EPA-453/R-94-042a
Medical Waste Incinerators-Background Information for Proposed
Standards and Guidelines: Industry Profile Report for New and Existing
Facilities
July 1994
U. S. Environmental Protection Agency
Office of Air and Radiation
Office of Air Quality Planning and Standards
Research Triangle Park, North Carolina
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DISCLAIMER
This report is issued by the Emission Standards Division, Office
of Air Quality Planning and Standards, U. S. Environmental
Protection Agency. It presents technical data of interest to a
limited number of readers. Mention of trade names and commercial
products is not intended to constitute endorsement or
recommendation for use. Copies of this report are available free
of charge to Federal employees, current contractors and grantees,
and nonprofit organizations--as supplies permit--from the Library
Services Office (MD-35), U. S. Environmental Protection Agency,
Research Triangle Park, North Carolina 27711 ( [919] 541-2777) or,
for a nominal fee, from the National Technical Information
Service, 5285 Port Royal Road, Springfield, Virginia 22161
([703] 487-4650).
111
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iv
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TABLE OF CONTENTS
List of Tables v
1.0 INTRODUCTION 1
1.1 PURPOSE 1
1.2 BACKGROUND 1
1.3 ORGANIZATION . 1
2.0 SUMMARY 2
3.0 CHARACTERIZATION OF MEDICAL WASTE 2
3.1 DEFINITION OF MEDICAL WASTE 2
3.2 CHARACTERISTICS OF MEDICAL WASTE 6
3.2.1 Infectious Component 6
3.2.2 Chemical and Physical Characteristics ... 9
3.3 DEFINITION OF MEDICAL WASTE INCINERATOR 11
4.0 MEDICAL WASTE TREATMENT, DESTRUCTION, AND DISPOSAL ... 12
4.1 TREATMENT 12
4.1.1 Incineration 12
4.1.2 Steam Sterilization 12
4.1.3 Thermal Inactivation 13
4.1.4 Chemical Disinfection 13
4.1.5 Gas Sterilization 13
4.1..6 Irradiation Sterilization 13
4.1.7 Microwave Sterilization ..'..' 14
4.1.8 Radiofreguency Sterilization 14
4.2 PHYSICAL DESTRUCTION 15
4.2.1 Incineration 15
4.2.2 Grinding or Shredding 15
4.3 DISPOSAL 16
5.0 MEDICAL WASTE GENERATOR POPULATION 16
5.1 HOSPITALS 20
5.1.1 Population and Waste Generation Rate .... 20
5.1.2 Waste Composition 21
5.1.3 Treatment and Disposal . 23
5..1.4 Trends 23
5.2 LABORATORIES 26
5.2.1 Population and Waste Generation Rate .... 26
5.2.2 Waste Composition 28
5.2.3 Treatment and Disposal 29
5.2.4 Trends 31
5.3 CLINICS/OUTPATIENT CARE 31
5.3.1 Population and Waste Generation Rate .... 31
5.3.2 Waste Composition 33
5.3.3 Treatment and Disposal 34
5.3.4 Trends 35
v
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TABLE OF CONTENTS
5.4 PHYSICIANS' OFFICES 35
5.4.1 Population and Waste Generation Rate .... 35
5.4.2 Waste Composition 36
5.4.3 Treatment and Disposal 36
5.4.4 Trends 37
5.5 DENTISTS' OFFICES , 37
5.5.1 Population and Waste Generation Rate .... 37
5.5.2 Waste Composition 38
5.5.3 Treatment and Disposal 39
5.5.4 Trends 39
5.6 VETERINARIANS 39
5.6.1 Population and Waste Generation Rate .... 39
5.6.2 Waste Composition 41
5.6.3 Treatment and Disposal 42
5.6.4 Trends 42
5.7 LONG-TERM HEALTH CARE FACILITIES 43
5.7.1 Population and Waste Generation Rate .... 43
5.7.2 Waste Composition 45
5.7.3 Treatment and Disposal 45
5.7.4 Trends 46
5.8 FREE-STANDING BLOOD BANKS 47
5.8.1 Population and Waste Generation Rate .... 47
5.8.2 Waste Composition 48
5.8.3 Treatment and Disposal 48
5.8.4 Trends 48
5.9 FUNERAL HOMES 48
5.9.1 Population and Waste Generation Rate .... 48
5.9.2, Waste Composition 50
5.9.3 Treatment and Disposal 50
5.9.4 Trends 51
5.10 SOURCE CATEGORIES EVALUATED ONLY BY JFA 51
6.0 MEDICAL WASTE INCINERATOR POPULATION 53
6.1 NATIONWIDE 53
6.2 STATE DATA 55
6.3 DISCUSSION OF INDIVIDUAL FACILITY CATEGORIES ... 55
6.3.1 Hospitals 61
6.3.2 Laboratories .. . . 66
6.3.3 Veterinary Facilities 66
6.3.4 Nursing Homes 67
6.3.5 Commercial Units 67
6.3.6 Other /Unknown 69
6.3.7 Municipal Waste Combustors (MWC's) That
Cofire Medical Waste 69
6.4 TRENDS IN MEDICAL WASTE INCINERATION PRACTICES . . 71
6.4.1 Potential Influences On Population Growth . 71
6.4.2 Growth Projections 73
7.0 REFERENCES 75
vi
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LIST OF TABLES
Page
TABLE 1. ESTIMATED NUMBER OF U.S. FACILITIES AND
QUANTITY OF MEDICAL WASTE GENERATED ANNUALLY
BY GENERATOR CATEGORY 3
TABLE 2. ESTIMATED U.S. MWI POPULATION WITH RATED
CAPACITY STATISTICS 4
TABLE 3. REGULATED MEDICAL WASTES 7
TABLE 4. TYPES OF MEDICAL WASTE DESIGNATED AS INFECTIOUS
BY THE CDC, THE EPA, AND 441 RANDOMLY
SELECTED U.S. HOSPITALS 8
TABLE 5. CHARACTERIZATION OF HOSPITAL WASTE ...... 10
TABLE 6. SUMMARY OF ESTIMATES FROM JACK FAUCETT
ASSOCIATE REPORT AND OFFICE OF SOLID WASTE
REPORT 18
TABLE 7. STATE OF WASHINGTON SURVEY RESULTS: PERCENT OF
FACILITIES GENERATING SPECIFIED WASTES, BY
SOURCE CATEGORY 22
TABLE 8. STATE OF WASHINGTON SURVEY RESULTS: PERCENT OF
FACILITIES USING SPECIFIED ONSITE TREATMENT
METHODS, BY SOURCE CATEGORY 24
TABLE 9. STATE OF" WASHINGTON SURVEY RESULTS: PERCENT OF
FACILITIES USING- SPECIFIED OFFSITE TREATMENT
METHODS, BY SOURCE CATEGORY 30
TABLE 10. PERCENTAGE DISTRIBUTION OF MWI POPULATION BY
RATED CAPACITY FOR EACH FACILITY TYPE ... 54
TABLE 11. SUMMARY OF AVAILABLE MWI AGE DATA 56
TABLE 12. MWI POPULATION BY STATE 57
TABLE 13. SURVEYED HOSPITAL MWI POPULATION BY COMBUSTOR
WITH RATED CAPACITY STATISTICS 62
TABLE 14. PERCENTAGE DISTRIBUTION OF SURVEYED HOSPITAL
MWI POPULATION BY RATED CAPACITY FOR EACH
COMBUSTOR TYPE . 63
TABLE 15. DISTRIBUTION OF PROJECTED ONSITE MEDICAL WASTE
INCINERATOR SALES BY TYPE AND SIZE FOR THE
5 YEARS AFTER PROPOSAL OF THE NSPS
74
vii
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LIST OF TABLES (continued)
TABLE 16. DISTRIBUTION OF PROJECTED COMMERCIAL
MEDICAL WASTE INCINERATOR SALES BY TYPE
AND SIZE FOR THE 5 YEARS AFTER PROPOSAL
OF THE NSPS
74
viia.
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INDUSTRY PROFILE REPORT
1.0 INTRODUCTION
1.1 PURPOSE
This report presents a profile of the medical waste
incinerator (MWI) source category. The purpose of this profile
is to characterize the source category for use in subsequent
environmental and economic analyses. Definitions of medical
waste and MWI's are presented, and the industry structure
associated with MWI's is described.
1.2 BACKGROUND
In recent years, public concern has grown about potential
health hazards from the improper disposal of medical wastes. The
washup of medical waste on beaches in 1988 heightened public
awareness even further. While not all medical waste poses
significant health hazards, improper disposal can lead to public
exposure to infectious organisms, such as the AIDS and
hepatitis B viruses, and can result in aesthetically unpleasant
situations. Public exposure routes include beaches with waste
washups and trash dumpsters in which medical wastes have been
placed.
Because significant public concern has been raised about
medical waste disposal, lawmakers and regulatory agencies have
acted to ensure that medical waste generators properly treat and
dispose of their waste. As a consequence of these regulatory
actions, treatment by sterilization or incineration and disposal
by subsequent landfilling are becoming the treatment and disposal'
methods of choice. Incineration is frequently preferred over
sterilization because it reduces the volume of treated waste to
be iandfilled and generally renders the waste unrecognizable.
This preference is likely to result in increased use of
incineration.
±.3 ORGANIZATION
The remaining sections of this report describe the
characteristics of the industry associated with medical waste
incineration. In Section 2.0, a summary of the findings is
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presented. Section 3.0 presents the definitions of medical waste
and MWI adopted for this industry profile. This section also
includes information on the characteristics of medical waste.
Section 4.0 presents the alternative technologies for treatment,
destruction, and disposal of medical wastes. Section 5.0
presents the available information on the medical waste generator
population. Information on the existing MWI population and
projected growth is presented in Section 6.0.
2.0 SUMMARY
It is estimated that approximately 3.4 million tons of waste
are produced annually by medical waste generators in the United
States. This total includes any solid waste generated at these
facilities. Table 1 presents estimates of annual infectious
waste and total waste generation for 14 categories of generators.
These estimates are discussed by category in Section 5.0. As
shown in Table 1, hospitals are the single largest generator,
producing approximately 70 percent of the annual total.
In Table 2, the estimated U.S. population of MWI's is
presented, along with statistics on the units' rated capacities.
In all, about 5,000 MWI's are believed to exist. Estimates are
presented for each type of facility at which MWI's are commonly
found. Over half of these MWI's are found at hospitals. These
estimates are discussed more fully in Section 6.0.
3.0 CHARACTERIZATION OF MEDICAL WASTE
3.1 DEFINITION OF MEDICAL WASTE
The Solid Waste Disposal Act of 1965 was amended by the
Resource Conservation and Recovery Act (RCRA) of 1976. In 1988,
RCRA was amended by the Medical Waste Tracking Act (MWTA).
Medical waste is defined by MWTA, Section 1004 (40) as ". .. . any
solid waste which is generated in the diagnosis, treatment, or
immunization of human beings or animals, in research pertaining
thereto, or in production or testing of biologicals."
("Biologicals" refers to preparations, such as vaccines, that are
made from living organisms.) Specifically excluded from this
definition are hazardous waste and household waste as identified
in RCRA, Subtitle C.
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TABLE 1. ESTIMATED NUMBER OF U.S. FACILITIES AND QUANTITY OF
WASTE GENERATED ANNUALLY BY GENERATOR CATEGORY1
Generator category
Hospitals
Laboratories
Medical
Research
TOTAL
Clinics (outpatient care)
Physicians' offices
Dentists' offices
Veterinarians
Long-term care facilities
Nursing homes
Residential care
TOTAL
Free-standing blood banks
Funeral homes
Health units in industry
Fire and rescue
Corrections
Police
TOTAL
No. of facilities
7,000
4,900
2.300
7,200
41,300
180,000
98,000
38,000
18,800
23.900
42,700
900
21,000
221,700
7,200
4,300
13,100
682,400
Annual infectious waste
generated, tons
360,000
17,600
8.300
25,900
26,300
35,200
8,700
4,600
29,700
1.400
31,100
4,900
900
1,400
1,600
3,300
<100
504,000
Annual total waste
generated, tons
2,400,000
117,500
55.500
173,000
175,000
235,000
58,000
31,000
198,000
9.000
207,000
33,000
6,000
9,000
11,000
22,000
< 1,000
3,361,000
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The definition of medical waste adopted for this industry
profile includes all materials encompassed by the RCRA/MWTA
statutory definition of medical waste. These materials are
included regardless of their infectious properties, whether they
are generated in association with humans or animals, or whether
they have been used before they are discarded. Waste generated
by health care providers who provide medical services to
individuals in private homes is covered by the working definition
when the waste is removed from the home and transported to the
provider's place of business for disposal. Similarly, veterinary
waste that is generated at a home or farm is also covered by the
definition when the waste is transported to the veterinarian's
place of business. Any mixtures of the types of medical waste
discussed above with any other waste are also considered to be
medical waste.
Because emissions from incineration depend greatly on the
materials that are combusted, the intent of the definition of
medical waste presented above is to include all the components of
the medical waste stream, regardless of what they were used for
prior to disposal. This approach differs from that adopted for
most medical waste regulatory and guidance activities to date,
which have been concerned with the potential for transmission of
infectious diseases. For this purpose, the term "infectious
waste" is generally, but not universally, used to refer to the
subset of medical waste that is capable of transmitting an
organism that causes an infectious disease. Other terms commonly
used for the infectious component of medical waste include
biological, biomedical, biohazardous, contaminated, red bag,
pathological, and pathogenic waste. The U. S. Environmental
Protection Agency (EPA) Office of Solid Waste (OSW) uses the term
"regulated medical waste" in its implementation of the MWTA.
Definitions of these terms generally take the format of a list of
types of waste to be included based on infection hazard. Other
factors that may be considered are the potential for injury
(e.g., from "sharps" such as hypodermic needles and scalpels) and
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aesthetic considerations (e.g., the unpleasantness of
encountering recognizable body parts).
The categories of regulated medical waste, as defined by
OSW, are presented in Table 3. Where "infectious agents" are
mentioned, OSW has indicated that this term means infectious to
humans. Thus, for example, veterinary waste (other than sharps)
that has no potential for containing human pathogens is not
included. As indicated above, the definition of medical waste
for this industry profile has been broadened to reflect potential
emissions from incineration rather than infection potential.
3.2 CHARACTERISTICS OF MEDICAL WASTE
Waste materials produced by facilities that generate medical
waste, primarily hospitals, are heterogeneous mixtures of general
refuse, laboratory and pharmaceutical chemicals and containers,
and pathological wastes. All of these waste components may
contain medical waste as defined above, as well as potentially
infectious agents. In some cases, these wastes also may contain
low-level radioactive wastes, wastes classified as hazardous
under RCRA Subtitle C, and cytotoxic wastes.
3.2.1 Infectious Component
The fraction of medical waste that is classified as
infectious waste depends on the type of generator, the activities
that produce the waste, and the definition of infectious waste
used. Probably the most widely used guidelines for classifying
infectious waste are those issued by the Centers for Disease
Control (CDC) and by EPA.3'4 A more recent development is the
"universal precaution" recommendations issued by the CDC in
August 1987.5 These recommendations were intended to reduce
potential occupational exposure to the AIDS virus within the
health-care setting and were not intended to affect waste
management practices.6 Nevertheless, the universal precaution
recommendations apparently resulted in some hospitals classifying
virtually all patient-contact waste as infectious.7'8 Table 4,
reproduced from a study conducted in 1987 and 1988, summarizes
the types of medical waste designated as infectious by the CDC
and EPA guidelines and by a random sample of U.S. hospitals.
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TABLE 3. REGULATED MEDICAL WASTES2
Waste class
Description
1. Cultures and stocks
Cultures and stocks of infectious agents and associated biologicals,
including: cultures from medical and pathological laboratories;
cultures and stocks of infectious agents from research and industrial
laboratories; wastes from the production of biologicals; discarded live
and attenuated vaccines; and culture dishes and devices used to
transfer, inoculate, and mix cultures.
2. Pathological wastes
Human pathological wastes, including tissues, organs, and body parts
and body fluids that are removed during surgery or autopsy or other
medical procedures and specimens of body fluids and their containers.
3. Human blood and blood products
(a) Liquid waste human blood; (b) products of blood; (c) items
saturated and/or dripping with human blood; or (d) items that were
saturated and/or dripping with human blood that are now caked with
dried human blood, including serum, plasma, and other blood
components and their containers, which were used or intended for use
in patient care, testing and laboratory analysis, or the development of
Pharmaceuticals. Intravenous bags are also included hi this category.
4. Sharps
Sharps that have been used in animal or human patient care or
treatment or in medical, research, or industrial laboratories, including
hypodermic needles, syringes (with or without the attached needle),
Pasteur pipettes, scalpel blades, blood vials, needles with attached
tubing, and culture dishes (regardless of presence of infectious
agents). Also included are other types of broken or unbroken
glassware that were in contact with infectious agents, such as used
slides and cover slips.
5. Animal wastes
Contaminated animal carcasses, body parts, and bedding of animals
that were known to have been exposed to infectious agents during
research (including research in veterinary hospitals), production of
biologicals, or testing of Pharmaceuticals.
6. Isolation wastes
Biological waste and discarded materials contaminated with blood,
excretion, exudates, or secretions from humans who are isolated to
protect others from certain highly communicable diseases or from
isolated animals known to be infected with highly communicable
diseases.
7. Unused sharps
The following unused, discarded sharps: hypodermic needles, suture
needles, syringes, and scalpel blades.
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TABLE 4. TYPES OF MEDICAL WASTE DESIGNATED
CDC, THE EPA, AND 441 RANDOMLY SELECTED
AS INFECTIOUS BY THE
U.S. HOSPITALS3
Source/type of medical waste
Microbiological
Blood and blood products
Pathology
Sharps
Communicable disease isolation
Contaminated animal carcasses, body parts, and bedding
Contaminated laboratory waste
Surgery
Autopsy
Dialysis
Contaminated equipment
Items contacting secretions or excretions
Intensive care
Emergency department
Surgery patients
Obstetric patients
Pediatric patients
Treatment/examination room
All patient related
CDC
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
EPA
Yes
Yes
Yes
Yes
Yes
Yes
Optional .
Optional
Optional
Optional
Optional
No
No
No
No
No
No
No
No
U.S. Hospitals13
Yes (99.0)
Yes (93.7)
Yes (95.6)
Yes (98.6)
Yes (94.4)
Yes (90.1)
Yes (88.8)c
Yes (83.2)
Yes (91.9)
Yes (63.4)
No data
Yes (63.2)
Yes (37.4)
Yes (41.1)
Yes (33.2)
Yes (35.1)
Yes (25.3)
Yes (30.3)
Yes (23.6)
aRefereace 15.
^Percent of responding hospitals that considered the waste infectious.
°The survey specifically asked if hospitals considered "miscellaneous laboratory wastes (e.g., specimen
slides)" as infectious.
or
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The survey from which Table 4 was reproduced indicates that
responding hospitals classified a median of 15 percent of total
waste as infectious.9 Those hospitals with definitions close to
the CDC guidelines averaged 5.5 percent, those approximating the
EPA guidelines averaged nearly 13 percent, and those extending
universal precaution practices to waste disposal averaged about
23 percent.
In the regulatory impact and flexibility analysis developed
for the Occupational Safety and Health Administration (OSHA)
proposed regulations on occupational exposure to bloodborne
pathogens, similar estimates were derived based on a review of
earlier studies and expert opinion. This analysis concluded that
the fractions of total hospital waste designated as infectious
waste at facilities using the CDC guidelines, facilities adhering
to the EPA guidelines, and facilities using universal precautions
in waste disposal are approximately 6, 11, and 18 percent,
respectively.10 Another source estimates that about 15 percent
of hospital waste is infectious; other estimates range from 5 to
35 percent and from 10 to 20 percent, with one study reporting an
overall range of estimates between 3 and 90 percent.11"14
It should be noted that these studies and estimates are
specific to hospitals and generally relate to the fraction of
total waste, not medical waste, that is infectious. The
percentage of the total waste stream that is medical waste is not
known. For the purpose of this project, the percentage of total
waste that is considered to be infectious at other facilities was
assumed to be the same as that at hospitals (15 percent).
3.2.2 Chemical and Physical Characteristics
The chemical and physical characteristics of the different
waste materials that are treated in medical waste incinerators
vary widely. These characteristics are important because they
affect combustion efficiency and emission characteristics.
Limited data have been generated from a study of hospitals in
Ontario, which provided information on the heating value, bulk
density, and moisture content of different waste materials. The
results from this study are presented in Table 5.16
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TABLE 5. CHARACTERIZATION OF HOSPITAL WASTE16
Component description
Human anatomical
Plastics
Swabs, absorbants
Alcohol, disinfectants
Animal-infected anatomical
Glass
Beddings, shavings, paper, fecal
matter
Gauze, pads, swabs, garments,
paper, cellulose
Plastics, PVC, syringes
Sharps, needles
Fluids, residuals
HHV dry basis,
Btu/lba
8,000-12,000
14,000-20,000
8,000-12,000
11,000-14,000
9,000-16,000
0
8,000-9,000
8,000-12,000
9,700-20,000
60
0-10,000
Bulk density as
fired, Ib/ft3
50-75
5-144
5-62
48-62
30-80
175-225
20-45
5-62
5-144
450-500
62-63
Moisture content
of component,
weight %
70-90
0-1
0-30
0-0.2
60-90
0
10-50
0-30
0-1
0-1
80-100
Heat value as
fired, Btu/lb
800-3,600
13,900-20,000
5,600-12,000
11,000-14,000
900-6,400
0
4,000-8,100
5,600-12,000
9,600-20,000
60
0-2,000
*HHV s* Higher heating value.
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These data indicate that the waste can vary considerably in
composition and, consequently, in heat content, moisture content,
and bulk density. In particular, the heating value can range
from a low value of about 1,000 British thermal units per pound
(Btu/lb) (primarily low-Btu, high-moisture anatomical waste) to
20,000 Btu/lb (low-moisture, high-heat content plastics such as
polyethylene).
The chemical composition of the waste materials,
particularly the metals and plastics content, are also of concern
because of their impact on air pollutant emissions. Metals that
vaporize at the primary combustion chamber temperature (e.g.,
mercury, cadmium, and arsenic) may be emitted as metal oxides.
Halogenated plastics such as polyvinyl chloride (PVC) produce
acid gases such as hydrogen chloride (HC1). The presence of the
chlorinated waste may also contribute to the formation of toxic
organic pollutants such as chlorinated dibenzo-p-dioxins (CDD's)
and chlorinated dibenzofurans (CDF's).
To date, only limited data have been compiled on the
plastics and metals content of medical wastes. Various studies
have reported plastics contents that range from as little as
10 percent to about 30 percent.7'12'17'18 No quantitative
estimates of metals content in MWI waste feed have been
developed. However, some facilities have reported significant
concentrations of lead and cadmium in incinerator ash. Sources
of metals include radiological materials (lead), stabilizers
(cadmium) and pigments (chromium, .cadmium) in plastics, and
batteries (nickel and cadmium). Additional data on plastic and
metals content of medical waste may be generated by OSW as data
gathering is carried out to implement the MWTA.
3.3 DEFINITION OF MEDICAL WASTE INCINERATOR
For the purposes of this analysis, an MWI is defined as any
device in which any amount of medical waste is burned. Based on
the current working definition of medical waste, the MWI source
category includes a wide variety of incinerators located at many
types of facilities.
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4.0 MEDICAL WASTE TREATMENT, DESTRUCTION, AND DISPOSAL
ALTERNATIVES
4.1 TREATMENT
The potential for disease transmission associated with
medical waste has been recognized by the medical community,
environmentalists, lawmakers, and the general public, and
increasing amounts of medical waste are being treated to reduce
the hazard prior to disposal. With the MWTA, Congress has
mandated the demonstration of a medical waste tracking program
that is designed to evaluate the generation, treatment, disposal,
and transportation of medical wastes. The merits of the program
will be evaluated at its completion, and the appropriateness of a
national program will be determined at that time. The treatment
methods discussed in the following paragraphs reduce or eliminate
the potential for disease transmission so that medical waste may
be managed and disposed of safely. These treatment methods have
been tested for the destruction of pathogens. However, their
effectiveness in completely sterilizing medical waste has not
been determined. Also, except for incineration, the methods
below have not been thoroughly studied to determine if any other
pollution or health effects are caused by their use.
4.1.1 Incineration19
Medical waste is burned in incineration units under
controlled conditions to yield ash and combustion gases. Modern
incineration units usually consist of two chambers. The waste is
combusted in the primary chamber, usually at temperatures between
1200° and 1400°F. Airborne contaminants, such as volatile
organics, that are released from the primary chamber are
combusted in the secondary chamber.
4.1.2 Steam Sterilization19'20
Steam sterilization, or autoclaving, is the process of
exposing medical waste to saturated steam under pressure for a
specified period of time, to render the waste noninfectious. The
effectiveness of autoclaving can be influenced by the duration of
the cycle, the amount of pressure, the temperature, the
12
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characteristics of the waste stream, and the design of the
equipment.
4.1.3 Thermal Inactivation21
Thermal inactivation is similar to steam sterilization but
uses dry heat rather than steam. Thermal inactivation may be
used to treat both solid and liquid wastes. Solid wastes are
treated in an oven, while liquid wastes are treated in a heat
exchanger apparatus. Thermal inactivation is not as efficient as
steam sterilization and must be monitored carefully so that
wastes are exposed to the proper temperatures for the specified
duration. This process is not practical for large scale waste
treatment.
4.1.4 Chemical Disinfection21
Chemical disinfection kills infectious organisms by exposing
them to chemicals that are strong oxidizing agents such as
hydrogen peroxide or chlorine bleach. This method of treatment
is generally used on the surfaces of medical equipment, but has
been applied to large-scale medical waste disinfection. Chemical
disinfection is generally combined with grinding or shredding
prior to, or during, the disinfection process to increase the
efficiency of the process and to render the waste unrecognizable.
4.1.5 Gas Sterilization21
Gas sterilization involves exposing medical waste to
vaporized chemicals that cause oxidation reaction damage to
cellular structures. The chemical most often used is ethylene
oxide. Unfortunately, ethylene oxide is a suspected human
carcinogen and, thus, must be handled and used with extreme
caution. Typically, reusable medical equipment is placed in a
closed vacuum vessel, ranging in size from a few cubic feet to
several thousand cubic feet and exposed to the sterilant gas.
Although it is possible to apply this method of treatment to
medical waste, the hazards associated with the chemicals preclude
- the widespread use of gas sterilization.
4.1.6 Irradiation Sterilization21'22
Irradiation is currently used to sterilize medical supplies,
food, and consumer products and is a technique that may be
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applicable to medical waste. Irradiation of medical waste with
ionizing or ultraviolet radiation kills infectious agents and
destroys the ability of bacteria to replicate.
The most common source of ionizing radiation is from Cobalt-
60, which produces gamma radiation. Gamma radiation can
penetrate up to several meters of waste and requires minimal
amounts of electricity. The exposure time that is required to
treat the waste varies as the radiation source decays. One
commercial facility formerly used gamma irradiation for medical
waste treatment. This facility, however, has switched to radio
frequency irradiation treatment.'
Ultraviolet radiation does not penetrate the waste as deeply
as gamma radiation but has been used successfully in treating
wastewaters. The water is exposed to ultraviolet light at a
wavelength of approximately 245 nanometers. This wavelength is
very close to the optimum germicidal wavelength that renders the
wastewater free of infectious organisms.
4.1.7 Microwave Sterilization23
Microwaves have been used to treat medical waste. Before
being treated with the microwaves, the waste is shredded so that
the waste is more efficiently exposed to the microwaves. The
shredded waste is sprayed with water and treated with microwaves
to a temperature of 200°F.
4.1.8 Radiofrequency Sterilization24
The treatment of medical waste using radiofrequency (RF)
irradiation is described in a Draft OSW Report to Congress as a
treatment method that:
... involves the exposure of shredded infectious medical
waste material to high-strength, low-frequency, shortwave
radiofrequency (RF) radiation to heat the waste to the
desired temperature. The heated waste is then stored in
insulated containers to maintain the elevated temperature
for a period of 4 hours. At the end of the storage period,
the waste is disposed of in a landfill or recycled as
refuse-derived fuel, or the segregated plastic portion of
the waste may be sold as recycled material.
14
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Only one facility is known to be treating medical waste with RF
irradiation. This facility combines RF irradiation with waste
shredding.
4.2 PHYSICAL DESTRUCTION
Physical destruction of medical waste serves two purposes.
First, the waste is made unrecognizable, which is desirable for
aesthetic reasons. A number of jurisdictions require that
certain types of waste such as tissue and body parts be destroyed
prior to disposal. In the regulations adopted by OSW to
implement the MWTA, regulated medical waste must be tracked until
it is both treated and destroyed, at which time it is no longer
considered regulated medical waste. The second effect of
destruction is that the volume of the waste is reduced. This
consideration is increasingly important as existing landfills
approach capacity and new landfills become more costly and
difficult to construct. The two major destruction technologies
are incineration and grinding or shredding. Most other
technologies do not render waste unrecognizable and achieve
little or no volume or weight reduction.
4.2.1 incineration
An MWI combines the functions of waste treatment and
destruction. In a well-designed and -operated unit, infectious
organisms are destroyed by exposure to high temperature, and the
combustible waste materials are reduced to a fine ash. Both the
volume and weight of the waste are reduced by up to 95 percent.
4.2.2 Grinding or Shredding
Technology more recently applied to medical waste is
grinding or shredding using hammermills or other devices. While
these devices can reduce the volume (by about 80 percent) and
recognizability of the waste, the weight and potential for
infection are not affected. In medical waste applications,
grinding or shredding is generally coupled with a disinfection
treatment technology. Because the grinding or shredding reduces
the waste to small, uniformly sized pieces prior to treatment,
the effectiveness of the disinfection process is increased. Two
shredding/microwave sterilization systems are in use: one in
15
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Europe and one at a hospital in the United States. A number of
domestic companies offer shredding/chemical disinfection systems,
and one commercial facility combines shredding and radiofrequency
sterilization. Steam sterilization systems that employ shredding
typically do so after the waste has undergone sterilization.
4.3 DISPOSAL25
Medical waste, with or without prior treatment or
destruction, is typically disposed of in a landfill or a sanitary
sewer. Solid wastes are usually landfilled, while liquid wastes
are disposed of in a sewer. The regulations and requirements for
medical waste disposal vary from State to State and from landfill
to landfill.
Many States now have some requirements for treating medical
waste prior to landfilling. Regulatory activity in this area has
increased greatly in the wake of the beach washups in 1988.
Incinerated medical waste generally may be landfilled the same as
any other solid waste, although there have been some cases where
high concentrations of toxic metals have made disposal as a
hazardous waste necessary.
Sanitary sewer disposal of treated or untreated liquid
medical waste is minimally regulated in comparison to solid
medical waste disposal. Many States do not require any treatment
of liquids before they are disposed of in the sewer. Specific
types of liquid wastes are sometimes required to be treated
before disposal, but, in most cases, regulation of sewer disposal
is left to local authorities. Often, all that is required for
sewer disposal is written permission from the local sewer
authority.
5.0 MEDICAL WASTE GENERATOR POPULATION
The estimated number of medical waste generators and annual
quantity of infectious waste and total waste produced were
presented earlier in Table l. The amount of total waste was
calculated using the estimated amount of infectious waste and the
results of a large national survey that indicates that a median
of 15 percent of a hospital's total waste is designated as
infectious.9 These calculations are based on the assumption that
16
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the percentage of total waste considered to be infectious at
other facilities is the same as that at hospitals. The estimates
of infectious waste are based primarily on information presented
in two recent reports. The first is a Jack Faucett Associates
(JFA) report, which presents an analysis of the impacts of the
proposed OSHA standards for occupational exposure to bloodborne
pathogens.26 This report provides estimates by Standard
Industrial Classification (SIC) code of the number of generators
of infectious waste, the unit generation rate, the unit disposal
cost, and the total net compliance cost for disposal. The
estimated total quantity of infectious waste generated annually
can be derived using the information in this report. (One item
necessary for the calculation, the baseline compliance rate, is
found in the preamble to the proposed OSHA standards where the
JFA study results are presented. This value is the estimated
percentage of facilities of each type already in compliance with
the proposed regulations.)
Note that the data in this industry-profile that are
attributed to the JFA report were drawn from the text of that
report, which provides estimates for the total number of
generators. Data that are presented in the tables in the JFA
report and in the preamble to the OSHA regulations for which the
report was prepared are only for the portion of the total
population that would be affected by the proposed OSHA .standard.
The second report is OSW's first interim report to Congress,
which was required by the MWTA.27 This report presents estimates
by category of the number of generators of regulated medical
waste, the generation rate per facility, and the total quantity
generated annually. The estimation methodology is documented in
a draft memorandum. The interim OSW report indicates that little
information is available on the number of generating facilities
or on waste generation rates, particularly for small generators
such as doctors' offices. However, a discussion of additional
data gathered during the course of the demonstration tracking
program is expected in the final report to Congress.
17
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TABLE 6. SUMMARY OF ESTIMATES FROM JACK FAUCETT .
REPORT AND OFFICE OF SOLID WASTE REPORT26'
OCIATES
General category
Hospitals
Laboratories
Medical
Research
TOTAL
Clinics (outpatient care)
Physicians' offices
Dentists' offices
Veterinarians
Long-term care facilities
Nursing homes
Residential care
TOTAL
Free-standing blood banks
Funeral homes
Health units in industry
Fire and rescue
Corrections
Police
TOTAL
JFA
No. of
facilities
7,000
4,900
2.300
7,200
41,300
179,405
94,994
'a
18,785
23.897
42,682
672
15,051
221,700
7,200
4,300
13,100
634,600
Annual
infectious
waste
generated,
tons
162,500
8,400
21.800
30,200
8,100
35,100
24,800
a
100,800
29.200
130,000
4,900
500
1,400
1,600
3,300
<100
402,400
OSW
No. of
facilities
7,100
4,300
15,500
180,000
98,400
38,000
12,700
900
20,400
b
b
b
b
377,300
Annual
regulated
medical waste
generated,
tons
359,000
15,400
16,700
26,400
7,600
4,600
29,600
2,400
3,900
b
b
b
b
465,600
aThese sources of medical waste are
^These sources of medical waste are
covered under other categories in the JFA report.
covered under other categories hi the OSW report.
18
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Estimates from the two reports discussed above are
summarized in Table 6. For some categories, the estimates from
both reports show fair agreement; for other categories, they
diverge greatly. Some .of the difference in the estimates of
waste quantity may result from the differences in the waste
definitions used in the two studies. The JFA report is based on
"infectious waste" as defined by OSHA to include "blood and blood
products, contaminated sharps, pathological wastes, and
microbiological wastes." The OSW report is based on "regulated
medical waste" as previously presented in Table 3.
In total, the JFA report identifies 14 categories of
infectious waste generators, which comprise an estimated
634,600 facilities generating a total of 402,400 tons/yr of
infectious waste. The OSW report characterizes nine categories
of regulated medical waste generators made up of
377,300 facilities generating a total of 465,600 tons/yr. As
would be expected, the human health care industry dominates both
estimates in the number of facilities and the quantity of medical
waste generated annually. Nevertheless, medical waste generation
goes well beyond health care facilities, particularly for the
purposes of this project, where medical waste is defined broadly.
Each category presented earlier in Table 1 is discussed
separately below. For each category, estimates of facilities and
infectious waste generation rates are discussed, as are the
available data on the makeup of the medical waste stream, the
common treatment and disposal practices, and the historical and
projected trends in these areas.
In addition to the JFA and OSW reports, three studies are
frequently cited in the discussion that follows. One is an
EPA-sponsored study of medical waste generation and management in
New Jersey and New York.28 For this EPA study, medical
waste-generating facilities in New Jersey and New York were
surveyed, and many site visits were conducted. This study is
frequently cited in the OSW report and serves as a basis for some
of that report's waste generation estimates.
19
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A second document often referenced in the discussion to
follow summarizes the results of another survey of New York
medical waste generators.29 This survey of four source
categories was conducted by the New York Department of Health in
1986 and 1987. For the EPA study discussed above, these four
source categories were not resurveyed. Instead, the EPA study
incorporated the New York survey results.
The third study frequently cited below is a State of
Washington survey of infectious waste generation and management
practices.30 In this study, 10 source categories were surveyed.
Some data were collected on waste generation rates, but this
information is in terms of gallons and cannot be compared readily
with estimates in terms of weight.
While these studies each contain useful data,' they are not
directly comparable. The studies are inconsistent in the
categories of generators and medical waste examined, in the types
of information gathered, and in the data analyses presented.
5.1 HOSPITALS
5.1.1 Population and Waste Generation Rate
The JFA report and the OSW report agree that there are
approximately 7,000 hospitals in the U.S.; however, the OSW
report indicates a total annual generation rate over twice that
derived from the JFA report, 359,000 tons/yr versus
162,500 tons/yr, respectively. For this category, there is
independent evidence that the OSW estimate is likely to be more
accurate. As discussed earlier in the section on the
characteristics of medical waste, one investigator determined in
a large national survey of hospitals that a median of nearly
15 pounds of total hospital waste is produced per patient per day
(Ib waste/patient-day) and that a median of 15 percent of this
waste is designated as infectious.9 Using total hospital beds
and an average occupancy rate, the rate of infectious waste
generated nationally at hospitals was calculated to be
'1,002 tons/d. This rate translates to about 365,700 tons/yr. As
indicated in Table 1, for the purposes of this industry profile,
20
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it is estimated that there are 7,000 hospitals generating
360,000 tons/yr of infectious waste.
The difference between the JFA estimate of annual hospital
infectious waste generation and the national hospital survey
estimate can be attributed almost entirely to the underlying unit
generation rates. In the JFA report, the unit generation rate is
estimated at 1 Ib infectious waste/patient-day, while the value
derived from the national hospital survey is about double that.
5.1.2 Waste Composition
The medical waste stream at hospitals is a heterogeneous
mixture of materials that may consist of any of the types of
waste discussed earlier in the section on the definition of
medical waste. Table 7 presents the Washington State survey
results on the types of waste generated by the surveyed source
categories. Over 90 percent of the responding hospitals generate
sharps, surgery waste, human blood and blood products, waste
containing excretions or secretions, and microbiological waste.
Over 75 percent of the respondents generate isolation patient
waste and pathological waste. Of the respondents that classify
some of their own waste as infectious, 43 percent accept
infectious waste from other facilities for treatment,31
According to the EPA study, over 40 percent of responding
New Jersey hospitals indicated that the laboratory is the largest
single source of medical waste in the hospital, generating an
average of over 45 percent of total medical waste. The operating
room was listed by over 30 percent of the hospitals in New Jersey.
as the largest single medical waste source.32
One source has estimated that up to 10 percent of medical
waste can be radioactive.13 Some materials may be considered
hazardous under RCRA, particularly organic solvents and some
antineoplastic. agents (used for cancer chemotherapy).
The national hospital survey cited above indicates that as
the size of a hospital (i.e., the number of beds) increases, the
quantity of total waste generated per bed also increases.9 This
is not surprising because larger facilities are more likely to
21
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offer procedures and types of cafe not found at smaller hospitals
(e.g., burn units and operating rooms).
5.1.3 Treatment and Disposal
The most common methods of treatment for waste designated as
infectious at hospitals are incineration and steam sterilization.
According to the National Solid Waste Management Association
(NSWMA), 60 percent of hospital infectious waste is incinerated
onsite, 20 percent is steam sterilized onsite, and 20 percent is
treated offsite.33 The Washington State survey results
(presented in Table 8) indicate that 60 percent of hospitals
operate onsite incinerators for infectious waste, 50 percent
operate steam sterilizers, and 65 percent pour some waste
directly to the sanitary sewer system. (Note that these figures
represent the percentage of facilities that use each treatment
technique on some portion of the infectious waste stream, not the
percentage of waste treated by that technique.) About half the
infectious waste in New York is incinerated onsite, and about
half the hospitals in New Jersey operate waste incinerators.34'35
At least two hospitals have opted recently for
shredding/chemical disinfection systems to meet their infectious
waste treatment needs.24'36 These facilities are both located in
New Jersey.
5.1.4 Trends
The quantity of waste generated at hospitals has been rising
in recent years. The national hospital survey discussed above
indicated a generation rate for total waste 15 percent higher
than data reported in a similar survey of North Carolina
hospitals conducted in 1980.37 This rise is attributed to the
increased use of disposable items in recent years.
Based on past trends, a similar or larger increase in
medical waste generation rates is likely in the future because
the portion of total hospital waste that is segregated for
. special treatment has increased even more rapidly than the
-absolute generation rate. Two surveys of hospitals in the State
of New York give evidence of this trend. The New York Department
of Health survey in 1986 indicates an infectious waste unit
23
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generation rate of about 4 Ib/patlent-day.38 A second survey of
hospitals in New York conducted by the State Hospital Association
in late 1988 indicates that the unit generation rate has
increased by about 30 percent to about 5.2 lb/patient-day.39
However, waste minimization laws and high disposal costs may
reverse these trends in the future.
The increase in infectious waste generation rates can be
partially attributed to the trend toward more inclusive
definitions of infectious waste. This trend began with the
issuance of the CDC and EPA guidelines for infectious waste
disposal in the early 1980's and has continued as a result of the
CDC's universal precaution recommendations. The OSHA standards
on occupational exposure to bloodborne pathogens essentially
extend the universal precaution recommendations to the status of
regulations. While these recommendations and standards do not
directly relate to waste disposal, experience shows that
hospitals adopting the universal precaution recommendations
report significant increases in the quantity of waste designated
as infectious. Recently enacted infectious waste management
regulations in some States also have extended all or part of the
earlier waste disposal guidelines to regulation status.
Depending on the results of the current demonstration tracking
program under the MWTA, a similar program may be put in place for
the entire United States. An additional factor leading to
increased quantities of waste being handled as infectious is the
refusal of some solid waste haulers and landfills to accept
medical waste even if it is not designated as infectious under
applicable regulations or guidelines.
Some factors may tend to limit the growth in medical waste
generation at hospitals. One is the fact that hospital occupancy
rates are falling as a result of efforts to stem the rise in
health care costs. Another factor is the possibility that some
hospitals will narrow their definitions of infectious waste and
improve their waste segregation practices as the cost of
treatment and disposal of these materials increases with stricter
regulation. The extent to which cost considerations will
25
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counteract concern over potential liability from accidental human
exposure to medical waste is not known.
5.2 LABORATORIES
5.2.1 Population and Waste Generation Rate
As indicated in Table 6, the JFA report considers clinical
laboratories and research facilities separately, while the OSW
report groups these two classes together. The estimates made in
the JFA and OSW reports differ significantly both in the number
of facilities and in the total quantity of infectious waste
generated.
The JFA report estimates about 4,900 medical (clinical)
laboratories and about 2,300 research laboratories, for a total
of about 7,200 facilities. These estimates were derived from
Census of Service Industries and Census of Manufacturers data,
published by the U. S. Bureau of the Census, and from a survey of
academic laboratories prepared for OSHA.40 The OSW report
estimates a total of 4,300 laboratories. According to draft
documentation of this estimate, it is intended to include both
clinical and research laboratories. However, the estimate is
based on U.S. Department of Health and Human Services data for
independent medical laboratories that are eligible for Medicare
reimbursement; research laboratories are very unlikely to be
included.41 For the purpose of this industry profile, the JFA
report estimate of the number of laboratory facilities was used
because this estimate includes both clinical and research
laboratories.
The information in the JFA report supports estimates of
8,400 tons/yr of infectious waste from medical laboratories and
21,800 tons/yr of infectious waste from the estimated
2,300 research laboratories that would be affected by the OSHA
standards. These estimates are based on a value of 1.75 Ib
generated per facility employee per day. The JFA report says the
unit generation rate results from "subjective estimation and
information from BBL Microbiology Systems."42
As shown in Table 6, the OSW report estimates 15,400 tons/yr
of regulated medical waste generated at all types of
26
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laboratories. This estimate is based on a value of about
600 pounds per month (Ib/mo) generated per facility. The unit
generation rate was derived from about 40 responses to a survey
of laboratories in New Jersey, according to draft
do cumentat i on.4 ^
It is difficult to assess the relative accuracy of these
estimates. There are no data by which to evaluate the
subjectively derived JFA factor. However, the extent to which
the responding facilities used to derive the OSW factor are
typical is also unknown. Only three of these facilities were
research laboratories. According to draft documentation of the
OSW estimates, the three research facilities averaged monthly
generation rates that were only about 35 percent of the average
generation rate for the clinical facilities.41 This result is
contrary to the results from the JFA report, where research
laboratories generated nearly six times as much infectious waste
as clinical facilities on an annual, per-facility basis.
An alternative method of estimating total infectious waste
generated by laboratories is to use the number of facilities
estimated in the JFA report and the per-facility generation rate
estimated in the OSW report. On this basis, laboratory
infectious waste generation totals about 25,900 tons/yr. This
estimation method has been adopted for this industry profile (see
Table 1). Note that regardless of the estimation technique used,
the laboratory waste totals less than 10 percent (and perhaps
less than 5 percent) of the estimated quantity of medical waste
generated by hospitals.
None of the estimates presented above include the
noninfectious component of laboratory medical waste. One
significant component of medical waste included under the working
definition for this project not included in the infectious and
regulated medical waste estimates discussed above is carcasses of
test animals that have not been exposed to infectious agents.
According to one estimate, about 17 million animals are used
annually for research. Rats and mice account for about
27
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85 percent of this total.43 No attempt has been made to quantify
the total weight of test animal carcasses generated annually.
5.2.2 Waste Composition
According to the EPA study, of the responding laboratories
in New Jersey, 95 percent generate sharps, 55 percent generate
cultures and stocks, 55 percent generate blood and body fluids,
20 percent generate pathological waste, and less than 5 percent
generate animal carcasses and bedding. Twenty-three percent of
the New Jersey facilities also generate other materials that are
treated as regulated medical waste.44 Some testing laboratories
accept waste from other generators (such as physicians) for
disposal, either as a free service to their customers or for a
fee.
45
As shown in Table 7, The State of Washington survey of
infectious waste generation and management at 25 Medicare-
licensed laboratories (out of a total of 90 in the State)
indicated that 92 percent generate sharps, 88 percent generate
human blood and blood product waste, 64 percent generate wastes
with excretions/secretions, 44 percent generate microbiological
waste, and 32 percent generate pathological waste. Other types
of infectious waste are generated at less than 15 percent of the
facilities. Twenty-five percent of the laboratories that
classify some of their own waste as infectious reported accepting
infectious waste from other facilities for treatment.
Table 7 also includes data from the 17 research facilities
that responded out of a total of 23 identified in Washington
State. Of these facilities, 88 percent generate sharps;
65 percent generate microbiological waste; 59 and 53 percent
generate animal and human blood and blood product waste,
respectively; 47 percent generate contaminated animal carcasses
and bedding; 29 percent generate wastes with excretions or
secretions; and 24 percent generate pathological waste. Other
types of infectious waste are generated by less than 15 percent
of the responding research facilities. Of the 14 research
facilities that consider some of their own waste infectious, only
one reported that it accepts infectious waste from offsite
28
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sources for treatment. However, this facility indicated that it
accepts over 240 gallons of waste from offsite each week (though
it is not necessarily all liquid waste).46
5.2.3 Treatment and Disposal
Clinical laboratories typically contract with a waste hauler
rather than treat waste onsite. In the New Jersey survey for the
EPA study, about 76 percent of the responding clinical
laboratories (a total of 42) contract with a commercial
transporter. About 12 percent of the respondents steam sterilize
all infectious waste prior to landfilling. (Of all types of
laboratories, including clinical facilities, 29 percent steam
sterilize some portion of their infectious waste.) Nearly
5 percent send their infectious wastes to a hospital for
treatment/disposal. No onsite incinerators were identified.47
According to the New York survey, about 83 percent by weight
of infectious waste that is generated at clinical laboratories is
sent offsite for treatment and disposal. Of this amount, about
37 percent is incinerated, and 63 percent is treated by
unspecified means. The predominant onsite treatment method is
steam sterilization. °
As shown in Table 9, the State of Washington survey
indicates that, of the Medicare-licensed laboratories that
classify some portion of their waste as infectious, 75 percent
have some of the infectious waste treated offsite. Reported
offsite treatment methods include incineration (87 percent of
facilities that use offsite treatment) and steam sterilization
(33 percent). Apparently, some facilities use both methods. As
Table 8 shows, onsite treatment of some portion of the infectious
waste stream was reported by 65 percent of the laboratories that
designate some waste as infectious. Of laboratories that treat
onsite, 69 percent use steam sterilization, 54 percent disinfect
with chemicals, and 15 percent pour directly to a sanitary sewer.
Clearly, some facilities use a combination of onsite treatment
methods.
The Washington State survey report also gives information on
research facilities in the State. For these facilities, only
29
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21 percent reported having infectious waste treated offsite. All
these facilities used offsite incineration (see Table 9).
Eighty-six percent of these facilities reported that some
infectious waste is treated onsite. As presented in Table 8, of
the facilities reporting onsite treatment, 92 percent use steam
sterilization, 67 percent use chemical disinfection, 17 percent
pour directly to a sanitary sewer, 8 percent use thermal
inactivation, and 8 percent use irradiation. Again, some
facilities use a combination of methods.
None of the surveys discussed in the preceding paragraphs
indicate incineration as an onsite method of treatment.
Although, MWI inventory lists, which were used to produce
Table 2, indicate that onsite MWI's do exist at laboratories (no
distinction is made between clinical and research labs).
5.2.4 Trends
It is likely that the same influences that cause the
quantity of waste designated as infectious by hospitals to grow
will likewise affect laboratories. These influences include the
increased use of disposables and increasingly comprehensive
definitions of infectious waste. However, according to
information in the OSHA standards preamble, laboratories already
typically apply a broad definition of infectious waste, so the
definitional effects should be relatively small.49
5.3 CLINICS/OUTPATIENT CARE
5.3.1 Population and Waste Generation Rate
The estimated population of clinics and annual total
infectious waste generation rates differ markedly between the JFA
and OSW reports. These differences result from divergence in
both the definition of this source category and the estimated
unit generation rate.
The JFA report designates this source category as
"outpatient care." Within this broad category, totaling
approximately 41,000 facilities, individual population estimates
are made for eight segments. These segments, and the estimated
national population of each, are (1) home health care--7,000;
(2) health maintenance organizations--654; (3) hospices--812;
31
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(4) drug treatment centers--3,887; (5) ambulatory care centers--
4,300; (6) kidney dialysis clinics--861; (7) government
outpatient services--22,117; and (8) others that did not warrant
individual treatment, such as family planning clinics--!,709.
These estimates are drawn from a variety of government, industry,
and independent sources. The estimates have been adjusted to
avoid double counting, both between segments of the outpatient
care industry (e.g., excluding hospices that are administered by
home health care agencies) and across generator categories (e.g.,
excluding dialysis clinics that are based in a hospital). The
weakest estimate is for government clinics, for which it was
assumed that each of the county and municipal governments in the
United States would have one outpatient care facility.
The OSW estimate of clinics is derived from American Medical
Association (AMA) data. In draft documentation, OSW indicates
that the estimated clinic population is based on the AMA
definition of "medical group" (a formal organization of three or
more physicians) and the AMA estimate of 15,485 for the
population of such medical groups in 1984.
For the purpose of this project, home care waste (at least
those materials that are returned to the central facility for
disposal) is included in the definition of medical waste. The
OSW definition of regulated medical waste specifically excludes
medical waste generated in a home-care setting, regardless of
where it is disposed. The JFA report population estimate is used
for this industry profile because this estimate includes home
care settings where medical waste is generated, as well as other
outpatient care settings not likely to be included in the OSW
estimate.
Despite the fact that the population estimate based on the
JFA report is over 2.5 times the OSW estimate, the OSW report
estimates an annual generation rate over twice as great as the
annual rate indicated by the JFA report. This difference results
from the unit generation rates estimated in the two reports. The
JFA report uses a rate of 1.5 Ib of infectious waste per facility
52
per day based on a survey conducted in King County, Washington.
32
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For the annual total, it is assumed that these facilities operate
261 days per year. Thus, the unit generation rate on a monthly
basis is about 33 Ib/mo per facility. According to draft
documentation, the basis of the OSW estimate of the annual
generation rate is the New York survey, which reports an
infectious waste generation rate for "diagnostic and treatment
centers" of about 180 Ib/mo per facility.53
It is not known why these unit generation rates differ so
much. Possible causes include differences in the types of
facilities included in the surveys, regional differences in the
management of medical waste (i.e., different definitions of
infectious waste), and differences in the size of the facilities
surveyed (i.e., the number of patients seen per day). In the
absence of better data to support using one estimate over the
other, the approach adopted for this industry profile is to use
the mean of the two unit generation rates, which results in a
unit generation rate of about 106 Ib of infectious waste per
facility per month. Coupled with the population estimate from
the JFA report, this rate yields a total annual generation rate
of about 26,300 tons/yr (see Table 1), which is larger than
either the JFA or OSW report estimated. Even so, this estimate
represents less than 8 percent of the estimated quantity of
medical waste generated annually by hospitals.
5.3.2 Waste Composition
The types of medical waste generated by clinics vary because
of the many different services these facilities offer. According
to the EPA report, the most common waste items are sharps, blood
and body fluids (including discarded materials that are
contaminated), and lesser amounts of cultures, stocks, and
pathological wastes.54 This assessment is generally borne out by
the findings of the Washington State survey, which are presented
in Table 7 separately for clinics and ambulatory surgery centers.
Only 4 percent of the clinics and none of the ambulatory surgery
centers accept infectious waste from offsite sources for
treatment.
31
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5.3.3 Treatment and Disposal
Onsite treatment of infectious waste at clinics is unusual.
According to the New York survey, less than 3 percent by weight
of the infectious waste generated at the responding diagnostic
and treatment centers is treated onsite, and steam sterilization
is the predominant onsite treatment method.55 The New Jersey
survey results presented in the EPA report indicate that
48 percent of clinics contract with a commercial medical waste
transporter (for treatment and disposal), and 30 percent have
infectious waste taken to a hospital or laboratory for disposal
with that facility's waste. Onsite treatment by steam
sterilization was indicated by 19 percent of New Jersey
respondents, onsite incineration by 16 percent, disposal of some
infectious waste to the sewer by 13 percent, and landfilling
without treatment by 8 percent.56 -
Even though onsite incineration was acknowledged by
16 percent of the State of New Jersey survey respondents, Table 2
does not include a category for "clinics" because very few
facilities on the State MWI inventory lists (the basis for
Table 2) could be identified as such. The few that were
identified as clinics are included in Table 2 under
"Others/unidentified facilities." Medical centers that could
possibly be categorized as clinics are included in Table 2 under
"Hospitals."
The State of Washington survey data are presented in
Tables 8 and 9. These data generally agree with the New York and
New Jersey results. Only 26 percent of clinics and 40 percent of
ambulatory surgery centers that consider some waste infectious
treat any of the waste onsite. For clinics, steam sterilization
predominates; the methods used by the two ambulatory surgery
centers that responded are more varied. Among clinics that have
some infectious waste treated offsite, incineration is most
commonly used. Combining the data from Tables 8 and 9 shows that
at least 13 percent of the clinics and 40 percent of the
ambulatory surgery centers did not indicate any treatment for
their infectious waste prior to disposal. Presumably, the
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infectious waste from these facilities goes to landfills without
prior treatment.
5.3.4 Trends
The quantity of medical waste generated by clinics has been
increasing recently as health care cost considerations have
favored outpatient care over hospitalization. This trend is
expected to continue. The portion of this waste that is
segregated for special treatment and disposal is also likely to
increase as a result of the definitional and regulatory factors
discussed previously for hospitals. This portion is expected to
be larger for clinics than for hospitals or laboratories.
According to information in the preamble to the OSHA standards,
clinics historically have paid less attention to potentially
infectious waste than these other sources.
49
This assertion is
borne out by data from the Washington State survey concerning the
number of facilities that consider some of the waste they
generate to be infectious and that, nevertheless, do not have the
waste treated either on- or offsite. In addition to these
facilities, 22 percent of responding clinics and 38 percent of
responding ambulatory surgery centers indicated that they do not
consider any of the waste they generate to be infectious. Of
these, 62 percent of the clinics and all the ambulatory surgery
centers generate some of the classes of waste listed in
Table 7.57
5.4 PHYSICIANS' OFFICES
5.4.1 Population and Waste Generation Rate
The estimates of physicians' offices in the JFA and OSW
reports are each around 180,000. The estimated annual generation
rates also show relatively good agreement, with the estimate
derived from JFA data exceeding the OSW estimate by about
33 percent (35,100 tons/yr versus 26,400 tons/yr, respectively).
The JFA estimate is based on a unit generation rate of
1.5 Ib of infectious waste per office per day for 261 days per
year. This rate is derived from a survey conducted in King
County, Washington.58 The draft OSW documentation uses a unit
generation rate of 20 Ib/mo per physician estimated from
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information collected from physicians and medical waste
transporters. Applying a factor of 1.2 physicians per office,
OSW concludes that 24 Ib/mo are generated by each physician's
office.59 To avoid underestimating the annual generation rate,
the higher estimate (based on the JFA report) is used for this
industry profile (see Table 1).
5.4.2 Waste Composition
The medical waste stream from physicians' offices varies
with specialty. According to the EPA report, all facilities
surveyed in New York and New Jersey generate sharps and "other
patient-care waste"; some also generate cultures and stocks,
blood and body fluids, and pathological waste.60 Table 7
presents the State of Washington survey results. Of these
respondents, all generate sharps; over 60 percent generate
surgery waste, waste with excretions or secretions, and human
blood and blood products; and about 30 percent generate
pathological waste. Less than 10 percent generate the other
listed classes of waste. Thirteen percent of the physicians'
offices that consider some of their own waste to be infectious
also accept some infectious waste from offsite sources for
treatment.3 i
5.4.3 Treatment and Disposal
The EPA report indicates that 82 percent of respondent
physicians' offices segregate some waste from the general waste
stream prior to disposal; the figure from the State of Washington
survey is 83 percent.61'62 As shown in Table 8, the methods of
onsite infectious waste treatment reported in the Washington
State survey are steam sterilization, direct pour to sanitary-
sewer, incineration, chemical disinfection (all used by
50 percent or more of the facilities that use onsite treatment),
and grinding to sanitary sewer (i.e., using a device similar to a
garbage disposal) (used by 30 percent). In the EPA report, steam
sterilization, incineration, grinding to^sanitary sewer, and
chemical disinfection also were named as onsite treatment
61
Even
methods, as was the use of special containers for sharps.
though a fairly high percentage of Washington respondents (3/24)
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indicated operating onsite incinerators, Table 2 does not include
a category for physicians' offices because State MWI inventory
lists (the basis for Table 2) indicate that physicians' offices
do not operate onsite incinerators in significant numbers.
0 Seventy-one percent of the Washington State respondents that
have some infectious waste treated offsite have the waste
incinerated (see Table 9). No figure is available from the EPA
report for comparison. According to the report, about 40 percent
of physicians' offices responding to the New York/New Jersey
survey contract with a medical waste hauler for treatment and
disposal of such waste.61
5.4.4 Trends
As for other sources (e.g., clinics, hospitals), the
increased use of disposable materials has probably resulted in an
increasing quantity of medical waste generated. The quantity of
medical waste being segregated from the general waste stream for
special handling is expected to increase in the future as a
result of the changing definition of waste to be regarded as
infectious and the increasing compliance expected as past
guidelines are embodied in regulations and made applicable to
physicians. As in the case of clinics, the growth in the rate of
segregation should be large for physicians' offices because,
historically, these facilities have not closely managed the
medical waste stream.49
5.5 DENTISTS' OFFICES
5.5.1 Population and Waste Generation Rate
As in the case of physicians' offices, the JFA and OSW
reports agree quite closely on the number of dentists' offices
nationally, reporting about 95,000 and 98,000, respectively. A
representative of the American Dental Association (ADA) has
indicated that there are about 140,000 to 150,000 dentists
nationwide.63 Because of group practices, the number of dental
offices likely is in the range reported by JFA and OSW.
The estimates of total annual generation differ
significantly between the JFA and OSW reports. At
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24,800 tons/yr, the estimate derived from the JFA report is over
three times as great as the OSW estimate (7,600 tons/yr).
The JFA estimate is based on a unit generation rate (2 Ib
per office per day) that is a "subjective estimation," which does
not lend much credence to the JFA annual estimate.58 The fact
that the unit generation rate for dentists' offices exceeds that
for physicians' offices in the JFA report casts further doubt on
the accuracy of the JFA estimate.
According to the OSW draft documentation, the total annual
generation estimate is based on the estimated number of
individual dentists (rather than dental offices) and a generation
rate per dentist. The unit generation rate, 10 Ib/mb per
dentist, is the average of information submitted by the dentists
who responded to the survey conducted for the EPA report. The
number of practicing dentists, about 127,000, appeared in a 1982
ADA publication.64 The total thus calculated is presented in the
OSW report; the unit generation rate presented in that report
(13 Ib/mo per dental office) is a calculated value based on this
total and the estimated number of dental offices (98,000).
Because the OSW unit generation rate is based on survey data, it
is likely to be more accurate than the subjective JFA report
value.
To estimate the quantity of medical waste generated annually
at dentists' offices, a reasonable approach is to use the figure
on the number of dentists (about 145,000) from the recent ADA
telephone contact and the OSW unit generation rate (10 Ib/mo per
dentist). By this method, the annual generation rate for
dentists' offices is about 8,700 tons/yr. This quantity
represents less than 3 percent of the estimated amount generated
by hospitals annually. The number of dental offices is estimated
at 98,000, based on the OSW documentation memorandum.
5.5.2 Waste Composition
The most frequently reported type of waste at dental
facilities is sharps. As seen in Table 7, 91 percent of the
dentists' offices responding to the State of Washington survey
indicated that sharps are generated, as did 78 percent of the
38
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respondents to the New York/New Jersey survey cited in the EPA
report. "Other patient care" waste (70 percent) and pathological
waste (30 percent) were the other waste types frequently reported
in the EPA report.65 These responses agree fairly closely with
the Washington State findings in Table 7. No dental offices in
the Washington study reported accepting infectious waste from
offsite for treatment.31
5.5.3 Treatment and Disposal
Eighty-three percent of the dental facilities studied for
the EPA report segregate some infectious waste from the general
waste stream; 69 percent of the respondents to the Washington
State survey do so.62'66 Onsite treatment methods in Washington
are summarized in Table 8. Only 35 percent of facilities treat
infectious waste onsite. Steam sterilization is the predominant
method. Among the New York and New Jersey dentists taking part
in the study for the EPA report, the primary onsite treatment
method is also steam sterilization when use of a sharps container
is removed from consideration as a treatment method.66
All the Washington survey respondents that use offsite
treatment have waste incinerated (see Table 9). No information
is available from the EPA report on offsite treatment methods
used by New York and New Jersey dentists, but 27 percent have
medical waste removed for treatment and disposal by a specialized
medical waste hauler.67
5.5.4 Trends
The trends in medical waste generation for dentists' offices
are expected to be the same as those discussed in the earlier
section on physicians' offices. Increased use of disposables and
a broader, more rigorously enforced definition of the wastes that
should be specially handled are expected to result in larger
quantities of medical waste from these facilities.
5.6 VETERINARIANS
5-6.1 Population and Waste Generation Rate
As shown in Table 6, the OSW report estimates that there are
38,000 veterinarians generating about 4,600 tons/yr of regulated
medical waste. The unit generation rate upon which the annual
39
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total is based is 20 Ib per veterinarian per month. The OSW
draft documentation indicates that the estimated number reflects
veterinarians in practices treating animals, according to a 1988
publication of the American Veterinary Medical Association
(AVMA) . The unit generation rate is the average of information
submitted by about 60 veterinarians who responded to the survey
undertaken for the EPA report.68 The JFA report does not
evaluate veterinarians.
Additional information was gathered through contacts with
veterinary professional organizations. The AVMA currently has
about 49,000 members, and there are "a few thousand" nonmember
veterinarians. A great deal of veterinary medicine is practiced
on farms, and most waste is left on the farm where the animals
are treated.69 The American Animal Hospital Association (AAHA)
estimates that there are about 14,000 animal hospitals that
specialize in pet treatment. (It is not known if this number
includes individuals with small animal practices.) Such
facilities typically produce less than 50 Ib/mo of regulated
medical wastes, as defined by EPA to exclude animal carcasses and
treatment waste that do not pose a threat of human infection.
*7 O
Most of the medical waste produced consists of sharps. A
representative of the New Jersey Animal Hospital Association
(NJAHA) indicated that there are typically two to four doctors
per animal hospital and that, as a rule of thumb, each doctor
generates about 100 Ib of medical waste per year. This figure is
based on the CDC infectious waste guidelines, which, like the EPA
regulations, require animal treatment waste to be specially
handled only if it is potentially infectious to humans.71
Based on the AAHA data (14,000 animal hospitals and less
than 50 Ib each per month), the annual medical waste generated by
animal hospitals is less than 4,200 tons/yr. If the quantity of
medical waste from large animal practices that is segregated for
special handling is assumed to be small, as indicated by the
AVMA, a total of 4,200 tons/yr is a reasonable estimate of the
quantity of waste entering the medical waste stream from
40
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veterinary facilities. It is uncertain whether medical waste
from single veterinarian practices is included in this total.
Combining the data from the NJAHA contact (100 Ib per
veterinarian per year and about three veterinarians per practice)
and the AAHA figure for the national population of animal
hospitals (14,000) results in an estimate of 2,100 tons/yr of
medical waste generated from this source category. This value is
lower than the OSW estimate or the estimate derived above solely
from AAHA data.
The annual medical waste generation rates estimated by OSW
and derived above from AAHA data agree within 10 percent. The
actual annual quantity generated by veterinary facilities is
likely to be in this range. To be conservative, the higher
estimate of 4,600 tons/yr reported by OSW is accepted for this
industry profile. This quantity is only about 1 percent of the
estimated amount generated by hospitals.
5.6.2 Waste Composition
The most common medical waste generated by veterinary
facilities is sharps. In fact, the representative of NJAHA
indicated that sharps represent 99.9 percent of the medical waste
generated by animal hospitals (using the OSW definition of
regulated medical waste).71 The other professional organizations
agreed that sharps are the primary medical waste generated, but
also named such items as blood vials, vaccine vials, and waste
with potential to cause disease.69'70 According to the EPA
report, 86 percent of the respondent veterinarians in New York
and New Jersey generate sharps, 77 percent generate "other
patient waste," and significant numbers generate cultures and
stocks, blood and body fluids, and pathological waste.72 The
results of the Washington State survey are presented in Table 7.
Again, sharps are most frequently generated (96 percent of
respondents), with surgery waste, pathological waste, waste
contaminated with excretions or secretions, and contaminated
animal carcasses each reported by more than 75 percent. Ninety-
three percent of the New York and New Jersey respondents for the
EPA study segregate some infectious waste. Most frequently,
41
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31
sharps are segregated (by 92 percent of the respondents that
segregate waste); other materials that are removed from the
general waste stream include pathological waste (37 percent),
blood-contaminated waste (22 percent), and various other types
(20 percent). Forty percent segregate more than one kind of
waste.73 Only 64 percent of the respondents to the Washington
survey reported segregating the infectious waste from the general
waste.62
5.6.3 Treatment and Disposal
According to the Washington State survey none of the
respondents accept infectious waste from offsite for treatment.
The onsite treatment methods used are presented in Table 8.
Forty-eight percent treat some infectious waste onsite. The most
frequently used method is steam sterilization (67 percent of
those that treat onsite), followed by chemical disinfection,
direct pour to sanitary sewer, and incineration. The most
frequent onsite "treatment" technique reported by the New York
and New Jersey respondents is use of a sharps box, followed by
steam sterilization, incineration, and grinding to sanitary-
sewer, in that order.73
As seen in Table 9, only 16 percent of the respondents to
the Washington State survey reported having some infectious waste
treated offsite. Seventy-five percent of these have the waste
incinerated. The EPA report indicates that 29 percent of the New
York and New Jersey survey respondents have infectious waste
picked up by a specialized medical waste hauler for treatment and
disposal.73 The contacts at professional organizations indicated
that most veterinarians use medical waste haulers for
disposal.69"71
5.6.4 Trends
The quantity of waste from veterinary facilities that enters
the medical waste stream for special handling is expected to
increase for the same reasons discussed in earlier sections.
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5.7 LONG-TERM HEALTH CARE FACILITIES
5.7.1 Population and Waste Generation Rate
The JFA report identifies a total of about 42,700 facilities
that fall into this category, including about 18,800 nursing
homes and about 23,900 residential care facilities. Nursing
homes take direct responsibility for providing medical care,
while residential care facilities do not.
The OSW report estimates the number of long-term health care
facilities at 12,700. Based on the OSW draft documentation, this
estimate represents nursing homes certified by Medicare or
Medicaid according to a 1987 Health Care Financing Administration
publication.74 The figure corresponds with the number of
Medicare- and Medicaid-certified nursing homes (about 12,600)
identified in the JFA report based on 1982 survey data from the
National Center for Health Statistics. The greater total number
of nursing homes estimated by JFA (18,800) can be explained by
the inclusion of noncertified facilities and facilities for
emotionally disturbed youth and the mentally ill.
The JFA report indicates estimates of about 100,800 tons/yr
generated by nursing homes and 29,200 tons/yr generated by
residential care facilities, for a total annual generation rate
from the long-term health care source category of about
130,000 tons/yr. The OSW report estimates a total of about
29,600 tons/yr for this category. Given the large discrepancy
between the numbers of facilities estimated in the JFA and OSW
reports, the large difference in the estimated annual generation
rates is not surprising.
The difference between the annual estimates in the reports
is exacerbated further by differences in estimation methodology.
In the JFA analysis, an infectious waste unit generation rate of
0.5 Ib per bed per day was used for both nursing homes and
residential health care facilities.75 The basis for this
estimate is a conversation with a representative of the New York
Center for Environmental Health. The OSW report used a rate of
390 Ib per nursing home per month, citing the EPA report.76
According to the draft documentation memorandum, residential care
43
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facilities not providing skilled care generate negligible amounts
of regulated medical waste.74
The EPA report includes the results of separate surveys of
New Jersey nursing homes and residential health care facilities.
Although the analysis in the report used the median unit
generation rates reported for these facilities, the OSW estimate
is based on the mean unit generation rate for nursing homes
(3.34 Ib/patient-month) and the median number of patients
(116 per nursing home). Over half the responding residential
health care facilities indicated that they generate no medical
waste, resulting in a median generation rate of zero. The mean
77
for this type of source is 0.56 Ib/patient-month.
Data on "residential health care facilities" are also
reported in the New York study. Unfortunately, the meaning of
this term is uncertain in this context. The report uses the
terms "residential health care facilities," "nursing homes," and
"health-related facilities" apparently interchangeably. Whatever
the precise meaning of "residential health care facilities," the
New York survey reports an average unit generation rate for
infectious waste of less than 0.5 Ib per bed per week.78 This
value, which is equivalent to approximately 2 Ib per bed per
month, compares reasonably well with the mean value reported for
New Jersey nursing homes in the EPA study, especially considering
the uncertainty of what types of facilities are included in the
New York survey and the fact that occupancy rates are not
accounted for in the New York data.
The more inclusive accounting by JFA of facilities in the
long-term health care category is likely to result in a more
accurate estimate of total facilities. However, the unit
generation rate used in JFA report seems far out of line when
compared to the findings of the New Jersey and New York surveys.
In fact, because the JFA report cites a New York source, it
appears that the unit generation rate determined on a weekly
basis by New York could have mistakenly been used by JFA on a
daily basis.
44
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An improvement on both the JFA and OSW annual estimation
methods can be made by using data from the JFA and EPA reports.
Using the mean unit generation rates from the New Jersey survey
and data on the number of patients at nursing homes and
residential care facilities from the JFA report results in
estimates of about 29,700 tons/yr from nursing homes and
1,400 tons/yr from residential health care facilities. Thus, the
total for all long-term health care facilities is estimated to be
about 31,100 tons/yr. This value is only about 15 percent higher
than the value estimated by OSW.
5.7.2 Waste Composition
The type of medical waste most commonly generated at nursing
homes is sharps, with 98 percent of the Washington State
respondents and 89 percent of the New Jersey respondents
indicating that waste sharps are produced. As shown in Table 7,
over 75 percent of the nursing homes that responded to the State
of Washington survey indicated generation of waste with
excretions or secretions and isolation patient waste. No types
of waste other than sharps were indicated by more than 10 percent
of the New Jersey nursing home respondents."^
In the New Jersey survey of residential health care
facilities for the EPA report, 68 percent reported that no
infectious waste is generated. Twenty-one percent indicated that
sharps waste is produced.80 The Washington State survey did not
include this type of facility, so no other data are available.
5.7.3 Treatment and Disposal
The EPA report indicates that the most common method of
treating and disposing of medical waste among the respondent
nursing homes in New Jersey is to contract with a commercial
medical waste hauler. Sixty-three percent of the respondents use
this method. Another 12 percent transport medical wastes to a
local hospital or laboratory for inclusion in that facility's
medical waste stream, and 6 percent send the waste to landfills
without prior treatment. Fewer than 5 percent indicated the use
of steam sterilizers, incinerators, or sanitary sewers.8^
45
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62
Among Washington State nursing'home survey respondents that
consider some waste infectious, 21 percent treat some of this
waste onsite, and 47 percent have some treated offsite (see
Tables 8 and 9). Of the nursing homes that acknowledge
generating infectious waste, only one respondent accepts waste
from offsite for treatment.31 Only 12 percent indicated that
they do not segregate infectious waste from the general waste.
As indicated in Table 8, over half the facilities that treat
some waste onsite use incineration; other methods used are steam
sterilization, chemical disinfection, direct pour to the sanitary
sewer, and gas sterilization. For offsite treatment, 81 percent
use incineration (see Table 9).
5.7.4 Trends
Long-term health care facilities are subject to the same
forces that have resulted in increased medical waste generation
in other source categories. The use of disposable items has
increased in recent years and will likely continue to increase
unless strong economic or regulatory incentives for reuse or
recycling are enacted. The aging of the "baby boomers," and the
increase in life expectancy due to improved technology are two
factors that are likely to result in an increase in the elderly
population. In accommodating this growing population, the number
of long-term health care facilities and the amount of medical
waste generated at these facilities is also expected to increase.
The broadening of the definition of infectious or regulated
medical waste and a continued transition from guidelines to
regulations is expected to increase the fraction of the general
waste stream that is segregated for special treatment. However,
this latter effect is not expected to be as great in this
industry segment as in many others because, as indicated in the
preamble to the OSHA standards, nursing homes and residential
care facilities have historically handled medical wastes
AQ
conservatively. y
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5.8 FREE-STANDING BLOOD BANKS
5.8.1 Population and Waste Generation Rate
The JFA report designates a blood/plasma/tissue centers
category made up of 260 independent blood banks, 400 independent
plasma centers, and 12 independent tissue banks, for a total of
672 facilities. The JFA data indicate that about 4,900 tons/yr
of infectious waste are generated by these facilities (see
Table 6). The estimate of the annual national total is based on
a unit generation rate of 1.75 Ib per employee per day. This
value was estimated based on information from BBL Microbiology
Systems.52
The OSW estimates, as presented in Table 6, are
900 independent blood banks generating 2,400 tons/yr of regulated
medical waste. This estimate is based on a unit generation rate
of 440 Ib of regulated medical waste per facility per month.
According to the OSW draft documentation, these estimates are
based on two site visits to blood banks and on contact with a
representative of the American Association of Blood Banks.82
Little basis exists for choosing between these estimates.
In a telephone contact, a representative of the Council of
Community Blood Centers indicated that there are about 400 to
500 community blood centers nationwide. This figure does not
include American Red Cross blood centers.83 Based on this
contact, it is likely that the OSW estimate of 900 blood banks is
more accurate than the JFA estimate. However, the figure cited
for community blood centers may include centers associated with
hospitals (i.e., that are not "free standing") or centers that
JFA classified as plasma centers.
The unit generation rate selected by JFA is not documented.
The value used by OSW is based on only two facilities. Data from
the District of Columbia Chapter of the American Red Cross
indicate that this facility generates approximately 1 ton of
medical waste per month while operating 15 mobile blood
'*. collection units.84 However, it is not known how this facility
relates in size to others.
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To avoid understating the quantity of medical waste
generated by blood banks, the larger estimate (4,900 tons/yr)
derived from JFA data is used for this industry profile. The
assignment of a value to this category is not crucial because
this is a minor source, comprising 1 percent or less of medical
waste generated nationally.
5.8.2 Waste Composition
The medical waste stream from blood centers consists of
virtually everything from the blood collection process, including
needles, tubing, finger sticks, sponges, paper, etc. In
addition, wastes are generated during testing for the AIDS virus
that include diluents from the test's washing process. When
blood or blood product units reach their expiration date without
Q o 94.
being used, they must be disposed of as well.00'
5.8.3 Treatment and Disposal83'84'
Medical wastes from blood banks are treated and disposed of
according to local regulations. Most are taken to local
hospitals for onsite incineration, some are incinerated at
commercial facilities, and some are treated by steam
sterilization and discarded in the general waste stream. The
proportional breakdown by treatment method is not known.
5.8.4 Trends
Blood bank medical waste will increase as discussed for
other source categories. The impact of definitional changes is
not expected to be great; these sources have historically managed
medical wastes carefully.49
5.9 FUNERAL HOMES
5.9.1 Population and Waste Generation Rate
Based on 1982 Census of Service Industries data, the JFA
report estimates that there are about 15,000 funeral homes and
crematories in the United States. The OSW report places the
number at about 20,400, citing a 1988 trade publication. It is
unknown whether the OSW figure includes crematories. Data
independent of these two reports were obtained from the National
Funeral Directors Association (NFDA). According to this source,
there are about 21,000 funeral homes nationwide that are operated
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by about 17,500 separate business entities.85 The close
agreement between the OSW and NFDA estimates suggests that the
true population is likely to be near 21,000. The lower JFA
estimate may be the result of older data.
The data in the JFA report indicate that approximately
500 tons/yr of infectious waste are generated at funeral homes,
based on a unit generation rate of 0.5 Ib per necropsy. No basis
for this unit generation rate is presented.86
The OSW report estimates that about 3,900 tons/yr of medical
waste are generated by funeral homes annually. The OSW estimate
is based on a unit generation rate of 32 Ib per facility per
month. These figures are based on the EPA report.87
The EPA report includes results from a survey of funeral
homes in New York and New Jersey. The median medical waste
generation rate of the respondents that gave complete data is
31.5 Ib per month. The New York/New Jersey survey respondents
process a median of nine bodies per month; the unit generation
rate on a per-body basis is about 3.5 Ib.88
The per-body unit generation rates presented in the JFA and
EPA reports differ significantly, at 0.5 Ib versus 3.5 Ib,
respectively. Information from the NFDA indicates that less than
1 Ib is generated per body.85 The variation in estimates may
result from the use of different definitions of medical or
infectious waste. For example, during embalming, the blood is
drained from the body and, typically, directed to the sanitary
sewer. While this blood would be included under any of the
applicable definitions, it clearly has not been counted in the
JFA or NFDA unit generation rates because it does not enter the
general or medical waste stream. A possible explanation for the
higher rate derived in the EPA report could be that some
respondents included blood in their accounting of the quantity of
medical waste generated.
In any case, the total quantity of medical waste generated
iby funeral homes is a small portion of the overall total. Even
the OSW estimate amounts to less than 1 percent of the estimated
national total. For purposes of this industry profile, the NFDA
49
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estimate, rounded up to 1 Ib generated per body, was used because
the NFDA is considered to be the most reliable source. Using
this factor and NFDA statistics indicating that over 90 percent
of the 2.2 million persons that die in the United States annually
are embalmed, the total quantity of medical waste generated by
Q Q
funeral homes is estimated to be about 900 tons/yr.
5.9.2 Waste Composition
According to the results of both the New York/New Jersey
survey (discussed above) and the State of Washington survey,
sharps and blood are generated at most funeral homes. Ninety-
four percent of the Washington respondents and 51 percent of the
New York/New Jersey respondents reported generating sharps;
88 percent and 77 percent, respectively, reported generating
blood.90 As shown in Table 7, other types of waste reported by a
significant fraction (greater than. 25 percent) of the Washington
State survey respondents included waste with excretions or
secretions, surgery waste, isolation patients waste, and
pathological waste. A significant portion of the New York/New
Jersey respondents reported generating "other waste associated
with patient care, " including such items as plastic
sheets/shrouds, rubber gloves, disposable aprons and facemasks,
etc. Surprisingly, 19 percent of the Washington funeral homes
and 11 percent of the New York/New Jersey facilities reported
generating dialysis waste.91 Seventeen percent of the Washington
State respondents that consider some of their own waste
infectious indicated that they accept infectious waste from
off site sources for treatment.31
5.9.3 Treatment and Disposal
As Table 8 shows, almost 80 percent of the Washington State
facilities that consider some of their waste infectious treat at
least some of the waste onsite. Chemical disinfection, pouring
to the sanitary sewer, and incineration are the treatment methods
cited. Among the New York/New Jersey respondents, pouring to the
sanitary sewer is mentioned by nearly 77 percent; incineration is
used by less than 5 percent. Chemical disinfection was not
included as a choice on this survey
50
92
^
-------
Offsite treatment methods used by the State of Washington
survey respondents are summarized in Table 9. Less than
10 percent of the facilities that designate some of their waste
infectious have such waste treated offsite. Two respondents make
up the population that uses offsite treatment; both have
infectious waste incinerated, and one also uses offsite chemical
disinfection.
Less than 10 percent of the New York/New Jersey respondents
have medical waste transported to offsite commercial disposal
facilities. Over 20 percent send medical waste to landfills
without prior treatment.92 According to the State of Washington
survey, 22 percent of the respondents that acknowledge producing
infectious waste do not segregate this waste from the general
waste. Another 13 percent gave no response or an invalid
response on this point.62
5.9.4 Trends
Funeral homes are expected to experience growth in the
quantity of waste designated as medical waste. It is not known
to what extent the use of disposables is growing in this
industry. The impetus to use disposables may not be as great at
funeral homes as in health care settings because there is no
danger of disease transmission between patients. However,
occupational exposures are a concern, so the use of disposables
may increase for this reason.
According to the OSHA standards preamble, the funeral home
industry has not historically managed potentially infectious
waste conservatively.49 For this reason, the definitional
changes and evolution toward regulations that have been discussed
previously are likely to result in a considerable increase in -the
fraction of the funeral home waste stream that is segregated for
special medical waste treatment.
5.10 SOURCE CATEGORIES EVALUATED ONLY BY JFA
As illustrated by Table 6, the JFA report includes estimates
for four minor source categories not evaluated for the OSW
Report. No survey or independent data are available for these
51
-------
categories. The categories are discussed briefly below. The
figures presented are accepted for this analysis.
The "health units in industry" category is made up of
facilities outside the health care industry that provide some
type of health-related services to their employees. This
category includes a total of about 221,700 facilities comprised
of health units with a physician in charge (2,300), health units
with a registered or licensed practical nurse in charge (8,500),
health units with some other person in charge (925,300), and
facilities with full- or part-time personnel trained in and
responsible for emergency medical care (185,600).93 Despite the
very large number of facilities, the JFA data indicate that the
total annual quantity of infectious waste generated by these
facilities is only about 1,400 tons/yr.
Fire and rescue services include facilities that provide
emergency treatment and transportation. Only services not based
in hospitals that retain some paid employees are included. The
JFA data indicate that there are about 7,200 such facilities--
6,700 fire departments and at least 500 private emergency
services. Based on an estimate of over 6.4 million medically
related emergency runs per year and a unit generation rate of
0.5 lb per emergency, this source category generates about
1,600 tons/yr of medical waste.94'95 This waste is typically.
added to the receiving hospital's waste stream.
The JFA report indicates that there are about 4,300 jails
and prisons in the United States. These facilities provide some
degree of medical services to the inmates, ranging from physical
exams to full hospital services. Based on the JFA data, the
total quantity of medical waste generated annually is estimated
to be 3/300 tons.
The final category evaluated in the JFA report is police
departments, of which there are about 13,100. Based on the JFA
data, it is estimated that these facilities generate only about
8 tons/yr of medical waste. This insignificant generation
category is included on the JFA report because the OSHA standards
for which the analysis was conducted concern measures to minimize
52
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occupational exposure to bloodborne pathogens. Police officers
are at risk because of the relatively high incidence of AIDS and
other bloodborne diseases among intravenous drug users and the
potential for encountering injured victims or suspects or
sustaining injury themselves. Police laboratory technicians also
are at risk. Presumably the medical waste produced by police
officers would consist primarily of articles soiled with blood;
lab technicians would generate sharps as well.
6.0 MEDICAL WASTE INCINERATOR POPULATION
6.1 NATIONWIDE
The estimated national population of existing MWl's has been
presented in Table 2. Estimates are presented in the table for
each type of facility at which MWI's are commonly found. For
each facility type, the table includes the observed capacity
range,.estimated average capacity, and estimated percent of total
MWI capacity represented by that facility type. In Table 10, the
approximate distribution of MWI's by capacity is presented for
each type of facility.
As Table 2 shows, hospital MWI's are by far the largest
category, both .in terms of number and in terms of percent of
total capacity. Table 10 illustrates that smaller units
predominate for all categories except commercial facilities, with
the majority having a capacity of less than 300 Ib/hr. The
characteristics of the MWI's at each type of facility will be
discussed individually in a later section.
The estimates presented in Tables 2 and 10 are based
primarily on data received from State air programs and State
hospital associations.1 To estimate the total number of MWI's,
the most reliable and complete data were compiled for each
category and extrapolated nationwide based on population.
Variations on this estimation methodology, as applicable, are
discussed in the section covering individual facility types.
Population was selected as the basis for extrapolation
because this is a straightforward computation with readily
available data. In addition, no method with inherently greater
accuracy was identified. An alternative might be to determine,
53
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TABLE 10. PERCENTAGE DISTRIBUTION OF MWI POPULATION BY RATED
CAPACITY FOR EACH FACILITY TYPE
Facility type
Hospitals
Laboratories
Veterinary facilities
Nursing homes
Commercial facilities
Other/unidentified
Rated capacity, Ib/hr
<100
25
24
69
47
0
33
100 to 199
26
21
19
24
12
31
200 to 299
11
20
5
18
12
. 19
300 to 499
16
13
3
1
6
15
500 to 999
14
12
2
7
18
2
>.1,000
6
8
2
3
52
0
=^^=^==
Totala
98
98
100
100
100
100
===
aMay not equal 100 percent because of rounding error.
54
-------
for each type of facility, the fraction that operate incinerators
in the States for which reliable incinerator data are available
and to extrapolate based on the total number of facilities in the
United States. However, as indicated in the section on generator
population, there is uncertainty about the number of these types
of facilities nationwide, and State-by-State accountings
generally are not available.
The figures presented in Tables 2 and 10 concerning rated
capacity are drawn from a compilation of the most complete State
data sets obtained. The most extensive data are from New Jersey,
New York, and Washington; data from other States for some
facility categories are included as well.1
An additional source of data was the responses to
information collection requests sent to six multiple-hospital
corporations and three commercial MWI companies. The hospital
corporations operate up to 20 MWI's each and the commercial
disposal facilities also operate several units each.
Data on the age of MWI's was obtained from California,
Washington, and Rhode Island, as well as from several of the
respondents to the information collection requests. Available
data on the age of MWI's are summarized in Table 11.
6.2 STATE DATA
Table 12 presents a summary of the data on MWI's received
from the States. This table is a combination of data from the
MWI lists, used to derive the nationwide estimates presented in
Table 2, and information received during telephone contacts with .
State air agencies and State hospital associations. Some data
from State reports are included also.
6.3 DISCUSSION OF INDIVIDUAL FACILITY CATEGORIES
In the sections that follow, the major categories of MWI
facilities are. discussed individually. To the extent possible,
the discussion includes information on the number of facilities,
combustor types, sizes, ages, duty cycles, waste types burned,
and other topics relevant to the individual category.
55
-------
TABLE 11. SUMMARY OF AVAILABLE MWI AGE DATA
__=_===...S=S========:
Other/unidentified facilities
Hospitalsa
Laboratories'3
Veterinary facilities"
Nursing homes0
Commercial facilities'1
Other/unidentified facilities0
^ *
No. of units in
sample
108
2
10
6
5
8
Age, years
Range
1-33
10-21
3-21
18-33
3-6
7-30
Average
14
16
13
24
5
16
========
aBased on data from CA, RI, and WA.
^Based on data from WA.
°Based on data from CA and WA.
dBased on data from CA and RI.
56
-------
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at one facility.
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Also have nursin
SRA telephone contact. One 1 ,200 Ib/h
consideration; no permit application yet
MWI's that typically burn < 10 lb/2 d.
&
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one contact. Plann
992.
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commercial units not online until 1991-
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nent. Moratorium
Have received lists from Allegheny Cou
Philadelphia. Estimate from State docut
commercial units lifted 6/90.
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The three commer
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SRA telephone contact and test results.
are located at one facility; they burn hot
capacity based on MSW.
S
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111
all MWI construct
al units were propc
sting commercial
Statement accompanying moratorium on
issued in February 1990. Six commerci
the time. Local agency indicates one ex
within jurisdiction.
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hospitals are requi
itact indicated that
erate their medical
SRA telephone contact indicated that all
have an incinerator. However, SHA coi
areas, only about half the hospitals incin
Q
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a
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unercial units penr
SRA telephone contact. Two of the corr
been issued; the third is pending.
S
i
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f
d commercial units
urvey data.
SRA telephone contact. The two planne
located at one facility. Expect hospital s
&
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6.3.1 Hospitals
As seen in Table 2, hospital installations are the largest
class of MWI's, both in terms of numbers (approximately 3,200, or
over 60 percent of all MWI's) and capacity (almost 65 percent of
total MWI capacity). Hospital MWI's are known to range in size
(i.e., rated capacity) from 3 Ib/hr to 2,500 Ib/hr and to average
about 270 Ib/hr. The national hospital MWI population estimate
is derived from data received from 20 States extrapolated based
on 1980 census data. The size range and average are based on
data from 12 States.
Data received in response to the request for information
distributed for this project are more informative with respect to
combustor type than the State MWI population data. However,
neither of these data sets contained significant amounts of
information necessary to classify combustor types beyond the most
fundamental designs. Based on the information received, MWI's
were divided into two combustor types, starved-air and excess-
air. Starved-air MWI's are the most prevalent type and are used
to incinerate all types of medical waste, except pathological
waste. Excess-air MWI's are generally used for the incineration
of waste that contains a very high percentage of pathological
material. Data on combustor type and rated capacity are
summarized in Table 13.
As illustrated in Table 10, the hospital MWI population is
concentrated at the low end of the capacity range, with over
50 percent below 200 Ib/hr, and is then spread out fairly
uniformly across the range above this level. This table is based
on data from State inventories. The size distribution by
combustor type among surveyed hospitals is shown in Table 14.
The combination of all combustor types in this table differs
slightly from the hospital data in Table 10.
Many MWI's at hospitals are very old. As shown in Table 11,
based on data from two States (California and Washington), at
least one hospital unit was installed as long ago as 1957. The
average age of hospital MWI's for which data are available in
these two States is about 14 years. Data from two surveys
61
-------
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62
-------
TABLE 14. PERCENTAGE DISTRIBUTION OF SURVEYED HOSPITAL MWI
POPULATION BY RATED CAPACITY FOR EACH COMBUSTOR TYPE
Combustor Type
Starved-air
Excess-air
Unknown
All combustors combined
Rated capacity, Ib/hr
<100
22
23
33
23
100 to 199
14
62
0
22
200 to 299
24
8
0
20
300 to 499
19
8
33
18
500 to 999
19
0
33
16
_>.1,000
2
0
0
1
Total
100
101
99
100
63
-------
conducted by State hospital associations (Ohio and Wisconsin)
indicate mean ages of about 11 years and 15 years,
respectively.96'97 Age data from the hospital MWI survey are not
representative. The questionnaires were sent to multiple-
hospital corporations with instructions to concentration on newer
MWI units.
The duty cycle of MWI's is determined by the design of the
waste feed system and the method of ash removal. All MWI's fall
into one of three distinct designs, and may be designated as
either a batch, an intermittent-, or a continuous-duty
incinerator. In a batch unit, the waste is introduced to a cold
unit in a single load. The incinerator is operated without
additional waste being added until combustion is complete. In
intermittent-duty MWI's, waste is introduced periodically during
incinerator operation, but the unit must be shut down for ash
removal. Continuous-duty means that ash is discharged from the
unit during operation, so waste can be fed for an unrestricted
length of time.
Some data on the incinerator duty cycles employed by
hospitals were obtained in response to the hospital request for
information. About 22 percent of MWI's for which responses were
received are batch units, 72 percent are classified as
intermittent, and 6 percent are continuous units. The batch
MWI's average only about 75 Ib/hr rated capacity, intermittent
MWI's 294 Ib/hr, and continuous MWI's 743 Ib/hr.
Some data on the prevalence of heat recovery at hospital
MWI's are also available from the responses to the requests for
information. Based on these data, heat is recovered from about
8 percent of hospital MWI's. Heat recovery is most practical for
larger units that burn a more general waste stream, although
equipment is available for moderate-sized incinerators as well.
It is not known how well the respondents represent the general
population of hospital MWI's. According to one source, at least
100 heat-recovery systems were installed on new hospital MWI
installations between 1974 and 1983.98
64
-------
It is common practice for hospitals to accept medical waste
from offsite sources for incineration. The quantity of offsite
waste accepted is generally small. Evidence abounds that waste
from doctors' and dentists' offices', laboratories, clinics,
nursing homes, veterinary facilities, home care agencies, nursing
homes, and smaller hospitals is sometimes burned in hospital
MWI's. Of the hospitals that responded to the request for
information, 22 percent indicated that some offsite medical waste
is accepted for incineration. Seventeen percent of the Ohio
Hospital Association survey respondents reported accepting
infectious waste from offsite for treatment, and 24 percent of
the hospitals that responded to the Wisconsin Hospital
Association survey indicated incinerating such waste.
The survey for this project also asked about the point of
origin within the hospital for the waste incinerated onsite.
Based on the means of the responses, 30 percent of the waste
comes from the operating room, 24 percent from patient rooms,
16 percent from the hospital laboratory, 13 percent from
pathology, 7 percent from the administrative offices, 4 percent
from the pharmacy, 2 percent from the cafeteria, and 4 percent
from other sources.
As discussed earlier, the true, long-term capacity
utilization rate cannot be computed without knowledge of the
operating schedule for which the unit is designed. However, some
data on operation practices were reported by the hospital MWI
respondents. On the basis of Ib/hr combusted, the percent of
rated capacity used ranges from only about 2 percent up to
100 percent, with a mean of 56 percent and a median of
55 percent. The number of operating hours per day ranges from 1
to 20, with a mean of 9 and a median of 8. The MWI's are
operated a mean of about 285 days per year (median--315 days per
year) and a mean of about 2,575 hours per year (median--
2,400 hours per year).
65
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6.3.2 Laboratories
As discussed earlier in the section on medical waste
generators, clinical laboratories do not often operate onsite
MWI's. However, research laboratories that generate animal
carcasses frequently do. Note that animal carcasses are not
considered infectious or regulated medical waste unless they have
been exposed to agents infectious to humans.
The estimated number of laboratory MWI's in the United
States is 500, as extrapolated from data received from 11 States
(see Table 2). Based on data from six of these States, the
average capacity of these units is approximately 340 Ib/hr, and
the range is from 3 to 3,000 Ib/hr. This category comprises
about 10 percent of the U.S. MWI population but nearly 12 percent
of total MWI capacity. As shown in Table 10, about 65 percent of
laboratory MWI's are less-than 300- Ib/hr, but the remaining units
are spread across the range, with 8 percent having capacities of
1,000 Ib/hr or greater.
The waste combusted in these units is primarily pathological
(i.e., animal carcasses). As shown in Table 11, few data are
available on the age of laboratory MWI's. No data are available
on duty cycle or heat recovery practices at laboratory MWI's. As
discussed in the medical waste generator section, some clinical
laboratories accept waste for treatment from offsite sources
either as a service to their customers or for a fee. However,
incineration is not normally the treatment method employed.
6.3.3 Veterinary Facilities
Data from eight States were used to estimate that about
550 veterinary facilities operate MWI's nationwide. As indicated
in Table 2, these units range in size from 15 Ib/hr to
2,000 Ib/hr, with an average capacity of about 120 Ib/hr based on
the four States with extensive capacity data. This category
comprises about 11 percent of the MWI population, but less than
6 percent of total MWI capacity. Based on data from three
States, nearly 70 percent of these units have capacities of less
than 100 Ib/hr; over 95 percent are less than 500 Ib/hr.
66
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Veterinary facilities incinerate primarily animal carcasses,
which are typically not considered infectious or regulated
medical waste. However, veterinary practices generate the same
sorts of treatment wastes typical of human health care. Thus,
incineration of veterinary waste has the potential to emit the
same pollutants that are characteristic of the incineration of
human patient care waste. This potential is the basis for
keeping veterinary facilities separate from animal shelters,
where health care waste is minimal.
As indicated in Table 11, installation date data are
available only for 10 units in the State of Washington. These
units range in age from 3 to 21 years, with an average of
13 years.
No data are available on duty cycle or heat recovery
practices at veterinary MWI's. Given the very small units
typical of this category, the use of heat recovery is unlikely.
It is unlikely that waste from offsite sources is accepted at
such facilities.
6.3.4 Nursing Homes
Table 2 presents the estimated population of MWI's at
nursing homes, about 500 units based on data from 13 States. The
average size of these units (based on five States' data) is about
170 Ib/hr, and the range is from 3 to 1,300 Ib/hr. Only about
3 percent of total MWI capacity is located at nursing homes.
Nearly 90 percent of nursing home MWI's are less than 300 Ib/hr
in capacity based on data from four States. Very little data are
available on the age of nursing homes MWI's (see Table 11).
While no data are available regarding duty cycles or heat
recovery at nursing homes, the distribution weighted heavily
toward the small end of the spectrum indicates that intermittent
units without heat recovery are most likely. It is unlikely that
medical waste is accepted from offsite at these units.
67
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6.3.5 Commercial Units
It is estimated that there are up to about 150 commercial
MWI units in operation. Multiple units at a single facility are
common. This estimate was extrapolated from data from 15 States
and roughly corroborated by the data on commercial units in
Table 12. Based on data from 10 inventories, an average capacity
of about 1,180 Ib/hr was derived. The range in these data is
from 100 to 8,000 Ib/hr. While commercial facilities comprise
only about 3 percent of the MWI population, slightly over
12 percent of total MWI capacity is in this category. Other data
gathered from incinerator manufacturer installation lists and
trip reports tend to indicate that the estimated average capacity
is low. This will certainly be true in the future; new and
proposed commercial facilities tend to be much larger than older
units, most frequently between 1,500 and 2,000 Ib/hr.
For this project, requests for information were sent to
three multiple-facility commercial incineration companies.
Responses for 21 MWI's were received. These units range in
capacity from 110 Ib/hr to 2,500 Ib/hr, with a mean capacity of
about 1,245 Ib/hr and a median of 1,350 Ib/hr.
Continuous-duty MWI's account for the majority of commercial
units. Among the survey respondents, 17 of the 21 are
continuous-duty. Three are intermittent-duty, and one is a batch
unit. Information from other sources indicates that at least two
rotary kiln combustors are also in use at commercial facilities.
The surveyed MWI's are being extensively utilized. Eighteen
of the 21 units are reported to operate 24 hours per day, with a
mean over all units of 22 hours per day. (Note that this is
inconsistent with the data indicating that only 17 units are
continuous-duty.) These commercial MWI's operate from 150 to
365 days per year, averaging 321. The range of operating hours
per year is 2,400 to 8,760, with a mean of 7,185 hours per year
and a median of 7,600.
The commercial MWI companies were also asked what types of
sources generate the medical waste that they incinerate. Based
on the means for the responding facilities, 64 percent of the
68
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waste comes from hospitals, 13 percent from clinics, 13 percent
from laboratories, 7 percent from physicians' offices, and
1 percent from veterinary facilities. (Rounding error accounts
for the total of less than 100 percent.) Again based on the
means of the responses, 79 percent of the waste Combusted at
these commercial'facilities is "red bag" waste, 18 percent is
pathological, 2 percent is general medical waste, and 1 percent
is municipal solid waste.
While heat recovery would seem more feasible for commercial
units than for onsite MWI's, available data do not indicate that
heat recovery is particularly common. Based on data from the
responses, less than 10 percent of commercial facilities practice
heat recovery.
6.3.6 Other/Unknown
This category is included to account for facilities that do
not fit elsewhere. In some cases, the facilities can be
identified but do not belong in any of the major categories.
Such facilities include the few clinics, blood banks, etc. that
operate onsite incinerators but are not plentiful enough to
justify a separate category. More often, the type of facility
simply cannot be identified. This frequently occurs when a
facility is included in a State list of MWI's, but the facility
name does not reveal the facility type. These facilities are
included in this category so that they may still be considered in
the characterization of the MWI source category.
As indicated in Table 2, there are approximately 150 such
facilities nationwide based on extrapolation from 11 States.
These facilities have an average capacity of about 170 Ib/hr and
range from 25 to 900 Ib/hr. They represent less than 2 percent
of total MWI capacity. Nearly 85 percent of these units have
capacities of less than 300 Ib/hr. The predominantly small size
of the units indicates that batch and intermittent MWI's prevail
and that heat recovery is uncommon. Data on the installation
dates of the units in this category are scarce (see Table 11).
69
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6.3.7 Municipal Waste Combustors (MWC'a) That Cofire Medical
Waste
Under the definition for MWI in this project, any device
that combusts medical waste is a MWI. Thus, MWC's that combust
any amount of medical waste are included. Technically, under the
definition of medical waste, most, if not all, MWC's burn some
medical waste (i.e., the portion of the waste generated during
the course of patient care that is not segregated from the
general waste stream for special handling). However, this
portion of the medical waste stream that cannot be differentiated
from general waste on sight will not be addressed here.
In many States and localities, there are no restrictions on
burning the waste designated as potentially infectious in a MWC.
However, it is not common for MWC operators to accept medical
waste for treatment. This practice often extends beyond the
fraction of the waste designated as infectious under applicable
regulations to include any waste of similar appearance.
In a report prepared for EPA, 11 MWC facilities (comprising
31 MWC units) that accept medical waste were identified. One of
these facilities accepts an average of 50 percent medical waste;
at all other facilities the fraction of the total waste stream
that is medical waste averages no more than 5 percent. Three
additional facilities were identified that previously accepted
medical waste but have ceased this practice. One facility
stopped because of changes in the regulations that applied, and
two ceased because of operational problems and potential hazards
QQ
believed to be associated with the medical waste."
Additional MWC facilities may accept medical waste in those
localities where medical waste management regulations allow it,
particularly where there are no restrictions on placing medical
waste in the general waste stream. For example, in a report
prepared by the State of Washington, all four MWC facilities in
the State are identified as potential incinerators of medical
waste even though only one of the facilities actively solicits
medical waste shipments as a commercial venture.100
70
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In Table 2, only the 31 MWC units identified in the report
to EPA have been included. No basis exists for extrapolating
beyond these units, although more MWC's may be cofiring medical
waste, knowingly or unknowingly. The MWC units in Table 2 have
not been included in the calculations of total capacity or
percent of total capacity because medical waste amounts to only a
fraction of the rated capacity of these units.
6.4 TRENDS IN MEDICAL WASTE INCINERATION PRACTICES
6.4.1 Potential Influences On Population Growth
The trend in medical waste management is toward more
inclusive definitions of medical waste and toward transformation
of what had been guidelines into more restrictive regulations on
handling, packaging, treatment, transportation, and disposal of
medical waste. As a result, the quantity of waste designated as
medical waste that requires special handling is expected to
increase. In addition, the cost of complying with more stringent
regulations for packaging, transporting, treating, and disposal
is expected to drive up the unit cost of having medical waste
treated offsite. To avoid the higher disposal costs, an increase
in onsite treatment, including incineration, is expected,
especially for large-volume generators like hospitals. To handle
the larger quantities of medical waste, larger onsite MWI's will
be installed. As the incinerator capacity necessary to treat the
medical waste grows, the more likely it becomes for facilities to
install waste heat recovery equipment. Facilities choosing this
course may also choose to accept medical waste from offsite
sources (for a fee) to offset costs and to maintain a steady heat
load. However, the advantages of acting as a commercial
incineration facility may be offset by the increased regulatory
requirements that apply to commercial facilities as well as
size/space logistical problems. There may be advantages to a
group of hospitals' building and using one site rather than
paying commercial rates or operating an onsite unit at each
hospital.
In addition to the effects on onsite incineration facilities
discussed above, the number and capacity of commercial units are
71
-------
expected to grow to handle the increased medical waste stream
from small generators for whom onsite treatment remains
impractical. Such small generators are likely to institute more
rigorous segregation of medical waste to minimize the increase in
the volume generated.
In the discussion above, only the effects of the changes in
medical waste management requirements are considered. Against
this backdrop, the effects of changing MWI regulations will be
played out as well. These effects will depend upon the
requirements enacted in each jurisdiction and at the Federal
level.
In some States, very restrictive MWI regulations have been
enacted for units of all sizes, both new and existing. Such
regulations will tend to counteract the move toward onsite
incineration discussed above, although the extent of the effect
is not yet known. The resultant climate will favor large onsite
units with heat-recovery equipment. These facilities may accept
medical waste from offsite sources, depending on whether the
benefits are perceived to outweigh the disadvantages of becoming
subject to commercial facility requirements.
In this climate, growth is most likely to be experienced in
the regional MWI sector, with ownership either by a group of
generators or by a commercial operator. This arrangement takes
advantage of economies of scale in MWI and heat recovery and
generally allows better equipment capacity utilization.
Restrictive regulations on all sizes of incinerators may
also add impetus to alternative treatment technologies. These
methods may become attractive as an alternative to the cost of
either onsite incineration or use of a commercial facility in
States with very restrictive MWI standards. On the other hand,
in some States the costs of other alternatives, such as
landfilling, may make onsite incineration economically
attractive. It is not yet known what effects restrictive MWI
regulations will have on alternative treatment technologies.
In contrast to the regulatory approach discussed above, some
States have adopted more restrictive requirements for large MWI's
72
-------
but have set limits for smaller units that can be met without an
add-on air population control device (APCD) by a MWI that is well
designed and operated. In these States, market forces will favor
better medical waste segregation practices so that smaller onsite
units can be used. These forces work against heat recovery and
incineration of waste from offsite sources. It is not clear what
impact the competing factors will have on the commercial sector.
Restrictive regulations on large MWI's will work in opposition to
the need for new commercial facilities to treat the waste stream
from small generators newly affected by medical waste handling
and disposal regulations.
Still other States have MWI regulations that are not
restrictive for units of any size. In these States, medical
waste management considerations unmitigated by MWI standards are
expected to drive MWI growth as previously discussed.
6.4.2 Growth Projections
In the preceding paragraphs the potential effects of changes
in medical waste management requirements and changes in MWI
regulations were considered; however, it is not known what impact
these factors will actually have on medical waste incineration
practices. As a result, these factors are not considered in
developing MWI sales projections.
Projected MWI sales and distribution by type and size for
the 5 years after proposal of the NSPS are presented in Tables 15
and 16.101 For onsite incinerators, Table 15 illustrates that
approximately 64 percent of future sales are expected to be
intermittent units. Batch units are expected to represent about
26 percent of future sales. Continuous units comprise the
remaining 10 percent of expected sales of onsite MWI's. All
future commercial incinerator sales are expected to be continuous
units, with nearly 87 percent in the 1,001 to 2,000 Ib/hr rated
capacity range.
These projections of new onsite and commercial units per
year are based on historic sales data obtained through
information requests from seven MWI vendors. These seven vendors
are believed to represent about two-thirds of the MWI market.101
73
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TABLE 15. DISTRIBUTION OF PROJECTED ONSITE MEDICAL
WASTE INCINERATOR SALES BY TYPE AND SIZE FOR THE
5 YEARS AFTER PROPOSAL OF THE NSPS1U1
Combustor type and size
Intermittent
50-400 Ib/hr
401-1,000 Ib/hr
>1,000 Ib/hr
Continuous
500-900 Ib/hr
901-1,100 Ib/hr
1,101-1,850 Ib/hr
Batch
150 Ib/batch
500 Ib/batch
1,600-3,780 Ib/batch
TOTAL FOR SALES PERIOD
Years after proposal of NSPS
1
57
19
4
6 '
1
5
6
22
5
125
2
57
19
4
6
1
5
6
22
5
125
3
57
19
4
6
1
5
6
22
5
125
4
57
19
4
6
1
5
6
22
5
125
5
57
19
4
6
1
5
6
22
5
125
TABLE 16. DISTRIBUTION OF PROJECTED COMMERCIAL MEDICAL WASTE
INCINERATOR SALES BY TYPE AND SIZE FOR THE 5 YEARS AFTER
PROPOSAL OF THE NSPS1U1
Combustor type and size
Continuous
500-1,000 Ib/hr
1,001-2,000 Ib/hr
2,001-6,588 Ib/hr
TOTAL FOR SALES PERIOD
Years after proposal of the NSPS
1
0
13
2
15
2
0
13
2
15
3
0
15
2
17
4
0
13
2
15
5
0
13
2
15
Percent of
total
3.3
86.7
10.0
100
74
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The increase in population .of new MWI's was fairly consistent
from 1985 through 1989. This consistent rate of increase was
assumed to continue in projecting future sales.101
7.0 REFERENCES
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United States Congress. Issues in Medical Waste
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Rutala, W. D. Management of Infectious Waste by U.S.
Hospitals. Journal of the American Medical Association.
262(12):1639. September 22/29, 1989.
Reference 8, p. 1636.
Jack Faucett Associates. Regulatory Impact and Flexibility
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Brenniman, G. R., R. J. Collen, and P. j. Graham. Disposal
of Infectious Hospital Waste: The Problems in Illinois.
The Environmental Professional. 6.-.250-251. 1984.
Gershon, R. M., and K. A. Strauss. Thermal Destruction of
Radiolabeled Biohazardous Waste Materials. Johns Hopkins
University School of Hygiene and Public Health. 1989
Incineration Conference. May 1 through 5, 1989.
Chang, Ron-Hsin, and Hsin-Erh Ong. An Experimental Study
on the Incineration of Hospital Waste. Taiwan. 1989
Incineration Conference. May 1 through May 5, 1989.
Reference 8, p. 1637.
Ontario Ministry of the Environment. Incinerator Design
and Operating Criteria. Volume II--Biochemical Waste
Incineration. October 1986.
Murynak, G., and D. Guzewich. Chlorine Emissions from a
Medical Waste Incinerator. Journal of Environmental
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Jenkins, A. Evaluation Test on a Hospital Refuse
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California. California Air Resources Board. January 1987.
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Meaney, J. G., and P. N. Cheremisinoff. Medical Waste
Strategy. Pollution Engineering. October 1989. pp. 100-
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U. S. Environmental Protection Agency. Medical Waste
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p. 6-11.
pp. 6-11 through 6-13.
p. 6-24.
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Jack Faucett Associates. Regulatory Impact and Flexibility
Analysis of Proposed Standards for Occupational Exposure to
Blood-Borne Diseases. Prepared for U.S. Department of
Labor. Washington, D.C. December 22, 1988. 486 p.
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76
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28
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30,
31.
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33.
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41.
U. S. Environmental Protection'Agency. Characterization of
Medical Waste Generation and Treatment and Disposal
Practices in New York and New Jersey. Draft report
submitted to Air and Waste Management Division, Region II,
and Office of Solid Waste. January 30, 1989.
New York State Department of Health. A Statewide Plan for
Treatment and Disposal of Regulated Medical Waste.
August 1989.
Turnberg, W. L. Survey of Infectious Waste Management
Practices Conducted by Medical Facilities in Washington
State (Draft). Olympia, Washington. October 10, 1989.
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Reference 28, pp.3-6-3-8.
National Solid Waste Management Association. Special
Report: Medical Waste Management. Washington, D.C. 1989.
p. 2.
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Byer, H. G., Jr., and J. E. Pickering. A Case Study: A
Cost--Effective Approach to Hospital Infectious Waste
Management. In: The Regulation and Management of Medical
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Materials Control Research Institute. 1989. pp. 49-53.
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Hospital Association of New York State.
Survey Summary. 1988. p. 2.
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Hospital Waste
Draft memorandum from D. Tomten, Waste Characterization
Branch, Office of Solid Waste, EPA, to RCRA Docket for
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No. F89-MTPF-PFFFF. June 20, 1990. Estimates of Numbers
and Types of Generators and Qualities of Medical Waste by
Generator Type. p. 6.
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77
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43. Telecon. R. Marinshaw, MRI with B. Tyus, American Humane
Association. March 16, 1990. Discussion of the use of
animals in research (cited figures from the USDA Office of
Technological Assessment, National Research Council, that
were published in the December 26, 1988, issue of Newsweek)
and the number of animals euthanized annually at animal
shelters.
44. Reference 28, p. 3-26.
45. Reference 28, p. 3-33.
46. Reference 30, pp. 55-56.
47. Reference 28, p. 3-28.
48. Reference 29, pp. 56, 61.
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Administration. Occupational Exposure .to Bloodborne
Pathogens; Proposed Rule and Notice of Hearing.
Washington, D.C. Federal Register 54:23074, Table E.S.-2.
May 30, 1989.
50. Reference 10, pp. 1-70 through 1-75.
51. Reference 41, p. 7.
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53. Reference 41, p. 8.
54. Reference 28, p. 3-41.
55. Reference 29, pp. 56, 60.
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57. Reference 30, pp. 24, 137, 138.
58. Reference 10, p. Ill-42.
59. Reference 41, p. 9.
60. Reference 28, pp. 3-69 through 3-70.
61. Reference 28, p. 3-78.
62. Reference 30, p. 29.
63. Telecon. M. Cassidy, MRI, with P. L. Fan, American Dental
Association. January 17, 1990. Discussion of medical
waste from dental offices.
78
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64
65
66
67
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
Reference 41, pp. 9-10.
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Telecon. M. Cassidy, MRI, with M. Brody, American
Veterinary Medicine Association. January 16, 1990.
Discussion of medical waste from veterinary practices.
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Hospital Association. January 18, 1990. Discussion of
medical waste from animal hospitals.
Telecon. M. Cassidy, MRI, with R. Alampi, New Jersey
Animal Hospital Association. January 18, 1990. Discussion
of medical waste from animal hospitals.
Reference 28, p. 3-87.
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Telecon. M. Cassidy, MRI, with J. McPherson, Council of
Community Blood Centers. January 23, 1990. Discussion of
medical waste from blood collection centers.
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American Red Cross. January 17, 1990. Discussion of
medical waste from blood collection centers.
79
-------
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86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
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97.
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99.
100.
Telecon. M. Cassidy, MRI, with H. Raether, National
Funeral Directors Association. January 18, 1990.
Discussion of medical waste from funeral homes.
Reference 10, p. Ill-47.
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Telecon. R. Marinshaw, MRI, with H. Raether, National
Funeral Directors Association. March 1990. Discussion of
the number and disposition of bodies processed by U. S.
funeral homes.
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p. 3-64.
pp. 3-64, 3-65.
p. 3-67.
pp. 1-100, 1-101.
p. 111-48.
p. 23102, Table VIII-17-C.
Memorandum and attachment from R. Sites, Ohio Hospital
Association, to M. Cassidy, MRI. December 22, 1989.
Transmitting results of September 1989 survey of Ohio
hospital infectious waste management practices.
Letter and attachment from M. Shoys, Wisconsin Hospital
Association, to M. Cassidy, MRI. January 5, 1990._
Transmitting results of a survey of Wisconsin hospital
waste incineration practices dated July 19, 1988.
Carl, B. R., Recovery Systems Reduce Hospital Energy Costs,
World Wastes. May 1983. pp. 14-15.
Memorandum from Energy and Environmental Research Corp. to
EPA/ORD and EPA/AEERL. Draft. March 15, 1989. Medical
waste incineration practices in municipal waste combustors
pp. 5-1, 5-4, 5-13, and Table 5-1.
Gordy, T. J., and W. L. Turnberg. Incineration of
Infectious Waste: A Literature Review and
Inventory/Characterization of Washington State. Draft.
October 10, 1989. (Prepared for the Washington State
Department of Ecology.) pp. ii,
80
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101. Memorandum from S. Shoraka to Project File. December 10,
1990. Projection of the future population of new medical
waste incinerators.
81
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1. REPORT NO.
EPA-453/R-94-042a
TECHNICAL REPORT DATA
(Please read Instructions on reverse before completing)
4. TITLE AND SUBTITLE
Medical Waste Incinerators - Background Information for
Proposed Standards and Guidelines: Industry Profile Report
for New and Existing Facilities
7. AUTHOR(S)
9. PERFORMING ORGANIZATION NAME AND ADDRESS
Emission Standards Division (Mail Drop 13)
Office of Air Quality Planning and Standards
U.S. Environmental Protection Agency
Research Triangle Park, NC 27711
12. SPONSORING AGENCY NAME AND ADDRESS
Director
Office of Air Quality Planning and Standards
Office of Air and Radiation
U.S. Environmental Protection Agency
Research Triangle Park, NC 27711
3. RECIPIENT'S ACCESSION NO.
5. REPORT DATE
July 1994
6. PERFORMING ORGANIZATION CODE
8. PERFORMING ORGANIZATION REPORT NO.
10. PROGRAM ELEMENT NO.
11. CONTRACT/GRANT NO.
68-D1-0115
13. TYPE OF REPORT AND PERIOD COVERED
Final
14. SPONSORING AGENCY CODE
EPA/200/04
15. SUPPLEMENTARY NOTES
Published in conjunction with proposed air emission standards and guidelines for
medical waste incinerators
16. ABSTRACT
This report presents a profile of the medical waste incinerator (MWI) source category. The purpose
of this profile is to characterize the source category for use in subsequent environmental and economic
analyses. This is one in a series of reports used as background information in developing air emission
standards and guidelines for new and existing MWI's. Definitions of medical waste and MWI's are
presented, and the industry structure associated with MWI's is described.
17- KEY WORDS AND DOCUMENT ANALYSIS
a. DESCRIPTORS
Air Pollution
Pollution Control
Standards of Performance
Emission Guidelines
Medical Waste Incinerators
18. DISTRIBUTION STATEMENT
Release Unlimited
b. IDENTIFIERS/OPEN ENDED TERMS
Air Pollution Control
Solid Waste
Medical Waste
Incineration
19. SECURITY CLASS (Report)
Unclassified
20. SECURITY CLASS (Page)
Unclassified
c. COSATI Field/Group
21. NO. OF PAGES
81
22. PRICE
EPA Form 2220-1 (Rev. 4-77) PREVIOUS EDITION IS OBSOLETE
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