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.
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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.
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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.
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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).
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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.
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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.
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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
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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.
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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.
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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
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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.
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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.
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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.
3-2
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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
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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.
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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
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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:
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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
-------
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).
3-11
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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
3-14
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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
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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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3-36
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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
-------
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
-------
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
-------
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
-------
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
-------
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
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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,
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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
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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
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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
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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)
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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).
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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
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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,)
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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).
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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
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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
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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
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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
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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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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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3-26
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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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