United States            Office of              Revised
                     Environmental Protection      Public Affairs (A-107)        November 1988
   ,  r                Agency               Washington DC 20460

                    Backgrounder      10019891
                   Medical  Waste
ISSU6               Tne recent incidents of floating debris, garbage, wood,
                    and medical waste on our nation's beaches, which
                    resulted in beach closures throughout  the summer, as
                    well as threats to the public health,  have focused
                    public attention on the nation's waste management
                    problems.  The handling and disposal of municipal solid
                    waste remains a major unresolved national dilemma.
                    The municipal solid waste situation has been aggravated
                    by increased use of disposables by all consumers,
                    including the medical profession, and  a near crisis in
                    the availability and cost of solid waste disposal
                      Of the 160 million tons of U.S. waste generated each
                    year, 3.2 million tons is medical waste generated by
                    hospitals.  EPA estimates that 10 to 15 percent of this
                    hospital waste is infectious.  In addition, there are
                    numerous other generators of small quantities of medical
                    waste.  These include private practices, home health
                    care, veterinary clinics, and blood banks.

            -' ^
                        The United States has made tremendous progress in
                      improving the water quality of its lakes, bays,
                      estuaries, and oceans by treating its  municipal sewage
                      and industrial effluents.  Billions of dollars have been
                      spent on the construction of sewage treatment plants,
                      and on the control of industrial discharges.  Extensive
                      measures have been taken in the attempt to eliminate
                      "floatables," i.e. solid waste which makes its way into
                      the water from a variety of sources.   In addition,
                      steps have already been taken to phase out permitted
                      ocean dumping.
                        But these measures have proved insufficient in the
                      face of the explosive development and  growth along our
                      nation's coasts.  An estimated 70 percent of our
                      population now lives within 60 miles of a coastline.
                        We, as a nation, have made little progress in
                      addressing our municipal solid waste management problems
                      and in fact have continued to produce  more and more
                      solid wastes, including, of course, medical wastes.
                      Because of the coastal population explosion, the
                      problems of medical waste management and water quality
                      control are closely linked.

   The medical waste found this past summer on our
beaches could have been generated by a number of
sources, including illegal dumping; sewer overflow;
storm-water runoff; illegal drug users; and inadequate
handling of solid waste at landfills and coastal
transfer facilities, which includes waste from doctors'
offices, laboratories, and even legitimate home users of
syringes, such as diabetics.
   While hospitals, clinics,  and health-care facilities
may generate the vast majority of these wastes, there
are numerous other generators, many of which produce
only small quantities.  These include private medical
and dental practices, home health care, veterinary
clinics, laboratories, and blood banks.  In fact,  there
may be over a million sources of medical wastes.
Individual behavior practices must change — not just by
those who knowingly litter or illegally dispose, but
also by home users of medical products and other
generators of small quantities of this waste, such as
doctors' offices.  Public education is a necessary
component to instruct people on safe disposal methods.
Tracking systems alone may not prevent improper consumer
disposal of such items as disposable syringes.

   The 3.2 tons per year of medical wastes include a
variety of wastes, such as wrappers from bandages and
catheters, containers such as intravenous (IV) bags and
used vials, disposable items such as tongue depressors
and thermometer covers, as well as infectious wastes.
   Approximately 10 to 15 percent of all medical wastes
is estimated to be "infectious" waste.  EPA presently
identifies six types of waste as potentially infectious:
      9 Cultures and stocks of infectious agents and
           associated biologicals.
      9 Pathological wastes.
      9 Human blood and blood products.
      9 Contaminated sharps (such as needles and
      9 Contaminated animal carcasses, body parts, and
      9 Isolation waste.

Treatment Technologies	
   Of the available treatment technologies, incineration
appears to be the most utilized.  EPA has data that
indicate 70 percent of hospital waste is incinerated on-
site, 15 percent is sterilized in an autoclave, and 15
percent is transported off-site for treatment.  Ten
percent of the waste treated off-site is incinerated.

            Health Concerns
               Certain medical wastes can be health hazards.  It is
            interesting to note that several studies have shown
            that hospital wastes are generally less virulent than
            typical domestic waste.  In addition, the Centers for
            Disease Control  (CDC) have no epidemiological evidence
            to suggest that hospital waste is any more infectious
            than residential waste, or that hospital waste has
            caused disease in the community as a result of improper
               Exposures to medical wastes that could result in the
            transmission of disease are primarily occupational and
            are most likely to occur among workers who handle these
               EPA understands the public concern about the
            transmission of blood-borne disease such as AIDS from
            exposure to used syringes and improperly disposed blood.
            Public health officials, including the Centers for
            Disease Control, believe the risk of contracting these
            diseases from exposure to these wastes in the environ-
            ment is extremely low.  None the less, EPA believes
            inadvertent exposure to such wastes is unacceptable, and
            EPA is continuing to investigate these concerns to make
            sure our conclusions are accurate.

ADDrOfiCh EPA believes that the use of good management and
  "^       housekeeping by those who generate, transport, store,
            treat, or dispose of medical waste may be the key to
            reducing potential risks to the public from these
            wastes.  A well-designed educational program is
            essential to the implementation of these practices.  EPA
            has already provided extensive technical support to
            states and to the health care community on the proper
            management of medical wastes—but EPA plans to do more.
              This problem involves all levels of government; it
            cuts across public health issues and local economies and
            includes both solid waste management and water quality
            control issues.

            New Legislation	
               On November 2, 1988, President Reagan signed into law
            the "Medical Waste Tracking Act of 1988," which requires
            EPA to establish a two-year demonstration program to
            track medical waste from its generation to disposal.
            The program applies to New York, New Jersey,
            Connecticut, and the seven Great Lakes states.  Any
            other state may be included in the tracking system, and
            any of the ten listed states may choose to opt out of
            the program.  EPA strongly encourages the 10  listed
            states to opt in the program, and it would welcome any
            additional states that may want to opt in.  States have
            within 30 days of promulgation of EPA's regulation to
            opt in or out of the program.

EPA Action
   Although the law gives EPA six months to promulgate
regulations, EPA plans to establish the tracking system
by February 1989.   If EPA meets that schedule,  states
will have until approximately March 1,  1989, to opt in
or opt out of the program.  For those states that
participate in the program, the tracking system should
be in effect by May 1, 1989.
   At the conclusion of the two-year demonstration
tracking program,  EPA is required to submit a Report to

                     1982  -Published draft guidance for states and health
                              care community on infectious waste management.
                     1982  -Began on-going educational program by providing
                              instructors and speakers for continuing
                              education programs for health-care workers and
                              trade and professional association meetings
                              and symposia.
                     1986  -Published "EPA Guide for Infectious Waste
                              Management," which finalized the 1982 draft
                     1986  -EPA announces Near Coastal Waters Strategy to
                              protect our overstressed coastlines.
                     10/87 -Issued a draft study of hospital-waste combus-
                              tion. The final report is due in early 1989.
                     11/87 -Called together a group of experts that included
                              representatives from the Centers for Disease
                              Control, the National Institutes for Health,
                              the American Medical Association, states, and
                              the Environmental Defense Fund to discuss
                              infectious waste management.  The panel agreed
                              risks were primarily occupational and that
                              public exposures were isolated.  The group also
                              agreed that EPA's initial efforts should be
                              through guidance and education.
                     1988  -Each region designated a Medical Waste contact
                              person and two consulting firms were contracted
                              to develop educational materials and guidance,
                              and to conduct studies of state programs.
                     4/88  -EPA, the National Oceanic and Atmospheric
                              Administration (NOAA), and the Department of
                              Transportation (DOT) begin to implement Sectior
                              2204 of the Marine Plactic Pollution Research
                              and Control Act of 1987 to educate the public
                              on the prevention of plastics pollution.  EPA
                              is developing a series of fact sheets and will
                              share in the distribution of NCAA's materials.
                     5/88  -EPA began to assist New York and New Jersey with
                              developing a bi-state tracking system on
                              medical wastes, which was completed in August

6/88  -Published a Federal Register Notice in which EPA
         requested comments on issues related to medical
         wastes.  The comment period closed on Monday,
         August 1, 1988.   (See Public Action, page 6)
      -Began to develop an inspection manual for
         hospital incinerators and a training manual for
         the operators of hospital incinerators.
      -Began preparing brochures, posters, and a
         bibliography of abstracts of infectious waste
         studies to supplement the agency's guidance
         document on infectious waste management.
         Guidance materials to assist states in
         implementing infectious waste management
         programs under existing municipal solid waste
         authorities are also under development.
7/88  -Creation of an Office of Pollution Prevention, to
         maximize and focus the agency's attention on
         reducing waste and pollution before it becomes
         a disposal or clean-up problem.
8/88  -Creation of a task force of solid recycling in
         EPA to work specifically on the national
         municipal solid waste dilemma.
      -Appointment of EPA Medical Waste Task Force,
         chaired by Dr. John Moore, to coordinate agency
         activities on medical waste.
9/88  -Region 2 hosted a Medical Waste Conference with
         state health and environmental commissioners
         from New York City, New York, New Jersey, Rhode
         Island, Connecticut, Pennsylvania, and
      -Federal officials from EPA, the Department of
         Defense, Department of Transportaton,
         Department of Commerce, National Science
         Foundation, State Department, and the
         Department of Interior met to discuss improved
         federal sharing of enforcement and resources to
         combat improper disposal of medical waste.
10/88 -EPA sponsored a two-day Ocean Pollution Enforce
         ment Conference in Point Judith, Rhode Island.
         Representatives of the National Association of
         Attorneys General, various state and federal
         agencies (including the Coast Guard and the
         FBI), and the Attorneys General of the 14 East
         Coast states attended.  The discussions
         covered a broad range of state and federal
         ocean pollution enforcement issues, including
         medical waste disposal.

Assessment Plan	
   Following is EPA's plan for dealing with solid waste
issues related to the management of medical waste.  The
objective of the plan are:
      1. To develop a universally accepted definition of
   "medical waste" to facilitate appropriate control

   and/or regulation of this waste.
      2. To evaluate the effectiveness of existing state
   programs in controlling the medical waste problem,
   and, in particular, to identify those components of
   state programs that are successful.
      3. To quantify the extent of the problem by
   determining the amount and types of medical waste
   that are generated, current treatment and disposal
   practices, the relative contribution of each source
   (doctors' offices, clinics, hospitals), and com-
   pliance costs.
      4. To develop the most effective means of tracking
   and reporting the handling of medical waste and to
   ensure the proper management and destruction of the
      5. To determine which transportation, treatment,
   storage, and disposal methods are most effective in
   minimizing environmental release by each waste type,
   and what resource requirements are required for each
      6. .To .determine the environmental, economic, and
   health risks of improper disposal of infectious
      7. To determine whether regulations are adequate
   for hospital incinerators.  The agency is completing
   an examination of available control technologies by
   the end of the year and will result in:
      + A hospital waste combustion study report.
      + A hospital incinerator operator training manual.
      + A hospital incinerator inspection manual.
      8. To ensure that the general public and interest
   groups are provided with the information necessary to
   understand the nature of this problem, and kept fully
   informed of all program developments, including
   program implementation requirements.  To provide
   educational information for the affected industry,
   regulators, and home medical product users.

Related Activities	
   ® Coastweeks »88 (September 17 — October 10)  The
Center for Environmental Education (CEE), under a
contract with EPA, coordinated a nationwide volunteer
beach cleanup of litter.  The effort involvee more than
30,000 volunteers working on selected beaches in all
coastal states.  Each volunteer was issued a score card
to record the frequency of many common marine debris
items.  This information will be tabulated and will form
a baseline national marine debris frequency distribu-
tion.  These data will represent the national marine
debris situation prior to the implementation of MARPOL,-
Annex V (international agreement to prevent pollution
from ships at sea).  Hopefully, this cleanup effort will
be repeated next year to compare the current situation
to that which will exist after the MARPOL regulations gc
into effect.

Chicago, IL  6C604   ' i-0^ I

' State Action
 Public Action
   9 '88 Oceans Conference (October 31 — November 2)
The Coast Guard hosted an annual conference in Baltimore
with Maryland's Governor Schaffer as chairman, and the
theme:  "Partnership in Marine Interests."  The con-
ference included a medical waste panel.

Most of the states (88 percent)  are or will soon
regulate infectious wastes.
   Thirty-one states single out  packaging/labeling
requirements in their rules, such as double-bagging and
rigid containers.
   Transportation controls and record-keeping are
required by three-fifths of the  states.

New York & New Jersey	
   The New York/New Jersey area in EPA's Region II is
the area most heavily affected by the medical waste
   EPA is working closely with the National Enforcement
Investigation center, the Coast Guard., and the FBI to
add federal support to state and local efforts to put a
halt to illegal dumpers and is providing direct
technical assistance to states that have recently
experienced infectious waste mismanagement incidents.
   In May 1988, EPA began working with the states of New
York and New Jersey to develop consistency in their
state infectious waste programs, including implementa-
tion of a tracking system.
   On August 10, 1988, the states of New York and New
Jersey enacted emergency legislation imposing a manifest
tracking system for facilities which generate more than
100 kilograms per month of medical wastes within their
states.  State officials will later determine whether
smaller generators, such as doctors offices and clinics,
should be regulated as well.

As of August 1, 1988, EPA received over 100 public
comments on a notice the Agency put in the Federal
Register in June 1988 seeking comments on a number of
issues related to infectious waste.  Comments were
received from trade associations, hospital groups, state
and local health departments, and interested individua-
ls.  There was no evidence presented by any commentors
suggesting that properly handled and disposed infectious
waste posed a public health problem.  The majority of
respondents agreed that workers in health-care faciliti-
es, transporters of infectious waste, and workers at
disposal sites run the greatest risk of exposure.