49, 106, 108).

CARB emissions testing of eight California medical waste incinerators served as the basis for developing the

ATCM. The emission rate for dioxins from these eight facilities ranged from 0.0003 to 14,140 rig/kg of waste

burned. A multipathway risk assessment (which considered exposure to inhalation, dirt ingestion, dermal

absorption, and mother’s milk) estimated that the risk for dioxin is 1 to 246 chances of developing cancer per

million, with the lower end of the range reflecting controlled facilities. Based on these findings, CARB identified

control equipment that could reduce dioxin emissions by 99 percent or to 10 rig/kg and determined that waste

disposal alternatives to incineration are available (106, 108). The proposed control measure is expected to reduce

the maximum individual risk by 90 to 99 percent, to 1 to 3 chances of developing cancer per million (49, 106, 108).

The proposed ATCM for dioxin of 99 percent reduction of dioxins or reduction to a level no greater than 10

rig/kg of waste burned is considered to be BACT (the best available control technology). Although CARB first

identified a dry scrubber and baghouse air pollution control system as the most effective in reducing dioxin

emissions, it later tested and reported that a well-designed incinerator equipped with a Venturi wet scrubber

achieved the 99 percent reduction (i.e., the proposed emission limit for dioxins). The proposed control measure also

includes requirements to ensure combustion efficiency to minimize dioxin formation, These include a minimum

temperature of 1,4000 °F in the primary chamber of a multiple chamber unit and a minimum temperature of 1,800°F

in the secondary chamber of a multiple chamber unit or the primary chamber of a single chamber unit, with a one

second gas residence time (106, 108).

In addition, a maximum temperature for flue gas at the outlet of the air pollution control equipment is specified

as 300°F (unless an alternative temperature achieves equal or greater control). The control measure also specifies

requirements regarding continuous record keeping for the operation of equipment and maintenance; reporting

violations, malfunctions, or upset conditions; annual source testing; operator training; and mandatory air district

permits (106, 108).

The proposed measure became effective July 1991, and the compliance timetable is for installation of BACT

15 months after the local air district’s adoption or to cease operation 6 months after the district’s adoption. The

dioxin control measure is expected to increase waste treatment costs by approximately $0.10 to $0.35 per pound

over current incinerator costs. In addition to the reduction in the risk to 1 to 3 chances of developing cancer per

million, the control measure is expected to produce other net environmental benefits (106, 108).

considered for permitting (e.g., wet scrubber sys- the wastes they burn may be most appropriate.10

terns). This provision was modified, however, to MSW incinerators tend to be large, mass-burn

State performance standards (e.g., a 99 percent

reduction requirement) without regard to the specific

technology necessary to meet them. The proposed

final standard became effective on July 12, 1990.

Reported test results from one facility show a 99

percent reduction and 10 rig/kg achievable with a

well-operated incinerator equipped with a highefficiency Venturi (wet) scrubber (107).

Given the large number of medical waste incinerators (on-site and off-site) operating in the country,

separate regulation taking into account the special

characteristics of these incinerators and the nature of

incinerators (i.e., waste is burned as-it is received,

not processed or sorted), which are typically onechamber combustion systems operating under conditions of excess air. Most medical wastes are

burned in excess air or controlled air incinerators

(sometimes referred to as starved air incinerators),

which burn waste in two or more chambers under

conditions of either excess oxygen or a deficiency of

air, respectively (1 14, 45, 30, 40) (see figure 8).11

As with MSW incineration, a trend may be

emerging for medical waste incineration to recover

energy and include front-end waste separation and

lo~e exact number of medic~ waste incinerators operating in the country is not known with certainty. The State of California, Xti 10 percent of

the U.S. population, reports 146 medical waste incinerators (49).

I IEpA finds, based on information gathered in ~States, that approximately 40 percent of total number of incinerators are ones operating under

excess air conditions and 35 percent are starved air units. These excess air incinerators are probably small incinerators used for pathologicrd wastes and

have limited or no air pollution control equipment. They are probably not required to meet most air quality standards due to their size unless they are

in a State (e.g., New York California) tbat has recently adopted new air quality standards (141).
Chapter Incineration Treatment Issues and Trends ● 45

Figure 8-Controlled Air Incinerator

To boiler

II

Secondary

chamber

Fossil fuel

I

burner

/

● /

Primary

chamber

I

I

Ash

discharge ram I

Ash sump

Ash quench

SOURCE: U.S. Environmental Protection Agency, Industrial Incinerators, EPA-450/3-80-013 (Washington, DC: May 1980).

recycling efforts. Such efforts, along with designing

the incinerator to account for the nature of the

wastes, affect incinerator performance. A recent

study of the performance of hospital incinerators

concluded that while performance-related problems

and emission exceedance problems can be caused by

poor equipment design, they are “more likely

caused by the incineration of wastes different, in

type or mixture, than originally anticipated” for the

system (81). Accurate waste analysis and designing

the incinerator to accommodate that waste feed will

help avoid waste-related operational problems.

In any case, the absence of controls at the Federal

level and the variation of controls at the State level

create a highly uncertain and complicated regulatory

climate for those who make, sell, and use medical

waste incinerators. Siting and permitting medical

waste incinerators in most areas of the country have

become as problematic as siting any type of waste

facility. Public resistance to siting some medical

waste facilities focuses on potentially hazardous air

emissions (e.g., dioxins, furans, HCl, cadmium and

lead emissions) and the disposal of potentially

hazardous ash residue (e.g., cadmium and lead

content). Pollution control equipment and engineering solutions are being applied to control these

emission and residue problems (e.g., scrubber equipment to control particulate and HC1 emissions and

higher combustion temperatures and retention times

in the secondary chamber of incinerators of one to

two seconds at 1,800‘F to control organics) as well

as efforts to separate materials for recycling, including such items as batteries, which contribute to the

level of metals in the ash.
46 ● Finding the Rx for Managing Medical Wastes

CAPACITY, COSTS, AND RISKS

Capacity

The advent of stricter environmental controls for

incinerators and the prospect of the resulting closure

of many existing facilities has fueled concerns over

whether adequate incineration capacity for medical

wastes is available nationally. This discussion will

focus on capacity issues, which are driving trends in

technology and permitting, and will indirectly (qualitatively) identify the general level to which a

capacity problem exists in this country.

It is extremely difficult to determine existing

incineration capacity (or demand/need for capacity)

on a national basis given the differences between

on-site and off-site incinerator capacity parameters

and the fact that the amount of medical waste

(including nonhospital sources) requiring treatment

is not definitively known (104). It does appear,

however, that the demand for capacity has outpaced

its availability in some regions of the country,

especially where new, more stringent State requirements lead to the closure of existing facilities and

newer facilities are not readily available (given the

lengthy permitting process and the persistent siting

problems).

The capacity problem is most likely to arise when

on-site incinerators shut down because they can no

longer meet regulations, when management practices (e.g., universal precautions widely applied)

increase the amount of waste requiring incineration,

or when increasing numbers of nonhospital generators enter the market. If a large number of on-site

incinerators cease operation, for whatever reasons,

in the same geographic region, a ‘‘capacity crunch’

can occur (104). This capacity deficit can result in

either accelerated permitting or increased export

(transfer) to other regions. In California, new regional incinerators are being permitted, which will

provide surplus capacity for medical waste, no

longer burned on-site (49). In New York State,

increased out-of-State shipment is anticipated at

least in the short-term after new regulations take

effect (94).

Increasingly, older, on-site units are being replaced either with larger, on-site units that can be

regional (accepting medical wastes from nearby

clinics and nursing homes) and/or co-incinerate the

facility’s medical and solid wastes, or with off-site

regional incineration. The customer base for regional incinerators continues to grow. Substantial

growth in this industry is projected.12 Interestingly,

although total on-site and off-site capacity may be

adequate to meet disposal needs, the regional

markets determine the fluctuations in available

capacity in a given area. That is, the varied

generation rates (in part related to regulatory trends

and shifts in management practices), the reluctance

of major regional incineration and autoclaving

operating companies to make capacity available to

competitors when the need arises, and regional

regulatory trends create an unstable level of treatment capacity (104)0

The Southeast (centered in and around South

Carolina), lower Midwest (centered in and around

Oklahoma), and the Ohio Valley area now appear to

have excess capacity for medical waste. Indeed,

these areas have been magnets for the waste from

other parts of the country where capacity has become

saturated. Wastes from locations on both coasts have

been transported great distances to facilities in these

areas.

The uncertain outcome of the pending changes in

the Clean Air Act has slowed the pace of permit

applications in a number of States. In the Northeast,

constraints on capacity have been driven by such

factors as permit difficulties (e.g., the (now expired)

moratorium on incineration activity in Pennsylvania). In other areas, there may be permit activity

(e.g., Texas, Illinois), but there is a lag between the

time when additional incineration and/or alternative

treatment capacity will be available in those markets

and the immediate capacity needs (104). This can

necessitate exporting medical waste out of the area

for treatment, at least until new treatment capacity is

available. In some areas, a “capacity crunch” is

being met by arrangements with local MSW incinerators to accept medical wastes (68; see below). The

State of California, when adopting new air emission

standards for medical waste incinerators, examined

the potential for a capacity shortfall. They concluded

12~e Swe iS tie for tie entire ~e&c~ ~a~te ~Mgement indus@y. ~cording to one study, me c~enfly estimated $750 mdfion medical waste

industry will expand to $1.5 billion by 1991 and grow to nearly to $5 billion by 1994 (cited in 75). Other studies project revenues to be even higher,

reaching $10.7 billion by 1991, with expenditures estimated to grow from $970 million to $2.9 billion by 1991 (cited in 74).
Chapter Incineration Treatment Issues and Trends ● 47

that upgraded or new incinerators, or other treatment

alternatives, could be permitted within the timeframe

before existing facilities would be required to shut

down. Further, the relatively low volume of medical

waste incinerated could be landfilled at existing

facilities with little impact on their capacity according to CAB.

Changes in regulation of a waste stream can result

in short-term shortfalls of permitted treatment capacity (e.g., the shortages of permitted MSW landfill

capacity experienced in some areas of the country as

States adopt more stringent landfill regulations,

leading to closure of many existing facilities). It

appears that such temporary shortfalls of permitted

capacity can occur for medical wastes. Yet, if

adoption of new regulations is coordinated with

careful planning and expedient permitting, such

shortfalls may be averted.

costs

The variable nature of the equipment design, size,

and add-on pollution control equipment make it

impractical to identify the typical cost of treating

medical waste by incineration (104, 54).13 Incineration costs can vary by more than 500 percent, and

OTA’s contractors independently identified wide

cost ranges from $0.07 per pound to over $0.50 per

pound (104, 54). The California Air Resources

Board estimates that uncontrolled incineration costs

are about $0.15 per pound and controlled incineration costs about $0.50 per pound (108). It is

generally believed that incineration is a more costly

alternative than most nonincineration treatment

alternatives; some estimates find autoclaving to be

30 percent of the cost of incineration (104).

CARB also calculated the estimated cost to

retrofit existing facilities to meet its proposed

standards to be an increase of $0.16 per pound of

waste burned. If on-site incinerators are shut down

and off-site incineration is used, costs are estimated

to increase by $0.35 per pound. If steam sterilization

is used, on-site, a $0.10 per pound cost is estimated,

and if incinerators are shut down and off-site steam

sterilization is used, a cost of $0.17 per pound is

expected (108).

Risks

Relative health risks associated with the combustion of medical wastes continue to be debated as data

remains limited. A thorough examination of health

and environmental risks posed by different pollutants is beyond the scope of this effort; these risks are

addressed elsewhere (116, 66, 12, 108). The intention here is to identify those pollutants of primary

concern in medical waste incineration because of

their potential human health and environmental

impacts.

These pollutants include dioxins and furans (some

of which are thought to be carcinogens), pathogens

(entities with infection potential), metals (e.g.,

cadmium, a neurotoxic chemical and thought to be

a probable human carcinogen), acid gases (e.g.,

hydrogen chloride (HC1), nitrogen oxides, and sulfur

dioxides), which can cause acute effects such as eye

and respiratory irritation, can contribute to acid rain,

and may enhance the toxic effects of heavy metals),

and particulate emissions (which can absorb heavy

metals and organics and 1odge in human lungs, and

serve as irritants possibly responsible for chronic

health effects). Their presence in either air emissions

or ash residue is a concern.14

A large data base for dioxins and furans and their

potential carcinogenicity makes them a particular

source of concern. It is presumed by regulators that

controlling emissions of these organics will control

emissions of other organics (PAHs), cadmium, and

perhaps particulate matter and HC1.15 Emissions of

these organic compounds from medical waste incinerators have been noted (see table 6 and figures 9,

10, and 11). Barton et al., in a study for the EPA and

CARB, hypothesize that dioxin and furan formation

can be minimized by controlling particle and trace

organic emission levels within the combustion zone,

minimizing the time particles are held at temperatures that maximize dioxins and furan formation and

maximizing the destruction of precursors (both

13EPA, as p~of its Nsps Pqram form~ic~ waste incinerators, is evaluating the capital and operating costs of various W pollution control devi~s

and incinerators; the preliminary results are expected in late 1990.

Idsee OTA, 1989 (1 16) for a discussion of fisks associated with MSW incinerator air emissions ~d ash residues, which maY be simil~ to ~“se

associated with some forms of medical waste incineration.

15~@ scrubber systems (i.e., acid gas remov~ plUS particulate removal), high removal of particulate matter gene~lY me~s ‘i@‘emovd ‘f ‘ea~

metals (except possibly mercury) and moderate to high control of dioxins~~s (~d other semi-volatile organics). It appears that particulate matter

control is the key to controlling the pollutants noted here, because they me converted to a solid (particulate) form to facilitate their removal from the

gas (20).
48 ● Finding the Rx for Managing Medical Wastes

Table 6-Emissions of Dioxins and Cadmium From

Medical Waste Incinerators in California

Percent of total waste Percent

incinerated v. percent statewide waste Percent dioxins

of statewide dioxins burned a emitted

emissions in California: (%) (%)

119 Onsite incinerators

Controlled units:

1. Multiple chamber . . . 21.4 1.3

2. Excess-air . . . . . . . . . 0.07 0.03

Uncontrolled units:

1. Multiple chamber . . . 25.3 21.0

2. Excess-air c 

. . . . . . . . . 9.9 36.3

Subtotal . . . . . . . . . . . 56.7 58.6

9 Off-site incinerators

Controlled units:

1. Multiple chamber . . . 31.1 2.5

Uncontrolled units:

1. Excess-air . . . . . . . . . 10.3 38.9

Subtotal . . . . . . . . . . . 43.4 41.4

Total . . . . . . . . . . . . 100.0 100.0

Percent of total waste Percent Percent

incinerated v. percent statewide waste cadmium

of statewide cadmium burned a

emitted

emissions in California: (%) (%)

119 Onsite Incinerators

Controlled units:

1. Multiple chamber . . . 21.4

2. Excess-air . . . . . . . . . 0.07

Uncontrolled units:

1. Multiple chamber . . . 25.3

2. Excess-air c 

. . . . . . . . . 9.9

Subtotal . . . . . . . . . . . 56.7

9 Off-site incinerators

Controlled units:

1. Multiple chamber . . . 31.1

Uncontrolled units:

1. Excess-air . . . . . . . . . 10.3

Subtotal . . . . . . . . . . . 43.4

Total . . . . . . . . . . . . 100.0

15.7

0.1

32.2

13.8

61.8

23.4

14.9

38.3

100.0

a

From table X-3.

b

From table XII-8.

qncludes types not specified.

‘From table X11-1 O.

SOURCE: State of California Air Resourees Board, Technica/ Support

Document to Proposed Dioxins and Cadmium Control Measure

forMedica/ Waste hwirterators, prepared by Toxic Air Contaminant Control Branch, Stationary Source Division, California Air

Resources Board (Sacramento, CA: May 23, 1990).

vapor and particle bound) within the incinerator

(12). They also note that to control dioxins from the

flue gas with low-temperature fine particle control

merely transfers the dioxins from the air to the ash

(12).16 Yet, metals will not be controlled by these

measures; only add-on pollution control equipment

or front-end source separation will reduce emissions

of metals (41).

As part of its standard-setting process, California

undertook what to date is probably the most

comprehensive health risk assessment of medical

waste incineration. CARB worked closely with the

California Department of Health Services to develop

a multipathway health risk assessment model to

assess the potential acute, chronic and cancer health

effects from exposure to pollutants emitted from

medical waste incinerators, MSW incinerators, fossil fuel combustion, and hazardous waste incinerators. For dioxins the multiple pathways used to

estimate potential risks are: inhalation, dermal

absorption, soil ingestion, and mother’s milk for the

frost year of an infant’s life (108). Other routes, such

as produce (leafy vegetable) ingestion, can increase

the risk relative to inhalation, but were not feasible

to consider in this effort. Further studies to supplement the California studies could address this and

other exposure routes.

The results of the California risk assessment

estimate for dioxins that the risk factor ranges from

1 to 246 in a million of developing cancer for

continuous daily exposure for 70 years to an airborne

concentration of one picogram per cubic meter of

total dioxins. For cadmium, the estimate is that the

risk factor ranges from less than 1 to 15 in a million

for continuous daily exposure for 70 years to an

ambient air concentration of one nanogram per cubic

meter (108).

CARB also reported results for potential chronic

noncancer effects from exposure to pollutants emitted from the eight hospitals it tested and reported as

well on the significance of emissions with the

potential to cause chronic health effects. The most

significant noncancer effects might come from iron,

manganese, and lead. Five facilities were identified

as having the potential to cause acute effects in

exposed individuals from HCl emissions (108). Yet,

the use of the risk assessment and its findings have

been problematic in California, and further work

needs to be completed in this area.

Beyond disputes over the actual health risks posed

by incineration, it appears that effective, available

technology will be able to reduce risks to whatever

16~e ~t~c~ent @on&@ of dio~/&m t. solids, i.e., the ash, is such tittheir removal by leaching in a Iantifl is not considered significant.

Thus, concentrating the dioxins/furans in residue allows for their control by landfiiling (20).
Chapter 4-Incineration Treatment Issues and Trends ● 49

Figure 9-Comparison of PCDD/PCDF Concentration in Medical and Municipal Wastes

c

100

10

Medical waste Municipal waste

SOURCE: R. Barton, G. Hassel, W. Lanier, and W. Seeker, State of the Art Assessment of Medical Waste Thermal Treatment, EPA Contract 68-03-3365 and

ARB Contract A832-155 (Irvine, CA: Energy& Environmental Research Corp., 1989).

Figure 10—Comparison of PCDD/PCDF Emissions From a Variety of Incinerators

Emitted PCDD/PCDF concentrations Medical

Municipal waste incinerators

waste

incinerators

12000 I

6000

Hazardous

waste

incinerator

ESP - Electrostatic precipitator

DI - Dry sorbent injection

FF - Fabric filter

SD - Spray drier

V - Venturi scrubber

CYC - Cyclone

DS - Dry scrubber

WS - Wet scrubber

*Note that ng/Ncm represents measurements normalized to standard concentration of 12% C02

SOURCE: R. Barton, G. Hassel, W. Lanier, and W. Seeker, State of the Art Assessment of Medical Waste Thermal Treatment, EPA Contract 68-03-3365 and

ARB ContractA832-155 (Irvine, CA: Energy& Environmental Research Corp., 1989).
50 ● Finding the Rx for Managing Medical Wastes

Figure n-Comparisons of Cadmium Emissions From a Variety of Incinerators

Cadmium

Municipal solid waste

Medical Hazardous

waste waste

- (

,

0

[

u

0.1

0.01

0001

0.0001

ESP = Electrostatic precipitator

DI = Dry sorbent Injection

FF = Fabric filter

SD = Spray drier

V = Venturi scrubber

CYC = Cyclone

DS = Dry scrubber

WS = Wet scrubber

IWS = Ionizing wet scrubber

WSH = Water spray humidifier

PBS = Packed bed scrubber

A = Data not available

D = Metal below detection Iimit

dscf . dry standard cubic foot; 1 gr/dscf = 2.290 g/Ncm

SOURCE: R. Barton, G. Hassel, W. Lanier, and W. Seeker, State of the Art Assessment of Medical Waste Thermal Treatment, EPA Contract 68-03-365 and

ARB Contract A832-155 (Irvine, CA: Energy& Environmental Research Corp., 1989).
Chapter 4-Incineration Treatment Issues and Trends ● 51

levels are defined by standards.17 CARB, for example, reports that tests demonstrate high efficiency

Venturi wet scrubber systems, as well as dry

scrubber systems, at well-designed and operated

incinerators can reduce risks to acceptable levels,

defined by their standards to one to three chances in

a million (49, 108). It should be noted though that the

heterogeneous nature of the medical waste stream

makes it nearly impossible to conclude with certainty what the emission levels of certain substances

will be in any given unit. For example, two hospitals

with similar incineration systems can have highly

different emission test results largely due to the

differences in their waste streams and charging

methods (104).

TRENDS IN AIR POLLUTION

CONTROL SYSTEMS

Until a few years ago when the first major study

of emissions from hospital incinerators was completed and some localities set more stringent air

emission standards, air pollution equipment associated with these incinerators was minimal (126).

Today, some form of scrubbing system is considered

a standard part of many new incineration systems,

although most medical waste incinerators remain

uncontrolled and pollution control equipment is not

necessarily a standard part of medical waste incineration systems (41). Pollution control devices currently in use on medical waste incinerators include

wet or dry acid gas scrubbers (to remove/neutralize

acid gases, etc.), baghouses (fabric falters) or electrostatic precipitators (to remove airborne particulate

matter), hybrid dry/wet scrubbers, and afterburners

(sometimes used on excess air combustors to reduce

toxic organic gases).

A fairly common list of toxic compounds and

criteria pollutants to be controlled has evolved

through the development of regulations and the

permitting process. These substances are: particulate, hydrogen chloride, sulfur dioxide, carbon

monoxide, nitrogen oxides, dioxins, furans, mercury, arsenic, cadmium, chromium, nickel, zinc, and

lead (104) (see table 7).

The selection of air pollution control systems

involves choosing between a wet or a dry scrubber

system. A scrubber is an emission control device that

adds alkaline reagents to react with and neutralize

acid gases, with the resultant products collected for

management of residue. For a dry scrubber this is

usually done through the use of a baghouse (fabric

falter) to trap solid particles (dust), while for a wet

scrubber byproducts are discharged as a slurry,

possibly requiring treatment before discharge to the

sewer. In the future, depending on the type of

scrubber used and the sewage discharge standards in

an area, wastewater treatment may also become a

more common feature of medical waste incineration

systems. This could add significantly to the capital

cost of an incineration system utilizing wet scrubbing (e.g., a wastewater treatment system can cost

$150,000 (8)). However, a condensing wet scrubber

system with zero liquid discharge, a technology used

for hazardous waste incineration, is being adapted

for application to medical waste incineration. It

appears that this could be an efficient and cost

effective system for controlling emissions from

medical waste incinerators (2).

These scrubber systems can control dioxin and

furan emissions as well as particulate emissions

because dioxins and furans in flue gases condense

onto fly ash particles if the gases are cooled enough.

They are then removed by the scrubber or particulate

control system (1 16). In MSW incinerators, the

combination of a dry scrubber and baghouse can

remove 97 to 99 percent of total dioxins present in

postcombustion flue gases (1 16).

As noted, the proposed regulations in California

first identified a dry scrubber as BACT18 The

incineration industry reported, however, that the dry

scrubber/baghouse combination is not suitable for

all medical waste incinerators, although this appears

to be primarily based on cost considerations. As one

study concluded, “Venturi [wet] scrubbers, due to

their lower capital costs and greater flexibility, are

the best choice for smaller and medium size hospital

incinerators’ and dry scrubbers, while ‘‘not as popular or as proven in the field, ” are cost competitive

for larger facilities (12 tons per day or more) (26).

17This is me ~ess ZtiO risk is re@red, which no technology---or waste management praCtiCC-Can ac~eve.

lsc~ifornia used EPA data on dry scrubbers used for MSW incinerators (usually a spray atomizer-baghouse system) to medicd w*te incin~ators.

Medical waste incinerators which do use dry scrubbers usually have dry inj@ion baghouse systems with injection of a dry alkaline substance into the

flue gas, which reacts with pollutants and is then captured in the baghouse (41).
52 ● Finding the Rx for Managing Medical Wastes

Table 7—Performance Data of Medical Waste Incinerators With Pollution Control Equipment

“Typical”

average of Lowest

Emission measured three samples reported Units of measurement

1.

2.

3.

4.

5.

6.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

Particulate including Method 5 impinger catch, 0.028 0.018

without CHEAF installed 69.2 44.5

89.0

Particulate including Method 5 impinger catch, 0.014 0.008

with CHEAF installed

HCI (hydrogen chloride)

SO2 (sulfur dioxide)

CO (carbon monoxide)

HF (hydrogen fluoride)

As (arsenic)

Be (beryllium)

Cd (cadmium)

Cr (chromium)

Ni (nickel)

Pb (lead)

Hg (mercury)

TCDD equivalent (dioxins)

TCDF equivalent (furans)

34.6 19.8

97.3

9.2 0.98

15.0 1.6

99.3

4.0 0.31

11.4 0.89

92.1

18.8 8.7

Note: Worst case reported is 68 ppm (voI) dry basis @77002

0.08 Not detected

0.094 —

95.6 —

<0.05 —

<0.25 —

1.02 0.96

0.045 0.03

0.112 0.06

10.74 5.82

2.96 1.86

0.0311 0.0264

0.1088 0.0967

Total TCDD & TCDF as TCDD equivalent 0.1399 0.1231

Opacity 2 0

Grain/sdcf @7%02

mg/Nm 3 dry @7% O2

% Removal

Grain/sdcf@7?4002

mg/Nm 3 dry @7% O2

% Removal

ppm (voI) dry basis @7% O2

mg/Nm 3 dry @7%O2

% Removal

ppm (voI) dry basis@7Y002

mg/Nm 3 dry@7% O 2

% Removal

ppm (voI) dry basis @7% O2

ppm (voI) dry basis @7% O2

mg/Nm 3 dry @7% O2

% Removal

mg/Nm 3 dry@ 7Y002

fg/Nm 3 dry@ 7% O2

fg/Nm 3 dry@ 7% O2

fg/Nm 3 dry @7%O 2

fg/Nm 3 dry@ 7Y002

fg/Nm 3 dry@ 7?4002

fg/Nm 3 dry@ 7%O2

fg/Nm 3 dry@ 7%02

fg/Nm 3 dry@ 7%O2

fg/Nm 3 dry@ 7%O2

Percent

NOTE: These data were collected from over 20 installations of medical waste incinerators with scrubbers in the United States in the period from Jan. 1,1988

through Apr. 1, 1990. They do not necessarily represent the best performance which can be achieved, but do represent “typical” performance which

can be expected from the equipment and systems reviewed by the study. Some data are supported by over 100 separate samplings, while some

(including the detailed metals and dioxin information) are based on only one or two installations with three samplings each. Nm 3 represents

normalization of measurements to standard 70/. 02 conditions. 1fg=10 -15 grams.

SOURCE: Anderson 2000 Inc., Technical Description, Performance Information, Material Balance and Flowsheet Data, Typical Guarantees and Turnkey

Installed Pricing for a 16.2 MM BTU/HR (1700#/HR) State-of-the-Art Medical Waste Incinerator With Wet Scrubber Emission Controls, Document

#1-5670-W (Peachtree City, GA: Anderson 2000 Inc., 1990).

EPA reports that there are no technical reasons

why a dry injection system or a spray dryer system

cannot be applied to medical waste incinerators (41).

Reports that the baghouse in medical waste incinerator applications is susceptible to corrosion because

of the intermittent operation, which can result in

holes in the bag, should not occur if the system is

properly designed and operated (41, 49). Further, dry

scrubbers do not have any associated waste water

problems.

Wet scrubbers can remove about 95 to 99 percent

of HC1 and 85 to 95 percent of sulfur dioxide

emissions in MSW incinerator applications (116,

45). Wet scrubbers can achieve 90 percent HCl

removal with plain water in medical waste incinerators, but lime slurries or caustic soda solutions can

result in 99 percent or better hydrochloric acid

removal (139, 126). The California Air Resources

Board reports 85 percent particulate removal, 99

percent hydrogen chloride removal and O to 75

percent cadmium removal by wet scrubber systems

for a medical waste incinerator (108). Reheating the

flue gases may be necessary to ensure adequate

dispersion from the stack and compliance with

ambient air quality regulations, although it is not

clear that any medical waste incinerators have had to

do this (41).19

The WCEI maintains that advanced (versus conventional Venturi) wet scrubbing systems can attain

high removal efficiencies for fine particulate, acid

ls7’hat is, wet scrubbing COOLS tie flue gases to the water sateration temperature which can be as low as 120 OF. AS a result, plumes leaving the s@ck

do not rise very high which can increase ground level concentrations of pollutants (1 16).
Chapter 4--Incineration Treatment Issues and Trends ● 53

gases and heavy metals at substantially lower

maintenance costs than the dry scrubber/baghouse

combinations (45). The industry anticipates that

soon (possibly within a year) the zero discharge wet

scrubber systems will be available (45, 2, 104). Yet,

wet scrubbers in current use can require a high

energy input to collect fine particulate, can suffer

problems of corrosion and erosion problems and

reentrainment of particulate, and may produce a

visible steam plume. Insoluble gaseous organics are

not controlled and permits for some local sewer

districts may be necessary prior to wastewater

discharge (126, 139).

Removal of HC1 and sulfur dioxides in one dry

scrubber system for a MSW incinerator were reported to be 90 and 70 percent, respectively (1 16). It

is not clear how comparable these results are to those

that could result from medical waste units. The

California Air Resources Board reports 99 percent

particulate removal, 85 to 95 percent HC1 removal,

and 99 percent cadmium removal by a dry scrubber

with a baghouse system for a medical waste incinerators (108).

Again, the type of waste burned in a unit and the

size and type of incinerator unit are key factors in

determining how appropriate a particular application of pollution control will be. In the types of

modular incinerators used for most medical waste

incineration, it appears from the California report

that dry scrubbers with fabric filters are effective in

controlling particulate, cadmium, and dioxin emissions (49). EPA is testing inlet and outlet emissions

for both a wet and a dry scrubber system to

determine their performance in controlling metals

and dioxins as part of their NSPS testing program for

medical waste incinerators (41).

In the past, manufacturers and users have preferred wet scrubbing systems (104). EPA reports that

the current trend for large, new medical waste

incinerators, at least in the States with more restrictive air standards, favors dry injection/baghouse

systems (41). It appears that more testing of both wet

and dry scrubbing systems and other pollution

control technologies is needed to determine the best

treatment technology for a particular setting. Indeed,

some companies are experimenting with dry/wet

hybrids which are ‘‘customized’ versions of these

systems to presumably best meet a particular facility’s needs (56, 104).20

It should also be noted that presorting waste to

remove non-combustibles and substances known to

contribute toxic compounds (see ch. 2) and allow for

completeness of combustion (i.e., minimizing carbon monoxide and hydrocarbon emissions) are

important factors affecting air pollutant emissions

from incinerators. In fact, these factors can be

considered complementary approaches for controlling emissions via applications of air pollution

control technologies (1 16). Additionally, welltrained operators can monitor and control combustion efficiency to limit combustor emissions.

OPERATOR TRAINING

Fundamental to the proper operation of incinerators are trained operators. In addition, satisfactory

equipment (e.g., proper design, controls and instrumentation, etc.) plus regular maintenance and repair

are key components affecting performance (1 14). It

is widely suspected that operators of medical waste

incinerators are not routinely receiving proper training, and this, in part, explains why many incinerators

perform poorly.

Recently, a number of efforts have been undertaken and/or completed that will facilitate operator

training and improved operating practices. EPA has

published a two-volume hospital incinerator training

course and a handbook on the operation and

maintenance of hospital medical waste incinerators

(127, 131). The stated purpose of the volumes is to

provide the operator ‘‘with a basic understanding of

the principles of incineration and air pollution

control” (127). The presumption is that sitespecific, hands-on training of operators will also

occur.

21

Some States (e.g., New York) have recently

adopted requirements for certification of operators

(94). The American Society of Mechanical Engineers is also developing an operator’s certification

program (6). The Waste Combustion Equipment

Institute endorses the development of a national

operator training and certification program (45).

Most of these programs suggest various levels of

Wests of one facility with a hybrid dry/wet scrubber systcm reportedly met lhc stnngcnt Swedish dioxin cmission limit Icvcls (66).

211t is ~tmc.t@ t. note tit al~Ou@ wo~kcr safety issues arc dlscusscd in tic EPA course, Ihc imp~rtancc of front-end separation of recyclable or

noncombustible materials are not covcrcd, and issues related to ash management arc addressed only briefly.
54 ● Finding the Rx for Managing Medical Wastes —

training and competence for operators to achieve

certification. In addition, privately published handbooks are also available to facilitate operator training (e.g., 32).

OFF-SITE INCINERATION

Off-Site v. On-Site Treatment

There was speculation after the passage of MWTA

about whether the exemption from tracking requirements for wastes treated on-site (which meet the

specified regulatory requirements) would encourage

use of on-site incineration. This may not occur,

given that other conditions (e.g., increased expense

and/or space limitations to expand existing facilities,

limited on-site expertise in waste management, etc.)

may provide strong incentives for off-site treatment.

It was in light of these conditions, which exist

widely, that the prospect of an increased number of

regional incinerators or other types of regional

treatment facilities has also been predicted in recent

years. It is not clear whether there is a trend for

more off-site or continued on-site incineration.

A trend toward more off-site incineration may

occur if changing requirements for waste management make it more advantageous for medical

facilities than on-site incineration. Yet, health-care

facilities still tend to favor on-site treatment because

they have control over the ultimate disposal and can

thereby limit their liability more easily. In addition,

properly designed, operated, and maintained on-site

facilities can meet emission standards and provide a

viable waste disposal option.

At a minimum, it appears that present circumstances will stimulate cooperative planning efforts

on a regional basis, whatever type of on-site or

off-site treatment technology or management strategy is actually adopted. 22 The two basic types of

off-site incineration options are: co-incineration of

medical wastes with other types of waste (e.g.,

MSW) or regional incineration facilities dedicated

to medical wastes.

Co-Incineration or Co-Firing of Wastes

To date, most off-site incineration has been in

units dedicated only to burning medical wastes.

Usually, capacity at off-site facilities is at such a

premium that companies do not want to use the

incinerators for nonmedical wastes. Yet, several

MSW incineration systems, operated by different

companies, do accept or are considering accepting

medical wastes because they have excess capacity

and/or the potential revenue from these sources is

much higher than from MS W (104).23 In fact, some

MSW facilities have marketed their ability to

incinerate medical wastes (e.g., locations in South

Carolina and Oklahoma).

From a technical perspective, MSW mass-burn

incineration systems are presumed adequate to

render medical wastes noninfectious (although no

data on this was found) and their pollution control

equipment should effectively control toxic compounds contained in it.24 Concerns have been raised

about the ability of some MSW incinerators (e.g.,

water-wall types) that may not attach a sufficiently

high temperature throughout the chamber to ensure

pathogen destruction in infectious medical wastes

(45).

The number of co-incineration efforts is not high

for a variety of reasons, including: 1) public concern

over the ‘‘importation of medical waste from

non-local areas; 2) employee concern over potential

exposure to medical wastes in the workplace; and 3)

mechanical considerations, such as the handling

system for MSW (in which ‘‘red bags’ can be

ruptured when a crane lifts them from the pit to the

feeder of the incinerator, risking worker exposure)

and the roller grate system in MSW facilities, which

cannot control the movement of certain items well,

such as needles and syringes (104).

More recent attempts at co-incineration of MSW

and medical wastes attempt to address these issues

by having a separate feed system that lifts intact

medical waste packages into a dedicated medical

waste hopper for the incinerator. Such systems are

used in some on-site applications of incineration as

well, particularly in a facility where heat is recovzzlt ,SI1ou Id bc no[cd W;lt rcgion:ll, commercial autoclave units ;dso exist in some mcas and arc being proposed in other areas.

z~[n ~lost ~:L~cs, MSW tipping fees at inclncmtors arc much Iowcr than medical wa.st~’ fees ( 104).

~Dl fficultlcs, Prim:lrlly related t. grc:ilcr Occupatlona] risk, ;lss~~latcd with ~ttcnlp(s I() nl;inflgc mc~ic~l W;LS[C at refuse-derived fuel faci]ilics have

been reported (10). Questions have also been raised about the ability of MSW incincratom 10 handle nccdlcs and liquid wastes (given their grate design)

and the possibility for greater pathogen survival given the typically cooler water walls assocmtcd with MS W (heat rccovcry) chambers (41).
Chapter G-incineration Treatment Issues and Trends . 55

ered. Another strategy is to use dedicated incinerators for medical wastes at sites permitted for MS W

incineration (104). Sweden and the Federal Republic

of Germany take a similar approach. In addition to

permitting the use of high-volume MSW incinerators for medical waste, these governments allow

co-locating infectious waste incinerators with MSW

incinerators and channeling their flue gases through

the high efficiency air pollution control equipment

of the larger incinerator (57).

A variation of co-incineration is a demonstration

project sponsored by the Department of EnergyMorgantown Energy Technology Center and Pennsylvania Energy Development Authority which

co-fires medical waste with coal in a circulating

fluidized bed with steam recovery (27). Suggestions

have also been made that medical waste regional

facilities configured as hazardous waste incinerators

(which burn at extremely high temperatures) could

be efficient enough to cofire hazardous or other

“problem wastes” with medical wastes. Waste

types suggested for co-incineration with medical

wastes include: household hazardous waste, scrap

tires, and some commercial waste (66). To date no

such co-incineration facility exists.

There are plans for a hazardous waste (rotary kiln

incinerator) facility in California to burn medical as

well as hazardous waste. This facility is in the permit

process and has an expected start date in 1992 (104).

In some European countries, MSW and medical

waste facilities are sometimes designed as hazardous waste incinerators (57).25

Regional Incineration

Regional facilities for medical waste management

may be privately owned and/or operated, or may be

cooperatively owned and/or operated by a number of

generators. It is also conceivable that, as with MSW

incineration, some of these facilities might be run by

a municipality or by a municipality in conjunction

with a private company and/or a number of generators (31). Regional incineration of medical waste on

a commercial basis began in earnest in 1986, when

the demand for services was high, capacity was

scarce, and permit requirements for air emissions

controls were simple and uniform (104).

In the four short years since then, the aggressive

pursuit of permits and development of facilities by

waste management companies have made greater

capacity available, even though the regulatory climate for permitting such incineration has become

complicated and variable. Indeed, the more complicated regulatory situation for incineration of medical

wastes is one reason the demand for off-site treatment has remained high. At this point, hospitals and

large generators in at least two metropolitan areas,

Baltimore and New York City, are cooperatively

planning a regional facility, usually as part of a

broader planning effort for a regional waste management strategy. This section discusses these different

approaches to off-site, regional incineration of

medical waste: commercial (privately run) regional

incineration and generator-run regional incineration.

Commercial Regional Incineration

The two largest waste management companies in

the United States, Waste Management, Inc. and

Browning-Ferris Industries, have aggressively developed medical waste incineration sites on a

national basis; a number of other smaller companies

(e.g., Medigen, Atwoods, and Incendere) have done

the same on a more regional basis (104). As the

conditions for permitting these facilities have become more problematic, closer scrutiny is being

given to the size, type, and location of the regional

sites. The waste management industry has called for

a ‘ ‘leveling of the playing field, ” i.e., for uniform

performance standards on a national basis in order

that companies operating in more than one State will

have similar requirements to meet. In addition,

on-site and off-site incinerators would be subject to

the same requirements; a state of affairs which can

favor a larger scale operation (104).

Permitting is a long, difficult process for any

facility—an-site or off-site—whether it be for medical wastes, MSW, hazardous wastes, or low-level

radioactive wastes. Yet, for medical waste incineration, it is probably more difficult to permit an off-site

than an on-site facility, although the on-site facility

might operate quite similarly to the off-site facility

(e.g., accept wastes from other generators). On-site

incineration has the benefit of possible waste heat

utilization and reduced transportation of waste.

Indeed, some waste companies have attempted to

locate on the site of a hospital or large generator.

MA f;lcl[lfy LIIa[ buns MSW :{nd mcdlc~ WaSkX In Stroud, Oklabom~ is ah equipped m a way Shih 10 a hz=dous waste facili~.
56 ● Finding the Rx for Managing Medical Wastes

Three significant hurdles in the siting and permitting

of off-site, commercial incinerators are: addressing

public concerns over potential risks posed by

incineration, meeting zoning permit requirements

and addressing transportation issues (e.g., the ‘ ‘importation’ of wastes for the facility).26

The lengthy and difficult nature of the permitting

process has had a dramatic impact on the economics

associated with the construction of a regional

medical waste incinerator. Permitting a site can take

up to two years or more to complete before

construction of a facility. This can encourage the

construction of larger facilities or multiple facilities

on a site.

Other factors can favor siting smaller units. For

example, some communities are willing to accept a

smaller facility that will manage their own community’s or local region’s medical waste, but are

opposed to a facility that acts like a magnet for the

importation of wastes from great distances. Also,

depending on the service needs of an area, having

several facilities rather than one large unit will

provide convenient backup capacity when a unit is

down for maintenance or repairs (104). It appears

that a mixture of large and small facilities will be

constructed depending upon the type of company

operating each, the scope of intended service, and

receptivity of the local community (104). It is likely

that the developmental trend of regional incineration

facilities for medical waste incinerators will mirror

somewhat the ups and downs of the regulatory

climate, at least until that becomes more uniform and

certain in nature.

Nonprofit/Generator Regional Incineration

Although the number of cooperative arrangements between hospitals and other medical waste

generators within regions is not as high as some

might have predicted a few years ago, several such

arrangements are being developed in different areas

of the country. Examples include: the Baltimore area

medical waste project; the Greater New York

Hospital Association plans for a facility for metropolitan New York, and the facility planned by the

Nassau-Suffolk Regional Council on Long Island,

New York.

The Baltimore regional facility is designed somewhat like a utility, A number of factors led to the

particular regional approach taken in this area.

Hospitals were responding to a dramatically

changed climate for medical waste management

brought on by the media coverage of washups of

syringes in the Baltimore area and related public

concern, new State and local regulations that resulted, and consequent concerns over the viability of

present management practices by various facilities

(given, for example, a newly instituted ban of

medical wastes by a local MSW incinerator, a

moratorium in one county on incinerator construction, etc.).

The Maryland Hospital Association at the request

of its members then solicited bids for a long-term

solution to the medical waste management needs of

the area hospitals (25).27 These efforts were soon

re-directed when a newly organized corporation, the

Medical Waste Associates (MWA), presented a

proposal to develop a privately-owned medical

waste disposal facility. Eventually, to secure a freed

cost for financing the facility, ‘‘tax exempt’ status

was obtained for the $24 million bond issue. The

central features of the arrangements between MWA

and the individual hospitals are that participating

generator facilities will sign ‘ ‘put or pay’ contracts

(i.e., each hospital agrees to pay for the disposal of

a minimum number of tons of waste per year) for 20

years (with renewal options every 4 years), and

MWA will charge a flat rate of $300/ton ($0.15/

pound) for their disposal privilege. A rebate arrangement exists to share the profits of ‘excess’ capacity

sold to others, and MWA will pay the ‘‘founding’

hospitals 50 percent of any net profits earned from

cogeneration activities (e.g., sale of byproducts such

as steam, ash, etc.) (25).

The facility will have a 160-tons-per-day capacity

in two incineration units; 120 tons are reserved for

the participating hospitals. This facility will accept

only medical wastes, including wastes from offices

of doctors on the staffs of a participating hospital.

Hospitals find it attractive that the facility will

accept nonsegregated medical wastes, but this feature and the ‘‘put or pay’ nature of the contract

create little incentive for reduction and recycling

~sl%bhc concern over the siting of medcal waste facilities and the importance of public involvement in the permitting and siting processes are topics

beyond the scope of this effort. Public concerns and the impacts of participation are net dissimilar to those expressed for MSW facilities that are discussed

in OTA, 1989, see especially, chapter 8 (1 16).

27Cmley ~d Born (25) provide a more detailed account of the development of the Baltimore rewond medic~ wrote facfli~.
Chapter 4-Incineration Treatment Issues and Trends ● 57

efforts. There are 31 hospitals in the region to be

serviced by the facility (as restricted by a special city

ordinance). Construction began on the facility in the

spring of 1990; it is expected to open in 1991.

The Greater New York Hospital Association has

formed a cooperative to build a state-of-the-art

facility to service the participating hospitals in the

metropolitan New York area. Citizen and environmental interests, unions, waste companies, and city

and State officials, as well as the generator interests,

are involved in the planning of this facility as part of

their development of a broader medical waste

management plan. The New York City Health &

Hospitals Corp. initiated a related but separate effort

for a comprehensive waste management study to

evaluate the potential of waste reduction and recycling opportunities for area hospitals before determining the most appropriate type of regional incinerator. The Natural Resources Defense Council

hosted an initial meeting of interested parties in their

New York office, November 30, 1989, to discuss

some of the initial study plans for developing the

regional medical waste management plan.

This plan also sets targets to reduce the volume of

medical waste, explores toxicity reduction efforts,

and identifies feasible recycling opportunities for

hospitals. A critical feature of the planning is

ensuring that the sizing of regional incinerator

facilities factors in the impacts that reduction and

recycling efforts might have on capacity needs in an

area.

The Nassau-Suffolk Hospital Council, Inc. represents 22 nonprofit hospitals on Long Island, New

York and also has been in the process of establishing

a nonprofit corporation for a regional disposal

facility, This regional planning effort, as with the

metropolitan New York effort, includes efforts to

implement reduction and recycling services in the

hospitals. At this point, the council has adopted an

interim strategy that involves use of autoclave/

compaction units (see ch. 3) by the hospitals on-site

and then shipment to several existing community

MSW incinerators with excess capacity. A regional

medical waste incinerator is still planned for the

future, and sites for it are being investigated now

(68).

Community involvement in the development of

plans such as these is key to their acceptability. For

example, the disinfection of wastes prior to shipment

to the off-site incinerator can allay community

concern over the transportation of the wastes. The

entire load of waste (which is mixed in the compaction process with nonregulated medical wastes) is

manifested to meet the requirements of MWTA. As

noted above, there are no technical reasons to

preclude the burning of medical waste in MSW

incinerators. The pollution equipment on a state-ofthe-art facility should adequately control emissions

from the medical wastes. Adjustments can be made

to facilitate safe handling of the wastes to minimize

worker contact and any risks associated with exposure. In the case of the Long Island hospitals,

pathological wastes and sharps will not be sent to the

MSW incinerators, but instead sent to an upgraded

hospital incinerator. This interim plan allows the

closure of 11 older incinerators, which would not

meet New York

in 1992 (68).

State new standards taking effect

SUMMARY

Incineration of medical waste is likely to remain,

at least for the next decade, the cornerstone of

management methods for medical wastes in much

the same way landfilling is for MSW management

efforts. Yet, as has already occurred with MSW

management, this necessary and appropriate treatment option for certain wastes can be effectively

supplemented by other treatment technologies (e.g.,

autoclaving, chemical/mechanical disinfection, etc.).

The size, type, and nature of pollution control

equipment will continue to change as the regulatory

issues evolve. There is general agreement among

regulators and the regulated community that development of uniform regulatory standards for air

emissions and site permitting would help stabilize

the regulatory climate for medical waste management and assist in the further identification and

assessment of risks associated with incineration. In

addition, regulatory determinations regarding th e

management of incinerator ash are necessary to

accurately project costs for ash management and

facilitate decision making by health-care facilities

regarding the attractiveness of the incineration

alternative on the basis of costs.
Chapter 5

Special Treatment Issues

A number of management issues associated with

packaging, handling, and disposal practices interface with decisions regarding treatment methods for

medical waste. This chapter examines managemen t

developments for a number of such treatment issues:

sharps management, small generator management,

sewer use, and shredding.

SHARPS MANAGEMENT

Special attention is given to the management of

sharps (e.g., hypodermic needles and syringes; also

scalpels, broken glass, etc.) because of both the

occupational and general public risks they pose.

Sharps, specifically syringes, are generated by both

households (e.g., in-home health-care) and healthcare facilities. They are therefore part of both the

general MSW and medical waste stream. In Washington State’s survey of occupational exposure of

waste industry workers to infectious waste (with 438

of the 940 workers surveyed responding), 21 percent

of the respondents reported having sustained a

needlestick injury on the job from both medical and

residential sources (139).1 The ATSDR, based on its

literature survey and study, estimates that 500 to

7,300 medical waste-related sharp injuries occur

annually to solid waste workers (93). Surveys of

health-care workers, including housekeeping staff,

usually indicate much higher incidence of needlestick injuries.

2 Sharps cause concern not only

because of their infectious potential, but also because of the direct prick or stab type of injury that

can result from them (114; see also 96). It is in part

for this reason that EPA included unused sharps in

its definition of regulated waste types under MWTA.

Most of the concern over the management of

sharps has focused on the packaging of used sharps,

the integrity of which is critical to containing the

sharps during their collection, storage, and transportation to the treatment or disposal site. Currently,

puncture-resistant containers are the preferred handling package for sharps (122, 118, 120, 121). Yet,

a number of new techniques for containing sharps,

particularly needles and syringes, continue to emerge

(e.g., encapsulation).

Education of health-care and refuse workers, as

well as the general public, about the proper disposal

of sharps will facilitate their safe handling and

management. Segregation of sharps and their separate collection and management without compaction

is key to reducing the risk of injury associated with

their management. In King County, Washington

(Seattle area), there is a local requirement that all

sharps be segregated and disposed of in leakproof,

impermeable plastic containers with tight lids for

separate, uncompacted collection and transportation

to a landfill. This management strategy greatly

reduces the risk of human contact with the sharps

and the potential of needlestick injuries (111).

Manufacturing

Some of the efforts to ensure the safer handling of

sharps have been made at the manufacturing stage.

The attempt by manufacturers of sharps is to

incorporate into the syringe a mechanism which will

render it “nonsharp’ immediately after it has been

used. One method for achieving this is a sheath

around the barrel of the syringe that will slide up

around the needle when used while the barrel part is

held. This makes it impossible for a needlestick

injury to occur and the end product can be disposed

of in a bag with other regulated waste items (unless

the facility’s protocol dictates otherwise) (104).

These syringes are costly, however, restricting their

use to date to high-risk areas of health care. Their

potential as a feasible and practical method of

protection in the home health-care setting seems

apparent, although this application has not yet

occurred, presumably due to their higher cost (104).

Tests of the performance and reliability of these

syringes were not identified by OTA.

lhte~s~ly, 32 percent of the respondents reported direct contact with waste blood on their clothing or shoes and l’g percent repofled Mving

received occupationrd cuts and scratches (139). Needlestick injuries while prevalent are not necessarily the most common type of occupational hazard

for waste workers (e.g., back strain and other types of injuries are more prevalent).

@ne survey by a local union of the Service Employees Intermtional Union (the Nation’s Iargest health-care union) of its hospital workers in the San

Francisco area, found that 62 percent reported accidental needlestick injuries on the job (100; see also 91).

–59–
60 ● Finding the Rx for Managing Medical Wastes

Mechanical/Chemical

Although grinding, clipping, and other practices

are no longer used for sharps management, primarily

due to their potential for worker injury or exposure

through aerosolization of microorganisms during

the procedure, new techniques have appeared, e.g.,

chemical treatment and shredding of sharps. The

primary alternative method of sharps management

of this sort is the mechanical/chemical disinfection

process discussed in chapter 3. In another process

the needle part of the syringe is placed in a box while

holding the barrel part. The needle completes an

electrical circuit that melts it and leaves only the

barrel in need of disposal. This process is a bit time

consuming given the individual treatment of each

sharp, but it does probably meet the “treated and

destroyed” criteria of MWTA (141). Again, it may

be a process for which the app

generator settings is most practica

Encapsulation

Another process introduced with

ication to small

(104).

in the last couple

of years that is experiencing some success is

encapsulation of sharps. This process involves use of

a phenolic solution to disinfect sharps and then

introduction of an oxidizing agent as a catalyst to

encapsulate the waste in a polymer matrix, i.e., a

solid block-like material. This material can then be

disposed of as solid waste without risk to the

workers handling it (114, 104). It does not, however,

meet the ‘‘treated and destroyed’ criteria of MWTA

regulations (141).

This system is also expensive, currently four to

five times higher than the cost of comparable

containers for sharps (104). This factor makes its

application for high-volume generators largely impractical, but the process could facilitate handling

sharps for the small generators and home health care

since it both disinfects and immobilizes the sharps,

allowing for their disposal with other solid waste.

Some States (such as California, where small

generators are required to manage their medical

wastes in an approved reamer) have endorsed the

process and in some cases permitted its use as an

alternative treatment technology. Until more States

endorse this process, it is unlikely that it will gain

widespread adoption (104).

Concern has been expressed over potential impacts of these blocks of encapsulated sharps to the

solid waste stream, in particular over what significance (if any) incinerating them with other wastes

would have. Where landfilling of the “blocks” is

not allowed, the encapsulated sharps are in some

cases shipped via the United Parcel Service (UPS) to

a manufacturer of the process in Georgia (see below)

(104).

Mail Shipment for Disposal

The mail shipment of wastes for disposal is an

increasingly common practice. As noted above,

encapsulated sharps are sometimes shipped by UPS.

Apparently, they are one of the few types of waste

that nonpostal shipping companies will accept

because they are rendered noninfectious prior to

shipment.

A number of companies now operating were

created primarily to cater to the needs of small or

rural generators for viable disposal options. They

operate out of several States and accept waste

shipments from generators and then transport the

wastes to treatment facilities. A contractor to OTA

identified such operations in four States: Indiana,

New Jersey, Oklahoma, and Texas (104). One of

these firms claims over 30,000 clients nationwide

and transfers the material to an incinerator in yet

another State (104).

Most States authorizing waste by mail mandate

that their State requirements be met, even if the

waste is being mailed out of the State. For example,

California authorizes out-of-state shipment only if

the waste is rendered noninfectious prior to disposal.

International shipment is allowed also if the waste is

treated frost in-state (104). Under MWTA, generators in States covered by the demonstration program

are allowed through an exemption in the regulations

to ship medical waste sharps through the mail,

provided they meet the specified packaging requirements (40 CFR 259). This exemption is intended to

encourage small quantity generators (e.g., doctors’

offices) to dispose of medical wastes properly (141).

For the most part, most of the medical wastes

shipped are sharps. Some tissues and laboratory

specimens are mailed to laboratories for diagnostic

purposes. Historically, laboratory samples, etiologic

agents, and other medical items have been shipped

through the postal service. Some basic postal

packaging requirements exist and the practices have
Chapter Special Treatment Issues ● 61

been the subject of congressional hearings (e.g., 54

Federal Register 1197(.)).

Concerns have been raised not only about the

potential hazard or at least negative perception

associated with handling medical wastes and household mail through the same postal system, but also

over the operation of these waste mail companies

that essentially operate as transfer stations (104).

The scope of current regulation does not cover such

operations. These practices warrant further investigation, particularly over the adequacy of current

regulations governing the shipment of wastes

through the mail and the desirability of such systems

for small generators and rural health-care facilities.

SMALL GENERATOR -

MANAGEMENT

The amount of medical wastes generated nationally from non-hospital settings is not known (although EPA will reportedly be including such

estimates in its first report to Congress). These small

generators include such sources of medical wastes

as: home health-care patients, doctors’ offices (including dental and veterinarian), and rural healthcare settings. Although some States are including

some small generators of medical wastes, such as

doctor and dental offices, in their regulatory programs for medical wastes, most exclude households.

The equity of including some and not all generators of medical wastes under regulations is hotly

debated. 3 It is widely recognized that the same types

of controls are not feasible for both large and small

generators. The focus of the debate is over whereto

draw the regulatory line between generators to be

included or excluded from regulation and over how

large the gulf should be between the level of scrutiny

and degree of requirements for large versus small

sources of medical wastes.

In the area of medical waste policy, the demand

for a comprehensive scope for controls is being

grappled with from the beginning of regulatory

efforts. EPA issued guidelines for home health-care

disposal shortly after it promulgated its standards for

MWTA (130). Other guidelines are being developed

and discussed in response to the increased attention

to wastes from these sources and their infectious

potential (102; see also 82, 83).

The need for developing feasible and economical

treatment and disposal options for small generators

is widely acknowledged. Few advocate including

households under medical waste regulations, but

concerns over solid waste worker safety are real. The

need for viable disposal options for rural hospitals,

small laboratories, and different types of doctors’

offices are also real. Some technologies have already

been adapted for nonhospital sources. For example,

for a number of years a mobile sterilization system

has been used in Berlin, West Germany, to collect

doctor office and nursing home medical wastes.

There are plans by a hospital council on Long Island,

New York, to attempt to bring this technology to the

United States (68).

For small generators, the most promising of the

emerging treatment methods discussed in this report

are the nonincineration treatment methods and the

newer management methods for sharps. These

options may provide safe and economically feasible

on-site treatment alternatives for small generators.

Off-site incineration is also an option, since some

medical waste companies will contract to pick up

and transport to their incinerator medical wastes

from doctor and dental offices and other small

generator sources.

Careful and creative management strategies will

be key to ensuring effective handling and treatment

of these wastes. Limited information and assistance

are available to households, small and rural hospitals, and other smaller generators to help them devise

effective medical waste management plans and

systems. Education efforts are clearly important but

to date are limited to an EPA brochure for households, to be distributed by health-care providers or

others (130).

qclemly, mWlatiom are usually adopted not beeause they are permived as “fair,’ but rather beeause they are necessary to achieve some social or

economic goal of the greater public. That regulations be “rea.somble” maybe dif.fkult to define, but a legitimate standard by which to judge them. In

most areas of environmental policy, regulatory attention is first focused on the largest generators of the problem. Later, refinements are made to the

regulations and their scope broadened to include other signit3cant sources.
62 ● Finding the Rx for Managing Medical Wastes

OTHER TREATMENT TECHNIQUES:

SEWER USE AND SHREDDING

Sewer Use

Certain medical wastes can be legally discharged

to sewers. These wastes include blood and blood

products, ground-up solid infectious wastes (e.g.,

body parts and organs), and other liquid and or

semi-liquid infectious wastes. Reportedly, about 23

percent of hospitals dispose of blood and body fluids

to sewers and about 14 percent grind solid infectious

wastes and discharge them to sewers using a grinder

similar to that used for in-sink home garbage

grinding (91). The State of Washington survey

found that 49 percent of the hospitals surveyed

reported pouring blood into the sewer system (139).

EPA (122), in its guidance manual for infectious

waste management, identified sewers as an acceptable treatment option for blood and blood products if

secondary treatment is available (i.e., occurs at the

sewage treatment plant).4 Secondary treatment systems, however, are designed to microbiologically

breakdown and remove organic constituents in

wastewater and are not designed to disinfect waste

water. At a primary or secondary municipal treatment facility, wastewater disinfection occurs as the

last step, usually by chlorination, prior to release to

the environment (11 1).

While there is little concern over the ability of

sewage treatment plants to handle liquid medical

wastes adequately, the absence of treatment at the

point of discharge (i.e., at the facility) has prompted

some concern.

5 Medical staff and plumbers risk

occupational exposure if there is a sewage backup

(104, 91). At least one such incident reportedly

occurred in 1987 at the Los Angeles CountyUniversity of Southern California Medical Center

when a pipe in the basement burst and dumped

possibly contaminated blood and fluids on workers

(five of whom filed a lawsuit against the facility).6

This type of incident is an example of a plumbing

problem and concern over potential worker exposure

from these types of accidents should be distinPhoto credit: Vetco Sanitec Corp., Combustion Engineering,

Stamford, CT

Shredded medical waste meets the nonrecognizability

requirement of MWTA. Shredders can be used for

untreated wastes or be incorporated into the use of

various treatment technologies. Shown here are contents

of microwaved and shredded medical wastes.

guished from the issue of health-care facilities

discharging body fluids to the sewage system.

Another aspect of sewage disposal that is much

larger than the medical waste issue and its contribution to the flow of wastes to the sewers is potential

problems associated with combined sewer overflows (CSOs), i.e., where sanitary and storm sewers

are combined. In these situations when it rains

untreated sewage and any wastes discharged to

sewers may be discharged directly to waterways,

because the sewage treatment plant cannot accommodate the increased flow of waste water. In New

York City, for example, there are over 500 CSO

points and for some as little as a quarter of an inch

of rain can lead to the release of untreated sewage

(134).7

Shredding

The nonrecognizability requirement of MWTA

regulations has focused attention on methods to

destroy treated waste, notably shredding, to meet

this requirement. Currently, there are no criteria

(voluntary or mandatory) on the degree of shredding

Asteam stefitiation and incineration are, however, the two recommended treatment methods (122).

5~s is me pfic~mly when ~~eated ~sc~ged liquids can @-pass me ~eatment facifity h areas Mm combined sewer OV@OWS.

6@~nn v. Court of ~s Angeles, Case No. C669760, L.A. Superior COWI of tie State of C~Ofia.

7cs0s were ~fact ~plicated as amajor so~ce respo~ible for tie beach washups c)f rne&Cal wastes fi the SllIMIl er of 1988. Investigations concluded

that syringes discharged to the sewers, primarily from I.V. drug users and diabetics, were directly discharged to waterways in heavy rains and then other

weather patterns made the likelihood of washups containing these wastes high (137).
Chapter 5--Special Treatment Issues . 63

required to achieve nonrecognizability. This lack

may account for the apparent reluctance to apply

shredding technology to emerging treatment methods.8 The necessity for criteria or standards for this

and other treatment and destruction methods will

perhaps best be evaluated after the completion of

MWTA demonstration program.

Yet other factors, such as the difficulty existing

shredding systems have with the heterogeneity of

the medical waste stream and the high maintenance

associated with shredders, may account for their

limited application to date. It may be that improvements and refinements to shredding technologies

will occur, particularly if the nonrecognizability

criterion is more widely incorporated into medical

waste regulations, and the use of shredders is

increased. In any case, disinfection of infectious

medical wastes before shredding to minimize potential aerosolization of pathogens is desirable.

%teresfigly, mere are specific shredding standards for document destruction by the Department of Defense for confidentiality (1~).
Chapter 6

Comparisons of Treatment Alternatives

However great the achievements of reduction and

recycling efforts, there will continue to be a need for

effective treatment and disposal for wastes that

cannot be recycled. Although incineration remains,

and is likely to continue to remain, a primary

treatment method for medical wastes for the foreseeable future, a number of other treatment alternatives

are available and will supplement incineration

technology. As concerns over the cost, safety, and

permitting/siting of incineration facilities continue,

so too will the favorable climate for emerging

nonincineration technologies. New variations of

autoclave, mechanical/chemical, radiation, and microwave treatment methods are now commercially

viable. Other emerging technologies are in the

testing or even conceptual stages. Currently, States

play the critical role in evaluating and approving

alternative treatment technologies. Inconsistencies

exist among the States and increasingly Federal

guidance on evaluation and approval of treatment

alternatives is suggested as necessary and desirable

(e.g., suggestions of participants at the OTA Medical

Waste Workshop, 1990).

An important given when comparing alternatives

is that whatever treatment alternative is used, some

form of additional solid waste disposal must occur.

In all cases, ultimately, some degree of dependency

on landfills remains. For medical waste incineration,

the ash becomes a waste product requiring landfilling. For autoclaving, microwaving, and irradiation

either incineration and/or landfilling is necessary.

The residue from the chemical/mechanical treatment

alternative will be discharged to the sewer or

landfilled. The difficulty of landfilling even treated

medical wastes, given refusals by some landfill

operators, remains a significant obstacle for management in some areas of the country. Interstate

shipment and international exportation of solid

waste, including medical wastes, is an emerging

environmental and political issue nationally (1 16).

Valid comparisons of various treatment alternatives for medical wastes are problematic because different types of treatment goals are

served by different technologies (e.g., the goal can

be treatment to render wastes noninfectious; or

noninfectious and nontoxic; or noninfectious

nonrecognizable, and/or nontoxic). This means

that different techniques may be appropriate for

different waste types. Treatment alternatives will

differ in the nature of the emissions that warrant

test protocols, control measures and operating

parameters specific to each technology.

Obviously, costs and risks associated with the

alternatives will vary. Further, a number of

considerations concerning liabilities and costs

influence generator decisions about on-site versus off-site treatment. Treatment alternatives are

more easily scaled to various types and sizes of

facilities. Comparisons between off-site and onsite applications of various alternatives can also

be problematic. With all of these differences,

clearly, comparisons of the treatment technologies must be made carefully. Such comparisons

are imprecise, but helpful in highlighting the

various features and considerations associated

with the alternative treatment technologies.

CAPABILITIES AND RISKS

Table 8 compares the various treatment technologies discussed in chapters 3 and 4. All of these

treatment alternatives can effectively manage

most infectious wastes; the only ones that are

usually used to treat pathological waste are the

incineration and mechanical/chemical disinfection systems. Depending on the type of incinerator

and the nature of its controls, incineration is the one

treatment alternative that could manage all of a

health-care facility’s wastes, i.e., pathological and

other infectious, hazardous (possibly, depending on

the design and controls of the incinerator), administrative, food, and other non-patient wastes.

From other perspectives, nonincineration alternatives may have advantages over incineration. In general, there are more serious emissions

concerns associated with incineration than most

alternatives. Yet, it is true that because incineration

is a more established technology, emission concerns

have been more clearly identified. The human health

and environmental risks may be presumed to be less

from nonincineration treatment alternatives but additional study, particularly of water effluents from

some of the systems, is necessary. Generally, health

risks associated with the various treatment technolo-

-65-
66 ● Finding the Rx for Managing Medical Wastes

Table 8—Comparison of Treatment Technologies

Costs (approximate) d

“Regulated medical Operating or per pound

wastes” appropriate for charges (not including Capital (equipment

treatment method to render Volume reduction labor; depreciation; profit/ and installation)

Treatment technology wastes non-infectious (%) return) ($/lb./hr.) ($ K)

Steam autoclave . . . . . . . . All, except pathological o $0.05-$0.07 $100 K (on-site)

Autoclave with

compaction . . . . . . . . . . Ail, except pathological 60-80% $0.03-$0.10 $100 K

Mechanical/chemical . . . . . All 60-907. $0.06 $40-350 K

Microwave

(with shredder) . . . . . . . All a

60-907. $0.07-$0.10 b

$500 K

Irradiation

(with grinder) . . . . . . . . . All, except pathological 60-90% $0.15 Not available

incineration . . . . . . . . . . . . All c90-95% $0.07-$0.50 $1,000 K (on-site)

apathologi~l ~a~te~ are usu~ly nottreat~ by rnicrowavedue to esthetic reasons, Cytotoxical Orothertoxic Chemicals cannot IM adequately treated to dUCe

their hazardous nature.

b[n~~ing an energy cost of $0.07/kWh.

cAlthough separation of noncombustibles ad items with problematic ~nstituents improves combustion efficiency (See ch. 3).

dReiiable Cmt information is difficult to obtain and verify. Further, valid comparisons are difficult to m~e given the different circumstances under which VariOUS

technologies operate (e.g., amount of waste treated and its effect on costs, etc.)

SOURCE: Office of Technology Assessment, 1990.

gies have not been thoroughly studied. Presumably,

pollution controls could adequately control pollutants of concern for both nonincineration and incineration alternatives. Of course, the more pollution

controls necessary, generally, the more expensive

the treatment.

The concern

economic state

jeopardized by

COSTS

that the already generally precarious

of the health-care industry could be

further regulation of medical waste

management warrant s examination. Presently, the

exact amount a health-care facility spends on

medical waste management is often not known with

certainty even by the facility’s management. The

additional cost that new controls, alternative treatment technologies, or management practices might

entail can not be accurately assessed unless current

costs can be understood with some certainty.

Available cost estimates for various treatment

technologies indicate that on-site incineration

can be comparable or significantly higher in costs

than other on-site alternatives (30; 104). While

costs for on-site alternatives can be estimated fairly

constantly, the same is not true for off-site alternatives. OTA contractors found from informal discussions with generators of medical wastes and operators of medical waste services throughout the

country that the price charged for any type of off-site

treatment is never determined solely on the basis of

costs, but rather by ‘‘what the market will bear. ’

Given that it is a highly competitive industry, this

does not necessarily mean that off-site waste facilities reap an unusually high profit, but, as noted in

chapter 3, the medical waste industry is healthy.

It appears that hospitals and other health-care

facilities eligible to receive Medicare reimbursement can theoretically be reimbursed for some

on-site medical waste management costs. Although

there is no specific category for waste management

reporting, some percentage of capital costs and some

operating costs could be covered (54). In the State of

New York the eligibility of health-care facilities for

Medicare reimbursements for some on-site medical

waste costs (and regional utilization of an on-site

hospital treatment facility) is explicitly addressed by

the Department of Health (85). Although no hospitals have been known to request Medicare reimbursement to date, it was part of the New York State

legislative debate over increasing the reimbursement rates for hospitals (80).

Other types of grants offered by some State

energy offices, such as those that will cover some

portion of the capital costs for waste-to-energy

facilities, may also reduce a facility’s share of costs

for this type of incineration (31). For example, in

New York State, a proposed Environmental bond

issue, which will be on the ballot in November 1990,

will provide $50 million in State assistance for

regulated medical waste projects. The grant program

would be administered by the State Department of

Health and would provide funding for up to 50

percent of the project costs. To be eligible, a facility

must participate in a waste audit and must develop
Chapter 6-Comparisons of Treatment Alternatives and Policy Issues for Federal Action . 67

a plan for recycling, product reuse, and waste

reduction (94).

The volume of waste handled by a treatment unit

and its effect on the operating cost of the unit is

highly variable, but generally costs are lower for

on-site incineration and nonincineration alternatives. The capital costs associated with incineration

are significantly higher than those for most alternative treatment technologies. Yet, heat recovery (and,

as noted, programs that will reimburse up to half the

capital costs for waste-to-energy facilities) and

efficient operation (e.g., including recycling in

conjunction with incineration) may reduce incineration costs to the facility and result in a more

favorable cost comparison of incineration to the

other technologies (31). Nonetheless, the potentially

high cost of disposal of incinerator ash, if it is

classified as a hazardous waste, is also a potential

significant cost factor associated with incineration

that must be considered. Other factors that affect

costs, such as reduced cost of transportation, reduced

disposal costs, and reduced liability, are relevant to

a decision to manage wastes on-site v. off-site.

Costs, even so, are only one of a number of factors

(e.g., nonrecognizability, liability, and ability to

render wastes non-infectious) that health-care facilities consider when deciding what type of treatment

alternative to use and whether to manage wastes

on-site or off-site. Clearly, a facility may be able to

reduce its costs and liability and have greater control

by managing wastes on-site; however, on-site management also represents a major institutional commitment of resources to waste management, which

is not the primary function of the health-care facility.

As has been noted throughout this report, a number

of factors favor off-site treatment as well.

Ultimately, each generating facility must weigh

the various factors and determine which waste

reduction and management alternatives are most

appropriate for its circumstances. Public policies

should recognize and not preclude the variable

solutions necessary to meet individual generators’

waste management needs. In addition, medical

waste policies should

sort of protocols to

reliability and safety

tives.

help through the use of some

reduce uncertainty over the

of various treatment alternaIt remains to be seen what direction Congress and

Federal agencies, and the medical and health-care

industry and community will define for medical

waste management. It will be important, though, that

any legislative or regulatory activity acknowledges

and appropriately addresses the variety of management issues and available treatment technologies

discussed in this report. Experiences with management of other components of our society’s wastes

indicate that effective waste management is based

on a recognition that there are a variety of viable

management options available and appropriate to

meet particular site-specific circumstances, and

prevention or reduction and recycling efforts are

included in these options. Adopting a more comprehensive approach to medical waste policy may offer

the greatest prospect for adoption of a program that

will ensure the safe, cost-effective management of

medical wastes.
Appendix A

The Medical Waste Tracking Act

MWTA establishes a demonstration tracking system

(Sections 11001-11003) and, as noted in the introduction,

directs EPA and ATSDR to undertake studies of certain

medical waste management issues (see box D).1 Unlike

any other environmental law, MWTA was designed to

structure a process for gathering sufficient information to

evaluate the nature and risks posed by a waste, so that

Congress could then reevaluate and identify whether any

further policy action is warranted. The intent of the law is

to develop a basis for determining, after the completion of

the demonstration program and the governmentmandated studies, whether and in what ways the Federal

Government should regulate medical wastes.

MWTA specifically applies to the Great Lakes States

and Connecticut, New Jersey, and New York (Section

11001). All of the Great Lakes States were given the

option to decline to participate in the demonstration

program (and any other State was given the opportunity

to participate); and Connecticut, New Jersey, and New

York could petition out if their State had a program at least

as stringent as that of the Federal Government.2 None of

the Great Lake States chose to participate, while none of

the other three States petitioned out. Thus, MWTA

applies only to New York, New Jersey, Connecticut, and

also to Rhode Island and Puerto Rico, which voluntarily

entered the program. Louisiana and the District of

Columbia voluntarily joined the program, but later

petitioned out of it.

MWTA defines medical waste as “. . . any solid waste

which is generated in the diagnosis, treatment, or immunization of human beings or animals, in research pertaining

thereto, or in the production or testing of biologicals. ”3

Section 1004(40) of RCRA, as amended by MWTA,

notes further that medical waste “does not include any

hazardous waste identified or listed under Subtitle C or

any household waste as defined in regulations under

Subtitle C.’ Any solid waste mixed with a regulated (i.e.,

listed) medical waste (see below) is also a regulated waste

under MWTA. As noted earlier, special regulations exist

for the management of LLW (see box A).4 MWTA

regulations do require tracking of LLW medical waste,

unless it is mixed with hazardous wastes that would be

regulated under RCRA Subtitle C (40 CFR 259).5 It

should also be noted that domestic sewage is not included

in the RCRA definition of solid waste (Section 1004(27)).

It is possible that the EPA definition of regulated

medical wastes, codified as part of MWTA, might become

more widely used and help forge consensus on the

categories of wastes designated as infectious. These

categories are now frequently referred to as “regulated

medical wastes. Box D outlines the major features of the

tracking program established by MWTA.

EPA cost estimates, although provided to EPA by the

regulated community, are considered low by some waste

industry officials and regulated sources (141). These

estimates are that the cost to comply with MWTA will

increase disposal of regulated medical wastes by approximately $0.08/pound on average; with average annual

compliance costs per facility range, according to EPA,

from about $3,750 for hospitals to about $70 for dentists

(Fed. Reg., vol. 54, No. 56, Mar. 24, 1989). According to

the preliminary results of the New York City medical

waste study, while the per pound cost of medical waste

disposal has remained relatively stable since MWTA

passed, overall waste management has become highly

costly. For example, ‘‘a typical 500-bed acute-care

hospital in New York City has experienced a 400 percent

cost increase in waste disposal as a result of MWTA”

with an actual cost ‘‘in excess of $400,000 per year for

such a hospital” (63). This could result from poor

segregation practices at certain facilities and/or to shortages of personnel for such tasks.

Upon completion of the demonstration program, EPA

and the participating States will review the generator

reports and evaluate the program, including the impacts

of the program on management practices and the costs of

complying with the tracking regulations. As noted above,

EPA’s report to Congress on the program is due in

September 1991.

The importance of MWTA demonstration tracking

program to abating medical waste problems is not clear;

if a more comprehensive regulatory program is adopted in

the future, the contribution of a tracking system to the

1’I’MS discussion is based in part on that contained in (137); see tdSO (36), (86), and (22).

Zbdependently, a ntier of actions have been undertaken by States to address medical waste problems (e.g., New York Stite and New Jersey

cooperatively adopted a tracking system in August 1988 (before passage of the MWTA)). Also, the New York Bight FIoatables Action Plan, a

multi-agency effort led by EPA Region II, is part of the New York Bight Restoration Phin and addresses some medical waste handling procedures in

the New York Bight area.

3~ere is a difference beWeen ~.s defition of “medic,~ waste” in tie MWTA ad wastes iden~ied as “re@ated med.icd wastes” (S= ch. 1).

4~e ~w.~vel Radioactive Wrote policy Act of 1980 ~d fie ~w-~vel Radioactive Waste policy Amendments Act of 1985 (1 17).

5~w medi~ ~mte, upon radioactive d~ay, wo~d still ~ve to be @ack~ as re@at~ medic~ waste, disposed of ~OU@ @ sewer syStelQ Or

treated and destroyed onsite, or tracked as a hazardous waste.

-69–
70 ● Finding the Rx for Managing Medical Wastes

Box D—The Medical Waste Tracking Program

EPA established the 2-year pilot Federal tracking program authorized by MWTA by publishing its “Standards for the

Tracking and Management of Medical Waste; Interim Final Rule and Request for Comments ‘‘ in the Federal Register in March

1989, which took effect in June 1989.1 The tracking system for medical wastes designates recordkeeping requirements for

facilities that generate over 50 pounds a month of medical waste and requires the use of a four-part form for any off-she shipment

of medical wastes. EPA and the State must be notified if a generator does not receive a copy of the manifest form from the final

destination facility. Generators of medical waste that produce less than 50 pounds are subject to the same handling requirements,

except instead of using the tracking form they must maintain a log (i.e., as a reporting requirement).

EPA has authority to assess civil penalties of up to $25,000 per day for each violation, criminalpenalties of up to $50,000

per day per violation, and jail terms of up to 5 years may be imposed in States implementing the tracking system (sec. 11005).

States have the authority to conduct inspections and take enforcement actions as well. The MSWTA does not specify whether the

EPA or the States has lead enforcement authority and the EPA regulations do not specify enforcement roles, but the Agency

prepared an enforcement strategy which encourages State implementation. Flexibility is given to the States to develop a variety

of approaches to compliance and enforcement (134). EPA restricts its role to encouraging voluntary compliance through its

various education efforts and by providing States with guidance and assistance when needed (e.g., when a violation involves

wastes from or transported to a nonparticipating State).

EPA, also as part of the MWTA demonstration program, issued requirements that generators of waste must follow before

medical wastes leave the site to be shipped to authorized treatment or disposal facilities. Under the demonstration program,

generators include institutional and commercial sources of wastes in the participating States and territories. Of course, any

treatment facilities accepting regulated medical wastes may be subject to other Federal, State, and local laws and regulations.

The MWTA does not consider residential sources of medical waste to be regulated generator sources, nor does it address problems

with the disposal of wastes associated with illegal drug use. EPA issued guidance information on proper home medical waste

disposal and states in its pamphlet describing the MWTA that drug enforcement, Clean Water Act programs, and citizen litter

control projects will help eliminate ‘‘flagrant dumping of wastes. ’ (130)

According to the MWTA requirements, generators must separate regulated medical wastes from general refuse, meet storage

requirements (if such wastes are stored before treatment), and package regulated wastes in labelled, rigid, leak-resistant

containers. In addition, special separation and packaging requirements are specified for both sharps and fluids. To help ensure

that packages retain their integrity during handling and transportation, secondary packaging (i.e., a rigid outer container) is

generally required for shipping. This secondary packaging can be reused if thoroughly cleaned. The package labels must identify

the content, generator, and transporter of the wastes.

Medical wastes incinerated on-site, or treated by other methods (e.g., some type of disinfection unit) that meet both

regulatory criteria of treatment and destruction (i.e., waste is ‘‘processed by a means to reduce levels of infectious agents” and

waste is “no longer generally recognizable as medical waste”), do not need to be tracked under the demonstration program, but

instead generators must submit a report to EPA. The position of the EPA is that if the biological and physical hazard of the waste,

as well as their ‘visually offensive nature,“ is altered they can be managed according to regulations applicable to solid waste.

The required report must be a summary of the volumes and types of medical waste treated on-site during the first 6-month period

of the program; a second report covers the 13 to 18 months of the program.

I since this tie, the Agency has issued a number of guides for the public, generators and transporters about tie Fede~ ~program

(128).

improved management of medical waste will need to be

evaluated independently. GAO (134) has evaluated the

efforts to date of the EPA and States to implement

MWTA. For this reason, their implementation activity is

not evaluated here. Apparently, despite early controversy

over the listing of wastes by the Agency to be tracked and

concerns over compliance costs, as well as the initial type

of confusion usually associated with new regulatory

programs, the implementation of MWTA demonstration

program has been rather smooth. EPA reports that most

of the early violations were minor in nature (e.g., errors in

completing manifest forms, etc.), although fines have

been levied against responsible parties for such violations

as incomplete record keeping and failing to lock storage

areas (88).

A number of issues that EPA and ATSDR are required

by MWTA to address (e.g., health effects of medical

waste, generation information, cost implications, smallquantity generator issues) also is not discussed extensively in this study. The focus of this effort is on available

and emerging management methods, including waste

reduction and recycling possibilities. This emphasis on

the evaluation of treatment technologies is intended to

alleviate immediate concerns over the nature, availability,

and tradeoffs of various treatment methods and to

stimulate a broader consideration of management alternatives for medical waste than is currently typical.
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72 ● Finding the Rx for Managing Medical Wastes

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