&EPA Issue United States Office of August 1988 Environmental Protection public Affairs (A-107) Agency Washington DC 20460 Environmental Backgrounder Medical Waste The recent incidents of floating debris, garbage, wood, and medical waste on our nation's beaches — resulting in beach closures throughout the summer, as well as threatening 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 options. 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. Overview The United States has made tremendous progress in improving the water quality of its lakes, bays, 'estuaries, arid 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. ------- Sources The medical waste found this past simmer 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. Description The 3.2 million 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 ® Cultures and stocks of infectious agents and associated biologicals. ® Pathological wastes. ® Human blood and blood products. • Contaminated sharps (such as needles and scalpels). 9 Contaminated animal carcasses, body parts, and bedding. 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. 2 ------- 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 disposal. 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 wastes. 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. Nonetheless, EPA believes inadvertent exposure to such wastes is unacceptable, and EPA is continuing to investigate these concerns to make sure such conclusions are accurate. ParlAral Annroach EPA believes that the use of good management and reacrdl MpfJiuauii 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. Proposed Legislation EPA supports a bill recently passed by the Senate which, if approved by the full Congress, would authorize EPA to establish a limited (demonstration) tracking program for medical wastes generated and disposed of in New York, New Jersey, and Connecticut. The bill also provides for federal enforcement of the tracking requirements. Most medical waste produced in small quantities by doctor's offices, clinics, and household users would not be regulated, therefore many sources of medical waste would not be covered under this proposal. 3 ------- 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 disposal. 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 wastes. 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. Nonetheless, EPA believes inadvertent exposure to such wastes is unacceptable, and EPA is continuing to investigate these concerns to make sure such conclusions are accurate. PaHotaI Annmach EPA believes that the use of good management and reaeral Mpprvawi 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. Proposed Legislation EPA supports a bill recently passed by the Senate which, if approved by the full Congress, would authorize EPA to establish a limited (demonstration) tracking program for medical wastes generated and disposed of in New York, New Jersey, and Connecticut. The bill also provides for federal enforcement of the tracking requirements. Most medical waste produced in small quantities by doctor's offices, clinics, and household users would not be regulated, therefore many sources of medical waste would not be covered under this proposal. 3 ------- Sources 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. Description The 3.2 million 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. • Contaminated sharps (such as needles and scalpels). 9 Contaminated animal carcasses, body parts, and bedding. 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. ------- cdA Artinn cnronoltm CrM MwUviiI 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 guidance. 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 Ad- ministration (NOAA), and the Department of Transportation (DOT) begin to implement Section 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 win share in the distribution of NOAA'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 1988. 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 -Appointment of EPA Medical Waste Task Force, chaired by Dr. John Moore, to coordinate Agency activities on medical waste. -Creation of a task force on solid waste in EPA to work specifically on the national municipal solid waste dilemma. 9/88 -Region 2 is hosting a Medical Waste Conference in mid to late September with state health and environmental commissioners from New York City, New York, New Jersey, Rhode Island, Connecticut, Pennsylvania, and Maryland. -Federal officials from EPA, the Department of Defense, Department of Transportaton, Depart- ment of Commerce, National Science Foundation, State Department, and the Department of Interior will meet to discuss improved federal sharing of enforcement and resources to combat improper disposal of medical waste. 10/88 -EPA is sponsoring a two-day Ocean Pollution Enforcement Conference in Point Judith, Rhode _ Island during the week of October 3. Represen- tatives 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 are expected to attend. The discussions will cover a broad range of state and federal ocean pollution enforcement issues, including medical waste disposal. Oceans '88 Conference in Baltimore with medical waste panel included on agenda (10/31-11/2). Assessment Plan Following is EPA's fact-finding plan for determining the best management of medical waste. The objectives 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_c9m- :; pliance costs. 5 ------- 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 -Appointment of EPA Medical Waste Task Force, chaired by Dr. John Moore, to coordinate Agency activities on medical waste. -Creation of a task force on solid waste in EPA to work specifically on the national municipal solid waste dilemma. 9/88 -Region 2 is hosting a Medical Waste Conference in mid to late September with state health and environmental commissioners from New York City, New York, New Jersey, Rhode Island, Connecticut, Pennsylvania, and Maryland. -Federal officials from EPA, the Department of Defense, Department of Transportaton, Depart- ment of Commerce, National Science Foundation, State Department, and the Department of Interior will meet to discuss improved federal sharing of enforcement and resources to combat improper disposal of medical waste. 10/88 -EPA is sponsoring a two-day Ocean Pollution Enforcement Conference in Point Judith, Rhode Island during the week of October 3. Represen- tatives 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 are expected to attend. The discussions will cover a broad range of state and federal ocean pollution enforcement issues, including medical waste disposal. -Oceans '88 Conference in Baltimore with medical waste panel included on agenda (10/31-11/2). Assessment Plan Following is EPA's fact-finding plan for determining the best management of medical waste. The objectives 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),Tand-com- - pliance costs. niia_-:ce 5 ------- PDA Action curonolo^Y CrM MtuUll i qa 7 -Pub 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 guidance. 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 Ad- ministration (NOAA), and the Department of Transportation (DOT) begin to implement Sectio 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 NOAA'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 1988. 6/88 -Published a Federal Register Notice in which EPA requested comments on issues related to medic?' 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 ------- 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 waste. 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 method. 6. To determine the environmental, economic, and health risks of improper disposal of infectious waste. 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, will coordinate a nationwide volunteer beach cleanup of litter. The effort win involve more than 30,000 volunteers working on selected beaches in all coastal states. Each volunteer will be 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 distribution. 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 go into effect. • *88 Oceans Conference (October 31 — November 2) Annual conference planned in Baltimore with Maryland's Governor Schaefer as chairman, and the theme: "Partner- ship in Marine Interests." The conference is planning to include a medical waste panel. State Action Most of tne states (88 percent) are or will soon regulate medical waste. 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. Wpw York fr New Jersey The New York/New Jersey area in EPA's Region 2 is the area most heavily affected by the medical waste problem. 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 medical waste mismanagement incidents. In May 1988, EPA began working with the states of New York and New Jersey to develop consistency in their state medical waste programs, including implementation 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 medical waste. Comments were received from trade associations, hospital groups, state and local health departments, and interested individuals. There was no evidence presented by any commentors suggesting that properly handled and disposed medical waste posed a public health problem. The majority of respondents agreed that workers in health-care facili- ties, transporters of medical waste, and workers at disposal sites run the greatest risk of exposure. ------- 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 waste. 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 method. 6. To determine the environmental, economic, and health risks of improper disposal of infectious waste. 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 win result in: 9 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, will coordinate a nationwide volunteer beach cleanup of litter. The effort will involve more than 30,000 volunteers working on selected beaches in all coastal states. Each volunteer will be "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 distribution. 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 wil. exist after the MARPOL regulations go into effect. • *88 Oceans Conference (October 31 — November 2) Annual conference planned in Baltimore with Maryland's Governor Schaefer as chairman, and the theme: "Partner- ship in Marine interests." The conference is planning to include a medical waste panel. State Action Most of the states (88 percent) are or will soon regulate medical waste. Thirty-one states single out packaging/labeling requirements in their rules, such as double-bagging- anc rigid containers. nr.- - . ------- |