United States         Office of Solid Waste       SW-957
             Environmental Protection     and Emergency Response     c=^««mi«i, 10*7
             Agency           Washington DC 20460      September 1982



             Solid Waste
<>ERA      Draft Manual for
             Infectious Waste  Management

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           DRAFT MANUAL  FOR

    INFECTIOUS WASTE  MANAGEMENT
U.S. Environmental Protection Agency
       Office of Solid  Waste
       Washington, D.C.  20460

            September  1982
     U.S. Environment?.! Protection  Agency
     Region V, L.ibrs/y
     230 South De^bcrn Street
     Chicago,  iiiincis  60604

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                             ACKNOWLEDGEMENTS
       This manual  was  prepared  by  the Office of Solid Waste  of the
       U.S. Environmental  Protection Agency  with coordination  con-
       ducted by  Claire Welty.  The  major portion  of  the text  was
       written  by Judith G. Gordon  of  Reston,  Virginia, a  consultant
       to EPA.  Initial review was  kindly  conducted  by  Dr.  W.  Emmett
       Barkley, Director  of the Division  of  Safety at the National
       Institutes of  Health,  Dr.  John  H. Richardson,  Director  of
       the Office  of Biosafety  at  the Centers for  Disease Control,
       Dr. Daniel F.   Liberman,  Biohazard Assessment Officer  of the
       Environmental Medical  Service  at  Massachusetts  Institute  of
       Technology,  and  Dr.   Byron S.  Tepper,  Director  of  Safety at
       the Johns  Hopkins  Medical  Institutions and  Chairman   of  the
       Coordinating Committee  for  Environmental Health  and   Safety
       on College   and  University  Campuses.   The  manual  was  also
       extensively  reviewed  by  various offices  within  EPA.    Many
       individuals  --  too numerous  to list —  kindly  shared  their
       data, knowledge,  and  insights,  and   their   assistance   was
       invaluable.   Finally, Pearl  E.  Summers  and Natalie  G. Alexan-
       der spent long hours patiently  typing  all  drafts.
",S.  FnvlSrmentaf Protection Agency
                                   NOTICE

      The mention  of  trade  names  of  commercial  products in  this
      publication  is  for  illustration  purposes  and does  not consti-
      tute  endorsement or recommendation  for use by the  U.S.  EPA.
                                     11

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                           ABSTRACT
This manual  discusses  environmentally  acceptable techniques
for infectious  waste management.   Topics  covered  include a
definition of  infectious waste,  and  packaging,  transporta-
tion, treatment,  storage,  and  disposal  practices.   Recom-
mendations are  presented for  methods  of  treating  different
types of infectious waste.
Described in  detail  are  infectious  waste  treatment methods
including steam sterilization, incineration, dry heat steril-
ization, gas/vapor ste.rilization,  sterilization  by irradia-
tion, and chemical disinfection.   Included  in the discussion
of each method  is a description  of  the method,  the process
variables that affect  the efficacy  of  the  treatment,  design
parameters for standard  operating  procedures,  and monitoring
re comme nda t ions.

In addition,  the  manual  provides  citations  of  federal  and
state regulations  as  well  as  non-governmental  guidelines
that apply to  infectious waste management.   A  list  of state
offices that  may   be   contacted  for  further  information  is
also included.

The information contained in this  manual should  be  of value
to those persons  concerned  with  the  management of infectious
waste in  hospitals,   veterinary  hospitals,  medical  labora-
tories, research  laboratories, commercial  diagnostic labora-
tories, animal experimentation units,  pharmaceutical  plants
and laboratories,  and  other  facilities  which generate  infec-
tious waste.  This document should  also  be of value  as  re-
source material for development of infectious waste standards
by State and  local  regulatory agencies.  EPA  may update  the
manual as new information becomes available.
                             111

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                      TABLE OF CONTENTS


                                                       Page

ACKNOWLEDGEMENTS                                       ii

ABSTRACT                                               iii

LIST OF FIGURES                                        viii

LIST OF TABLES                                         ix

FOREWORD                                                X


Chapter

  1   INTRODUCTION                                     1-1

      1.1  Scope of Manual                             1-1

      1.2  State Regulations Pertaining to
           Infectious Waste                            1-3

  2   INFECTIOUS WASTE CHARACTERIZATION                2-1

      2.1  Introduction                                2-1

      2.2  Pathogens                                   2-2

      2.3  Diseases and Disease Induction              2-3

      2.4  Designation of Infectious Wastes            2-5

      2.5  Types of Infectious Waste                   2-5

           2.5.1   Isolation Wastes                    2-6
           2.5.2   Cultures and Stocks of Etiologic
                   Agents                              2-6
           2.5.3   Blood and Blood Products            2-7
           2.5.4   Pathological Wastes                 2-7
           2.5.5   Other Wastes from Surgery and
                   Autopsy                             2-8
           2.5.6   Contaminated Laboratory Wastes      2-8
           2.5.7   Sharps                              2-10
           2.5.8   Dialysis Unit Wastes                2-10
           2.5.9   Animal Carcasses and Body Parts     2-11
           2.5.10  Animal Bedding and Other Wastes
                   from Animal Rooms                   2-11
           2.5.11  Discarded Biologicals               2-11

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Chapter                                                Page

  2

           2.5.12  Contaminated Food and Other
                   Products                            2-13
           2.5.13  Contaminated Equipment              2-13

      2.6  Generators of Infectious Waste              2-13


  3   INFECTIOUS WASTE MANAGEMENT                       3-1

      3.1  Introduction                                 3-1

      3.2  Infectious Waste Management Options          3-3

           3.2.1  Treatment of Infectious Waste         3-3
           3.2.2  Selection of Management Options       3-6

      3.3  Segregation of the Infectious Waste
           Stream                                       3-9

      3.4  Packaging of Infectious Waste                3-13

      3.5  Storage of Infectious Waste                  3-19

      3.6  Transport of Infectious Waste within
           the Facility and Off-Site                    3-21

      3.7  Recommended Treatment Methods for the
           Different Types of Infectious Waste          3-22

           3.7.1   Isolation Wastes                     3-27
           3.7.2   Cultures and Stocks of Etiologic
                   Agents                               3-27
           3.7.3   Blood and Blood Products             3-28
           3.7.4   Pathological Wastes                  3-29
           3.7.5   Other Wastes from Surgery and
                   Autopsy                              3-30
           3.7.6   Contaminated Laboratory Wastes       3-31
           3.7.7   Sharps                               3-32
           3.7.8   Dialysis Unit Wastes                 3-33
           3.7.9   Animal Carcasses and Body Parts      3-34
           3.7.10  Animal Bedding and Other Wastes
                   from Animal Rooms                    3-35
           3.7.11  Discarded Biologicals                3-38
           3.7.12  Contaminated Food and Other
                   Products                             3-39
           3.7.13  Contaminated Equipment               3-41
                              VI

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Chapter                                                Page


  4   TECHNIQUES FOR TREATMENT OF INFECTIOUS            4-1
      WASTE

      4.1  Introduction                                 4-1

      4.2  General Approach to Treatment of
           Infectious Waste                             4-2

      4.3  Monitoring                                   4-4

      4.4  Steam Sterilization                          4-8

      4.5  Incineration                                 4-16

      4.6  Dry Heat Sterilization                       4-22

      4.7  Gas/Vapor Sterilization                      4-26

      4.8  Sterilization by Irradiation                 4-29

      4.9  Chemical Disinfection                        4-32

      4.10 Other Methods                                4-37


REFERENCES                                              R-l

APPENDIX  A  State Regulations Pertaining to
             Infectious Waste Management                A-l

APPENDIX  B  Etiologic Agents                           B-l
                             VII

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                       LIST OF FIGURES


Figure                                                    Page

3-1                The Biological Hazard Symbol           3-11

4-1                Temperature Curves for Steam
                   Sterilization with and without
                   Complete Removal of Air                4-11

4-2                Bactericidal Effectiveness of
                   Ultraviolet Radiation                  4-30
                              Vlll

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                        LIST OF TABLES

Table                                                      Page

2-1              Common Contaminated Wastes from
                 Medical Laboratories                      2-9

2-2              Important Zoonoses                        2-12

3-1              Recommended Packaging Practices           3-18

3-2              Recommended Techniques for Treatment
                 of Infectious Wastes                      3-24

3-3              Tests of Effectiveness of Steam
                 Treatment of Animal Bedding               3-36

4-1              Biological Indicators for Monitoring
                 Infectious Waste Treatment                4-5

4-2              Steam Sterilization                       4-9

4-3              Dry Heat Sterilization                    4-25

4-4              Summary of Disinfectants Used in Gas
                 Sterilization                             4-28

4-5              Activity Levels of Selected Classes
                 of Liquid Disinfectants                   4-34

4-6              Summary of Practical Disinfectants        4-35
                              IX

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                           FOREWORD
The Solid  Waste Disposal  Act,   as  amended  by  the  Resource
Conservation and Recovery  Act of 1976,  as  amended,  requires
EPA, among other things, to  foster  development  of and evalu-
ate methods  for the  management  of  solid   waste which  are
environmentally sound and  which maximize the  utilization of
valuable resources.   In addition,  the  Act  requires  EPA to
establish a  "cradle-tor-grave"  management  system for  solid
wastes which are identified as hazardous.

Congress defined hazardous waste generally  to mean  "a solid
waste, or  combination  of solid  wastes,  which  because of its
quantity, concentration, or physical, chemical, or infectious
characteristics may  (A)  cause,  or  significantly contribute
to an increase  in mortality or an increase in serious irrevers-
ible, or  incapacitating  reversible,   illness;   or  (B)  pose
substantial present  or  potential hazard to human health or
the environment when improperly  treated, stored,  transported,
or disposed of, or otherwise managed."

As a  first  step in  fulfilling  the Congressional mandate to
establish a hazardous waste  management  system,  EPA published
proposed regulations in  the  Federal Register on  December 18,
1978  (43 FR 58946-59028) which included a proposed definition
and proposed  treatment  methods  for  infectious  waste.   EPA
received approximately  sixty  comments  during   the  ensuing
90-day public  comment  period  which  specifically  addressed
the infectious waste provisions  of  the  proposed  regulations.

In response to  the  comments  on  the  proposed infectious waste
regulations, EPA  spent  considerable  resources  refining  the
definition of infectious waste and analyzing acceptable alter-
native management techniques.   On May 19, 1980 when EPA pub-
lished the first phase  of  the hazardous waste  regulations in
the Federal Register  (45 FR  33066-33588), the  Agency stated
in the preamble to  Part 261  that the  sections on infectious
waste would  be published  when  work  on treatment,  storage
and disposal standards  was completed.   Although much Agency
effort has  been expended  evaluating  management  methods  for
infectious waste,  considerable effort will still  be necessary
to develop a regulatory package.

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Because EPA  has  meanwhile  received   numerous   requests  for
technical information  and  guidance on  infectious  waste man-
agement, the  Agency  wishes  to  appropriately  respond.   The
Agency feels that publishing  its findings to date  on infec-
tious waste in  the  form  of a  guidance manual would be useful
to persons who  have asked  for this kind  of  information.  It
is EPA's  belief that  the  recommendations contained  in this
document represent environmentally sound, technically achiev-
able practices  available  for  infectious waste management.

Publication of  Agency  recommendations  in   the  manual  thus
serves several purposes.  First, it gives EPA the opportunity
to share accumulated  information on  infectious  waste manage-
ment with the numerous parties who have requested this infor-
mation for use  in planning infectious  waste management sys-
tems.  Second,  it  provides  a  source  of  technical  informa-
tion to State agencies that may be under legislative mandate
to establish infectious  waste  regulations.   Third,  it serves
as a  potential   focal  point   for  information   exchange  for
those persons interested in infectious waste management and
treatment technology.

EPA wishes to point out  that,  for  the most part, this manual
addresses the management of a  waste  solely from the perspec-
tive of  the  problems  posed  by  its   infectious  characteris-
tics.  Often  an  infectious  waste poses  additional  hazards
that should be  assessed  in making a decision for its proper
management.  EPA  draws  attention  to   this  information  gap
and would  appreciate  comment  on the  appropriateness  of ex-
panding this manual  in the future to  address  the management
of wastes which  exhibit  other hazardous  properties  in addi-
tion to being infectious.

Because the  public  has   not   yet  reviewed  the  information
presented in this document  as  a  whole,  EPA  is  soliciting
written comments  on  both the  substance and  the  format of the
manual.  In response  to these comments, EPA  may  publish  a
revised edition of the manual.   For due consideration, written
comments should be  submitted  to EPA  no later  than  6 months
from the  date   that  the  availability  of this  document  is
announced in the Federal Register.

Comments should be sent to:
     Docket Clerk
     (Docket  No.  3001/3004,    Infectious  Waste  Management)
     U.S. Environmental Protection Agency
     Office of Solid Waste (WH-562)
     401 M Street, S.W.
     Washington, D.C.  20460
                              XI

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For further information,  contact Claire Welty  at  (202)  755-
9187.

Requests for  copies  of this  document should be directed to
Superintendent of Documents, U.S. Government Printing Office,
Washington, D.C. 20402, telephone (202) 783-3238.
                               ^ .   , .0      /'
                         Rita M. Lavelle
                     Assistant Administrator
            Office of  Solid  Waste  and  Emergency  Response
                             xii

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                          CHAPTER 1

                         INTRODUCTION
The purpose  of  this  manual is to provide comprehensive guid-
ance for proper  management of infectious waste.  Recommenda-
tions are  based  on techniques that  are  practical and effec-
tive, and  that  assure  protection  of human  health  and  the
environment.  This  document  is  written  for  use by  all  who
seek specific  information  on   infectious  waste  management
including  biological safety officers,  environmental engineers,
hospital infection control committees, laboratory supervisors,
principle  investigators, and  others.

1.1  Scope of Manual

Fundamental  to management decisions regarding  infectious waste
disposal is  the  proper  identification  of infectious  waste
based on  the known  or  potential  infectious  characteristics
of the waste.  A waste management system  can then be developed
which addresses  the following aspects:

     0 Handling  infectious waste

     0 Storage (when necessary)

     0 Packaging  for  safe transport  and effective treatment

     0 Transport both within  the facility and off-site

     0 Selection of appropriate treatment and disposal methods

     0 Establishment  of  standard  operating  procedures  for
       the selected treatment methods

     0 Monitoring of treatment methods

     0 Compliance  with  local,  state  and  federal ordinances
       and regulations

These components of an appropriate system for managing infec-
tious waste  are  described in  this   manual  in  detail.   EPA
realizes that an optimal  system will vary from facility to
facility because  of  the  particular  combination  of operating
variables  that may be unique  to each physical setting.  This
manual should provide assistance to  a manager in meeting the
challenge of developing  an environmentally  sound  waste manage-
ment system  that adequately addresses the above listed  ele-
ments.
                             1-1

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The reader should  note  that  it is EPA's intention to provide
a guidance manual  that  can also  be used as  a resource docu-
ment. ' There  is valuable  information  in  each  section,  and
EPA recommends that this manual first be read in its entirety
so that  the   reader  will  understand  the  principles  behind
the recommended approach  to infectious waste management and
will be  familiar  with the  types  of  information  that  are
available in the manual. Nevertheless,  there  will subsequent-
ly be  times  when  users will  choose  to refer directly  to a
particular section.   Therefore,  each  section  was  written
so that  it  would  be  a  complete  and  independent part  of the
manual.  Background  material  is  presented  followed  by  a
summary of  recommendations  for  each  aspect of  infectious
waste management  and,  for  convenience,   reference  is  made
to other  sections  of  the  manual  whenever  relevant.   The
reader should  expect  some  repetition when  this publication
is read through from beginning to end.

In the interest of promoting good management practices, this
manual addresses a few problems  related to  waste management
that do  not  pertain  strictly  to the  infectious  properties
of a  waste.    For  example,  it  is  prudent as   well as  more
convient to  uniformly  manage  certain  types  of  waste  that
are usually  but not  always  infectious.   For  the  most part,
however, EPA is emphasizing  how  to  manage  wastes solely from
the perspective of their infectious properties.  EPA realizes
that often other  properties of  an infectious waste  — such
as toxicity,  corrosivity,  ignitability, or  radioactivity —
may complicate and often affect the decision  on  how to manage
the waste.  This is particularly  a problem in research labor-
atories.  EPA  therefore warns  the reader  that when an infec-
tious waste  is characterized  by any additional hazard, the
decision on  how to manage  the waste  must take  into account
all of the various hazards present in the waste.  The person
responsible for  waste  management decisions  must weigh  the
hazards carefully  and  give  priority  to   the  primary  hazard
that characterizes the waste.

Several federal regulations and guidelines pertain to hazardous
properties of  wastes   other  than infectiousness,  and  these
must be  taken  into  consideration.   For  example,  the  EPA
hazardous waste  regulations  address   the  toxic,  ignitable,
corrosive and  reactive  properties  of  wastes   (1);  Nuclear
Regulatory Commission  guidelines  address  radioactive  prop-
erties (2);  and EPA guidelines written under the Toxic Sub-
stances Control Act address the  total  management  of certain
chemicals (3).   Although  EPA  realizes that  the  problem  of
multiple hazards  is  a  very  real  one  to those who must make
decisions pertaining  to infectious waste  management,  a de-
tailed discussion  of  the   additional  management  considera-
tions  for  wastes  posing   multiple  hazards  goes  beyond the
scope  of the current  version of this  manual.
                              1-2

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1.2  State Regulations Pertaining to Infectious Waste

For the most part,  State regulation of  infectious waste has
been carried out by  state  health  departments  in  the past.
Since the passage  of the federal  solid  and  hazardous waste
act -- the Resource  Conservation and  Recovery Act of  1976 —
many States  have passed hazardous  waste statutes  that give
the State authority to  control  the treatment,  storage,  and
disposal of  infectious waste.  Only several States, however,
have actually promulgated regulations  controlling infectious
waste under these statutes.

In the absence  of infectious waste regulations under hazardous
waste laws,  some States  control  infectious  waste under their
solid waste  laws through the  permitting  process for sanitary
landfills.  In  addition, most States  have  general  require-
ments for  licensing  of hospitals  and   nursing  homes  that
pertain to infectious waste disposal.  Requirements  that are
specific to  hospitals and  nursing  homes,   however,   do  not
pertain to other sources of  infectious  waste  in  the  State.

It should be  noted  that there is  not unanimity  of  opinion
among the States as  to  what  constitutes  safe disposal  of
infectious waste.   The  degree  of concern regarding  the dan-
gers posed by infectious wastes ranges from none to extremely
high, and State  control  of  infectious  waste that varies from
none to the most stringent  reflects  this  range  of attitudes.

A complete list of  States,  statutory  authorities and regula-
tions pertaining to  infectious  waste  management,  summary of
requirements, and  responsible  State   agencies   is  given  in
Appendix A.
                             1-3

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                          CHAPTER 2

              INFECTIOUS WASTE CHARACTERIZATION
2.1  Introduction

The question  of  how to  define  infectious  waste has  been
discussed for  years  without  resolution satisfactory  to all
interested parties.   Regulatory agencies,  hospitals,  and re-
search laboratories,  for example, all have different perspec-
tives that influence  their  views of infectious waste.  There
is no general unanimity of opinion about which types of waste
should be  classified as  infectious.   Even  the   terminology
that has been used for this type of waste is imprecise — the
terms infectious, pathological, biomedical, biohazardous, tox-
ic, and  medically hazardous  have  all  been  used  at  various
times to describe similar material.   The  result  has  been a
proliferation of  definitions   that  are  often confusing  and
sometimes even  contradictory.  Because  the  purpose  of  this
manual is to discuss  methods  of infectious waste management,
it is first essential to  clarify what constitutes infectious
waste.

Infectious or  infective  is  defined as  "capable  of producing
infection; pertaining to or characterized  by the presence of
pathogens" (4).   A pathogen is "any disease-producing micro-
organism or material" (4).   Etiologic  agent is  defined  as
"a viable microorganism  or its toxin  which causes,   or may
cause, human disease"  (5).   The related term  "biohazard"  —
which is defined  as  an  "infectious  agent presenting  a  risk
or potential risk to the  well-being  of  man, either directly
through his  infection or  indirectly  through disruption  of
his environment"  (6)  — is  commonly  used,  and the biological
hazard symbol  (see Figure 3-1)  is  used universally to denote
the presence of etiologic agents.

From these definitions  it would appear to  be  simple enough
to define infectious  waste as  "waste that contains pathogens."
However, infectiousness as  a  characteristic of  some  wastes
is difficult  to  define   and   impossible  to quantify.   The
difficulties in  establishing   the  definition  of  infectious
waste derive from the characteristics  of pathogens, the nature
of disease,  and  the  factors that determine  the  induction of
disease.  These topics are discussed  briefly in this  chapter
as they relate to the determination of which wastes should be
classified as   infectious  because  of  their  potential  for
causing illness in people or animals.
                             2-1

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2.2 Pathogens

Pathogenic microorganisms  include  bacteria,  fungi,  viruses,
viroids, rickettsiae, and  protozoa.  They  cause  a variety of
diseases in many  hosts  in the  animal  and  plant  worlds.   In
addition to the natural  strains of pathogens, there  are  now
strains that are  characterized  by  resistance to  antibiotics;
such resistant  strains  are   often found   in  hospitals  and
other health-care facilities.   Most pathogens  cause a single
disease whereas a few may induce different diseases depending
on the  route  of  transmission and  the  susceptibility  of  the
host.  Pathogens  are diverse  in  their  physiology and  life
cycle.  Some  microorganisms   are  obligate  pathogens  (i.e.,
they can  survive  only in  specific hosts)  while  others  are
facultative pathogens (i.e.,   they  can  infect hosts to induce
disease but they can also survive without a host when environ-
mental conditions are  suitable).  Similarly,  no generaliza-
tions can be  made about  the  type  of environmenal conditions
that are  necessary   for  pathogen  survival.   Some  pathogens
are obligate aerobes or anaerobes  (i.e.,  they require aerobic
or anaerobic conditions, respectively,  for survival)  whereas
others are  facultative  aerobes  or  anaerobes   (i.e.,  they
flourish under  one  set  of conditions but they   are  able to
survive under  the  other).   Because   of   the  great  natural
diversity in environmental conditions,  pathogens are ubiqui-
tous in the environment.

Not all pathogens are microorganisms.   Many parasites such as
the nematodes  (helminths)  and trematodes  (flukes) are higher
forms of life.  Other  pathogenic agents are not  viable,  but
they are produced by living  organisms.   Bacterial toxins  and
mycotoxins are  examples   of   this   last  type  of  pathogenic
agent, specific  examples  being the  bacterial   toxins  that
cause diphtheria  and botulism  and  the  mycotoxin  aflatoxin
that can  cause cancer.  Disease-causing  materials that  are
neither .living  organisms  (or parts thereof)  nor produced by
living organisms  — e.g.,  chemical  carcinogens  -- are  not
discussed in this guidance manual.

The pathogens  of  relevance to this document  are  those whose
presence in  various wastes  renders the  waste  hazardous —
that is,  a  potential  cause   of disease.   The pathogens  of
greatest concern  are  those   that   cause   diseases  that  are
severe, difficult to treat, and for which there are no effec-
tive and reliable immunizations.   Theoretically,  it would be
useful to have  a  comprehensive  list of  all pathogens, espe-
cially one which ranks pathogens according  to hazard.  Differ-
ent schemes  for  classifying  pathogens have  been  developed
by various experts  and  organizations.   For  example,  some of
these are based on the severity of the hazard that  the pathogen
presents to  the  public  health  (7,8)  or  to  laboratory  and
                             2-2

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research workers   (9-16).   None  of  these  classifications,
however, is appropriate for use in defining infectious wastes
because none  takes into  consideration  all  relevant factors
such as  the  obligate nature  of  some  pathogens,  resistant
strains, pathogen  concentrations,  the  nature  of  the waste,
and the  conditions within  the  waste to which  the pathogens
are exposed.   Nevertheless,  as one  example,  Appendix A pre-
sents the  list of etiologic  agents that  was  published  by
the Centers  for  Disease  Control  for use in  setting minimum
packaging requirements  for  the interstate  shipment  of mate-
rials containing etiologic agents (17).
2.3  Diseases and Disease Induction

Diseases differ  greatly  in type and  severity.   Illness need
not even be manifest  as  a  disease;  it can be subclinical and
asymptomatic.  Some  of  the  difficulties  in establishing  a
definition of infectious  waste are related to the variabilities
in disease and in the disease-causing process.

The principal factors that are necessary for the induction of
disease include:

     0 the presence of a pathogen,

     0 the presence of a susceptible host,

     0 a route  of exposure for  transmission of the pathogen
       to the host,

     0 exposure to a virulent pathogen, and

     0 exposure to an infective dose.

These factors are  discussed  below  in general terms  as they
relate to the definition of infectious waste.

The presence of a pathogen.  The induction of disease by path-
ogens requires the presence of pathogens.   Therefore, in order
for a waste to be  infectious,  it must contain pathogens with
sufficient virulence in adequate numbers to provide an infec-
tive dose.   See Section 2.2 for a detailed  discussion of path-
ogens.  Pathogen virulence and  infective  dose  are discussed
below.

The presence of a susceptible host.   Pathogens cause  disease
in a  host,   and  therefore  disease  induction  requires  the
presence of a  susceptible  host.  In  the  general population,
there is great  variation in  susceptibility  to disease.  Sus-
ceptibility depends  on  a  variety  of  factors  that  include
the person's state of  health  (or illness),  age, general immune
                             2-3

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state, and  the  degree of  immunity to a  particular pathogen
that may have been conferred by  previous exposure or immuniza-
tion.  The  groups that  are  most  susceptible  are the  very
young, the very old,  the  chronically ill, and the immune-defi-
cient (as  the result  of  genetics,  illness,   or  treatment).

A route of exposure for transmission of the pathogen to the
host.  In order for a pathogen to induce disease in a suscep-
tible host, there must be  a route  of exposure that transmits
the pathogen  to the  host.   The  principal  routes of transmis-
sion that  are relevant  to infectious waste  as a  source  of
disease are ingestion, inhalation,  and percutaneous transfer.
Every exposure route  is  not necessarily  conducive to disease
induction; for  example,  some pathogens  are  pathogenic  only
in the respiratory  system and they are rendered  harmless  or
are killed  in the digestive tract.   Ingestion  of pathogens
can result  from  eating material that  contains the pathogens
(contaminated food products,  for example).  With most infec-
tious wastes,  however,  it  is  more  likely  that  ingestion
would result  from hand-to-mouth transfer  of  pathogens  when
hands are contaminated, for example,  from handling the waste.
Inhalation of  pathogens   associated  with  wastes   results  in
the introduction  into the respiratory  system of  air-borne
pathogens associated  with dust particles  or  in  aerosolized
or splattered  liquids.   Percutaneous transfer  occurs  when
pathogens, present on the skin or in waste that is touched,
penetrate the  skin  through  cuts or  abrasions, when  cuts  or
puncture wounds  are   inflicted  by  sharps  contaminated  with
pathogens, and  when  animal  vectors  transmit  pathogens  by
contact with  cuts or abrasions or by biting  or stinging the
host.

Exposure to a virulent pathogen.  Pathogen virulence — i.e.,
"the degree of pathogenicity  of a  microorganism as indicated
by case  fatality  rates   and/or its  ability  to  invade  the
tissues of  a  host;   by   extension,  the  competence  of  any
infectious agent  to produce pathologic effects" (4) — varies
with the species as well  as with the individual microorganism.
The virulence depends on  numerous factors including  the strain
of the pathogen,  the environmental conditions  to which it was
subject, and  the  route of  exposure.

Exposure to an infective dose.  It is  impossible to quantify
infective dose — i.e., "that amount of pathogenic microorgan-
isms that  will   cause  infection  in  susceptible  subjects"
(4) — because  the  number  of pathogens  that  are required in
order to  induce  a  disease  varies  greatly.    The  principal
factors that  determine infective  dose are the  nature of the
pathogen  (i.e., species,  strain, and virulence), the suscepti-
bility of the host, and the method of transmission.
                             2-4

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2.4  Designation of Infectious Wastes

Any definition of infectious waste must take into consideration
the factors that have been discussed  in this  chapter.   For a
waste to be infectious in the sense that it presents the hazard
of causing disease, it must contain pathogens or biologically
active material  in sufficient  concentration  or  quantity so
that exposure to the waste could result in disease.

Testing of wastes  for the presence  of pathogens  is certainly
not advocated.  The results  of such  culturing  of the wastes
would not  be  meaningful  for  identifying  infectious  waste.
Negative cultures do not necessarily confirm that no pathogens
are present because many microorganisms require very specific
conditions for  growth  and  there are some pathogens  (e.g.,
those causing hepatitis) that cannot be cultured.  The expense
of providing all possible culture conditions and specific tests
for every  batch  of waste,  or  even  for some  batches,  is  not
warranted.

Therefore, the most rational  approach to defining infectious
waste is to designate as infectious those  wastes  that  in all
probability contain  pathogenic  agents  that  --  because  of
their type, concentration,  and  quantity — may cause disease
in persons exposed to the waste.  In  the interests of clarity
and for  ease  of reference,  EPA recommends that  13  types of
waste be  designated  infectious  wastes  (see Section  2.5).
This designation is  based  primarily  on specific  waste  type
rather than on the source of the waste.  Therefore, a partic-
ular type  of  infectious waste may  be generated  by different
industries and  by  more that  one  source  within  a  facility
(see Section 2.6).
2 . 5  Types of Infectious. Waste

After consideration of the  comments  submitted in response to
the proposed regulation  on  the listing of  infectious wastes
(18) and  after  numerous discussions  with  experts  in  the
affected industries and  in  the biological  safety  field,  EPA
concluded that infectious  wastes can  be classified  into 13
categories.  Certain  of  these  wastes  (e.g.,  pathological
wastes and  sharps)  are  not  necessarily always  infectious,
but they are included in the  list because they should always
be handled  in  accordance  with  management  practices  that
minimize the hazards  and  address the  special  problems  of
these wastes.

EPA recommends that the  following types  of  waste (as further
defined in this  section)  be considered  infectious  waste  and
that they be managed  in accordance with the  recommendations
of this manual:
                             2-5

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     0 isolation wastes

     0 cultures and stocks of etiologic agents

     0 blood and blood products

     0 pathological wastes

     0 other wastes from surgery and autopsy

     0 contaminated laboratory wastes

     0 sharps

     0 dialysis unit wastes

     0 animal carcasses and body parts

     0 animal  bedding and  other  wastes  from  animal  rooms

     0 discarded biologicals

     0 contaminated food and other products

     0 contaminated equipment


2.5.1  Isolation Wastes

Isolation wastes are those that are generated by hospitalized
patients who  are  isolated  in  separate  rooms  in  order  to
protect others  from their  severe  and  communicable  diseases
(19) .  These  wastes contain pathogens  that are shed  by the
patients.  It  should  be  noted that  the  wastes from hospital
patients who are placed in protective isolation  (i.e.,  isola-
tion imposed  only  in  order to  protect  these  patients  from
the diseases of others) are not  infectious, and these  wastes
should be  handled  as part of  the  general  non-infectious
waste stream.


2.5.2  Cultures and Stocks of Etiologic Agents

All cultures and stocks of etiologic agents constitute infec-
tious wastes with  a particular hazard because the pathogenic
organisms are present at high concentrations in these materi-
als.  Included  in  this  category are  cultures  of  specimens
from medical  and  pathological  laboratories,  cultures  and
stocks of  etiologic  agents  from  research  laboratories  and
pharmaceutical companies,  and  wastes from  the  production of
biologicals and antibiotics by  pharmaceutical companies (e.g.,
eggs used in the production of vaccines).
                             2-6

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2.5.3  Blood and Blood Products

The principal  hazard  in  blood  and  blood  products   (e.g.,
plasma, serum)  is  the  possible  presence  of  the hepatitis
agent  (20).  Less  common are the pathogens of other diseases
(malaria,  congenital rubella, disseminated neonatal Herpesvi-
rus hominis,  dengue,   smallpox,  Lassa  fever,   Marburg  virus
disease, yellow fever,  and Colorado tick fever) in which the
etiologic  agent circulates in  the  blood.   Hospitalized  pa-
tients with these  diseases are placed in  isolation,  and the
Centers for Disease Control recommends that blood precautions
be taken   with  these  patients  "to  prevent acquisition  of
infection  ...  from contact with blood or  items contaminated
with blood" (19).   Even  though blood samples are often  tested
in the laboratory, it is impractical to test for the presence
of all infectious  agents.   In addition,  a negative hepatitis
virus test,  by current  technology,  only demonstrates that
the viral  concentration is  below  the limits  of detection.
Therefore, all  waste  blood  and blood  products  should  be
managed as  infectious   waste  regardless  of  test  results.
Hospital and  medical  laboratories,  blood  banks,  dialysis
centers, and  pharmaceutical  companies  generate  wastes  in
this infectious waste category.

2.5.4  Pathological Wastes

Pathological wastes consist  of tissues,  organs,  body  parts,
blood, and  body  fluids  that  are  removed during  surgery  and
autopsy.   Pathological  wastes from patients  with infectious
diseases should be managed as infectious waste because  of the
probability that  these  wastes  contain  pathogens.   However,
it is prudent to handle  all pathological wastes as infectious
because of the possibility of unknown infection in the patient
or corpse  — it has been reported that pathogens are consis-
tently removed from the  bodies  of people who  were certified
as having  died  of  causes  other   than  infectious  diseases
(21).  Furthermore, there are also other considerations  (e.g.,
aesthetics) that affect  practices in  pathological waste dis-
posal.  The  best   and  simplest  procedure  is  to  manage  all
pathological wastes uniformly.  Pathological  wastes  are usu-
ally generated in  hospitals  in  the operating  rooms,   patho-
logical departments,  autopsy  departments,  and laboratories.*
* Burial  practices  in this  country (22)  provide  sufficient
  containment to prevent  dispersal  of viable  pathogens  into
  the environment.   Because  of the long period  of time that
  would elapse before disintegration  of  both the  outer  con-
  tainer (or  vault)  and  the  casket,   it  is highly  unlikely
  that pathogens from the cadaver would  still  be viable  when
  dispersal would be possible.
                             2-7

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2.5.5  Other Wastes from Surgery and Autopsy

The surgery or autopsy  of  septic ("dirty")  cases or patients
with infectious diseases generates waste that may be contami-
nated with pathogens from the  patient, and these wastes should
be managed  as infectious  waste.   Wastes  in this  category
include soiled  dressings,   sponges,  drapes,  casts,  lavage
tubes, drainage  sets,  underpads,  and  surgical  gloves.   The
American Hospital  Association recommends  that  all  surgical
dressings from patients should  be regarded  as  contaminated
whether or  not  clinical  evidence  of  infection is  present
(23).  Because of the  possibility of  unknown  disease  (see
discussion of  pathological  wastes  in  Section  2.5.4),  it
would be  prudent to  manage  as  infectious  all  wastes  from
surgery and autopsy  that have been  in  contact  with patient
tissues, blood,  body   fluids,   secretions,   and  excretions.
2.5.6  Contaminated Laboratory Wastes

Contaminated laboratory waste refers  to the wastes that were
in contact with  pathogens  in any type  of  laboratory  work --
e.g., in medical,  pathological,  pharmaceutical or  other re-
search, commercial, or  industrial  laboratories.   The variety
of wastes  in  this category  includes  culture dishes;  devices
used to transfer, inoculate, and mix  cultures;  and paper and
cloth items that were in contact with specimens  or cultures.
Wastes from medical  and pathological laboratories  that are
generated  in the  process of culturing patient specimens pose
a special  hazard  because   of   the  prevalence  of  resistant
strains of microorganisms  that have  developed  in hospitals
and other  institutions.  Table  2-1  lists contaminated wastes
that are frequently  generated  by medical  laboratories  (24).
Contaminated wastes from the culturing and handling of patho-
gens in  research,  commercial,   and  industrial  laboratories
should also be  managed  as  infectious waste  because they are
usually contaminated with etiologic agents  from pure cultures,
often at high concentrations.

In addition,  there  are the  wastes  that  are  generated  in
research and industrial applications  of various  biotechnolo-
gies (including  recombinant DNA).   For example,  biotechnolo-
gies are utilized in vaccine  production,  fermentation bio-
logy* cell  biology  and virology,  microbiology,   and   other
aspects of  applied  biology and  applied  microbiology.   At
this time  there is  divergence  of  opinion among  experts  in
the field  about the extent and degree of the potential hazard
posed by these wastes.   Therefore,  in  the interests  of safety,
all biotechnological wastes — that  is,   from research work
as well  as from commercial  production --  should  be managed
as infectious waste.
                             2-8

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                          TABLE 2-1

  COMMON CONTAMINATED WASTES FROM MEDICAL LABORATORIES  (24)
Culture dishes

Pipettes

Syringes and other sharps

Tissue culture bottles and flasks

Membrane filters in plastic dishes

Collection bottles, cups, and tubes from specimens of
  blood, urine, feces, saliva, exudates, or secretions

Micro-titer plates used for hemagglutination testing,
  complement fixation, or antibody titer

Slides and plates from immunodiffusion testing

Slides and cover slips from blood specimens or tissue or
   colony picking

Disposable rubber gloves, lab coats, and aprons

Swabs, capillary tubes, and spreaders used to take or
  transfer samples containing pathogens

Tubes, cards,  tabs and assemblies used for diagnostic
  purposes to speciate enteric or other pathogens

Centrifuge tubes
Reprinted from Laboratory Management, 16(6): 37-44, 1978,
                             2-9

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A special  source  of  contaminated  laboratory  waste  is  the
maximum containment  facility.   (Under  accepted  laboratory
practices and  the  proposed biosafety  guidelines  prepared by
the Centers  for  Disease  Control and the  National Institutes
of Health (13), certain levels of containment should be insti-
tuted to protect the laboratory employees, the general public,
and the environment from the  etiologic  agents  that are used
in these experiments.  [In the United  States,  containment or
biosafety levels are designated 1 through 4 or PI through P4,
with level  4 denoting the  greatest  degree of  containment.
The facilities that provide  these levels of containment are
known as  the  basic laboratory,  containment facility,  high
containment  facility, and maximum containment facility.]  The
specific biosafety level that is appropriate for a particular
experiment depends  on  the  type of etiologic agent involved,
its concentration and  quantity,  and the  types  of laboratory
procedures that are used.)  Wastes from the maximum containment
facility consist of laboratory wastes, laboratory wastewater,
and effluents  from  showers and toilets.  (Wastes  from other
levels of  containment  facilities  can be  classified  in  the
various other categories of infectious wastes — e.g., stocks
and cultures  of  etiologic agents,  sharps  —  and  should  be
managed in  accordance with   the  recommendations  for  those
types of waste.)
2.5.7.  Sharps

Discarded sharps (e.g., hypodermic needles, syringes, pasteur
pipettes, broken glass,  scalpel blades)  present  the  double
hazard of inducing  disease and  inflicting injury.  The disease
potential is great if  the  sharp was  used in the treatment of
a patient with  an  infection or infectious disease;  however,
even with  apparently healthy  persons,  there  is  always  the
possibility of unknown hepatitis.  Other contaminated sharps
are generated in the inoculation of people  or animals.   All
sharps also pose the hazard of physical  injury through  cuts
or puncture wounds.  A typical  injury  rate from sharps is 15
per month for a 475-bed hospital with  an average cost of $65
per injury (25).  With good management practices, the hazards
of disease  and  injury from  sharps  can  be  minimized.   All
waste sharps should  be managed uniformly  in  accordance  with
the practices established for infectious sharps.
2.5.8  Dialysis Unit Wastes

This category  of  infectious wastes  consists of  wastes that
were in contact with the blood of  patients  undergoing hemo-
dialysis  at  hospitals   or  independent  treatment  centers.
These wastes  are   classified  as  infectious  because   of  the
high rate  of  hepatitis  among  these  patients  (26,27).   The
                             2-10

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wastes in this category include disposable dialysis equipment
such as tubing and  filters  and other  wastes  such as sheets,
towels, gloves, aprons, and  lab coats.  Sharps from dialysis
units-should be managed  in  accordance with the practices for
all sharps (see Sections 2.5.7 and 3.7.7).
2.5.9  Animal Carcasses and Body Parts

This infectious  waste  category  includes  the  carcasses  and
body parts  of  all animals that were  exposed to pathogens in
research or were  used in  the  production of biologicals or in
the in vivo testing  of  Pharmaceuticals  as well as those that
died of known or suspected infectious disease.*
2.5.10  Animal Bedding and Other Wastes from Animal Rooms

Animal bedding  and other  wastes  that  were in  contact with
diseased and  laboratory  research  animals  (as   described  in
Section 2.5.9)  or their  secretions, excretions,  carcasses,
or body parts probably  contain pathogens shed  by these ani-
mals.*  For  this  reason,   these   wastes   are   designated  as
infectious.
2.5.11  Discarded Biologicals

This infectious waste category is  designated  for waste biolog-
icals (e.g.,  vaccines)  produced by  pharmaceutical companies
for human or veterinary use.  These products may be discarded
because of  a  bad manufacturing lot  (i.e.,  off-specification
material that  does  not pass  quality control or  that  is re-
called), out-dating,  or  removal   of  the  product from  the
market.  Because of the possible presence of etiologic agents
in these products,  the  discarded  material  constitutes infec-
tious waste.   It should be noted that wastes from  the produc-
tion of  biologicals are  included  in other  infectious  waste
categories such  as  stocks and  cultures of  etiologic agents
(Section 2.5.2), sharps (Section 2.5.7), and animal carcasses
(Section 2.5.9).
* Another  factor  that should be  taken  into  consideration is
the prevalence  of zoonotic  diseases  (i.e.,  diseases  trans-
missible from animals  to man) in  animal  colonies (see Table
2-2 and references 6  and 28).   Nearly 200 zoonoses have been
identified, and animals  or  animal tissues are  probably in-
volved in  30% to  40%  of  laboratory-acquired infections (28).
Experts in  the  biosafety  field   recommend  that  it  may  be
prudent to  regard all laboratory animals —  those used  in
research of infectious diseases as well as apparently healthy
laboratory research  animals —  as  infectious,  and also  to
manage their  carcasses,  excretions,  secretions  and  bedding
as infectious waste.

                             2-11

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                          TABLE 2-2
                      IMPORTANT ZOONOSES
 S-pecies
    Disease
Frequency
in U.S.
Animal
Colonies
Severity
in Man
Chickens,
turkeys,
Japanese quail
Mice, rats,
hamsters,
guinea pigs

Rabbits
ornithosis                   +H-
Newcastle disease            ++
equine encephalomyelitis     +•
salnonellosis                +

lymphocytic choriomeningitis +
encephalomyocarditis         +
leptospirosis                +

tularemia                    +
Opossum, skunk, rabies
fox             leptospirosis
Cats
Dogs
Cattle, sheep,
 goats, pigs
Nonhuman
primates
 toxoplasmosis
 cat scratch disease
 ringworm

 rabies
 leptospirosis
 visceral  larva migrans
   (Toxocara canis)

 louping" ill
 Q-fever
 anthrax
 tuberculosis
 brucellosis
 listeriosis
^contagious ecthyma
 ringworm
 vesicular stomatitis
 cow pox
 erysipelas
 leptospirosis

 tuberculosis
 hepatitis
 Marburg viral disease
 salmonellosis
 shigellosis
 Herpes  siniae  infection
   (B  virus)
 malaria
 yaba  and  tanapox
 measles
 amebiasis
 SV 40
 rabies
                                                          -t-t-
                                             •n-
                                             -i-
Courtesy of R.A. Griesemer and J.S. Manning, "Animal Facilities,"
in Biohazards in Biological Research, A. Hellman, M.N. Oxman, and
R. Pollack, eds.,  Cold Spring Harbor Laboratory, Cold Spriny
Harbor, New York, 1973.


+   Low frequency or degree of severity.
++  Moderate frequency or degree of severity.
+++ High frequency or degree of severity.
                           2-12

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°.5.12  Contaminated Food and other Products
Food and other products  that are
contamination with  etiologic agents
Examples of wastes  in this  category
food additives,  cosmetics,  and  drugs
     that  is   recalled  because
          from the  presence  of
food that  is   recalled  because  of  the  danger  of  botulism
resulting from the  presence  of the toxin  of  the Clostridium
botulinum bacterium should be  managed  as infectious waste in
order to  prevent exposure  to  the toxin,  dispersal  of  the
                                  being  discarded  because of
                                      are  infectious  wastes.
                                      are contaminated foods,
                                         In  addition, canned
                                     the  danger of   botulism
                                     toxin  of the Clostridium
order to
toxin in
food.
          the  environment,  and  access  to  the  contaminated
2.5.13  Contaminated Equipment

Equipment and  equipment  parts  that  are   contaminated  with
etiologic agents and  are  to be  discarded  constitute a cate-
gory of  infectious waste.   These  wastes   include   equipment
that was  used in  patient  care, in  medical laboratories,  in
research with  etiological  agents,  and  in  the  production and
testing of  various Pharmaceuticals.   Another  example  is the
HEPA filter  that  is used  in  biological safety  cabinets and
in the  ventilation systems of  biological  containment facil-
ities —  if the  filter is  not decontaminated  in  situ,  it
should be handled  as infectious waste.
2.6  Generators of Infectious Waste

Various industrial,  institutional,   and  research  facilities
are sources  of  infectious  waste.    The   largest  generators
of infectious waste are:

     0  the health care industry

     0  academic  and   industrial   research  laboratories

     0  the pharmaceutical industry

     0  veterinary facilities

     0  the food, drug, and cosmetic  industries

This manual should provide guidance and be useful  to these
as well  as to  all  other  generators  of   infectious  waste.

This section contains  a  brief discussion of  each  of these types
of facilities as a source of infectious wastes.   In addition,
various regulations, guidelines, and standards that relate to
infectious waste management  in  these facilities are  cited.
The deficiencies of  these regulations  are also  noted;  they
constitute part of  the  rationale for the  need for  a  manual
                             2-13

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that provides guidance on  good  practices  in infectious waste
management.
The health care industry is  a  source  of  infectious  waste
because it provides care for  sick people  many of whom harbor
and are  shedding  pathogens.   Furthermore,  as  was  mentioned
above, hospitals  are  reservoirs  of  resistant  strains  of
pathogens that  often  are the cause  of  nosocomial (hospital-
acquired) infections.

The Department  of  Health and Human  Services  has established
minimum requirements  for  construction and equipment  of hos-
pitals and medical  facilities.   These requirements  apply to
all such  facilities  undergoing  construction  or  renovation
that are  receiving Federal  funds.    The   sections  on  waste
processing services require that general hospitals,  long-term
care facilities, and  outpatient  surgical  facilities  have an
incinerator (or access  to  one) for  destruction of  patholog-
ical and infectious waste (29).

The Joint  Commission  on Accreditation  of Hospitals  has in-
stituted a standard  for sanitation  in hospitals (30).   This
standard, however,  is  general and non-specific  and  does not
deal adequately with  the topic  of   infectious  waste manage-
ment.  The mortuary  industry  is not specifically  included
(see the footnote to Section 2.5.4 on page 2-7).

Academic and industrial research laboratories that work with
pathogens or animals  or  that  use  various  biotechnologies are
sources of infectious wastes.  The  proposed  biosafety guide-
lines for  microbiological   and  biomedical laboratories that
were developed  by  the  Centers  for  Disease  Control  and the
National Institutes  of  Health  included   sections  on  waste
management (13); however, these guidelines are being substan-
tially revised  and they have  not  yet been published  in  final
form.  The Guidelines for Research Involving Recombinant DNA
Technology of  the   National  Institutes  of  Health   (41)  are
mandatory only  for  institutions that receive  NIH funding for
research projects  that  involve   recombinant  DNA  molecules.
Some state  and  local  jurisdictions have  extended  or  are
considering extending  these  guidelines   to  all  activities,
academic as well as  industrial,  that involve  use of recombi-
nant DNA  biotechnology.   Two  proposals  for  major  revisions
of the  Guidelines  were  published  recently   (42,43).   EPA
recommends that  the  NIH  guidelines  for  waste  treatment in
the Laboratory Safety Monograph  (6)  be  followed by  all who
work with  recombinant DNA molecules  in  research as  well as
in commercial activities.  It should be noted that the Guide-
lines (41) are  revised fairly frequently,  and the  Monograph
(6) was  updated in January 1979;  those  in the field should
always maintain familiarity with the most recent version of
each document.

                             2-14

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The pharmaceutical industry generates infectious wastes  in the
process of producing Pharmaceuticals such as biologicals  (e.g. ,
vaccines) and antibiotics.  Infectious wastes are also  gener-
ated during  the  testing  of  these and  other  products  (e.g.,
antitumor drugs)  for  efficacy and  safety  by  means  of   in
vitro and  in vivo  studies.   When  biological  products  become
out-dated and are  discarded,   infectious  waste  is generated.
Infectious wastes  are  also  generated  in the  processing   of
blood and blood  components.   The  United States  Food  and Drug
Administration regulations  pertaining  to  wastes  from  the
manufacture  of Pharmaceuticals and blood  and blood components
specify only that the wastes  should  be  disposed of in a safe
and sanitary  manner   (44,45).   The United  States Department
of Agriculture regulations  on production  of  biologicals are
nonspecific about  waste  disposal  (46).   The  United  States
Food and  Drug  Administration  regulations  for  nonclinical
laboratory studies  do  not   address  waste  management   (47).

Veterinary facilities,  including  the pet  industry and  animal
supply houses, constitute a source of  infectious waste that
parallels the human  health  care  industry.  The  United  States
Department of Agriculture  has promulgated  regulations that
govern the  treatment and disposal of  diseased agricultural
animals and  contaminated  animals  in  the food supply  (31-40).
However, there are  no  similar regulations  for  the pet care
industry that pertain  to the  disposal  of  diseased   animals.

The food, drug,  and cosmetic industries generate infectious
waste on  occasion,  but usually  not routinely.   Examples   of
such waste are  specific  lots  of  food  additives,  food  prod-
ucts, drugs, and cosmetics  that  are  disposed  of because they
are contaminated.  There  are  no  Food  and Drug Administration
regulations pertaining  to  methods  of  disposing  of  these
wastes.
                             2-15

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                          CHAPTER 3

                 INFECTIOUS WASTE MANAGEMENT
3.1  Introduction

Infectious wastes  should  be  treated  properly  in  order to
eliminate the  potential  hazard that  these  wastes  pose to
human health  and  the environment.   EPA  recommends that  each
facility establish  a  plan  for  infectious  waste  management
that will ensure  proper treatment  of  the  waste  and provide
for effective  and efficient management  practices  prior to
ultimate disposal  of the treated waste.   Such  a  plan should
cover all aspects of  infectious waste  management  from the
time of  generation  when  an  infectious  material  becomes  a
waste, through  treatment of the waste to  render  it non-in-
fectious, to  final disposal  of  the treated waste.

A waste management plan  for an institution  should be a  com-
prehensive written plan  that includes  all aspects of manage-
ment for  different  types   of  waste  including   infectious,
radioactive,  chemical,  and general  wastes  as well as wastes
with multiple  hazards   (e.g.,  infectious  and  radioactive,
infectious and toxic, infectious and radioactive and carcino-
genic).  In  addition,  it  is appropriate  for each laboratory
or department to have specific detailed, written instructions
for the management of  the types of waste that  are generated
in that  unit.  The  waste  management   section would probably
constitute one part of a general, more comprehensive document
that also  addresses  other  policies   and  procedures.   Many
such documents  that  include  sections  on  the management  of
infectious waste  have  been  prepared by  various institutions
and government agencies.  A  few examples pertaining to hospi-
tals are Isolation Techniques for Use  in  Hospitals  (19), Poli-
cies and Procedures for the  Control of Infections;   Cytopath-
ology (48),  and Isolation  Technique (49).   Similar documents
that are relevant  to  research laboratories include Safety Man-
ual for Biological  Research  Laboratories (50),   Laboratory
Safety Monograph (6),   Biological  Safety Instructions  (51),
Biological  Safety  Manual   for  Research Involving Oncogenic
Viruses (52),  and  "Hot" Suite Operations;  Standard Operat-
ing Procedure (53).

An infectious waste management  plan should address  the follow-
ing topics:

     0 Segregation of the infectious waste stream.  Directions
       for discard of infectious waste  directly into separate,
       special, distinctive  containers.

     0 Handling of the  infectious   waste.   Designation   of
       waste that  is  to be  treated by the technical personnel;
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       instructions for  removal  of  certain  wastes  from the
       room or  laboratory  by  the  housekeeping  staff  for
       treatment elsewhere  (either  within  the  facility  or
       off-site); and  special  instructions   for   the  house-
       keeping staff.

     0 Packaging and transport.   Designation  of  containers
       to be used for holding the different types of infectious
       waste during  collection  and  during  movement  within
       the facility or off-site for treatment.

     0 Treatment techniques.   The  type  of treatment  that is
       to be  used  for  each  type  of  infectious  waste,  and
       detailed  procedures   for  each   treatment  process.

     0 Alternative arrangements.   The alternatives to be used
       if treatment equipment  is  inoperable  and  the instruc-
       tions for  storage of  wastes, if  necessary,  if  they
       cannot be promptly treated.

     0 Disposal methods.  Procedures for  the  disposal of the
       treated infectious wastes.

An infectious waste management plan cannot be effective unless
it is fully implemented.   The management plan should designate
those persons  (e.g.,  laboratory  supervisor,  operating  room
supervisor, principal investigator)  who  are  responsible for
implementation of  the  plan.   These  people  should  have the
responsibility as  well  as  the authority to  make  sure  that
the provisions  of  the  management plan  are  being  followed.
In addition,  someone  should be  delegated the responsibility
for evaluating  the  relative  hazards  in wastes   with  mixed
hazards and  for  deciding which  is  the  major hazard  so  that
the waste  can  be managed accordingly,  i.e.,  first according
to the greatest  hazard  followed  by  treatment for  the  other
hazards as necessary.

Every facility that generates infectious waste should provide
training for  its employees  in infectious waste  management.
Such education  is  important  for  all employees  who generate
or handle  infectious  wastes   regardless  of  the  employee's
role (i.e.,  supervisor or  supervised) or type of work (i.e.,
technical/scientific or  housekeeping/maintenance).   Training
is necessary for new employees whose work will involve infec-
tious wastes.  Training is also necessary whenever a facility
changes its  infectious  waste  management practices  so  that
employees will learn what new procedures they  should follow
and why.   Occasional refresher courses  for  all personnel are
also useful and  important — they remind personnel how infec-
tious waste should be handled, and they can also be useful in
promoting the infectious waste management plan.
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3.2  Infectious Waste Management Options
The objective  of infectious  waste  management  is  to provide
protection to  human  health  and the  environment   from  the
hazards of  infectious waste  by ensuring  that the  waste  is
handled properly from the moment of generation  through treat-
ment to final disposal of the treated waste.  This protection
can be assured  only if the infectious waste  is contained  by
proper packaging and  the  integrity  of  the packaging is main-
tained throughout.  The  integrity of  the packaging cannot  be
ensured during  landfilling or  within  a  sanitary  landfill,
and, as a  result,  containment  of the  infectious  waste might
be disrupted with dispersal of pathogens  into the environment.
Therefore, infectious waste should  be treated  prior to dis-
posal.

Within the bounds  of  this  practice, there  are certain areas
in which alternative options are available for  the management
of infectious  waste.   These  areas  include:   treatment  site
(i.e., within  the  facility,  or even  in the  room  where  the
waste is  generated,  or   off-site);  treatment  technique   or
techniques for  the  different  types  of  infectious  waste;
specific kinds  of  equipment   for  the  different  treatment
techniques;  alternative  arrangements   for  waste  treatment
when treatment  equipment  is  inoperative;  and  various  waste
handling practices.

The waste management  plan should specify  which options have
been selected  and   which  practices  must  be   followed.   The
plan should be as specific  as necessary  to provide sufficient
details.   It  should be detailed and  unambiguous  so  that  it
will be evident  which management  options and  practices  are
to be used  in the  facility as  a whole  and which pertain  to
the particular  units   or  departments  where  the  infectious
waste is  generated.   Adherence  to  a  carefully  developed
management plan  is  the only way to maintain  full  control  of
the infectious  waste  and  thereby  to  succeed  in  protecting
people and the environment from  the hazards posed by untreated
infectious waste.
3.2.1  Treatment of Infectious Waste

The purpose  of  treating  infectious waste  is  to render  it
non-infectious by  killing the  pathogens  that  are  present.
Steam sterilization and incineration are  the  techniques most
commonly used to  treat infectious wastes.   Infectious waste
can also be sterilized by treatment with dry heat, radiation,
or chemicals.   Some   sterilization  techniques   involve  a
combination of  these   agents;   for example,   both  heat  and
radiation are  applied  during   thermoradiation  in  order  to
effect sterilization of  the  waste.  The  different  treatment
techniques are discussed in detail in Chapter 4.
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Many incinerators of different  types  have  closed down in the
last decade because of  problems  in meeting air quality regula-
tions (especially  the  standard  for  particulate  emissions).
Operation of  some  pathological  incinerators  has also  been
affected by air pollution concerns.   There are no regulations
pertaining to  the   emission  of  viable  microorganisms  from
pathological (or other)  incinerators.   Nevertheless, regula-
tions and ordinances have  restricted  the  operation of patho-
logical incinerators in some  localities  because of air quality
considerations.  In addition, energy  conservation policy has
resulted in  reduced use  of  some   pathological  incinerators
because of  fuel  consumption, and  some  facilities  no longer
accept pathological  and other  infectious  waste  from  other
generators for incineration.

Incineration plays  a  uni'que  role in  the  treatment of patho-
logical waste, and  it  is  also  used  to treat other infectious
wastes.  Therefore, it would be  advantageous if  developments
in the  state-of-the-art  would make feasible  continued  wide
use of  incineration as  a method   for  treating  pathological
and other types  of infectious  waste.   Of course,  every in-
cinerator that  is   used  to  treat   infectious  waste  must  be
operated properly  in  order to ensure effective  treatment  of
the waste (see Section 4.5 for details).

After treatment, most  infectious  waste may  be  handled and
disposed of as ordinary  waste.   Therefore,  the treated waste
may be combined with the general  waste  stream  from the facility
for final  disposal.    For  some  wastes, however,  additional
treatment might be  necessary  before  disposal.  At the  time  of
disposal, needles and  syringes  should be  non-usable and body
parts should  not be recognizable,   but  initial treatment may
not have achieved these results (see  Sections 3.7.7 and 3.7.4 on
treatment of  sharps  and pathological wastes,  respectively).
For wastes with multiple  hazards,  further treatment might be
needed to eliminate the other hazards.

It is important to be able to distinguish treated from untreated
infectious waste in  order to ensure  that  only treated waste
enters the  general  waste  stream.    Some  treatment  methods
alter the  packaging —  e.g.,  incineration  which  burns the
waste and its packaging and steam sterilization which  crumples
many plastic bags.   If the treatment process does not produce
obvious changes, some  method of distinguishing  the treated
waste should  be  used  immediately after treatment.   Suitable
procedures  include   removal   or obliteration   of biohazard
symbols, placement  of  biohazard bags within paper or opaque
plastic bags that mask the red or orange color, and compaction
or grinding of the treated infectious waste.

The most common  option for disposal is  the burial of treated
waste or residue from  an incinerator in a sanitary landfill.
Other, less   common,   disposal  options   are   suitable for
                             3-4

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specific types  of  treated  infectious  waste;   these  include
the pouring  of liquid  wastes down  the drain  to  the  sewer
system.  Certain  solid wastes  (e.g.,  pathological)  may  be
ground up and  subsequently flushed  to  the sewer  system,  if
this procedure  is  in  accord with   local  sewage  treatment
regulations.  Infectious  wastes  may  be  treated on-site  at
the generating facility if the necessary  equipment  is avail-
able.  However,  infectious  wastes may  be  transported  to  an
off-site treatment  facility  if  on-site  treatment  is  not
possible because of an absence or malfunctioning of treatment
equipment.  For  example,  many  hospitals  that  do  not  have
pathological incinerators send  their pathological  wastes  to
another institution for  incineration, or to a  mortician for
cremation or  burial.   Some hospitals send all  their infec-
tious wastes off-site for treatment at another hospital or at
a central community treatment facility.

Off-site treatment  of  infectious  waste  is  an  acceptable
alternative to treatment  on-site at  the  facility  where the
infectious waste  is  generated,   provided  that  appropriate
precautions are taken  in  packaging and  labeling the waste to
be transported.   In fact, provision  for  off-site  treatment
may be appropriate  as  an  alternative  arrangement when infec-
tious waste is usually treated on-site.   The infectious waste
generator should  ascertain  that  the  infectious  waste  is
being treated  properly at the  off-site  treatment  facility.


Recommendations

The following  recommendations pertain  to  the   treatment  of
infectious waste.   For those recommendations  that  are  of  a
general nature, reference  is  made  to other sections  of this
manual  for   details    and  more   specific  recommendations.

     1.  Selection   of  treatment    techniques   and  location
         (that is,  on-site  or off-site)  as appropriate  for
         each facility.

     2.  Arrangements at each facility for alternative methods
         of infectious  waste  management  in the event  that
         the designated  method   cannot  be  implemented  (for
         example, because of  equipment failure).

     3.  Treatment  of  infectious  waste-  in accordance  with
         the specific  recommendations  for each waste  type
         (see Section  3.7)  and   also  in accordance with the
         standard operating  procedures   developed  for  each
         treatment method (see Chapter 4).

     4.  Treatment of  all the hazards in  waste  with multiple
         hazards, with priority of treatment assigned to the
         greatest hazard.
                             3-5

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     5.  Ascertainment by the waste  generator that the waste
         is treated properly, whether the treatment equipment
         is situated on-site or off-site.

     6.  Easy  and  apparent  differentiation  of  treated  from
         untreated infectious waste.

     7.  Management and disposal of  treated  infectious waste
         as non-infectious  waste,  including  possible  mixing
         with the general non-infectious waste stream.

3.2.2  Selection of Management Options

The selection  of  options  for management of  infectious waste
at a  generating  facility  depends  on  a  number  of  factors
including the  nature  of  the infectious  waste,  quantity  of
infectious waste generated,  equipment  types and applicability,
the availability  of  equipment  for  treatment  on-site  and
off-site, physical  constraints,  regulatory  constraints,  and
cost considerations.   These factors  are  discussed in  this
section in order to provide an overview of the considerations
that are  involved  in  decision-making  for  infectious  waste
management.

The first factor  that  should be considered  is the nature  of
the infectious  waste  that   is  being  generated.   Different
types of  infectious  waste   should  be  treated  in different
ways, as  is  apparent from  the  recommendations for treatment
of each type of infectious waste that  are presented in Section
3.7.  Therefore, the  types  of  waste  that  are  generated  will
determine which   treatment   methods   should  be   considered.

The quantity of each type of infectious waste  that is generated
at the facility  is  another  important factor in the selection
of management options.  If a certain  type of waste constitutes
only a minor  component of  the  infectious waste  stream,  its
management should  not be  the focus  of the decision-making
process.  The  management  options  should  be  selected  on  the
basis of the major components of the infectious waste stream.
If a  selected  option  is  not suitable  for  treatment  of  all
the wastes,  then other  options should  be  included  in  the
infectious waste management  plan as  necessary.  For example,
if a facility generates only a small quantity of pathological
waste and  that is the only waste  for which incineration  is
the preferred  treatment method  and  there are difficulties  in
installing or  operating   a  pathological   incinerator,  then
it would  be  inappropriate to select  on-site incineration  as
the practice for  treatment  of pathological wastes.  It would
be better  to  select  a   different   treatment  option  (e.g.,
steam sterilization)  that  is suitable for most  of the waste
and to use  another option  (e.g.,  off-site incineration)  for
the pathological  waste.   Many  facilities  use a  combination
of treatment techniques or management options for  the differ-
ent components of the  infectious waste stream — e.g., steam
                             3-6

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sterilization for  laboratory cultures  and other  wastes  and
incineration for pathological waste.

The next  factor that  should be  considered  is the  type  of
treatment equipment  and its applicability.   Different  kinds
of equipment are needed for the different treatment methods,
and various models of each kind of equipment are manufactured
that have  different  features  (e.g.,  size,  instrumentation,
degree of  automation).   For example,  there  are pathological
and rotary  kiln  incinerators,   autoclaves  and retorts  for
steam sterilization, etc.  The  factors pertaining to equipment
that  should  be   considered   prior   to purchase  include:

     0 technical capability  (Will it do the job?),

     0 applicability  (Is it suitable  for treating the  types
       of infectious waste being generated?), and

     0 versatility  (Is   it  suitable  for   treating  more  than
       one type of  waste?   If  it will  not be  used full-time
       for infectious waste treatment, can  it also  be  used
       for other purposes?).

Another important factor pertaining to the equipment that would
affect the selection  of infectious  waste management  options
is the availability  of  the  necessary  equipment both  on-site
and off-site.   A  facility  that  generates  infectious   waste
does not  have   to  have   all or  even  part of  the treatment
equipment situated  on-site  at  the facility.  All  or  part of
the infectious  waste  stream may be  transported off-site  for
treatment.  The  treatment   equipment or  incinerator  may be
situated at  another  institution  or  at  a  special treatment
facility.  The  off-site treatment  option may  be  especially
advantageous to generators  of  small  volumes   of  infectious
waste because it would eliminate the  need to purchase equipment
that would not  be  fully utilized.  Another option is  a cen-
tral treatment  facility or  incinerator  that handles  infec-
tious waste from various generators  in the area;  it could be
owned and operated by those  whom  it  serves or  it could be an
independent operation.

If the purchase of  treatment equipment is being  considered,
certain possible physical  constraints  should   be  evaluated.
These include:

     0 space (Is there  sufficient space  within the building
       or on the facility grounds?),

     0 auxiliary equipment  (Are  the  necessary  steam  or gas
       lines available and  accessible?),

     0 structure (Will  the  structure support  the  additional
                             3-7

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       weight?  Is new construction necessary?  Would the ven-
       tilating, steam, gas, etc.  systems  be affected?),  and

     0 traffic  patterns  (How will  equipment  location  affect
     - the traffic  patterns  of  waste,  supplies,  and  people
       at the facility?),

Various regulations at  the federal,  state,  and  local  levels
may also  be  relevant  to  the  selection  of  infectious  waste
management options,  and  regulatory  constraints  should  be
assessed during  the decision-making  process.    For  example,
air pollution  regulations  could have a direct effect  on the
use of  incineration for the  treatment  of  infectious  waste:
if the incinerator  is  subject  to the regulations and the air
quality standards are  not  met,  operation  of the incinerator
might be  prohibited.   It  should  be noted  that  there  are no
air pollution regulations that apply specifically  to infectious
waste incineration  and  therefore  no standards  for  emission
of viable microorganisms.   Conversely,  compliance with  air
pollution regulations  does  not  necessarily mean  that  the
incineration process  is  properly  treating  the  infectious
waste.  Since  the   goal  of  infectious  waste management  and
therefore infectious waste treatment  is  to prevent dispersal
of viable pathogens into the  environment from the waste, the
criterion that  no  viable  spores be  recovered from  the  stack
gas or the  ash should  be  met  whenever infectious  waste is
treated by incineration.  Water quality regulations should also
be considered when a system for  treating infectious wastewater
is being selected and  designed  — for  example, regulations and
standards pertaining to thermal  discharges would be relevant
to heat  sterilization  systems  while  other  water  quality
regulations and  standards  would   be  relevant  to  chemical
treatment systems.

It is important also to consider prevailing  community attitudes
in such matters as  site  selection for incinerators and other
off-site treatment  facilities.    These  include  the  official
legal policies  as  evidenced by local laws,  ordinances,  and
zoning restrictions as  well as the  unofficial  public  atti-
tudes that can be  expressed  by  changes  in and  adoption of
legal positions.   The various   site  alternatives should be
evaluated with  consideration of  all relevant factors includ-
ing for example type of equipment,  the  environs, and impacts
on the  locality (e.g., potential  for  odors,  emissions  and
noise, effects of traffic).

In addition  to matters of technical  feasibility and legali-
ties, cost considerations are very  important in the selection
of the  infectious   waste  management  options.    For  example,
for new  equipment,  capital  costs  must  be  considered.   For
new as well  as  existing  equipment  there  are operating  and
maintenance costs that should  be planned for;  these include:
                             3-8

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     0 labor  (Is  the  option labor intensive?  What are the pay
       scales of  the  employees  who  would  be  operating  the
       equipment?),

     0 supplies,  parts (How  often  do  they  need  replacement?
       Are they  readily  available?  Are  they expensive?),  and

     0 energy  (What  are  the energy requirements?   If  steam,
       for example,  is needed,  is  it available  in  sufficient
       quantities?  What  are   the   forecasts  for  supply  and
       cost of fuel?).

The cost  effectiveness  of   each  management  option   should  be
evaluated and  then  compared with  that  of  each  alternative.
For example,  the  costs  of  on-site  and  off-site  treatment
should be compared.


Therefore, selection  of  the  options for management  of infec-
tious wastes  should  be based on  the following considerations:

     1.  The  nature  of  the  infectious   waste  stream  —  that
         is, the  types of  infectious waste,  the quantity  of
         each, and appropriate  treatment methods.

     2.  Evaluation of types  and  models  of treatment equipment
         for technical  capability,  applicability,  and  versa-
         tility.

     3.  Alternative  locations  of  treatment equipment  (that
         is, on-site  and  off-site)  as  well  as  the  option  of
         using equipment  jointly   with  other  infectious  waste
         generators.

     4.  Physical constraints  (relevant  factors  include space,
         auxiliary equipment, structure,  and traffic patterns).

     5.  All relevant regulations and standards at the federal,
         state, and local levels and the regulatory constraints
         that would  affect  the selection of  infectious  waste
         management options.

     6.  Costs  —  that  is,  capital  costs  for equipment  as
         well as  operation   and  maintenance   costs  (including
         labor, supplies, parts, and energy).


3.3  Segregation of the Infectious Waste Stream

For  proper  infectious   waste  management,  infectious  waste
should be separated  from all other wastes.   Such  segregation
of infectious waste  is  important  for several  reasons.   First,
the inclusion  of all infectious  waste   in  a  separate  waste

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stream will  ensure  that  all  such  waste  will   receive  the
necessary special  handling  and  treatment.   Second,  there
will be no need to screen or  search  the  general  waste stream
for bags  or packages  of  infectious waste.   Third,   such  a
separation system  is  cost effective, as  was demonstrated at
the University  of Minnesota  Hospitals  (54).   The   cost  of
disposing of  infectious  waste  is  greater  than  the  cost  of
disposing of  general non-infectious  waste,  and,  therefore,
disposal costs are increased unnecessarily when general wastes
are included  in  the  infectious  waste stream.  A system that
properly segregates  infectious  waste simultaneously prevents
the inclusion of non-infectious waste in the infectious waste
stream.  As a result, with proper management, the incremental
cost of infectious waste management  will  be expended  only on
those wastes that do require such special handling.

Infectious wastes  should  be  separated from the  general non-
infectious wastes at  the source,  that  is, at the point where the
infectious material becomes a waste, because separation is best
done by those who work with the infectious material and  who are
qualified to assess the hazards  of  the waste.   It is important
that the burden of deciding which waste is infectious should not
be placed on  individuals  who are not qualified  to  make this
decision, e.g., the housekeeping and  maintenance  staffs unless
they recieve special  instruction.  The infectious and the gen-
eral wastes  should  be   discarded  directly  into  distinctly
different containers  so that identification of the infectious
waste will  be  readily apparent to everyone who  subsequently
handles the waste.   Futhermore, if  the   infectious waste  is
segregated into  a separate  waste   stream  at the  point  of
origin, handling will be  minimized and therefore  the possibil-
ity of exposure  to pathogenic organisms  during handling will
also be minimized.

Provision should  be  made for the  segregation of infectious
wastes that have  multiple hazards  according  to  the types  of
hazards.  These wastes  should be combined  with  other infec-
tious wastes only  if  (a)  infectiousness  is the major hazard,
(b) treatment for  infectiousness will simultaneously  provide
appropriate treatment  for  the  other  hazard or  hazards,  and
(c) commingling  of  the  wastes is  suitable  and  convenient
(e.g., it would  generally not  be  advisable  to  mix  radioac-
tive and non-radioactive  wastes because  of the  special pro-
tective containers and  management   required  for radioactive
materials).   If wastes are mixed, management (e.g.,  labeling
and treatment) should  be in  accordance  with  the  hazards  of
the various components of the mixture.

All infectious waste  containers  should be clearly marked with
the universal biological hazard symbol  (Figure 3-1)  which is
used to indicate  the actual or potential presence of a biohazard
(6,17,55,56,57).   Alternatively, since red  and orange colors
are traditionally used to identify biological hazards,  plastic
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                          FIGURE 3-1
                 THE BIOLOGICAL HAZARD SYMBOL
The symbol is fluorescent orange or orange-red.  The background
may be any  color that  provides  sufficient contrast  for the
symbol to  be  clearly  defined  (6).    For  specifications  of
dimensions, see  p.  114  of  reference 6  (Laboratory Safety
Monograph.  A  Supplement to the NIH  Guidelines for Recombi-
nant DNA Research.  U.S.   Department  of  Health  and  Human
Services, National  Institutes  of Health, Office  of Research
Safety, National Cancer Institute, and the  Special Committee
of Safety and Health Experts.  January 1979).
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bags of these colors may be used for infectious waste.  However,
red and orange should never be used for non-infectious waste,
and, therefore, general wastes should be collected in bags of
other colors.  (See Section  3.4 for recommended specifications
for plastic bags.)  One example of a good system for separating
the infectious from the general wastes, with easy identifica-
tion of the  two  waste  streams, involves the use  of  rigid or
semi-rigid plastic waste receptacles lined with plastic bags.
All the  receptacles  for infectious   waste  are  round  with
red or  orange  plastic  bag  liners.   All the receptacles  for
general waste  are  rectangular with   non-red  liners.   With
this scheme, the infectious wastes  are immediately identifi-
able by all concerned,  that  is,   the  lab personnel  and  the
housekeeping  staff  as   well as  emergency  response  crews
(e.g., firefighters  and  police)  who  may  have  to enter  the
room or laboratory.   (Note:   only noncombustible  plastic or
metal waste  containers  should be  used in order  to  minimize
the fire hazard (58).)

For wastes  characterized by  mixed  hazards,  the  containers
should be   suitable  for  the   type  of waste  and  types  of
hazards.  Each container  should  be clearly  labeled  to indi-
cate the  hazards  involved.    It  may also  be appropriate to
tag these   containers  with  specifications  for  the   type or
types of treatment the wastes should receive and the sequence
of the treatment processes.

Every waste management plan should  also include instructions
for the handling of contaminated re-usable items.   Re-usables
are not part  of  the waste  stream  until they  are discarded.
Nevertheless, because they  are generated  in the  same  rooms
and laboratories as  are  the  disposable items,  the management
of re-usable items should also be addressed in a waste manage-
ment plan.   Separation  of  re-usable  from  disposable  items
is best accomplished at  the source, that  is,  at the  point of
discard.  This  practice   minimizes  the  need for  subsequent
handling and therefore  is  important  from considerations of
both safety and efficiency.  Such separation  is also essential
because many plastic  items  are heat-labile  and  melt during
steam sterilization; melted  plastic  fuses to  glassware  (for
example) and cannot  be  removed,  and  therefore  the  affected
items cannot be re-used.  Re-usable items that are infectious
should be  placed after use directly into a separate container;
items like  syringes,  needles, and pipettes  should  be placed
horizontally into a pan of chemical disinfectant.
Recommendations

The following recommended practices pertain to segregation of
the infectious  waste  stream.   For  details  about  containers
and packaging, see Section 3.4.
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     1.  Placement  of  the infectious wastes  and the general
         non-infectious wastes  into  separate  containers with
         further separation of the re-usable from the disposa-
         ble items.  Placement of  infectious wastes with mul-
         tiple hazards  into  separate containers as necessary
         for subsequent management and treatment.

     2.  Discard of  infectious  wastes directly  into suitable
         containers at the point of origin.

     3.  Distinctive and  clear  marking  of the containers  for
         infectious waste.  For example, use of  red or orange
         plastic bags  for  infectious  waste   but  never   for
         general waste.   Marking  of  boxes  and  bottles   for
         infectious waste with the universal biohazard symbol
         (and with other symbols also as  necessary  to indicate
         the presence of other hazards).

     4.  Tying,  sealing,  or tight covering of containers of
         infectious waste when full or at the end of the shift.
3.4  Packaging of Infectious Waste

The purpose  of  properly packaging  infectious  waste  is  to
provide containment  of  the waste  so as  to  protect handlers
of the  waste  as well as the  public from  injury and disease
that might be caused by contact with  the waste.   Such contain-
ment is  essential  from  the  moment  the  waste  is  discarded
until it has  been  treated.   The type of packaging depends on
the type of waste, whether it will be moved within the facil-
ity or  transported  off-site,  and how  it  will  be  treated.

It is  important to  note that  some  packaging  materials  and
packaging methods may be suitable for containing the waste,
but they can  interfere  with the  effectiveness  of treatment.
Therefore,  the type  of  packaging that  is selected  should  be
appropriate for the intended method of treatment.  For example,
plastic containers  can   impede  treatment  when  conduction  of
heat is an  important factor in  the  treatment process (e.g.,
in the  steam-  and  dry-heat-sterilization  methods)  because
plastic is a poor conductor of heat.  Packaging considerations
that are specific  for each type of treatment  are  discussed
in detail in Chapter 4.

Plastic bags  are frequently used  to collect many  types  of
infectious waste.  However, numerous problems may be encoun-
tered when plastic  bags  are used  to collect and to contain
infectious waste.  It is  important  to be aware of  these poten-
tial problems because plastic  bags are now  in  common usage.
The problems  relate  primarily  to  the  following  factors:
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     0  Preserving the integrity of the package,

     0  Handling before and during transport,

     0  Interference with the effectiveness of treatment, and

     0  Side effects of treatment.

These factors are discussed below.

     Preserving the integrity of the package.  The  integrity
     of the package will be  disrupted  and  pathogens  could be
     dispersed in the environment if a plastic bag containing
     infectious waste is torn or  otherwise opened before the
     waste is treated.  Such disruption may  result  from sep-
     aration at a seam, from puncturing or tearing by a sharp
     object either from  within  or  outside the bag,  or from
     rupturing caused by overfilling.  These problems can be
     alleviated somewhat,  but  not eliminated  completely,  by
     measures such as:   using  only  seamless,  tear-resistant
     plastic bags; not placing sharp items  or items with sharp
     corners in the bags; not filling a bag beyond its weight
     and volume capacity;  and exercising  special  care during
     handling in  order  to  keep  the plastic  bags  from coming
     into contact with external  sharp objects.

     Handling during transport.   Extra care must be exercised
     in order to prevent tearing whenever  plastic bags contain-
     ing infectious  waste  are  handled  and  especially  when
     they are moved.  For  example,  mechanical  devices should
     not be used  to load onto a truck  plastic  bags that con-
     tain infectious  waste because  of  the  possibility  that
     the bag  will be  torn in  the  process.    Good  practices
     for handling  the  plastic  bags   include:   loading  the
     bags by hand, transporting the loaded dumpster  in order
     to minimize  handling,  and  placing  the  plastic  bags
     within rigid  or  semi-rigid  containers before  handling
     and transport.

     Interference with the effectiveness  of treatment.  Plas-
     tic bags can  interfere  with  the effectiveness of treat-
     ment by preventing sufficient exposure of the infectious
     waste to the  treatment  agent  (e.g.,  heat  or chemical).
     In steam sterilization,  for example, plastic bags (some-
     times even those designated  as "autoclavable")  can pre-
     vent proper  treatment by trapping air within the bag or
     by otherwise  impeding  steam  penetration, thereby  pre-
     venting the  waste  from attaining the  necessary treat-
     ment temperature (59, 60).   Plastic  is  a poor conductor
     of heat, and  therefore  the use of plastic bags  in both
     the steam  and  dry heat  treatment methods  will  necessi-
     tate longer  treatment times  than  if  a good heat conduc-
     tor such  as  metal  is used  to contain the  waste.   In
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     gas/vapor treatment,  the plastic bag  must be permeable
     to the  chemical  in  order for the treatment to be effec-
     tive.   The effects of plastic bags and possible remedies
     to the  problems  created  by  their use  are discussed  in
     the sections  in  Chapter 4 on  steam sterilization  (Sec-
     tion 4.4),  dry heat  treatment  (Section 4.6),  and  gas/
     vapor treatment (Section 4.7).

     Side effects of treatment.   In  steam  sterilization and
     dry heat treatment,  the heat can melt heat-labile  plas-
     tic and  thereby  disrupt the integrity  of  plastic  bags.
     Melting or crumpling of  the  plastic can result in spill-
     age of  waste  within the autoclave or  oven.  This  would
     cause clean-up problems and could  also clog the  drain
     of the  autoclave.  (Selection of waste containers suita-
     ble for  steam sterilization and dry heat treatment  is
     discussed in Sections  4.4  and  4.6,  respectively.)  When
     infectious waste  in  plastic bags  is  incinerated, the
     chlorine content  of  the plastic  can  create problems.
     Two specific  problems   are  the  formation   during the
     incineration process  of corrosive hydrochloric acid and
     of highly reactive  free radicals.  The problems  can  be
     minimized to some extent by using only bags of non-chlor-
     inated plastic  — e.g.,  not polyvinyl  chloride —  to
     contain waste that will be treated by incineration;  how-
     ever, these problems cannot be eliminated if the chlorine
     content of the waste itself is  high.   (See  Section 4.5
     on incineration for details.)

Collection in plastic  bags  is  suitable for most  infectious
wastes (the  exceptions,   sharps   and  liquids,   are discussed
below).  For  containment  purposes,   the   plastic  should   be
seamless, impervious,  and  tear   resistant  (e.g.,   a  minimum
thickness of  3.0 mils  when  single bags are  used,  1.5  to 2.0
mils with double bagging).  For aesthetics, the  plastic should
be opaque.   The  bags  of  infectious  waste should be  tied
securely closed to  contain the waste.  However,  a loose tie
may be more appropriate when the waste will be steam  sterilized;
if the  waste is  to be  transported   within  the facility   or
off-site before such treatment,  the bag should be tied tightly
or placed within a  container that is  covered with a tightly
fitting lid.   For  identification purposes,  the bags  should
be the distinctive red or orange color that signifies biohaz-
ardous material.   As was  mentioned  above,  the  use  of plastic
bags may not be suitable  when the infectious waste is trans-
ported to an off-site treatment  facility  (see  also  Section
3.6) and  when  certain treatment  methods  are used (see  also
Chapter 4).

An alternative  to  plastic  bagging  is the  use of  plastic,
metal, or  glass  receptacles  to  contain  infectious   waste
during movement within the  facility  or  off-site, and  also
sometimes to contain  it  during treatment.   These  containers
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may be  used  with  plastic liners.   If  such  liners  are  not
used or  if  they  are  not  sealed,  the  containers  should be
covered with  secure  lids during  movement and  storage.   The
lids may have  to be opened  or removed  during  the treatment
process.

Sharps should receive special containment because  they present
a special  hazard of  physical  injury  in addition  to  their
infectious hazard.   They should  be  packaged  in  a  way   that
eliminates the possibility of contact during subsequent hand-
ling, treatment,  and disposal.   After use, sharps  should be
placed directly  into special  containers.   Needles should not
be recapped  because  of  the  possibility  of  injury  by  self-
inoculation (61).  Furthermore,  contaminated  needles  should
not be broken  or clipped  unless the  clipping  device effec-
tively contains  aerosols and  needle  parts.    Otherwise,  the
aerosol or splatter  that is generated  during  clipping  might
contain pathogens  that  were  present  on the  needles,  and
there is also  the possibility of  injury from needle  parts
that might become airborne  (62).   (See  Section  3.7.7  for
details on management of sharps after treatment.)   Containers
for sharps should be  impervious,  rigid,  and  puncture-proof
(that is, capable of withstanding crushing and also punctures
by sharps).  Suitable materials for sharps containers include
glass, metal,  rigid  plastic,  wood,  and  heavy  cardboard.
Sharps containers should be sealed, and they should be marked
with the universal biohazard symbol (6,17,55,56,57).

One management system for handling disposable sharps that has
received some  attention  involves  placement  of  used  sharps
directly into pans of disinfectant, followed by steam steril-
ization treatment  and  subsequent  clipping  of   the  treated
needles and  syringes.   Although  this  type of  treatment  re-
moves the  infectious  hazard,  the  hazard  of physical  injury
from the sharps  nonetheless  remains.   Because  of the poten-
tial for physical  injury,  EPA therefore  believes that  it is
not prudent to  retrieve  needles  from a loaded pan, to handle
them, and  to  clip  them.  The  preferable management  system
for sharps is  placement directly into  a puncture-proof   con-
tainer so  that  subsequent  handling  (of  the   container) is
without risk of physical injury from the sharps.

Liquid infectious wastes should  be  contained  in bottles or
flasks that  are  capped  or  tightly  stoppered.   The  bottles
and flasks  should be  marked  with  the  universal  biohazard
symbol as should  any boxes  or containers into which they may
be placed.    Infectious  wastewater may  be contained and  then
treated in batches  within a  closed  system  (e.g.,  a  tank);
however, if the  wastewater  is directed  to a  continuous   flow
treatment process,  no  special  containment  other  than  the
piping system is  necessary.
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     3.  Discard  of  sharps  directly  into  impervious,  rigid,
         puncture-proof containers.   Placement of  intact  nee-
         dles directly  into  collection containers  --  that  is,
         without  recapping,  clipping, or breaking  (see  text
         for exception).

     4.  Discard  of  liquid  infectious   waste   in  capped  or
         tightly stoppered bottles and flasks.

     5.  Marking  of  all   containers   (except  plastic  bags  —
         see recommendation  #1),  as  well  as   any  container
         into which  they  may  be  placed,  with  the  universal
         biohazard symbol  (and with other  labels, as necessary,
         to denote multiple hazards).

     6.  No  compaction  of  infectious waste   or packages  of
         infectious waste prior to treatment.

     7.  Use  of  packaging materials  that are  appropriate  for
         the type of  treatment.   (See Chapter  4  for  a discus-
         sion of  the  packaging  factors  that  are important  to
         the effectiveness  of  the  different   treatment  meth-
         ods. )

     8.  Use  of  packaging materials  that  are  strong  enough
         to remain  intact during  whatever  type of  handling,
         storage, and   transfer  the  packages  may   undergo.
3.5  Storage of Infectious Waste

Infectious waste  should  always be treated  as  soon as possible
after generation,  preferably  the  same  day.  However,  this  is
not always possible — for  example,  treatment  equipment may be
unavailable because  of insufficient  capacity  or  malfunction;
there may be  insufficient  time to treat that day;  or personnel
may be  unavailable because of employee  absence,  the  time  of
day, or  the  day  of  the  week.   Some  special   situations  may
necessitate temporary  storage of  the  infectious  waste.   For
example, if  an  incinerator  is  operated  on  a  5-day-a-week
schedule, the  waste  may have  to be  stored over  the  weekend.
If treatment equipment is  temporarily  inoperable  while under-
going maintenance or  repair,  waste may  have to  be  stored while
alternative arrangements for treatment are being made.

Four primary factors  are  important  in infectious waste storage
— the  integrity  of  the  packaging,  the  storage  temperature,
the duration of storage,  and the storage area.

Packaging of  waste that must  be  stored temporarily  prior  to
treatment should be  carefully evaluated.   Packaging  serves  to
contain the waste.  It is also an important factor in excluding
rodents and  vermin  that  may  be  animal  vectors  of  disease.
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Storage temperature  is  important  for two  reasons.    One  is
biological — most  microorganisms  grow rapidly  at  warm tem-
peratures, especially when  an organic substrate  is  present.
The other  is aesthetic  —  decomposition  begins rapidly  at
warm temperatures,  and   the  odors  can  be very  unpleasant.
Temperature and time are  interrelated —  that  is, the colder
the temperature, the longer the acceptable period of storage.
However, as was noted above,  storage  times  should be kept as
short as  possible.   If  infectious  waste  cannot be treated
immediately, it should  be stored no  longer than one  day  at
room temperature  (18°-25°C,   64°-77°F)  or  three  days  in  a
refrigerator (1°-7°C,  34°-45°F)   or  90   days  in  a  freezer
(at -10°C,  14°F  or  lower).   These  recommendations  are  for
total storage time  prior  to treatment,  regardless of whether
the waste is stored  at the generating facility or  at a separate
treatment facility.   It  is  realized  that  in some situations
(in many  hospitals   for  example),   infectious  waste  that  is
generated during the  weekend  must  be held until  Monday for
treatment because of staffing practices.   It  is preferable
that infectous waste be  kept  no longer than one  day at room
temperature; however, this may be impossible when refrigerator
storage capacity  is  insufficient  to  contain  the  weekend
accumulation of infectious waste.  In these circumstances, it
is especially  important  that   the  stored  waste  be  properly
contained (e.g.,  in containers with  tightly  fitting covers)
and that  it be kept in a secured storage area.

All unpreserved  pathological   wastes  and  animal  carcasses
should be placed  immediately  into a  refrigerator  or freezer
where they should be kept until treatment.

The storage  area  should  be located at the  treatment  site  or
as near to  it  as possible.  The  security  of the storage area
is also  important.   The area  should  have  limited  access --
that is, only by authorized personnel -- in order to restrict
the entry  of persons who have no  knowledge  of  the hazards
inherent  in  the  stored  infectious  waste.  The  storage area
should be  kept  free of  rodents and  vermin.    The  biohazard
label should be posted  on the door as well as  on  the waste
containers, refrigerators, and freezers.

Recommendations

EPA makes the following  recommendations concerning the storage
of infectious waste:

     1.  Avoidance of storage  of  infectious waste by treatment
         of the  waste  as  soon  as  possible,  preferably the
          same day it is generated.

     2.  Minimization of storage  time, with storage in refrig-
          erator or  freezer if  storage time exceeds  one day
          (see text  for details).
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as well  as  some  research   laboratories  and  pharmaceutical
companies.  After treatment, the  liquid  portion  of the blood
may be  decanted  into  the  drain while the  remainder  can be
disposed of together  with the  general  waste stream,  or all
the treated waste  may be disposed of with  the  general waste
stream.

Although it has  been  recommended  that  untreated  excess blood
from laboratory  specimens and  untreated  bulk blood be poured
down a  drain  (61),  EPA regards  this  practice  as imprudent
because there is not sufficient evidence  that  this disposal
procedure is safe.  At present there is divergence of opinion
about whether  hepatitis  is  transmissible  through  inhaled
aerosols.  If it is,  then the  aerosols that  are  generated in
pouring blood down  a drain  constitute a risk to  the person
who is disposing of the blood  in  this manner.   In addition,
large quantities of whole blood  should  not be discarded  into
the drain  because  coagulation  of  the blood could  clog the
plumbing.  Other considerations about  disposal  of infectious
wastes to the sewer  system  are discussed above  in the intro-
duction to Section 3.7.
Recommendations

EPA's recommendations  for  treatment  and  disposal  of  blood
and blood products are as follows:

     1.  All blood  and blood products:   steam sterilization
         or incineration  in accordance  with  the  determined
         standard operating procedures.

     2.  Other wastes associated with blood and blood products:
         steam sterilization or incineration.

     3.  Treated blood, blood products, and associated wastes:
         disposal with   the general   non-infectious   waste
         stream.  Any  liquid may  be decanted  into the drain
         to the sewer system.


3.7.4  Pathological Wastes

In addition  to the  biohazard  of  pathological waste,  other
considerations that  affect  the management  of  this type  of
waste are aesthetics and religious practices.  From biohazard
considerations, pathological waste should be  treated by incin-
eration or steam sterilization before disposal.  For aesthetic
reasons, recognizable  body  parts  should  not be disposed  of
in a landfill,  and, consequently,  most  pathological  wastes
are incinerated.  For religious reasons,  some patients prefer
that their body parts (for example, amputated limbs) be trans-
ferred  to a mortician for burial in a cemetary or for cremation.
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Some hospitals  that  do  not  have access  to  a  pathological
incinerator send their pathological wastes  to morticians for
treatment and  disposal.    Mortuary practices  are  generally

adequate to eliminate or contain  any  biohazard in the waste.
(See footnote on page 2-7.)

Alternatively, pathological waste may  be treated by a two-step
procedure that  first  sterilizes  the  waste  and then  renders
it unrecognizable before disposal.   Such treatment  consists
of steam sterilization followed  by incineration or by grinding
of the waste and flushing it to  the sewer system in accordance
with state and  local  regulations.  Treatment of  pathological
waste by steam sterilization followed by grinding and flushing
to the  sewer  system  would be appropriate,  for example,  when
burial  is  not  requested   and   pathological   incineration  is
not available.
Recommendat ions

EPA recommends the  following  alternatives for  the treatment
and disposal of all pathological wastes:

     1.  Incineration in a pathological  incinerator in accord-
         ance with  the  standard operating procedures  deter-
         mined for  this  type  of waste.  The  incinerator ash
         may be disposed of in a sanitary landfill.

     2.  Treatment by steam sterilization followed by incinera-
         tion.  The  incinerator  ash may be disposed of in a
         sanitary landfill.

     3.  Treatment by steam sterilization followed by grinding
         of the  waste  and  flushing  to the  sewer  system.

     4.  Handling by  a mortician  with  burial in  a  cemetary
         or cremation.


3.7.5  Other Wastes from Surgery and Autopsy

Surgery and autopsy wastes from infectious and  septic  (that
is, "dirty")  cases  should be treated by steam sterilization
or incineration.   This  is  the  general  practice in hospitals.
Recommendations

EPA recommends  the  following alternatives  for  the treatment
and disposal  of surgery and  autopsy wastes  from infectious
and septic cases:
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     1.  Steam sterilization in accordance with the determined
         standard operating procedures.

     2.  Incineration  in accordance with  the determined stan-
         dard operating procedures.

3.7.6  Contaminated Laboratory Wastes

Contaminated wastes from laboratories  at  biosafety levels  1,
2, and 3 or levels  PI/  P2,  and  P3  should  be treated by steam
sterilization or incineration.

All wastes from laboratory  work  that requires maximum contain-
ment because of the type, virulence, or quantity of etiologic
agent present  (i.e.,   wastes  from  biosafety  level  4  or  P4
laboratories) should be  sterilized  prior  to disposal.  Solid
and containerized  liquid wastes  should  be  steam sterilized
before they  are  removed from the laboratory;  this  should  be
done in pass-through double-door  steam sterilizers to ensure
that all waste that leaves  the laboratory  has been sterilized.
Liquid effluents  from  maximum  containment  facilities should
also be treated.   Laboratory  wastewater should be sterilized
by heat  or  radiation  while  effluents  from   the  auxiliary
facilities  (for  example,  hand-washing sinks, toilets,  and
shower rooms)  should  be  treated  with  heat,   radiation,   or
chemicals.

Large scale  laboratory  work  or  commercial   production  can
generate large quantities of liquid waste (e.g., from fermen-
tation vessels).   These  wastes  should  be   treated  before
disposal.  The  preferred  treatment  technique  for  this  waste
is steam sterilization.  Alternatively, the  liquid waste may
be heat sterilized, either by continuous  flow or batch treat-
ment, or it  may be treated  with  chemicals if  the  method  is
in accordance with procedures that  have been demonstrated  to
be effective.  When available,  gamma-irradiation  may  be used
to treat the wastewater.

Additional sources of information  on the management of various
laboratory wastes are available.  These include the biosafety
guidelines for  microbiological and biomedical  laboratories
that are being  developed  by the Centers  for  Disease  Control
in conjunction  with  the National  Institutes  of  Health  (the
original draft  (13) is  being  substantially revised).   Guide-
lines for certain aspects  of  biotechnology,  specifically the
use of recombinant DNA  technology,  appear in Guidelines for
Research Involving Recombinant DNA Molecules of November 1980
(41)  and  the  supplementary  Laboratory Safety Monograph   of
January 1979  (6);   these  are   revised  occasionally  so  the
reader  should  always   consult  the  most   recent  edition.
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Recommendations

EPA recommends the  following  alternatives for  the treatment
and disposal of  contaminated  laboratory wastes  from  labora-
tories at biosafety levels 1,  2,  and  3 or levels PI,  P2, and
P3:

     1.  Steam sterilization  in  accordance with the standard
         operating procedures  determined  for   this  type  of
         waste.

     2.  Incineration in accordance with the determined stan-
         dard operating procedures.

EPA makes the  following  recommendations  for  the treatment of
wastes from biosafety  level 4 or P4 (i.e., maximum containment)
laboratories:

     1.  All  solid  and  containerized  liquid wastes:   steam
         sterilization in  a   pass-through  double-door  steam
         sterilizer before  removal  from  the   laboratory  in
         accordance with  the   standard  operating  procedures
         determined  for   the   particular  type  of  waste.

     2.  Laboratory wastewater:  heat sterilization (or gamma
         irradiation,  if  available)  prior to discharge  into
         the sewer system.

     3.  Effluents from auxiliary facilities:  treatment with
         heat, radiation, or  chemicals  prior  to discharge into
         the sewer system.

EPA recommends the  following  alternatives for  the treatment
of liquid wastes  from  large  and  commercial scale production:

     1.  Sterilization by steam or heat  (or gamma irradiation,
         if available)  in  accordance  with  the  determined
         standard operating procedures.

     2.  Alternatively, chemical treatment in accordance with
         procedures demonstrated to be effective.
3.7.7  Sharps

Sharps present  the  double  hazard  of  disease  transmission
and physical  injury.   Therefore,   the  handling,  treatment,
and disposal  of  sharps  should  be  governed  by consideration
of these two factors.  As was mentioned above  in the discussion
of packaging  (Section 3.4),  sharps  should be placed directly
into rigid puncture-proof containers at the site of origin in
order to avoid injury of subsequent handlers.   Sharps should
be treated before  disposal  in  order to eliminate the disease
                             3-32

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potential.  Steam  sterilization  is  the recommended treatment
method; it is commonly used for treating sharps.

Many states have  regulations  that  require the destruction of
needles and  syringes  so  that they  cannot  be  re-used after
discard.  All needles and syringes  should  be rendered non-usa-
ble before disposal.   This  can  be  achieved  by  grinding  or
compaction after  treatment.   Alternatively,  the  sharps  can
be heated in an oven so that the syringes melt and the sharps
are enclosed within the resultant block.  Clipping of  steril-
ized needles and  syringes after treatment  is  not advisable;
although treatment will  have removed  the  infectious  hazard,
the sharps will still pose a hazard of physical  injury during
handling and possibly also during clipping.

Recommendat ions

EPA recommends  the following  procedures  for  the  handling,
treatment, and disposal of sharps:

     1.  Treatment by steam  sterilization in  accordance with
         the standard  operating  procedures  determined  for
         this type of waste.

     2.  Destruction  of   the  treated  sharps  by  grinding  or
         compaction prior  to  disposal.   Alternatively,  heat
         treatment to melt the  syringes  into  a  block  with
         the sharps.
3.7.8  Dialysis Unit Wastes

The principal  biohazard  of  infectious  wastes  from dialysis
units is the hepatitis agent.  Therefore, these wastes should
be treated before disposal by incineration or steam steriliza-
tion.  This recommendation is consistent with the recommenda-
tions for treatment of the  specific  components of the infec-
tious waste stream from dialysis  units  (e.g.,  blood,  sharps,
laboratory wastes).
Recommendations

EPA recommends the  following  alternatives for  the treatment
of infectious wastes from dialysis units:

     1.  Incineration in accordance with the standard operating
         procedures determined for these wastes.

     2.  Steam sterilization  in accordance with the standard
         operating procedures   determined for  these  wastes.
                             3-33

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3.7.9  Animal Carcasses and Body Parts

Management of animal  carcasses  and body parts  is  similar to
that of pathological  wastes described above.   There  are two
main considerations —  removal of  the infectious  agent and
destruction of  the  carcass.    Incineration   is  a  treatment
technique  that   accomplishes   both   goals  simultaneously.

Because of the high pressure in a retort,  steam sterilization
in a retort followed  by  grinding  up of the treated waste and
flushing to the  sewer system is another suitable  method for
treatment and disposal  of  this type of waste;  however, long
cycles (e.g., eight hours)  are necessary,  and it is important
to validate  the   duration  of  treatment  by  testing.   Steam
sterilization in autoclaves has only limited use in treatment
of animal carcasses because of  size constraints and the long
treatment times that are necessary in order to effect sterili-
zation.  For example,  Barbeito  and Gremillion  (64)  reported
that eight  hours  of  autoclaving  was  still not  sufficient
time to effect  sterilization of  guinea pig carcasses  in  a
fiberboard container  and that  tight packing  of the carcasses
within the container prolonged the time required for sterili-
zation.  Nevertheless,  autoclaving  can  be  useful  in  two
applications: to  decontaminate  the  surface  of  a  carcass
before it  is  transported  through  a facility to an incinera-
tor, and to treat  small carcasses  and  body parts before they
are ground up and flushed to the sewer.

Rendering is another  treatment method  that has traditionally
been used  to  dispose  of the  carcasses of  diseased animals.
For example, under the U.S. Department of  Agriculture regula-
tions for the control  and eradication of livestock and poultry
diseases,  rendering is acceptable treatment for the carcasses
of cattle  destroyed   because  of tuberculosis  and  swine de-
stroyed because of hog cholera (32,36).  Therefore, rendering
in a  rendering  plant  is  an acceptable  alternative  for the
treatment and disposal  of  animal   carcasses  and  body  parts
that constitute one type of infectious waste.
Recommendations

EPA recommends  the  following alternatives  for  treatment and
disposal of animal carcasses and body parts:

     1.  Incineration in accordance with the standard operating
         procedures for this type of waste.  When more virulent
         etiologic agents are  involved and  the carcass must
         be transported through a facility to the incinerator:
         preliminary autoclaving of  the  carcass for one hour
         at operating temperature  in  order  to  decontaminate
         the surface of the  carcass.  After incineration, dis-
         posal  of   the  residue   in   a  sanitary  landfill.

     2.  Steam  sterilization in a  retort, in accordance with


                             3-34

-------
         the standard operating  procedures for  this  type of
         waste, followed by grinding  up  of the treated waste
         and flushing to the sewer system.

     3.  Autoclaving of small  carcasses  and small body parts
         in accordance with the standard operating procedures
         determined for  this   type  of   waste.   The  treated
         waste may  be  disposed  of  by grinding  and flushing
         to the  sewer  system, or  it  may  be  incinerated and
         the residue  disposed  of   in a  sanitary  landfill.

     4.  Rendering in a rendering plant.

3.7.10  Animal Bedding and Other Wastes  from Animal Rooms

A number of  treatment methods are  suitable  for sterilizing
animal bedding  and  other  wastes   from   animal  rooms.   (It
should be  noted  that  this  section  refers  only  to  animal
bedding and other  animal wastes  from  diseased and laboratory
research animals  as  defined in  Sections  2.5.9  and 2.5.10.)
These methods  include  incineration  and  treatment  with gases
or vapors,  dry heat, or  radiation.   In  addition,  steam or
chemical treatment  may  also  be  appropriate   for  some  of
these wastes.   However,   these  last  two  methods  are  not
recommended for  the  treatment  of large  quantities  of  animal
bedding because  animal  bedding  has  certain  characteristics
that interfere   with  the  effectiveness  of   the   steam  and
chemical treatment processes.

Sterilization  is accomplished with steam when the waste mate-
rial, including that at the center of the  load,  is exposed to
sterilizing temperatures for  a  minimum  period  of  time  (see
Section 4.4 for a detailed  discussion  of  steam sterilization).
However, animal  bedding  is a  poor  conductor  of heat  (and  a
good insulating material),  and, therefore, even after several
hours of steam  treatment,  the  center   of  a  load  of  animal
bedding will  not  have  reached  the  required  temperature if
the layer of bedding  is  too deep or  if  it is  contained in a
plastic bag  or  a  plastic  container   (see Table  3-3).   The
addition of  water to animal  bedding  before  steam treatment
also impedes   the  heating   of  the  waste  load   (Table  3-3).
Therefore,  testing  and  standardization   of  procedures  are
essential in  order  to  ensure  the  sterilization  of  animal
bedding.

The most efficient technique   for  steam  sterilization  is to
treat the bedding  in shallow  layers  within metal  pans.   it
is recommended that animal bedding be steam sterilized directly
in the collection  pans (for which metal  is the best material
because of  its  high heat conductivity).  This practice provides
the advantage  of sterilizing  the  bedding  and  the equipment
simultaneously as  well  as  minimizing  handling  of  the  waste
                             3-35

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-------
and worker  exposure  to  pathogens  in  the  aerosols  that are
generated when bedding  is dumped or scraped  from the collection
pans (see  below).   After  treatment,  the  sterilized bedding
can be safely  scraped  into a  container for disposal with the
general waste stream.

Animal bedding  is  also  difficult  to treat  effectively with
chemicals (chemical  treatment  is  discussed   in  detail  in
Section 4.9).   Many  chemical  disinfectants  react  with the
organic matter that is  present  in the waste, and therefore the
chemical must be added  in  sufficient quantity to ensure that
an excess remains  for  killing  of  the pathogens.  Stirring is
also necessary to ensure contact of the chemical with all the
waste.   Chemical  treatment  is  an  appropriate  method  for
sterilizing animal  bedding  only   when small   quantities  of
bedding are to be treated and only after tests  of the procedures
have led to standardization of techniques.

Another important  factor  that  should be  considered  in the
process of selecting a  technique  for treating animal bedding
is aerosol generation during bedding changes.   Fecal material
may contain more than one billion bacteria per gram  (66), and
the bacterial  count  in the room air often rises  from a base
level of  less than  5  colony  forming  units   (cfu)  per  cubic
foot to  50-200 cfu  per cubic foot  during  bedding  changes
(28).  Handling of the waste and exposure to pathogens can be
minimized:  (a) by treating the bedding before it is scraped
from the  collection  pans,   (b)  by  using a vacuum  system to
collect the untreated  bedding  instead of dumping  it,  or (c)
by confining scraping  procedures to  the interior  of an oper-
ating biological safety  cabinet that  is   specially  designed
for disposal of bedding  (67).
Recommendations

EPA recommends the  following  practices for  the  treatment of
animal bedding and other  infectious  wastes  from diseased and
laboratory research  animals   (as  defined  in Sections  2.5.9
and 2.5.10):

     1.  Incineration in  accordance  with the  standard  oper-
         ating  procedures   determined   for   this   waste.

     2.  Steam sterilization of animal bedding in the collec-
         tion pans or cages  in accordance with  the standard
         operating procedures determined for  the  steam  ster-
         ilization of this waste.

     3.  Alternatively,  treatment with gases or  vapors,  dry
         heat, or  gamma   radiation   in  accordance  with  the
         standard operating  procedures  determined  for  the
         treatment of animal  bedding.
                             3-37

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         Chemical disinfection of  small  quantities  of animal
         bedding in accordance  with  the standard  operating
         procedures determined for the  chemical  treatment of
         animal bedding.
3.7.11  Discarded Biologicals

Biologicals that  are  discarded  should  first  be  treated  to
destroy the biological  activity  of these  products.   Because
biologicals are  thermolabile  (that  is,  sensitive  to  and un-
stable under heat), the  three  treatment methods that involve
application of  heat  are suitable  for  treating this  type  of
waste.  Steam  sterilization  and  incineration  are  commonly
used to treat  discarded biologicals.   Incineration  provides
the additional  advantage of destroying  labels  and often the
packaging as well so that the products are no longer indenti-
fiable.  Treatment  with dry  heat  is equally  effective  but
usually more costly.

Biologicals are  discarded in  the original packaging  which is
usually glass  vials with   banded  rubber   stoppers.   If  the
glass melts during incineration,  problems  with slagging might
develop.  It has also  been reported  that a  layer of molten
glass on top of  the waste might  insulate  the waste material,
thereby preventing proper incineration and complete combustion
of the waste.  Therefore, the tests that are run to determine
the standard operating  procedures for incineration  of biologi-
cals should also demonstrate  which  operating conditions will
provide proper treatment to  the waste while minimizing problems
that could  result from melting  of  the  glass.   For  example,
optimum conditions for incineration of biologicals may entail
lower temperatures and  longer  residence times  than  are optimum
for incineration of other infectious wastes.
Recommendations

EPA recommends the following alternatives  for the treatment of
discarded biologicals:

     1.  Steam sterilization  in  accordance  with the standard
         operating procedures  determined  for   this type  of
         waste.

     2.  Incineration in accordance with the  standard operating
         procedures  determined   for   this   type   of  waste.

     3.  Treatment  with  dry  heat  in  accordance  with  the
         standard operating  procedures  determined  for  this
         type of waste.
                             3-38

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 3.7.12   Contaminated Food and Other Products

 Products  that  are  being  discarded  because  of  biological
 contamination should  be treated before  disposal.   This  will
 ensure  the  safety  of  the people who handle the waste as  well
 as  those  who may come  upon  these  items  after they have  been
 discarded.   The  contaminated materials  may  be  in  solid  or
 liquid  form  in  any of  various types  of packaging.   Factors
 that affect  selection  of a  suitable treatment method include
 the nature of the contamination (that is,  type and concentra-
 tion of  etiologic  agents present), the  type  of contaminated
 material, its  volume,  the  type of  packaging  (e.g.,  boxes,
 bottles,  cans), and the  availability of  treatment facilities.
 The types of treatment that are effective for most contaminated
 products  are incineration, steam sterilization, and treatment
 with gases or vapor.  For each  type of contaminated material,
 the treatment method should first be tested to establish  that
 it provides  effective treatment.    Incineration  provides  the
 additional advantage of  destroying labels  and often the pack-
 aging as well so that  the products  are no longer identifiable.

 Food products  that are found  to  be  contaminated  with  the
 toxin of  Clostridium  botulinum  are normally  recalled  by  the
 manufacturer for destruction  or reprocesssing.   Because  this
 toxin is  one of the  most potent  poisons, an entire  lot  of
 processed food is  recalled whenever  the  presence  of toxin  is
 demonstrated or suspected in  any  can  in the lot and whenever
 processing conditions  were  such  that  toxin  formation   is
 possible.  The special  problems associated with the disposal
 of this  type of  waste  derive  from the  possible  presence  of
 botulinal toxin in  some of  the cans;  the difficulty in  pre-
 venting pilferage  of   the food during   storage,  transport,
 treatment, and disposal; and  the  volume  of  waste  which  is
 frequently quite  large  although  only  a  small  portion  may
 actually be  hazardous.   Therefore,  effective management  of
 this type  of waste  should  minimize  the  risk  to  those  who
 handle the waste  and  eliminate the possibility  that contam-
 inated food  will be  consumed, while providing an  option for
 local disposal so  that  prolonged  storage and  transport  are
 not necessary.

 In order  of preference,  three management alternatives  are
 recommended: (a)  incineration in a rotary kiln; (b) treatment
 in a retort,  steamer,  or autoclave followed  by  destruction
of the   cans;  and  (c)   crushing  and burial  of the cans  in a
 sanitary landfill.   The specifics  for  each  alternative  are
discussed below in  detail.   Appropriate  personal  protection
 (e.g.,  gloves,  protective  clothing,  face  masks)  should  be
used whenever  there   is  a  possibility  of exposure  to  the
 toxin from leaky cans  or aerosols because  the  toxin is haz-
ardous  by various  routes  of exposure,  i.e., by  ingestion,
 inhalation,  and percutaneous  transfer (68).   Any spills  or
leakage should be cleaned up  with  an alkaline  solution (e.g.,
                             3-39

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0.1 M  solution  of  sodium  hydroxide)  or  with  sodium hypo-
chlorite to denature the toxin (68, 69).

When incinerated, the  cases of  contaminated food  should be
fed intact  into  the rotary kiln.   This  treatment simultane-
ously destroys the  food.  The  ash may  be  disposed of  in a
sanitary landfill.

Alternatively, the cases of food should be treated in a retort
or autoclave, or  steamed a in steamer, with treatment of suffi-
cient duration to destroy the  toxin.  Because bacterial spores
might survive  this  treatment,  the  cans  should  be  destroyed
immediately after treatment to prevent pilferage and consump-
tion.  This can  be  accomplished  by,  for  example, destruction
in a hammermill  or  crushing with  a  bulldozer.   After treat-
ment and destruction  of  the cans, the waste  may be disposed
of in a sanitary landfill.

The final alternative, if permitted by the local jurisdiction,
is disposal of  untreated waste  in a sanitary  landfill  in a
manner that minimizes the risks of exposure during  the disposal
process and  that ensures  destruction  of the  toxin and  the
cans.  Crushing  the  cans  within  a sanitary landfill releases
the botulinal toxin  into  the soil  where  it  will be destroyed
by soil microorganisms while the landfill provides protection
of the groundwater.  At  the same time,  crushing ensures that
the food cannot be pilfered and eaten.   For this alternative,
the following procedures should be followed:
      o
        The  food product  should  be disposed  of immediately
        upon arrival  at the  landfill   in  order  to minimize
        opportunities for pilferage;

      0 The intact cases of food should be placed in a single
        layer in  trenches  that are  located  away  from other
        disposal operations;
      o
        The cases  should  be  covered with a one-foot layer of
        earth (to  inhibit  aerosol  genertion)  and should then
        be immediately  compacted  by a  bulldozer in order to
        destroy the  cans;  several  layers  of  cans  may  be
        compacted within a single  trench;

      0 The crushed  cans  should be covered with a  final two-
        foot layer of compacted earth;

      0 In accordance  with FDA practice,  an  FDA representa-
        tive, U.S. marshall,  or local  public health official
        should oversee  the operation  to ensure  proper dis-
        posal and prevention  of pilferage;
                              3-40

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      0 The bulldozer  operator  and  all others present at the
        disposal operation  should  use  appropriate  personal
        protection gear.
Recoiranendat ions
The following alternatives  are  recommended  for the treatment
of contaminated products:

     1.  Incineration in accordance with procedures demonstra-
         ted to be effective.

     2.  Steam  sterilization  in  accordance  with  standard
         operating  procedures   for   this    type  of  waste.

     3.  Treatment  with gases  or  vapors in  accordance  with
         procedures demonstrated to be effective.

For food  products  contaminated with botulinal  toxin,  the
following three  alternatives —  in   order  of  preference  —
are recommended:

     1.  Incineration  in a  rotary kiln  in  accordance  with
         recommended  procedures   (see  text   for   details).

     2.  Heat treatment  in a retort,  autoclave, or steamer in
         accordance with procedures demostrated  to  be effec-
         tive (see  text for  details),  followed by  crushing
         of the cans.

     3.  Crushing  of  the cans within a  sanitary landfill in
         accordance with the  specific procedures detailed in
         the text.
3.7.13  Contaminated Equipment

Contaminated equipment,  and parts  thereof,  that  are  being
discarded should first be treated  in  a way that destroys all
etiologic agents.  Sterilization  is  preferable to decontami-
nation to ensure protection  of  human  health and the environ-
ment.  Any treatment technique  that  results in sterilization
is appropriate.  The  effects of  treatment on  the  integrity
and the  functioning  of the  equipment  need  not be considered
because they  are immaterial  with  equipment  that  is  being
discarded.  Treatment  techniques  that may  be  applicable are
steam sterilization,  incineration, irradiation, and treatment
with heat, gases or vapors,  and chemicals.

Selection of  a  treatment technique  should  be based on  the
nature of the contamination  (that  is,  type and concentration
                             3-41

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of etiologic agents present),  availability of treatment equip-
ment, feasibility, and cost considerations.
Recommendations

The following  EPA  recommendations  pertain  to  the  treatment
of discarded contaminated equipment:

     1.  Treatment before disposal  of  contaminated equipment
         and parts that are being discarded.

     2.  Use of  a  treatment technique  (steam sterilization,
         incineration, irradiation, or  treatment with  heat,
         gases or  vapors,  or  chemicals)  in  accordance  with
         operating procedures  that are  demonstrated  to  be
         effective.
                             3-42

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                          CHAPTER 4

         TECHNIQUES FOR TREATMENT OF INFECTIOUS WASTE

4.1  Introduction

The purpose  of  treating  infectious waste  is to  change  its
biological character by any  method, technique,  or process so
as to  render the  waste non-hazardous  and  safe  for disposal.
Three general types  of treatment  are   suitable  for treating
infectious waste:  heat treatment   (i.e.,  the use  of   steam
heat, incineration, or  dry heat),  chemical  treatment  (i.e.,
the use of chemicals in gaseous or  liquid form),  and irradia-
tion.  The techniques  that  are used most frequently to  treat
infectious waste  are   steam  sterilization  and  incineration.
However, each  of  the  techniques  has  its   advantages   (and
disadvantages) and  is  appropriate  for  treating  different
types of infectious waste (see Section  3.7).

In Sections  4.4  to  4.9,  each  of  the  following  treatment
techniques is discussed in detail:

     0  Steam sterilization

     0  Incineration

     0  Dry  heat sterilization

     0  Gas/vapor sterilization

     0  Irradiation

     0  Chemical disinfection

The use  of   other  treatment  methods is  discussed  in  Section
4.10.  The  reader is  referred  to the  literature  for  more
information  on the principles of  sterilization, waste sterili-
zation, and  the  different  treatment  techniques.   See,   for
example, references 6, 70, 71, 72,  73,  74, and 75.

The reader  is  reminded  of  the  repetitious  nature  of  this
manual, particularly  certain elements  in  each  of  the  later
sections of  this  chapter.  Each  section of  this  chapter is
complete in all  aspects pertaining  to the particular treatment
technique, even   at  the  risk  of  repeating  some  discussions
and recommendations.   Also mentioned repeatedly in this  chap-
ter are the  problems  relative to  particular treatment  tech-
niques that  are encountered  when   plastic  bags  are  used to
contain infectious waste; this matter  is discussed in detail
and from a general perspective in Section 3.4.
                             4-1

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4.2  General Approach to Treatment qf_ Infectious Waste

The sterilization  of supplies,  instruments,  equipment,  and
products has  long  been  standard  practice  in health  care,
pharmaceutical, and many research facilities  and institutions.
Sterilization procedures have  been standardized  in  terms of
types of supplies,  package  size  and density, type of package
wrapping, loading  volume and  configuration,  and processing
variables.   There has not been,  however,  a similar standard-
ization of  the  procedures  for  terminal   sterilization
that is, sterilization  of  infectious waste  before disposal.

There is concern  in the  biological safety field  that persons
may derive a  false  sense of security from using  a particular
treatment technique without  considering  the numerous variables
that determine the  effectiveness of that treatment.   Various
studies reinforce  the  validity  of  this  concern; they have
demonstrated that,   for  example,  pathological   incineration
and autoclaving do  not   always accomplish  sterilization  (59,
60,71,76,77,78).  Indeed, as a consequence  of the recent EPA
endeavors to develop regulations for infectious waste manage-
ment, some institutions  have undertaken experiments to  ascer-
tain whether the procedures that are now being used do  indeed
sterilize the  infectious wastes.   Some  of   the  preliminary
test data were  surprising because  they demonstrated  that the
established procedures  do   not  always  sterilize   the   waste.

Standardization of   infectious  waste   treatment  methods  is
necessary to  ensure the  effectiveness  of   the  treatment in
achieving terminal  sterilization.   The  approach  to  terminal
sterilization that  is  recommended  by  EPA  is the  concept of
standard treatment  loads with development  (by consideration
of the  relevant  variables  in operating conditions and prac-
tices) of  standard  operating  procedures  that  will  be used
to treat each standard  load.   This approach  requires  stan-
dardization of both waste  loads  and operating practices, and
it therefore entails the following procedures:

     1.  Designation of  standard loads,

     2.  Determination, by testing, of the operating conditions
         and practices  required  for each  standard   load to
         ensure sterilization of the waste,

     3.  Development  of  standard  operating  procedures,  and

     4.  Establishment of a periodic monitoring program using
         biological  indicators placed in the waste.

The designation  of   standard  treatment loads  is  recommended
because the characteristics of the  load  (in  terms  of variables
such as  type  of  waste,  density,  moisture content, packaging,
size, and  loading configuration) have  significant impact on
                             4-2

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the effectiveness  of  treatment.   Therefore,  the  first step
in developing  standard  operating procedures  for  each method
of infectious waste treatment is to designate standard  loads.
Alternatively, a  single  worst-case  load  that  is  the most
difficult to  sterilize  can  be  designated the  standard load
for each  treatment  technique.   The  alternative of  a  single
worst-case standard load  for a  given treatment  method may be
preferred for simplicity of operations or when the composition
of the  infectious  waste  stream  is  so   variable   that   the
designation and use of  different standard loads would  be  too
cumbersome or  even  impossible.   The  alternative   of  using
several standard  loads   involves  different  treatment  cycles
that are  tailored to  the requirements of these  loads and,
therefore, this alternative provides  the advantage of savings
in time,  energy  and/or  materials  relative  to  the  treatment
cycle for  the  worst-case  load.   Whichever  alternative  is
selected, the  various  relevant  factors should  be  carefully
controlled and  recorded.   The  significance  of  the   specific
variables in  load  characteristics  that are relevant   for each
treatment technique  is  discussed  below  in  Sections  4.4  to
4.9.  Each  standard  load  should  be  described  in  sufficient
detail so that subsequently it will be possible to reconstitute
it easily.

For each  treatment technique there  are a  variety of  possible
operating conditions and  practices  (e.g.,  temperature, pres-
sure, concentration,  time,  feed  rate),   and  these   should
be standardized  in terms  of the  standard  treatment  loads.
Therefore, the  second  step in  the  procedure  is to  determine
which operating conditions and  practices  must  be  instituted
with each  standard load  to  ensure  that  the  waste  is being
properly treated.  This determination should  be made through
a testing program in  which  standard  loads  are subjected  to
treatment while  the  operating  variables  are carefully con-
trolled and  recorded.    Monitoring  of  the  effectiveness  of
treatment (see  below  and  Section  4.3) will  provide data  on
the effectiveness  of each set  of  conditions  in treating  the
various standard  loads.

The data  obtained by  testing  should  be  used  to   establish
standard operating procedures for  infectious  waste  treatment
by each treatment technique.  These standard operating  proce-
dures should  be developed  in written form for  each  treatment
method that is  used at  each  treatment facility  and  should be
posted near  the  treatment equipment.   In  addition,  it  is
important that all individuals who will be  treating infectious
waste be  educated in  the  standard  operating procedures that
have been developed and  be trained  to operate  the  equipment
effectively.
                             4-3

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Sterility of the waste is the only criterion that can be used to
ensure destruction of pathogenic organisms.   Therefore, ster-
ilizing the waste should be the objective of every infectious
waste treatment  process.    Monitoring  the  effectiveness  of
treatment is  necessary  in  order   to  develop  the  standard
operating procedures.  Monitoring should also be done periodi-
cally thereafter  to  provide  verification  that  the  standard
operating procedures  are  being  implemented  and  that  the
equipment is functioning properly.  The frequency of monitoring
depends on  the  treatment  technique  (see Sections  4.4  to 4.9
for specifics).  Monitoring is discussed in detail in Section
4.3.
4.3  Monitoring

The effectiveness  of  the  treatment  process  in  achieving
sterilization can  best  be  monitored  by  using  biological
indicators (71).  Biological indicators are standardized prod-
ucts that are  routinely used to demonstrate  the  adequacy of
the sterilization  process  (74).   They  consist  of  prepara-
tions of specific  microorganisms  that  are  resistant to par-
ticular treatment methods.   Bacterial spores  are the micro-
organisms that,  are used  as  biological  indicators   for  the
sterilization process  because  they  are much  more  resistant
than other  microorganisms  (that  is,  vegetative  bacterial
cells, fungi, and  viruses).   Therefore,  if  bacterial spores
are killed by a  given  treatment process,  it is reasonable to
assume that  this  indicates  that  all  microorganisms  were
killed by that processing.

Spores of  the  various  species  of  bacteria  differ  in their
resistance to the  different  sterilization processes.  There-
fore, the  more  resistant  species   have  been selected  for
use as biological  indicators,  and it  is  now  standardized to
use spores of  a resistant  strain of  a particular bacterial
species for  testing  each  specific   treatment process.   In
Table 4-1  are  listed   some  biological  indicators   and  the
treatment processes  for which  they  are  suitable indicators
as  recommended  by  The  United States Pharmacopeia   (74,79).

There are many commercial preparations of biological indicators
for verification of the sterilization  process.  These  include
spore strips (strips of filter paper  holding specified  numbers
of spores) and ampules  (which contain  the spores  in a  culture
medium).  The  specifications for  biological  indicators  in-
clude suggested  performance  characteristics   for resistance
to the  treatment process  (79);  that  is,  the  spores should
survive a  specific time  under  the  treatment  conditions  but
be killed  within  a  specified  time  limit  (see  Table 4-1).
This resistance  "window"  minimizes  the occurrence  of false
negative and  false positive  readings  and  thereby  enhances
the reliability of the biological indicators in demonstrating
                             4-4

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the achievement of sterilization.

The commercial  preparations  of   biological  indicators  also
differ in  the  number of  spores  present in each  unit (e.g.,
1()8 versus 10^).   Use  of preparations  with more  rather than
fewer spores is preferable because it increases  the reliability
of the  test.   Furthermore,  when  the   waste   is  especially
hazardous  (e.g., from biosafety level 4 and P4 laboratories),
it may be  advisable  to  use  several different  preparations of
biological indicators in each waste load.

In using biological  indicators,  certain procedures should be
followed.  The  indicators  should be placed within the waste
load, processed with the waste, and then  retrieved at the end of
the treatment  cycle.   They  should  then  be  incubated  in  an
appropriate culture medium  for the designated period of time.
Ail commercial preparations  of  biological indicators specify
the culture conditions that should be used — that  is, culture
medium (if not supplied), incubation temperature, and incuba-
tion time.   After  incubation, the spores  should  be examined
for signs  of  growth.    Sterilization   is  indicated  by  the
absence of viable spores.

The disadvantage that  is inherent  in  the use  of  biological
indicators for monitoring  infectious  waste treatment  is the
minimum 48-hour  incubation  period prior  to  determination of
the presence or absence  of  viable spores.   Such verification
is standard  practice  in clinical  laboratories,  for example,
and the use of a  "device  which indicates proper sterilization"
or "an adequate  recording thermometer"  is required  of those
laboratories that receive Medicare funds (81).  Nevertheless,
it is obviously impractical for all treated infectious wastes
to be retained until the results of monitoring can be ascer-
tained, and EPA does not recommend that all treated wastes be
held in storage  routinely.   Treated waste  should be retained
before disposal for  verification  of  the effectiveness of the
treatment process during  standardization  of  loads and proce-
dures for  new  wastes,   new  equipment,  or  new   techniques.

There are  other  indicators  that provide  an  instantaneous
indication --  usually  by a chemically induced  color change
-- of the  achievement of some condition (e.g., attainment of
a certain  temperature  or  exposure to  ethylene  oxide  gas).
However, these indicators are not suitable for use  in monitor-
ing the sterilization process because each treatment technique
involves a  combination   of  factors and therefore  no  single
factor is  a  valid  criterion of  the  effectiveness   of  the
process.  For  example,  in  the  steam and dry  heat treatment
methods, the wastes  must be exposed to a certain  temperature
for at least  a minimum  period  of  time in order  to achieve
sterilization.  Therefore,  any  indicator  that  indicates only
the attainment  of  a particular  temperature  is  not  suitable
for monitoring the effectiveness of infectious  waste treatment
                             4-6

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when time is a factor that is  equally as important as tempera-
ture.  There  are  some indicators  that  do  integrate time and
temperature; however,  these  do  not  seem to  be sufficiently
standardized and reliable for use  in monitoring sterilization
(82,83).  Similarly,   the  indication  of  mere  exposure   to
ethylene oxide does not mean  that  the degree of that exposure
has been sufficient  (in  terms of time  and gas  concentration)
to achieve  sterilization.   Until  other  indicators  have been
standardized for use  in monitoring the sterilization process,
biological  indicators  should  be  used  in  all  monitoring.

It is essential that  the  indicators be properly placed within
the waste load  so  that they  will  indicate  the effect of the
treatment on the waste at  the  interior of the load.  Ascertain-
ing that the outside of a package of  infectious waste has been
sterilized  provides no information about the effect of treat-
ment on the waste  inside the package.  There  are  only a few
exceptions  to this including  treatment of contaminated equip-
ment (when  placement  of  biological indicators on the surface
may be  appropriate)  and treatment of  food  products contami-
nated with  the toxin  of Clostridium botulinum  (because of the
risk of exposure in  opening  the container (69)).  Otherwise,
for accurate monitoring,  the  biological indicators should  be
distributed throughout the waste load.   It  is also important
that the indicators  be placed within waste  situated at those
locations within the  treatment  chambers  where treatment con-
ditions are  not  optimum  (for example,  near  the  drain  of  a
steam sterilizer)   so  that monitoring  will provide  accurate
data on the worst-case conditions.

As was mentioned above, monitoring is essential  in development
of standard operating procedures for each treatment technique
to verify that  the  treatment  process  is achieving  steriliza-
tion.  Monitoring  also  permits  refinement of the  standard
operating procedures  so that excess processing can be avoided
while savings are  realized  in  expenditures of time,  energy,
and/or materials.   Subsequent periodic monitoring  serves   to
verify sterilization, thereby verifying  that proper procedures
were used  and  that the  equipment was  functioning  properly.
Specific recommendations  for  monitoring  the  different treat-
ment techniques (i.e.,  appropriate  biological indicator and
frequency of periodic monitoring)  are included  in the discus-
sions of the  treatment techniques (see  Sections 4.4 to 4.9).
The recommended  monitoring  frequencies  are    less  frequent
than those  that are  standard  practice  for the same processes
when supplies are treated (84,85).

Recommendations

EPA makes the following recommendations for monitoring infec-
tious waste treatment:
                             4-7

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     1.  Monitoring of  all treatment processes  to establish
         standard operating procedures for treatment of stan-
         dard loads of infectious wastes.

     2.  Subsequent  periodic  monitoring  of  the  treatment
         processes, as recommended in Sections 4.4 to 4.9 for
         the different treatment techniques, in order to verify
         that  the  infectious   waste   is being  sterilized.

     3.  Use of biological indicators to monitor the efficacy
         of infectious  waste  treatment.   Placement  of  the
         biological indicators within and  throughout the waste
         load and  processing  with  the  waste.   Retrieval  of
         the indicators,  culturing  in   accordance  with  the
         manufacturer's instructions, and  examination  of the
         biological indicators  after  incubation.  Steriliza-
         tion is  indicated  by  an  absence of  viable  spores.
4.4  Steam Sterilization

The equipment that  is  used  for steam  sterilization  is known
as a steam sterilizer or autoclave.  A pressure vessel called
a "retort"  has  also  been  marketed  recently  for the  steam
sterilization of  infectious waste.   There  are   two  general
types of steam  sterilizers  --  the gravity displacement type,
in which  the  displaced  air flows  out  the  drain through  a
steam-activated exhaust  valve,  and  the  pre-vacuum  type,  in
which a vacuum  is pulled to remove  the  air before  steam is
introduced into  the chamber.   With  both  types,  as  the  air
is replaced with  pressurized  steam,  the temperature  of  the
treatment chamber and  of  the waste  load  increases.   When all
the air  is  removed  and  replaced  with steam,  the  saturated
steam that  is  essential  for  accomplishing  sterilization  is
present within the treatment chamber.  For a detailed discus-
sion of the theory  and practice of  steam  sterilization,  see
reference 71„

The operating temperature of the  steam sterilizer is related
to the  steam  pressure.   Most  gravity  displacement  steam
sterilizers operate  at  121°C (250°F) with  saturated  steam at
17 to 18 psi within  the  chamber,  although  some units of this
type operate at  132°C  (270°F).   Pre-vacuum steam sterilizers
operate at  132°C  (270°F)  with  saturated steam  at  27  to  32
psi within  the  chamber.  A  typical  retort  operates  at 132°
to 135°C  (270°  to 275°F) with  chamber pressure   at  35  to 38
psi.

The criteria  used to  set minimum  exposure  times  for steam
sterilization are the kill times for Bacillus stearothermophi-
lus spores  exposed  to  wet  heat,  e.g.,  15 minutes  at 121°C
(250°F) (79).   Kill  times at  various temperatures are listed
in Table 4-2  (86).   In practice, exposure times  are usually
                             4-8

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                        TABLE 4-2


                   STEAM STERILIZATION9
     Temperature                   Spore Kill Time"
 (°F)          (°C)                    (minutes)
240
245
250
257
270
280
116
118
121
125
132
138
30
18
12
8
2
0.





8
Data from Table 1A in reference 86 (E.  Hanel, Jr.   Chemical
Disinfection.  In:  Control of Biohazards in the Research
Laboratory, Course Manual.   The John Hopkins University,
School of Hygiene and Public Health, Baltimore, Maryland.
1981).

In steam sterilization,  exposure time for treatment is
usually at least double  the kill time (71).
                           4-9

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at least double the kill times in order to  provide  an adequate
margin of safety (71).  With steam sterilization of infectious
wastes, it  is  essential  to ensure that the entire waste load
has been exposed to the  necessary temperature  for the required
period of  time.   Heating  of  the  containers  and the  waste
usually lags  behind  the  heating  of  the chamber  (71,73).

There are reports  that the commonly used (and even prolonged)
treatment times are  often  not sufficient to sterilize wastes
because the  center  of   the  waste  load does  not reach   the
sterilizing temperature  (59,60,64,76,87,88).   One method  of
ascertaining when  the  interior  of a  load has  attained   the
proper temperature is to use  thermocouples.  However, thermo-
couples are  not  standard  equipment  for  steam  sterilizers.
It is  important,   therefore,  that  the  principles of  steam
sterilization be  understood  and  be  used  in  the  development
of standard operating procedures.

In steam  sterilization,  heating  of the waste occurs  by  two
mechanisms: steam  penetration and conduction  of  heat.  Steam
is lighter  than air, and therefore  the  air must be completely
displaced in order for  the steam to  penetrate throughout  the
waste load.  The presence of air within the sterilizer chamber
can prevent  effective  sterilization   Dy:   (a)   reducing   the
ultimate possible  temperature  of  the  steam, regardless  of
pressure; (b)  causing  variations  in  temperature  throughout
the chamber  because air  and steam do not mix  readily;   (c)
prolonging  the  time  needed to attain  the maximum temperature;
and (d)  inhibiting  steam  penetration  into  porous materials
(71).  The  temperature  curves  in Figure  4-1  illustrate  the
effects on  load temperature  of  the  presence  of  air  in  the
sterilizer  chamber.

Other problems  can result  from  the  use  of  plastic  bags  (which
may exclude  steam  or  trap  air), plastic  containers  (which
are poor  conductors  of  heat), and deep containers (which  may
prevent displacement  of  air from  the  bottom).   Therefore,
packaging,  containers,   and   loading   considerations  are  of
critical  importance  to   the  efficacy  of the  steam treatment
process.  The factors that should be considered in  designating
the standard loads for steam sterilization  include  the follow-
ing :

     0    Type of waste

     0    Packaging materials

     0    Integrity of the  package

     0    Type of containers

     0    Addition  of water to bags  or pans
                              4-10

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                           FIGURE  4-1

      TEMPERATURE  CURVES   FOR  STEAM   STERILIZATION   WITH  AND
              WITHOUT COMPLETE  REMOVAL OF  AIR (71)
Courtesy of American Sterilizer Company, Erie, Pa.
Run A:  when air  was  completely discharged from the chamber,
temperature in package rapidly approached that of surrounding
steam.  Run B:  when only  a small  amount of air was discharged,
temperature in package lagged about  50°F  behind that  of sur-
rounding steam  throughout  the 45-minute  exposure.   Pressure
was maintained at  20  pounds. Loads  A  and B  were  identical.
                             4-11

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0   Volume of the treatment load and its configuration in
    the treatment vessel

Type of Waste.  For factors that are relevant to the steam
sterilization of specific types of infectious waste, see
the discussion  of  the  recommended  treatment techniques
for the different  waste types  in  Chapter  3.   The type
of waste  (body  tissue,  paper,  rubber,  plastic,  glass,
liquid) is  an important  factor  in  steam   sterilization
because the density  of  the waste affects  the  degree of
steam penetration.  Waste  type  also  determines the type
of packaging  and  the  containers   that are   used.   If
different types  of  waste  are to  be  steam sterilized,
the composition of the standard loads should be designated
according to types of waste, either singly or in standard-
ized combination  that   is  based  on  the composition  of
the infectious  waste   stream.   Testing  of  the  steam
sterilization process to develop standard operating pro-
cedures may  indicate  that  changes   in standard  loads
(e.g., to  a  single  type of  waste  such  as  petri dishes
or flasks of  liquid)  will  provide  greater  efficiency in
processing.  Alternatively,  a  worst-case   load  can  be
designated the  standard  load,  with   all  loads  being
processed in  accordance  with  the  standard  operating
procedures determined for  this  load  that is most diffi-
cult to steam sterilize.

Packaging materials.  The type of material that is used to
package the infectious  waste for steam  sterilization can
hinder the  treatment  process.  For  example,  it may be
difficult to  achieve  steam sterilization  of  waste con-
tained in  plastic  bags,  especially  if  the   bags  are
sealed (see  below).  Plastic  bags  are convenient  for
collecting many  types   of  infectious   waste,   but  the
disadvantages of plastic must be understood  when  loads
and operating  procedures  for  steam  sterilization  are
standardized.  Plastic  bags are manufactured  from dif-
ferent types  and  thicknesses  of  plastic.  Heat-labile
plastic crumples  and melts  during   steam   sterilization
and therefore  should  not   be  used   when waste  will be
steam  sterilized unless the plastic  bag  is  placed within
a  strong paper  bag  or another container.  Minimum thick-
nesses are  specified for  plastic  bags  used  to contain
infectious waste  (3.0  mils for single  bags,  1.5 to 2.0
mils when  double  bagging  is  used),  but this thickness
might  interfere  with   the  effectiveness  of  treatment.
Even some  so-called "autoclavable"   plastic bags do not
permit the  penetration of  steam  (59,60).   Therefore,
the type  of  packaging  used to  contain wastes that will
be steam  sterilized  should  be  appropriate  for  steam
sterilization in order  to  assure efficacy  of  the  treat-
ment process.
                         4-12

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 Integrity of package.   The  integrity  of  the package  —
 that  is,  whether the plastic bag  or the  box or the pan
 is  closed or open during treatment — affects the ability
 of  the  steam  to penetrate  the  package.    It  has  been
 reported  that  longer  exposures  are  required  to   steam
 sterilize waste  in closed packages.   Karle's study (76),
 for example,  demonstrated  that  sterilization of   a  load
 of  petri dishes  in  a plastic  bag was  best achieved  when
 the top  of  the bag was  folded  back  to the  level  of the
 top of  the  waste.   However, as  Karle noted, because  of
 the potential  hazard,  this  procedure  is not  recommended
 if  the  bag  contains  infectious waste  (89).   Some  proce-
 dures that  have  been  recommended  include  tying the bag
 loosely  (87) and puncturing the  bag  before it is treated
 (61).   It  is  important  to  remember  that  open bags and
 pans of infectious material constitute a potential  hazard
 for dispersal of pathogenic agents  into the  environment.
 Therefore,  if the infectious waste is transported through
 the facility to  a steam  sterilizer,  any bag  that is  open
 or  not  securely  closed should be conveyed within  a  con-
 tainer  that is covered with a tightly fitted lid.    Bags
 and pans should  be opened,  if necessary, only within the
 steam sterilizer.  Other methods  to  enhance  displacement
 of  air from the bag (e.g., adding water to the  bag, placing
 the bag  in  a shallow metal pan  —  see  below)  should  also
 be  evaluated during standardization of  the waste loads for
 steam sterilization.

 Type of containers.  Plastic  bags  are often placed  in
 rigid containers to  prevent  spilling.  The use of  metal
 containers  is advantageous in steam sterilization because
 metal is  a  good  conductor  of  heat  which  therefore de-
 creases the time required  for the waste to attain  ster-
 ilizing temperature.   By  contrast,   plastic  containers
 are poor  conductors  of  heat  and  even prolonged   cycles
 may not be  sufficient  to bring the waste to  sterilizing
 temperature.  The  waste can  be  sterilized  directly  in
 the metal containers,  or other packages such as plastic
 bags and  cartons can  be placed  in  metal  containers  in
 the steam sterilizer.  Rubbo and Gardner (73) and  Litsky
 (87) reported that  shallow  pans  allow  more  rapid  steam
 penetration  than   deeper   containers   and   buckets.

 Addition of water.   There are some reports  that  the addi-
 tion of water  to  the bag or pan of waste can  help  to  ensure
 sterilization and to decrease  treatment time  by providing
 for steam  generation  and  air  displacement   within  the
 bag or pan  (see, for example, reference 73).  Different
 amounts of water have  been  recommended ranging from 100
milliliters (61)  to  one liter  (87).   Rubbo  and Gardner
 (73) reported that  the addition  of  one liter  of  water
 to metal  containers  greatly   accelerated  air  removal.
However, there are  other reports that the  addition  of
                        4-13

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     water to  plastic  bags  does   not  ensure  sterilization
     (60,88), and that the addition of water  to animal bedding
     slows the  heating  of  the  waste  (65).  Therefore,  the
     effect of adding water to the waste should be evaluated,
     and, if the addition of  water to plastic  bags and other
     containers is effective,  this practice should  be stan-
     dardized .

     Volume and configuration of the waste load.  The  volume
     of the waste can be  an important factor in the efficacy
     of the steam sterilization process.  It can be difficult
     to attain  sterilizing  temperatures  in  large  loads;  it
     may be more  efficient  to autoclave a  given  quantity of
     waste in  two  small  loads  rather  than one  large  load
     (76).  In addition, the configuration of the load within
     the sterilizer  affects  the  penetration  of  the  steam
     throughout the  load  — the steam  must be able  to move
     freely to  the  bottom  of  the  sterilizer.   Laying  a bag
     or container on  its  side can  facilitate  the  removal of
     air and is appropriate if such placement will not result
     in spilling within the autoclave (87).

Therefore, loads of  infectious waste  for  steam sterilization
should be standardized with  due consideration of the variables
in the factors  discussed  above.  The  standard  load should be
described in writing. The detailed description should address
the variables without ambiguity  and should provide specifics
about the type  of  waste,  quantity, size  of  the package, how
it is  closed,   use   of  other  containers,  whether water  is
added and  if  so  how much  and  when, how many  packages are
treated per load, how they  are  arranged within the autoclave
or retort,  and  all  other  relevant  details.    From   such   a
description, it  should  be  possible  to  reconstitute  easily
the standard waste loads for steam sterilization.

When the standard loads  have been designated,  tests  should then
be run to  determine the  necessary operating  conditions for
each standard load.   The temperature is a function of the steam
pressure, and the principal variable  in operating conditions
is the length  of the cycle.   The  total  length  of the cycle
includes the heating, processing,  and  cooling  phases.   It is
important to remember that  a minimum time  at  temperature is
necessary to  kill  the  pathogens,  and  during  this  time the
waste must be at sterilizing temperature.

Determination of  standard  operating  procedures  for  steam
sterilization will  provide  the  necessary  information  for
setting the  length  of  the  cycle to  ensure that  all  of the
waste is  exposed to  the  proper  temperature  for  sufficient
time.  (For example,  30 minutes  might suffice  for one stand-
ard load, but  processing  times  of 60 to  90  minutes,  or even
longer, might  be  necessary  with  other   loads.)   When  the
operating conditions  required  for   the  sterilization  of each
                             4-14

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standard load  have  been  determined,  the  standard operating
procedures should  be  developed  in written  form  and posted
near each  steam  sterilizer that  is  used to treat infectious
waste.

It should  be noted  that  improper  operating  techniques  can
result in the dispersal of etiologic agents into the  environ-
ment through  the  drain  and  the  exhaust  vent  of the  steam
sterilizer.  For  example,  such  dispersal  can  occur  when
infectious waste  is  handled  roughly  or  spilled  within  the
autoclave.  It  has  been  reported  that,  when  high vacuum
steam sterilizers  are  used,  viable  microorganisms  from  the
waste might  be  released  to  the  atmosphere  with  the vented
steam; this  is  most  likely  to  occur  when  aerosols  can  be
generated during  loading and  evacuation  (e.g.,  from liquid
wastes or animal  bedding)  (90).   The  possibility of  pathogen
release can  be  minimized  by  installing  appropriate  filters
in the  drain and  exhaust lines.  Various types  of  filters
are available  (e.g.,  roughing,  HRPA, and  chemical filters),
but selection,  installation,   and  maintenance  must   be  done
with care.   The  safety  of  steam  sterilization  can  also  be
enhanced by  other  design  features   such   as  provision  for
proper exhaust and heat  dissipation  (i.e, not in the breathing
zone of operating personnel)  and  by  careful placement of the
unit (i.e., away from traffic).

Additional precautions  should  be  taken when  certain wastes
are steam sterilized because of multiple hazards in the waste
as well  as hazards created  by  the  treatment  process.   For
example, volatile chemicals and those that might be volatilized
during steam  sterilization  should  be  autoclaved   only  if
there are  chemical  (i.e.,  hydrophobic)  filters  on  line.
Radionuclides should  be  steam  sterilized  only  if   properly
packaged to ensure that radioactivity is not dispersed within
the  sterilizer   ana    into  the   drain  and  exhaust lines.

All individuals  who  will be  steam  sterilizing  infectious
waste should  be  properly  trained to  operate the  equipment
effectively.  They should be educated  in the procedures that
have been developed for  making up the  standard loads  and for
using standard operating procedures.   It is these individuals
who are ultimately responsible for implementing  the procedures.

In addition,  personnel   should  be  educated   in  the  proper
techniques to use  in  order to minimize personal  exposure to
the various hazards they  might encounter while steam steril-
izing infectious waste.   These techniques  include  (a) avoid-
ance of  aerosol  formation during  waste transport  (e.g.,  by
proper packaging  and  sealing);  (b)  minimization  of  aerosol
formation during autoclave  loading  (e.g.,  by  avoiding  rough
handling of the waste, by loosening caps of liquid containers
and removing pan  lids  only after  the  waste has  been placed
within the  autoclave);  (c)  prevention  of  spillage of  waste
                             4-15

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during autoclave loading;  and  (d) use of equipment for personal
protection as  necessary  (e.g.,  laboratory  coats,  rubberized
aprons, insulating  gloves  that  are  impervious to  liquids,
respirators as necessary).

All steam  sterilizers  should  be  routinely   inspected  and
serviced.  Routine maintenance  should  include daily checking
of the  strainer,  weekly  flushing  of the  chamber  drain,  and
weekly checking of the controls  and  data signals.  Manufactur-
ers recommend  preventive  maintenance  by  certified personnel
on a  quarterly basis.  Servicing should  include  calibration
of the thermometer.

Operation of  the  steam sterilizer  should  be  logged  with  a
recording thermometer  which registers  on  a  recorder  chart.
This simple  device  records  the   temperature  at  the  drain
line.  The  log  should be checked routinely  to  ascertain
that a  sufficiently  high   temperature  was  maintained  for an
adequate period of time during  the  cycle.   Failure to attain
or maintain operating temperature is an indication of mechan-
ical failure.

Bacillus stearothermophilus  is  the  appropriate  biological
indicator to  use  in  monitoring  steam  sterilization  because
the spores are  very  resistant  to  steam heat.   After standard
operating procedures have been established, the steam steril-
ization process  should be  monitored periodically  to  verify
that proper procedures are  being followed and that the equip-
ment  is  functioning  properly.    A   schedule  of   about  once
every two  weeks  would be appropriate  for  monitoring  the
steam treatment  of  infectious  waste;  this is  less  frequent
than the at-least-once-a-week  monitoring with  Bacillus stearo-
thermophilus spores that  is recommended for  the  steam ster-
ilization of  supplies (84,85).  However,  when  the waste is
from a  biosafety  level 4  or  level  P4  laboratory,  each load
should be monitored with biological  indicators and the treated
waste should be  retained  before disposal  until sterilization
has been verified.
4 .5  Incineration

In incineration, the waste  is combusted, producing gases and
a non-combustible residue or ash.  The product gases are vented
to the  atmosphere through  the  incinerator  stack  while the
residue from incineration of  infectious waste may be disposed
of in a sanitary landfill.  Incineration provides the advantage
of greatly reducing the mass  and volume of the waste — often
by more  than  95  percent  --  which,  in  turn,   substantially
reduces transport and disposal costs.

An incinerator that is  used to  treat  infectious waste may be
situated on-site at the facility where  the  infectious waste
                             4-16

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is generated or  at some off-site  location.   Any incinerator
may be used to treat infectious waste if it properly incinerates
the waste by killing the  pathogens  and destroying any biologi-
cally active material  that  may  be  present.   Two types  of
incinerators (the  pathological  incinerator   and  the  rotary
kiln) and  the  concept  of "total  incineration"  are addressed
briefly below.    The remainder  of  this  section provides  a
detailed discussion  of  the  technique of  treating  infectious
waste by incineration.

Pathological incinerators have  traditionally  been  used  for
the incineration of pathological waste  as  well as  some other
types of  infectious waste.   Most pathological  incinerators
are multi-chambered  with  relatively  small  capacity;  they
provide high  combustion  temperatures   and  can  be  operated
intermittently.  Because of their  design and operating char-
acteristics, pathological  incinerators  are   appropriate  for
the incineration of  infectious waste when they  are  operated
properly (see below).  The  intermittent  mode of  operation is
suitable for incineration of  pathological  and other types of
infectious waste because these wastes are  seldom generated in
sufficiently large quantities by a single  facility to provide
enough feed  for  a  continuous-feed incinerator.   Most large
hospitals and medical  centers have pathological incinerators
on the  premises;  pathological  incinerators  are often found
in smaller hospitals also,  as  well  as in  large research facil-
ities.  Many research  laboratories use pathological inciner-
ators — either their own or others to which  they have access.

A rotary kiln is much larger  than  a pathological incinerator,
and it  is  therefore usually  found in  an industrial  setting.
It provides  a  controlled environment  which,  coupled with its
rotation, facilitates complete  combustion  of the waste.   The
rotary kiln  is the  traditional  type  of incinerator  that is
used to treat many  types of hazardous  waste.  It is now also
being used to treat  infectious  waste.   For example,  a rotary
kiln is used by at least one  pharmaceutical  company to incin-
erate production wastes,  including infectious waste.   Rotary
kilns are  used in  some  commercial  incineration operations to
treat various  hazardous  wastes including  infectious  wastes.

In recent  years  there  has  been increased interest  in total
incineration with  heat  recovery — that is,  incineration of
all the waste  that is  generated by a  facility  with utiliza-
tion of  the energy that  is  recovered  from  the  combustion
process.  If total  incineration is undertaken at  a  facility
that generates infectious waste, the possibility of including
the infectious waste in the  feed  to the  incinerator  should
be evaluated carefully.  There might be management  problems
because the  infectious  waste  should  be   accorded  special
handling —  for example, the  infectious  waste should  be  kept
as a  separate  waste  stream  that  is  not  mixed  with  other
wastes and  it  should be incinerated promptly.   In addition,
                             4-17

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the use  of  special  techniques  (e.g.,  in  feeding)  might be
required to ensure proper  combustion  of the  infectious waste
so that  it  receives  the treatment  necessary  for elimination
of the biological hazard.  In consideration of the management
and operational  difficulties that  might  be   encountered if
infectious wastes  were  included  in  a  total  incineration
program, it might  be  preferable  to  treat  infectious waste by
some alternative method,  especially if the quantity or  heat
value of  the  infectious  waste  stream  is  small  relative to
the total waste  stream  of  the  facility.  The treated waste
could then be included in the general waste stream and incin-
erated without special handling.

It is known that pathological  incinerators  that are properly
designed, maintained, and  operated  are effective  in killing
the pathogens that are  present  in  infectious  waste.   There
has not yet been sufficient experience with total  incineration-
heat recovery  systems  to  ascertain   their  suitability  for
proper incineration  of   infectious  waste.   Nevertheless, it
must not be inferred that all pathological incinerators will,
by definition,  automatically provide   appropriate   treatment
for infectious  waste  nor   that  incineration-heat  recovery
systems are riot  appropriate for infectious waste  incineration.
In theory, any  incinerator  —  including municipal and indus-
trial incinerators  —  could be  used  for  infectious  waste
incineration.  However,  incinerators do not  always  sterilize
the waste in  the  combustion process,  and  if  the incinerator
operating conditions are not correct, viable pathogenic organ-
isms can be  released to the environment  in  stack emissions,
residue ash, or wastewater  (64,77,78,91,92).

Regardless of  the  type  of  incinerator  that  is   used,  the
infectious waste  must  be  exposed  to a  sufficiently   high
temperature for an adequate period of  time to  ensure destruc-
tion of  all  pathogenic  organisms.   It  would  seem to  be  a
simple matter to designate the minimum  combustion temperatures
and residence times that will ensure destruction  of pathogenic
organisms during incineration of  infectious  waste.  However,
studies by Barbeito and co-workers (64,77,91) demonstrate  that
these requirements  vary  with  each   individual  incinerator
unit.  It  would   therefore  be  inappropriate   to   designate
operational standards for the incineration of infectious waste.
Consequently, EPA recommends that each  incinerator that is  used
to combust infectious waste  undergo a  trial burn to  determine
the standard  operating  procedures  for  that unit which,   when
implemented for  the  incineration of   infectious  waste,   will
ensure the  killing  of  pathogens  and  the   destruction of
biologically active material present in the waste.

Design features  as well  as operating  procedures  affect the
incineration process, and variations in these factors determine
if the etiologic agents in the waste are exposed for sufficient
time to  the  temperature that  is  necessary   for  kill.   In
                             4-18

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pathological incinerators,  the design  features  that  affect
combustion conditions  include  type  of  refractory  lining,
number and location of burners, stack height, designed linear
velocities, and  accuracy  and  reliability  of  temperature-
recording devices  (77).   Certain  design  features  will  help
ensure that the infectious waste is being properly incinerated.
Mechanical devices  such  as  a  lockout device  and  a shut-down
device can help  ensure  that the  infectious  waste  is exposed
to the appropriate combustion temperature.  The  lockout device
prevents ignition of  the  primary  chamber  until the secondary
chamber is at operating  temperature while the shut-down device
keeps the  secondary chamber  at  operating temperature  for a
certain period of time  after  the  primary  chamber  is shut off
or until it  cools  to a  certain  temperature.   Monitors  that
provide continuous  information  on  combustion  temperature,
waste feed  rate,  fuel   feed   rate,  and  air  feed  rate  are
important, and  indeed  essential,   for maintaining  operations
within the limits prescribed by the standard operating proce-
dures.  For  additional   details  on  incinerator  design,  see
references 93 and 94.

In order  to  establish  standard  operating procedures,  every
incinerator that is used for incineration of infectious waste
should be tested  for its efficacy  in  destroying  microorgan-
isms.  Data  from these  trial  burns should  then   be  used  to
standardize operating  procedures  for  the  incineration  of
infectious waste.  The trial burn would also provide informa-
tion on the  relative  efficiencies of  effective alternatives.
The standardization  of  procedures should  include  establish-
ing the acceptable  operating  limits for  the  various parame-
ters that  affect  incinerator operation.   These  parameters
include:

     0 Variation in waste composition

     0 Waste feed rate

     0 Combustion temperature

     0 Air feed rate

     0 Fuel feed rate

     Variations  in  waste composition.  The  composition  of
     the feed affects  the combustion conditions  because  the
     different  types   of  waste  differ  in  characteristics
     that are   important   in   incineration  (e.g.,  moisture
     content, heating value).   Because it  is  unlikely  that
     only one particular  type  of infectious  waste will  be
     incinerated at  a  facility,   it  is important  to  realize
     the effect  of  each  type of  waste or  each   mixture  of
     different wastes on the combustion process and to deter-
     mine which  adjustments   in  other  operating  variables
                             4-19

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must be made  in  order to maintain  proper incinerating
conditions.  Data from  the trial  burn may also indicate
which particular  combination  of waste provides the best
feed for efficient  incinerator  operation.  Another fac-
tor that should  be  considered is  the plastic content of
the waste, in particular  the  content of polyvinyl chlo-
ride and  other  chlorinated   plastics.    The  combustion
products of  these  plastics   include hydrochloric  acid
which is corrosive  to  the incinerator and would have to
be scrubbed from the stack gases if significant quantities
are produced.  Chlorine is also  important  in  free radical
formation which occurs under  the elevated  temperatures of
incineration.  Therefore,  the  content   of  chlorinated
plastics in  the  waste load  should  be  minimized  when
incineration is used to treat the waste.  This reduction
can be achieved by:  (a) eliminating  the  use of chlorin-
ated plastic items where  infectious waste are generated,
(b) substituting other types  of plastic  (e.g., polyethyl-
ene and  polypropylene) for  disposable items  and trash
bags, (c)  using  other  types  of  containers  to  hold the
infectious waste,   and  (d)   treating   infectious  waste
with a  high  chlorine  content  by   methods  other  than
incineration.

Waste feed rate.  The rate at which waste  is  fed into the
incinerator also  affects  the  efficacy and efficiency of
incinerator operations.   However,  it  is  important  to
avoid overcharging  which  often  results   in  incomplete
combustion and  therefore  in  unsatisfactory treatment of
the infectious  waste.   The optimum  feed  rate  should be
determined for  each type  of  feed.    It  should be noted
that infectious  waste  that is to be incinerated should
be properly contained  to  prevent  dispersal of pathogens
into the  environment  during  transport  and before  and
during  loading  of the  waste  into the incinerator.  Fur-
thermore,  in  order to facilitate complete  combustion,
the waste  should not  be  compacted  before incineration.

Combustion temperature.   The  trial burn will provide in-
formation  for  determining the  minimum temperature that
must be  maintained during  combustion  to ensure proper
treatment  of the infectious waste.  The combustion temper-
ature can  be  maintained,  as necessary,  by adjustments
in the  combustion air  feed  and   in  the  amount of fuel.
With pathological  incinerators,  in  particular,   it  is
essential  that  operating  temperatures be  attained before
charging of the  waste  or  ignition of  the  primary  chamber
in order  to achieve  complete  combustion of  the waste
and kill of the  pathogens.

Air feed rate  and fuel feed  rate.  The  air and  fuel  feed
rates should be  adjusted  to maintain the  combustion  tem-
perature at  the  necessary level.   Adjustments  will be
                         4-20

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     needed as  the  composition  of  the feed  and  the  waste
     feed rate vary.

The standard  operating  procedures that  are  developed should
specify the acceptable  operating  limits for these parameters
to ensure  that no  viable  bacterial  spores  are recoverable
from the  stack emissions.   The  following  practices  should
also be   included  in   the  standard   operating procedures:

     0 Operating  limits for charging,  temperature,  air flow,
       and fuel feed should be carefully observed while waste
       is being fed and combusted.

     0 The  incinerator and associated  equipment  should  be
       inspected  to detect  leaks and to check the operability
       of shut-down controls.

     0 The incinerator  should be  airtight,  or  it  should be
       operated under  negative  pressure to  prevent fugitive
       emissions  from the combustion zone.

In addition,   the  following practices  should be  included in
the standard  operating  procedures  for  batch-fed (e.g., path-
ological) incinerators:

     0 Infectious  waste  should  not be  fed  during  start-up
       and shut-down  in order  to ensure  that   the  waste  is
       incinerated  at   the  proper   combustion temperture.

     0 The primary  chamber should  not be  ignited  until  the
       secondary  chamber  is heated  to  operating temperature.

     0 Waste  should  not be fed until  the  previous  batch has
       completely burned  out  in  order to prevent  surges  up
       the stack  of incomplete combustion products including,
       possibly,  viable microorganisms.

The standard   operating  procedures  should  be  compiled  in
written form  and  posted  near  the  incinerator  so  that  they
will be available at the incinerator at all times.

It is  important   to  realize that  even the  best incinerator
design and standard operating procedures will be valueless if
the incinerator  is  not operated  properly.   The individuals
who will be operating the incinerator should receive training
in how to  operate the  incinerator  effectively.   They should
be educated in  proper  procedures  and  in  the  importance  of
following the  standard operating procedures that were developed
during the testing program.

At present, pathological  incinerators  (i.e.,  those  that burn
only pathological  waste)   are   not subject   to  the  federal
regulations promulgated under either the  Clean  Air  Act (CAA)
                             4-21

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(because of their small capacities) or the Resource Conserva-
tion and Recovery Act  (RCRA)  (because regulations for infec-
tious wastes  have  not  been  issued).   However,  other types
of incinerators that are  used to incinerate infectious waste
could be subject to  CAA  or RCRA regulations (95,96) because
of their  size or because they  incinerate  hazardous wastes.
Some states and  localities have  applied  emission standards,
in particular  standards  for  particulate  emissions,  to  all
incinerators  (including   pathological)  within  their  juris-
dictions .

A rule-of-thumb that is often used in incinerator operations
is that  operation  is  satisfactory  if there  is   no visible
opaque plume emanating  from the stack.  Although  this criterion
may be  satisfactory  regarding  particulate  emissions,  it  is
neither valid  nor  relevant for  emissions  of microorganisms,
and only specific testing  can ascertain that no viable patho-
gens from  the  waste  .are  being  emitted  from   the  stack.

In the  trial  burns  that  are  used to  establish the standard
operating procedures for the incineration of  infectious waste,
spores of Bacillus  subtil is  variety  niger  (globig ii)  should
be added to the waste.  The  stack gas should then be sampled
for viable  spores  by  the  use  of  sampling  trains  (77)   or
midget  impingers  (92).   The  number of  spores  added  to  the
waste (i.e.,  the spike) and the  sampling time (volume) should
be adjusted to ensure  a theoretical challenge of at  least 1 x
ll)6 spores in the collected sample (in other words, at least
1 x 106  spores would  be  present in the sample if no spores
were destroyed  by  the   incineration  process).   Monitoring
should be repeated  whenever  substantial repairs  are made  on
the incinerator (i.e.,  work other than routine maintenance).
4.6  Dry Heat Sterilization

Dry heat treatment  (that  is,  the application of heat without
the addition  of  steam)  is another  method that  is suitable
for sterilizing  infectious  wastes  (see  references  71  and
97).  Heat  treatment  is  often  used   to  sterilize   liquid
wastes in closed systems.   It  is also appropriate  for  other
types of infectious  waste including  contaminated  equipment.
Although the  sterilization of   solid  wastes  in an  oven  is
technically suitable,  this treatment technique  has the  dis-
advantages of  being  costly   and  time-consuming.   Neverthe-
less, this method is included among  the  alternative treatment
options because  it  is often  used  to treat liquid  infectious
wastes and  it may be  the  method of  choice  for treatment  of
solid wastes  at some facilities.

The cycles  used  for  dry  heat  treatment  are  longer  or  at
higher temperatures  than  those  used in steam  sterilization
because the  heat  is transmitted through the  waste load  only
by conduction (i.e., without  permeation  of  pressurized steam).
                             4-22

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Furthermore, higher  temperatures are  necessary  for protein
coagulation (the principal  factor  in  the killing  of micro-
organisms) when less water is present (71).

Two methods are used  in  the  heat sterilization of wastewater
— the batch and  the  continuous treatment processes.  In the
batch process,   wastewater  may  be   collected   in  a  holding
tank which  is  subsequently  heated to,  and maintained at, the
treatment temperature.  Alternatively,  in the continuous ster-
ilization process, the wastewater is heated  to the treatment
temperature and is then  passed through heat  retention tubing
so that  it  is  maintained at  the required temperature  for a
sufficient period of  time.   Heat exchangers  are often incor-
porated  into  the   system beyond the  heat retention tubing
in order  to  recapture heat  —  that  is  used  to  preheat the
incoming wastewater — and simultaneously to cool the treated
effluent prior to  its discharge.  In both the batch and the
continuous treatment  processes,  steam,  jackets  are  usually
used to heat the wastewater.

Standard operating procedures  should be  developed  to ensure
that infectious wastewater  is  being  sterilized by  the  heat
treatment process.  For  batch  treatment,  the  following vari-
ables are  important   in   developing  the  standard  operating
procedures:

     0  Load volume

     0  Temperature

     0  Duration of treatment

     0  Mixing requirements

For the continuous treatment process, the important variables
in operating procedures are:

     0  Temperature

     0  Exposure time  (a function  of  the flow  rate through
        the heat retention tubing)

Ovens and hot air sterilizers are used for the heat treatment
of infectious  solid  wastes.   The principal factors  that are
important in designating the   standard  loads  for  dry  heat
treatment of solid wastes are:

     0   Type of waste

     0   Load volume

     0   Packaging materials and containers
                             4-23

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     0   Loading configuration

     Type of waste.  The type or types of waste  that constitute
     the waste  load  should be standardized  because the heat
     conductivity of each kind of waste is different.  The heat
     conductivity affects the time that is needed for the waste
     load to reach the sterilizing temperature.

     Load volume.  Load  volume is  an important variable that
     should be  standardized  for each  oven that  is  used for
     infectious waste treatment.   Overloading  makes sterili-
     zation difficult if  not  impossible to achieve  even when
     standard operating procedures are  followed.

     Packaging materials and containers.  The type of packag-
     ing materials and containers  (that  is, plastic or metal)
     affects the sterilization process  because of the differ-
     ence in  heat  conductivity  of the  different materials.
     (This topic is  discussed  in  detail under  steam sterili-
     zation, Section 4.4.)

     Loading configuration.  For  an  effective  and  efficient
     sterilization process,  the   configuration  of   the  load
     should permit free circulation of  the heated air through-
     out the chamber.

The variables  that  are   important  in developing the standard
operating procedures for  heat  treatment of standard loads of
solid wastes include:

     0   Treatment temperature

     0   Length of cycle

Obviously, differences  in the  composition  of  the  standard
load and the operating  temperature affect  the  required oper-
ating conditions.   Therefore,  standard  operating procedures
should be determined for each  standard load to ensure repro-
ducibility and  effectiveness  of  the   sterilization  cycle.

Spore kill  times  for  dry  heat  sterilization  at  different
temperatures are listed  in Table  4-3.   A  typical  cycle for
dry heat  sterilization   is treatment at 160°  to 170°C  (320°
to 338°F) for  two  to four hours.   The appropriate biological
indicator for monitoring the effectiveness of dry heat treat-
ment is spores of Bacillus subtilis variety niger (globigii).
Monitoring of  the   dry   heat  process  for   the   treatment  of
infectious waste should be conducted periodically; a monitor-
ing schedule of once every three months would be appropriate.
(For the  sterilization  of  supplies  by dry heat treatment,
monitoring frequencies  of  at least  weekly  (30)  and at  least
once a month  (85)  have  been recommended for monitoring with
Bacillus subtilis spores,)
                             4-24

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                       TABLE 4-3

                 DRY HEAT STERILIZATION9
      Temperature             Spore Kill Time13
                                   (hours)
      121      250                    6

      140      285                    3

      150      300                    2.5

      160      320                    2

      170      340                    1

      180      356                    0.5
Data from reference 86, Table 1A.  (E. Hanel, Jr.  Chemical
Disinfection.  In: Control of Biohazards in the Research
Laboratory, Course Manual.  The John Hopkins University,
School of Hygiene and Public Health, Baltimore, Maryland.
1981).

In heat sterilization, exposure time for treatment is usually
at least double the kill time (71).
                          4-25

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4.7  Gas/Vapor Sterilization

In the gas/vapor treatment method, the sterilizing agent is a
gaseous or  vaporized  chemical.   Four  chemicals,  primarily,
have been used for  this  purpose in the  past — ethylene oxide,
formaldehyde, peracetic acid,  and  beta-propyl  acetone  — but
the latter two are rarely used today.  All four chemicals are
toxic, and ethylene oxide,  formaldehyde,  and beta-propiolac-
tone are listed  as  chemicals having substantial  evidence  of
carcinogenicity (98).   Therefore, caution should be exercised
when these  compounds  are  used,  and personnel  protection  is
essential (see p. 4-27 for details) . When use of  this treatment
method is considered,  the  relative hazards should be weighed —
that is, does  the  hazard  of  treatment exceed  the  hazard  of
the waste?  Nevertheless, gas/vapor sterilization is included
in this manual as an  alternative treatment  option because it
is sometimes  the  method  of  choice  for  treating  certain
infectious wastes.

Ethylene oxide gas  is usually used for the  sterilization  of
supplies, especially those that are thermolabile,  i.e., unsta-
ble to heat.   Obviously,  however, the effects  of heat would
not be a  consideration  in selecting the  method for treating
waste materials.  Furthermore,  ethylene  oxide  sterilization
is usually more  expensive than,  for example,  steam sterili-
zation.  Therefore, ethylene oxide may not be used frequently
to sterilize infectious wastes.   (See references 99, 100, and
101 for details on ethylene oxide sterilization).

Formaldehyde gas  is  used for  sterilizing   contaminated  and
infectious wastes (see  references  102  and 103).  Common uses
of formaldehyde are for sterilization  of  contaminated equip-
ment, ventilation systems, and spaces  (i.e., rooms and build-
ings) .

In the gas/vapor treatment method, the wastes must be exposed
to a sufficiently high  concentration  of the  gas/vapor for an
adequate period of time in order to accomplish  sterilization.
Therefore, both  loading considerations and  operating  condi-
tions are important in-  ensuring proper treatment.

The factors  that  should   be  considered  in designating  the
standard loads  for  gas/vapor  sterilization   of  infectious
wastes are those that  affect the diffusion  and permeation of
the gas/vapor  into and  throughout  the  waste  load.   These
factors include the following:

     0  Type of waste

     0  Packaging materials

     0  Load volume

     0  Loading configuration
                             4-26

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     Type of waste.  The type of waste  that is subject to this
     treatment is  an  important element  in  standardizing the
     waste load because of the different porosities of differ-
     ent types of infectious waste.  The density of the waste
     also affects the  rate  at which the gas diffuses through
     the material.

     Packaging materials.  The materials that are used to pack-
     age the waste must  be  permeable to the  sterilizing gas.
     Of the plastic materials,  for example,  polyamide,  poly-
     ethylene, and polypropylene  are  suitable  for  use  with
     ethylene oxide whereas  polyvinyl  chloride  and nylon are
     not (104).

     Load volume.  With  gas  sterilization as with  the  other
     treatment processes,  overloading   causes  problems.   Of
     special concern is  the  ratio of  load volume  to chamber
     size.

     Loading configuration.  The waste should be loaded with-
     in the treatment chamber so that there is maximum exposure
     of the waste to the  gas and  so that the  gas can diffuse
     freely thoughout the chamber and  the waste.

The operating variables that are important in determining the
effectiveness ot treatment include:

     0  Type of chemical

     0  Concentration of the gas/vapor

     0  Relative humidity

     0  Temperature

     0  Length of the cycle

Typical operating  conditions  for  gas  sterilization  using
ethylene oxide  and  formaldehyde   are  listed  in Table  4-4.
Other important data on  the  applications,  effectiveness, and
characteristics of these  two compounds are also  included  in
the table.

It is  important  to  note that,  because of  the toxicity  of
these chemicals,   care  must  be  taken  to  avoid  exposure  of
personnel during  the   treatment  process.   Furthermore,  with
both ethylene oxide and  formaldehyde,  there  is the potential
for worker  exposure  after the treatment process  because  of
"degassing" from the waste,  even  after the  bulk  gas has been
eliminated.  (Because  ethylene oxide  is  absorbed  by rubber
and plastic and formaldehyde frequently polymerizes to form a
residue, these  chemicals continue  to  be  released  from the
waste for awhile  after treatment.)  The gas should be properly
vented at  the  end of  the treatment  cycle,  and  the treated

                             4-27

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                                   TABLE 4-4

              SUMMARY OF DISINFECTANTS USED IN GAS STERILIZATION
                                                          Gas
                                        E thy lane Oxide	Formaldehyde
Inactivates:
 Vegetative bacteria                          +                         +
 Lipoviruses                                  +                         +
 Nonlipid viruses                             +                         +
 Bacterial spores                             +                         +•

Treatment Requirements
 Gas concentration                       8-23 g/ft3                 0.3 g*/ft3
 Temperature, *C                             37                        >23
 Relative humidity, %                        30                        >60
 Contact time, minutes
    Lipovirus                                60                        60
    Broad spectrum                           60                        60

Characteristics
 Corrosive
 Flammable                                    +b                        +c
 Explosion potential                          +b"                       +c
 fnactivated by organic matter                - '                        -
 Skin irritant                                +                         +
 Eye irritant   ,                              +                         +
 Respiratory irritant                         +                         +
 Toxic                                        +                         +•

Applicability
 Waste liquids
 Books, papers                                +
 Dirty glassware
 Equipment, surface decontamination
 Equipment, penetrating decc.itamination       +                         +
 Ventilation systems                          -                         +
 Large area decontamination                   -                         +


Source:  U.S. Department of Health and Human Services, National Institutes of
         Health.  Laboratory Safety Monograph.  A Supplement to the NIH Guide-
         lines for Recombinant DMA Research.  pp. 104-105.NIH, Office of
         Research Safety,National Cancer Institute, and the Special Committee
         of Safety and Health Experts, Bethesda, Maryland.  January 1979.

         + Yes.
         - No.
         * Paraformaldehyde.
         ° Neither flammable nor explosive in 90% C02 or fluorinate hydrocarbon,
           the usual use form.
         ° At concentrations of 7% to 73% by volume in air; solid exposure to
           open flame.
                                      4-28

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material should  be  well  aerated  before  it  is  handled   for
disposal.  All personnel  should use  protective  equipment as
necessary --  i.e.,  respirators,  gloves,  aprons,  etc.    For
details on practices for the  safe  use of ethylene oxide,  see
reference 101.

The biological indicator that is suitable for use in monitor-
ing the effectiveness of gas/vapor sterilization  is spores of
Bacillus  subtilis  variety  niger  (globigii).   In  order to
monitor the effect of the fumigation process, the spores should
be placed within  and throughout the  waste  load.  Monitoring
of the  treatment  process  should be  conducted  on a periodic
basis.  A monitoring schedule  of  once  in every  two  weeks
would be  appropriate for  treatment  of  waste;  this  is   less
frequent than the  schedule (at least once a week) recommended
for monitoring  the  gas  sterilization  of  supplies  (84,85).
4 .8  Sterilization by Irradiation

Irradiation is  an  effective method  of  sterilizing materials
(105,106).  At present, the use of radiation as a sterilant  is
generally limited  in  the  United States;  it is  more  widely
used for  this  purpose  in  Europe  and  Canada.   The  lag   in
commercial use  in  the United  States may  be attributable  to
policies of the Food and Drug Administration,  i.e., irradiated
foods are not  approved for  consumption in  this  country and
irradiated drugs must first be granted approval as "new drugs."
In other  countries,  extensive  experience   in  the  use   of
irradiation to  sterilize   products  (e.g.,   medical  supplies)
and to preserve foods probably provided impetus for development
of other  applications including  treatment  of wastes  (e.g.,
municipal wastewater  and   sewage  sludge).   The  ultraviolet
ray, gamma ray,  and accelerated electron  types  of radiation
are suitable for use in waste treatment.

Ultraviolet radiation  is  generated  by  a   special  lamp  which
emits 95 percent of  the  radiant energy at the  254-nanometer
wavelength (86); this  is  near  the peak germicidal wavelength
(Figure 4-2).  Ultraviolet rays cannot penetrate surfaces and
therefore ultraviolet  irradiation  is  useful in  sterilizing
only those surfaces  that   are  exposed  directly to  the  rays.
Consequently, ultraviolet  irradiation   is  of limited  use   in
sterilizing infectious waste.  One  application  found in many
containment laboratories  is the  pass-through ultraviolet box
for sterilizing sheets of paper.  The ultraviolet bulb should
be kept free of dust  because dust  diminishes its  output, and
the output should  be  checked  routinely.   It is  important  to
protect the eyes and to avoid prolonged exposure to ultraviolet
radiat ion.

Gamma radiation for sterilization purposes is usually derived
from the radioisotope cobalt-60  which  is  produced  in nuclear
reactors.  Gamma rays penetrate  to  a depth of several  meters
and therefore  can  be  used to irradiate  packages.   Another

                             4-29

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                          FIGURE 4-2


     BACTERICIDAL EFFECTIVENESS OF ULTRAVIOLET  RADIATION
            100%
              CO
              CO
              0)

              £

              •H
              •U
              O
              4>
              Pd

              0;
       254 nm
                  200
   250

Wavelength
300 nm
Source:  E. Hanel, Jr.  Chemical Disinfection  (illustration IE).
         In:  Control of Biohazards in  the  Research Laboratory,
         Course Manual.  The John Hopkins University,  School of
         Hygiene and Public Health, Baltimore,  Maryland.   1981.
                             4-30

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advantage of gamma rays is  the small requirement for electric-
ity in  the   irradiation  process.   Many  experts   think  that
gamma radiation has potential as a replacement  for the heat
treatment of wastes,  especially in cold  climates, primarily
because of the high  cost of  fossil fuels  needed  to generate
electricity and  steam.   Furthermore,   because  heat  is  not
involved, the treated waste (treated wastewater, for example)
does not have to  be  cooled before it  is  disposed  of or dis-
charged.  Gamma  radiation  devices  require sheilding  of  the
source during storage  as  well as during  use.   The  type  of
shielding that is appropriate  is determined by source strength
and facility design  (see  reference  105  for information  on
sterilization device  shielding).   In  a   typical  treatment
facility, the source  is  stored in a  pool  of  water  and  is
raised into  the   air  for  exposure of  the  waste.  Packages
are conveyed mechanically  through  a maze  to the  source  for
exposure.  When  wastewater is  treated,  it may be channeled
through a sluice  for  continuous treatment  or  accumulated in
a tank  for  batch  treatment.   Provision  should  be  made  for
replenishment of the source as  it decays in order  to maintain
the gamma radiation at required levels.

Electron accelerators  are  used  to  generate electron  beams.
Electrons penetrate to a depth of a few centimeters, and they
can be  used  to  treat  some packages as  well as  wastewater.
The principal disadvantages of this type of treatment are the
requirements for  a high  electrical energy source and  for
shielding during the treatment process (shielding during non-
use is not needed  because  the radiation can be  turned  off).
Because of the high energy  requirements,  electron  beam irra-
diators  are economically   feasible   only  when   inexpensive
sources of electrical energy  are available.

Special factors  must  be taken into  consideration  to  ensure
that the wastes  are exposed  to sufficient radiation  to achieve
sterilization.   The factors that are important in designating
standard waste loads  for  sterilization  by  irradiation  are:

     0   Type of waste

     0   Load volume

     0   Waste configuration

     Type of waste.  The type  of waste  is an important factor
     because the degree of  contamination  determines the dose
     that is needed to  sterilize the waste. Waste loads  can
     be standardized  on  the  basis of  presumed  approximate
     degree of  contamination   (testing  is   not  recommended),
     or  a  worst-case   standard  load  can be  established.

     Load volume and configuration.  Load volume as a function
     of the configuration  of  the waste  is  another important
     factor in  standardizing   the  waste   loads.    The  three
                             4-31

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     types of radiation  (i.e.,  ultraviolet  light,  gamma ray,
     and electron  beam)  differ  in  penetrating  capability
     (see discussion above),  and configuration  of  the waste
     load or depth  of   the  wastewater should  be established
     and standardized accordingly.

The factors  that  are  important  in  developing  the  standard
operating  procedures   for   each   standard   load  include:

     0  Type of radiation

     0  Efficiency and power of source

     0  Exposure time

Dosimetry (i.e., measurement of  the  radiation dose)  is often
part of the  irradiation process.   It is  especially important
with gamma radiation because the power of  the source diminishes
as the  cobalt-60  decays.   Exposure  time  can  be  varied  to
assure an adequate dose of radiation by altering the speed of
the conveyor moving  packages  around the radiation  source  or
the velocity of  the wastewater  flowing  past  the irradiation
zone.

Spores of  Bacillus   pumilus  are  the appropriate  biological
indicator to use  in determining  whether the  irradiation has
sterilized the waste.  Periodic monitoring should be conducted
once every two weeks.
4.9  Chemical Disinfection

Various chemicals  are  frequently  used  for  disinfection  of
hospital supplies, equipment, and surfaces.   (Chemical disin-
fection is discussed  in  references  6,  75,  86, 107, and 108.)
These chemicals  are  usually  of  the  following  types  and
substances:  acids,  alkalies,  aldehydes,   alcohols,  amines,
halogens, heavy  metal  salts,  ketones,  quaternary  ammonium
compounds,  phenolic   compounds,   and  hydrogen   peroxide.

Chemical treatment must  be considered a  disinfecting rather
than a  sterilizing  process.   Because  of the  type  of action,
the many  factors  that  affect  treatment   results,  and  the
difficulties in establishing proper standard  operating proce-
dures, there are too many variables for chemical treatment to
be relied  upon exclusively  for effective  treatment  of most
infectious wastes.  Therefore,  judgment  should be exercised,
and chemical treatment of  infectious  waste is an option that
should be  reserved  for  certain wastes  and  special  circum-
stances.

The factors that should be considered  in designating standard
waste loads for chemical treatment include:
                             4-32

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     0   Type of waste

     0   Volume of waste

     Type of waste.  Not all types of  waste can be effectively
     treated with  chemicals.  The  porosity and  absorbency of
     the waste are factors that  should be  considered.   For
     example, wastes  such  as  glassware,   plasticware,   and
     some liquids  could  be  chemically  treated  (at  least
     initially) whereas  this   treatment technique  would  be
     ineffective with  bulk wastes  and  porous   or  absorbent
     materials.

     Volume of waste.  The  volume  of  the  waste  affects  the
     practicality of using  chemical  treatment.   For example,
     procedural difficulties  would be  encountered  if  large
     waste loads  were  treated chemically  by hand  (i.e.,  in
     a non-mechanical system)  because of problems in handling
     (e.g., containing, mixing) the large volume of waste and
     chemical.

In the development of  the standard operating procedures  for
each standard  load,  the following  factors  are  important to
ensure sufficient  exposure of the wastes  to  the  action of
the chemicals:

     0  The type of contaminating microorganism

     0  The degree of contamination

     0  The amount of  proteinaceous material present  in the
        waste

     0  The type of chemical

     0  The concentration and quantity of chemical

     0  The contact time

     0  Other relevant factors

     Type of contaminating microorganism.  Chemicals are  not
     equally effective against the  different  types  of  micro-
     organisms.   See  Tables   4-5  and  4-6   for a guide.

     Degree of contamination.   The  degree   of  contamination
     affects the  time  required for disinfection,  the  amount
     of chemical required, and other variables.   For example,
     the greater  the degree of contamination,  the longer the
     contact time needed for effective treatment.

     Amounts of proteinaceous material present.  Proteinaceous
     material or  "organic  dirt"  (e.g.,  blood,  plasma,  feces,
     tissue) absorbs and  inactivates  some  chemical disinfec-
                             4-33

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                                  TABLE 4-5

                              ACTIVITY LEVELS OF
                 SELECTED CLASSES OF LIQUID DISINFECTANTS (107)
        Class
Use-Concentrations
Activity Level8
  Glutaraldehyde,
    aqueous

  Formaldehyde +•
 2%
   high
alcohol*
Formaldehyde,
aqueous*
Iodine +
alcohol
Alcohols
Chlorine
compounds
Phenolic
compounds
Iodine,
aqueous
lodophors
Quaternary
ammonium
compounds
Hexachlorophene
Mercurial
compounds**
8% + 70%
3 to 8%
0.5% + 70%
70 to 90%
500 to 5000 ppmb
1 to 3%c
1%
75 to 150 ppmd
1:750 to l:500e
1%
1:1000 to l:500e
high
high to intermediate
intermediate
intermediate
intermediate
intermediate
intermediate
intermediate to low
low
low
low
 Courtesy of American Sterilizer Company, Erie, Pa.



 a  Degree of disinfecting activity.

 b  Available chlorine.

 c  Dilution of concentrate containing 5% to 10% phenolics.

 d  Available iodine.

 e  In appropriate diluent.

 *  See Section 4.7 for discussion of formaldehyde toxicity and necessary
    precautions for personnel protection.

**  Should not be released into the environment and therefore no longer used.
                                   4-34

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-------
     tants  (71).  Halogens,  for example, combine  readily with
     proteins.  Therefore,   when  proteinaceous   material   is
     present  in  the  waste,  the  halogens  must  be  added   in
     sufficient quantity  to  provide  the   excess  needed   to
     react  with  the micoorganisms and  thereby disinfect  the
     waste.   Official  methods  have  been published  for deter-
     mining,  for example, available chlorine  germicidal equiv-
     alent  concentration  (75).

     Type of  chemical.  Different  chemicals   have   different
     modes  of  action  and levels  of  activity  (Table  4-5).
     Therefore, they  are  effective  for different uses (Table
     4-6).  It  is  important  to understand  the mode  of action
     (e.g., reaction  with the cell  wall, protein,  DNA,   or
     RNA)   in   order   to   select   the  appropriate  chemical.

     Concentration  and quantity of chemical.   Most of the
     chemicals have a range of concentrations that are suitable
     for use  for disinfection (Table 4-5).   In the development
     of standard  operating  procedures,  it  is  important   to
     ascertain  the  concentration  and  quantity   of chemical
     that are best  used for  the disinfection  of each standard
     waste  load.

     Contact  time.  It  is  essential  that  contact time   be
     sufficient to  allow  for action of the  chemicals  on  the
     microorganisms.   For  example,  as  was noted  above,   the
     time required  for disinfection  is proportional  to   the
     degree of contamination.

     Other  relevant factors.    Other  factors  that  should   be
     considered in  establishing standard operating  procedures
     for chemical disinfection include temperature, pH,  mix-
     ing requirements,  and  aggregation of   microorganisms.

If the waste  loads  are consistently  similar,  waste loads   as
well as  the operating  procedures  for  treating  them can   be
standardized.  However, if there  is  variability  in  the  waste
loads so that they  cannot be  standardized,  each  load  should
be monitored for effectiveness of treatment.  Bacillus subtilis
variety niger (globigii) spores are  the appropriate  biological
indicator to use in demonstrating  the  efficacy of  the standard
operating procedures  developed for  each standard waste  load
(75).  The Bacillus subtilis spores should be used  for subse-
quent monitoring of the standardized  treatment process on a
weekly basis.  However, if the waste consists of pure cultures,
it would  be  appropriate  to  assay  each waste  load for  the
target organism after treatment.

4.10  Other Methods

Any other method of  treating  infectious waste  should be demon-
strated as  effective  in sterilizing  the  waste before  it   is
used routinely.   Efficacy of  the method should be demonstrated
                             4-37

-------
by the use of appropriate biological indicators.  As with all
the other treatment methods,  standard waste  loads  should be
designated (with  reference  to  the  relevant variables)  and
standard operating procedures  should be developed (with refer-
ence to the relevant variables)  for each such standard load.
Monitoring should  be   conducted  on a  periodic  basis  using
appropriate biological indicators.
                             4-38

-------
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                              R-10

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105. Eymery, R.  Design of radiation sterilization facilities.
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                              R-ll

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     3.  Immediate  refrigeration  or freezing  of unpreserved
         pathological wastes and animal carcasses with removal
         from storage just before treatment.

     4.  Proper packaging to  ensure  containment of the waste
         and exclusion of rodents and vermin.

     5.  Limited access to storage areas.

     6.  Posting of biohazard  signs on doors,  waste containers,
         refrigerators, and freezers.


3.6  Transport of Infectious Waste within the Facility and
     Off-Site

Many infectious wastes can be  treated where  they are generated
— that  is,  there  may be a  steam sterilizer in the  room or
access to a  steam  sterilizer  or an incinerator directly from
the room —  and  therefore no transport  is  necessary.   Often
though, infectious  waste  must be moved  through the facility
to the treatment equipment,  or  to a storage  area,  or to the
loading dock for transport to an off-site treatment facility.
The factors  that   should  be  considered  in  determining  the
transport conditions  are  those  that  affect  the  safety and
health of facility employees, patients (if it is a hospital),
visitors, waste handlers,  and the general community.

The most important  factor is the integrity  of  the packaging
to ensure containment of  the  waste.   Packaging was discussed
in detail  in Section  3.4;   therefore,   it  is  sufficient  to
restate here that  single  plastic bags are  not  adequate when
the waste  must  be  transported.   For  movement  within  the
facility, the  waste  should  be   double-bagged  or  the  bagged
waste should be placed within a  rigid or semi-rigid container,
and all  containers  should   be   securely closed  or  sealed.

Carts are suitable  for  moving the packaged  infectious waste
within the facility.  The  carts should be washable or otherwise
cleanable,  and they should be cleaned and  disinfected frequent-
ly.  They should  be used only  for  moving  infectious waste.
The time and route of waste  transport within  a facility should
be selected so that few  people are encountered while the waste
is being moved.

For transport off-site,  special  packaging  may  be  necessary
in order to  ensure containment  of  the  waste.   In  addition,
each package of  infectious  waste should be  labeled  with the
universal biohazard symbol  in accordance  with the  Department
of Transportation  specifications  (57).    Other  appropriate
hazard symbols should be used as well if the waste has multiple
hazards.
                             3-21

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Mechanical devices should not be used to transfer or load the
packages of  infectious   waste  if  such  use  will  result  in
tearing of  the  packaging.   The  packaged  infectious  waste
should not  be  compacted  before  or during  transport because
the compacting process would disrupt the packaging and there-
fore the containment of  the waste.   It is important to prevent
scattering and spillage  of the waste during  its transport off-
site; therefore,  the  waste  should  be transported  in  closed
and leak-proof dumpsters or trucks.


Recommendations

The following  recommendations  are  made to ensure  the  safe
transport of  infectious, waste  within the  facility as  well
as during its transport off-site for treatment.


     1.  Proper packaging to ensure containment of the waste.

     2.  Selection  of  time and  route  of   transport  so  that
         exposure to the waste is minimum.

     3.  Use  of  special  carts  for moving  infectious  waste
         — that  is, they  should  not  be  used  for  other
         purposes.  Frequent  cleaning  and   disinfection  of
         the carts.

     4.  Handling, transfer, and  loading  of  packages  of infec-
         tious waste  in  a manner  that  does  not  destroy the
         integrity of the packaging.

     5.  No compaction of packaged  infectious waste prior to
         or during transport.

     6.  Transport of infectious waste off-site only  in closed
         and leak-proof  dumpsters or trucks.
3.7  Recommended Treatment Methods for the Different Types of
     Infectious Waste

The purpose of treating  infectious waste  is to eliminate any
hazard that the waste may  present  because of the presence of
pathogens.  Therefore, to be effective, treatment must remove
the disease-causing potential  by killing  the  pathogens that
are present in  the waste.  Various  methods are  now  used to
treat infectious wastes.

Each type of  infectious  waste  is not necessarily amenable to
treatment by each treatment method.  The treatment techniques
that are  recommended  are  those  that:   (a)  are  known  to be
                             3-22

-------
effective for  treating  each  type  of infectious waste and  (b)
are generally  in  common  use.   The  recommended  treatment
alternatives for  each  type of waste  are equally appropriate
if proper procedures are followed to ensure the effectiveness
of treatment.  (Treatment  techniques and  procedures  are dis-
cussed in detail  in  Chapter 4).   Table 3-2  summarizes  the
recommended treatment  techniques  that  are most  appropriate
for the different types of infectious waste.  These recommen-
dations are based on the efficacy  and feasiblity of treatment;
other factors such as time and energy requirements and expense
were not taken into consideration  in formulating the recommen-
dations (they  are discussed  in  Chapter 4).  The omission from
the table of  a treatment technique for  a particular  type of
waste does  not mean  that  that  method  should never  be used
for treating that type  of  infectious  waste because the  ulti-
mate criterion  of suitability is  effectiveness.   Therefore,
any treatment  technique may  be  used  to  treat  any  type  of
waste if the method provides effective treatment.

Before discussing  the  recommended  treatment  techniques  for
the different  types  of  infectious waste,   however,   it  is
important to  consider  the  possibility  and  advisability  of
discharging untreated infectious wastes into the sewer system.
This procedure  is advocated  by  some  who maintain  that  the
wastewater treatment plant  is the  best  system  for treating
biological organic wastes.  There are,  however, certain  draw-
backs to this  approach.   Aerosols are  created when  waste is
poured or ground  up and  flushed  into  a  drain;  if  the  waste
is infectious,  these aerosols  might  contain pathogens  and
unnecessary exposures  might   result.   In  addition,  plumbers
could be exposed  to pathogens that might be present  in  the
plumbing as the result of  introducing the  untreated infectious
waste into the drains.   Another factor is the type of treatment
the wastewater  receives.   Secondary biological  treatment is
needed to ensure killing of pathogens, but not  every wastewater
treatment facility  provides   secondary treatment.   Further-
more, with the  combined sanitary-storm sewer  system  that  is
common in many municipalities, some wastewater is often dis-
charged untreated  during  periods  of  heavy  rain,  and  this
practice could result in discharge of the  untreated infectious
waste.  In consideration of these factors, EPA  does not endorse
the introduction of untreated infectious wastes into the  sewer
system unless  it  is known that  the wastewater will  receive
secondary treatment, proper precautions are taken during dis-
posal, and such disposal is allowed by the local  governments.
Disposal to the  sewer system (by  the  pouring of  liquids  or
the grinding up and flushing of  solids) is  appropriate  for
treated infectious wastes  and is therefore  recommended only
after the waste  has been  treated  and  only  if the waste  is
compatible with  the  wastewater   treatment  plant  (e.g.,  it
does not contain heavy metals or toxic  substances).

After infectious  waste  has  been  treated,  the  waste may  be


                             3-23

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disposed of as ordinary non-infectious waste with the general
waste stream.  Liquids  may be  decanted and poured  down the
drain to the  sewer system.  Wastes  may be disposed  of  in a
sanitary landfill  or  may  be incinerated,  for  example,  in an
institutional or municipal  incinerator.   Incinerator ash may
be disposed of  in  a  sanitary  landfill.   It is  important to
note, however, that  if  the waste is otherwise hazardous  (for
example, a hazardous  waste as  listed  in Title  40,  Part 261
of the  Code  of Federal  Regulations  or  a  radioactive waste),
it should be  further  treated prior  to  disposal,  or it should
receive other  special  handling  in  accordance  with  the  re-
quirements of applicable  Federal,  State,  and  local  laws or
the acceptable practices  for  the management of  such wastes.
3.7.1  Isolation Wastes

Isolation wastes (as defined  in  Chapter 2) contain pathogens
that were  shed  by patients  whose diseases  are  sufficiently
severe and contagious to warrant the imposition of isolation.
Therefore, the waste from these patients should be sterilized
before disposal  in  order  to  protect the  general population
from the  pathogens  that  are  present   in  the  waste.   Steam
sterilization and incineraton  are the  two treatment methods
that are  recommended  for  isolation  wastes.   The  equipment
that is  needed  for  these two processes — steam sterilizers
and pathological incinerators  —  is  available  at most hospi-
tals.  When proper procedures are followed for steam sterili-
zation and incineration, these techniques provide appropriate
treatment of isolation wastes.
Recommendations

EPA recommends the  following alternatives for  the treatment
of isolation wastes:

     1.  Steam sterilization  in  accordance with the standard
         operating procedures  determined  for  this  type  of
         waste.

     2.  Incineration in accordance  with determined standard
         operating procedures.

3.7.2  Cultures and Stocks of Etiologic Agents

Cultures and stocks of etiologic agents constitute infectious
waste of particular  hazard  because  the  pathogenic organisms
are present at high  concentrations.   Therefore,  these  wastes
should be  sterilized  (63).   A  single  treatment method  —
steam sterilization — is recommended for this type of  infec-
tious waste because  it  is  the  simplest  and most effective
treatment method.   Steam sterilization of these wastes  should
                             3-27

-------
not be difficult to perform because autoclaves are present in
most laboratories that culture infectious agents.

It could be argued  that  chemical  decontamination can provide
suitable treatment  if  the  chemical that is used  is  known to
be effective  against  the   target  organism.   However,  many
experts in the biological safety field share the opinion that
this type  of  waste must  be  sterilized  and  that  chemical
decontamination does not ensure  sterilization.   For example,
chemical treatment  may  only inactivate  rather  than  kill the
pathogens.  Furthermore, steam  sterilization  is simpler than
chemical treatment  and  also  easier  to execute  effectively
because there  are  fewer  process  variables and  interfering
factors (see discussions of  steam  sterilization and chemical
treatment in Sections 4.4 and 4.9,  respectively).

Recommendations

EPA makes the following recommendations for the treatment and
disposal of cultures and stocks of etiologic agents:

     1.  Steam sterilization of  cultures and  stocks of etio-
         logic agents in accordance with the standard operat-
         ing procedures  determined for  this  type  of  waste.

     2.  Management  of the  treated  waste  with  the  general
         non-infectious waste stream  for incineration  or for
         disposal in  a  sanitary  landfill  (liquid  treated
         waste may  be poured  down  the drain  to  the  sewer
         system).
3.7.3  Blood and Blood Products

The principal hazard of  blood  and  blood products arises from
the possible  presence  of  the  hepatitis  agent,  and  it  is
general practice  in  clinical  laboratories  to  handle  every
blood specimen  as  though it were  positive  for hepatitis and
to take appropriate precautions.  Other blood-borne etiologic
agents may  be present  in  blood,  but  they  are  less  common.
Because it  is  impractical  to  test  all  blood for the presence
of each possible etiologic agent,  it is prudent  to manage all
blood and  blood products  as  potentially  hazardous.    It  is
logical to  extend this practice to the wastes associated with
blood specimens  --  for example, the excess  amounts  of blood
and the  containers, needles,  and  syringes  —  and  to handle
them as though  they were contaminated.   Therefore,  all blood
and blood products  and  all wastes that  were in contact with
blood should  be  treated  before  disposal.   Two  treatment
methods are recommended: steam sterilization  and  incineration.
Equipment for both  these processes is  generally available in
or to facilities  that  generate this  type of infectious waste
— that is, blood banks, clinical  laboratories,  and hospitals
                             3-28

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