finding the rx for managing medical wastes

Finding the Rx for Managing Medical Wastes

October 1990

OTA-O-459NTIS order #PB91-106203

Recommended Citation:

U.S. Congress, Office of Technology Assessment, Finding the Rx for Managing MedicalWastes, OTA-O-459 (Washington, DC: U.S. Government Printing Office, September 1990).

For sale by the Superintendent of DocumentsU.S. Government Printing Office, Washington, DC 20402-9325

(Order form can be found in the back of this report.)

Foreword

The adequate management of medical wastes first became a major focus of publicattention when medical wastes with other debris washed ashore on the East Coast in thesummer of 1988. In October of that year, as part of OTA’s assessment of municipal solid wastemanagement, OTA issued a background paper entitled Issues in Medical Waste Management.That study provided an overview of medical waste disposal practices and potential risksassociated with them, and discussed the need for further Federal involvement in managingmedical wastes.

Also in October of 1988, Congress passed the Medical Waste Tracking Act, establishinga 2-year demonstration tracking program for medical waste management and directing theEnvironmental Protection Agency and the Agency for Toxic Substances and Disease Registryto complete several studies to evaluate management issues and potential risks related tomedical waste disposal.

Some studies by these and other government agencies, and by private-sector interests,have been completed since that time on various aspects of medical waste management issues.The focus of concern has shifted primarily to the adequacy of handling, treatment, and disposalpractices for medical wastes. Public concern remains high and much of the confusion andinconsistency associated with medical waste policy persists.

This OTA report was requested by the House Committee on Science, Space, andTechnology, the House Subcommittee on Transportation and Hazardous Materials, Commit-tee on Energy and Commerce, and the House Subcommittee on Regulation, BusinessOpportunities and Energy, Committee on Small Business. The report evaluates medical wasteissues in the broader context of a waste management policy for the Nation. Waste reductionand recycling options for medical waste management, as well as incineration andnon-incineration treatment alternatives are examined.

Applying a more comprehensive waste management approach to medical wastes, suchas has evolved for municipal solid waste and hazardous waste, could help ensureenvironmentally sound and economically feasible waste practices. At a minimum, we realizethat (as with most waste problems) there is no one management scenario to “solve” ourmedical waste problems; rather the most important task is to devise policies that will facilitateadoption of individually optimal solutions to specific problems.

OTA benefited from the assistance received from many organizations and individualsduring the course of this study. We express our gratitude and thanks to the review panel andthe many other reviewers for their input which greatly facilitated the preparation of the report.OTA, however, is solely responsible for the contents of this report.

Review Panel and Medical Waste Workshop Participants forFinding the Rx for Managing Medical Waste

Barry Rabe, ChairmanSchool of Public HealthUniversity of Michigan

Richard BernsteinGeneral Medical Corp.

Leland CooleyRadiation Safety/Biosafety OfficeUniversity of Maryland at Baltimore

Frank CrossCross/Tessitore & Associates, P.A.

John CusackAsea, Brown & Boveri

Janet EmmermanWaste Management, Inc., Medical Services

Roger EtterJohn Zink Co.

Martin S. FaveroCenters for Disease Control

Randell ForsheySan-i-pak Pacific, Inc.

Barbara FryState of CaliforniaAir Resources Board

Allen HershkowitzNatural Resources Defense Council

Ode KeilJoint Commission on Accreditation

of Healthcare Organizations

Janis KurthMetropolitan Hospital

Jenny LezakHealth Organization to Protect Our Environment

Daniel LibermanMassachusetts Institute of Technology

Thomas J. MurphyThomas J. Murphy Associates

Edward NormanState of North Carolina Health Department

Claude D. RoundsAlbany Medical Center

James SharpStericycle

Robert Spurgin, OTA ContractorSpurgin & Associates

Martha TruslerMethodist Health Systems

Wayne TurnbergDepartment of EcologyState of Washington

Michelle WilsonU.S. Environmental Protection Agency

NOTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the workshop participants,advisory panel members, and reviewers. These participants do not, however, necessarily approve, disapprove, or endorse thisspecial report. OTA assumes full responsibility for the special report and the accuracy of its contents.

iv

OTA Medical Waste Management

John Andelin, Assistant Director,

Project Staff

OTAScience, Information, and Natural Resources Division

Robert Niblock, Oceans and Environment Program Manager

Kathryn Wagner, Project Director

Contractors

Robert Guttman, Esq.

Robert Spurgin, Spurgin & Associates

Administrative Staff

Kathleen Beil Sally Van Aller

Reviewers and Contributors

Robert AshworthBrowning-Ferris Industries

Charlotte BakerUniversity of California

Robert G. BartonEnergy & Environmental Research Corp.

John N. Basic, Sr.Basic Environmental Engineering

William F. BinaNaval Medical Command

Jack D. BradyAnderson 2000, Inc.

Theodore G. BrnaU.S. Environmental Protection Agency

Joy BuckCity Hospital, Inc.

Robert E. CampbellJohnson & Johnson

Sherry ClayTexas Department of Health

Peter S. DaleyChemical Waste Management, Inc.

Milton DezubeAmerican Hospital Association

Henry L. Diamond, Esq.Beveridge & Diamond, P.C.

Lawrence DoucetDoucet & Mainka

Dennis DowningCornell University

Al DozierAdvanced Concepts, Inc.

Kenneth L. DuFourMedical Disposal Systems

George EstelNew York State Department of Health

Jacquelyn FloraBrowning-Ferris Industries

Robin GillespieService Employees International Union

Martin E. Gilligan, Jr.Donlee Technologies, Inc.

Mary GreeneU.S. Environmental Protection Agency

Roger GreeneState of Rhode Island

Dieter GroschelUniversity of Virginia Medical Center

Robert Guttman, Esq.

Shari HaleyAmerican Hospital Association

John HallSan-i-pak Pacific, Inc.

Susan HarwoodU.S. Department of Labor

Steven A. HickersonEMCOTEK

Travis HoneycuttIsolyser

Wally JordanWaste Tech

Edwina JuilletMartha Jefferson Hospital

Larry KingPoly-Flex

Jonathan KiserNational Solid Waste Management Association

Carolyn KonheimKonheim & Ketcham

Judy KowalskiNew Mexico Energy, Minerals

and Natural Resources Department

Jack LauberNew York State Department of

Environmental Conservation

Cc. LeeU.S. Environmental Protection Agency

Howard LevensonOffice of Technology Assessment

Maureen LitchveldAgency for Toxic Substances and Disease Registry

Edward LondresNew Jersey Department of Environmental

Protection

Hugo LopezBeth Israel HospitalRebecca Goldberg

Environmental Defense Fund

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Robert LordNassau-Suffolk Hospital Council, Inc.

Rodney W. LowmanThe Council for Solid Waste Solutions

Donald C. MalinsPacific Northwest Research Foundation

Ted MalloyStanford University

John ManuelOntario Ministry of the Environment

Gretchen McCabeHuman Affairs Research CenterBattelle

Jean-Ann McGraneNew York City Health & Hospitals Corp.

Jim McLaineyAmerican Hospital Association

Allan McLeanThe University of Chicago Medical Center

John McVicarCenters for Disease Control

Tom MerskiUniversity of Pittsburgh

Thomas W. MoodyState of Florida Department

Environmental Regulation

Pat MooreU.S. General Accounting Office

Sue MorelandUniversity of Tennessee

Phil MorrisSouth Carolina Department of

Health and Environmental Control

Regina MornsNew York Department of Sanitation

Liisa NenonenThe RACOURSE Network

Jerry NessNorthwestern Memorial Hospital

Ross PattenBFI Waste Systems

Jacqueline PolderCenters for Disease Control

Sven E. RodenbeckAgency for Toxic Substances and Disease Registry

Claude RoundsAlbany Medical Center

William RutalaUniversity of North Carolina

School of Medicine

Jacqueline W. SalesHazmed

W. Thomas SchipperKaiser Permanence

Steve SchulerJoy Energy

Harvy SchultzNY City Department of

Environmental Protection

Robert SheehanMedi-Gen

Robert SpurginSpurgin & Associates

Jeffrey SteinerMayo Clinic

Tom StewartState University of New York

Christopher B. StrasserThe Allentown Hospital—

Lehigh Valley Hospital Center

Pam SulmerState of Minnesota

Attorney General’s Office

Kevin TonatNational Institutes of Health

Jim TripodesUniversity of California

Jacqueline WarrenNatural Resources Defense Council

Joe WilsonMedical Safetec

Robert PetersNational Solid Waste Management Association

vii

Contents

PageIntroduction, Major Findings, and Policy Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4POLICY ISSUES FOR FEDERAL ACTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Chapter 1. Characterizing Medical Wasteland Applying a Comprehensive Management Strategy. 9MEDICAL WASTE IN A COMPREHENSIVE WASTE MANAGEMENT STRATEGY . . . . . . . . . . 9WASTE CHARACTERISTICS AND TYPES-TREATMENT IMPLICATIONS . . . . . . . . . . . . . . . . 11

Chemical Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Biological Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Physical Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Chapter 2. Before Treatment: Waste Reduction and Recycling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19BEFORE-TREATMENT APPROACHES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19WASTE REDUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19RECYCLING AND SOURCE SEPARATION PRACTICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Chapter 3. Non-incineration Treatment Technologies and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27AUTOCLAVING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Capacity and Siting Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Suitability for Different Medical Wastes and Associated Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Costs and Volume Reduction Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

AUTOCLAVING AND COMPACTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32MECHANICAL/CHEMICAL DISINFECTION. , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33MICROWAVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36IRRADIATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36OTHER POTENTIAL TREATMENT TECHNOLOGIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Chapter 4. Incineration Treatment Issues and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41REGULATORY TRENDS AND MEDICAL WASTE INCINERATION . . . . . . . . . . . . . . . . . . . . . . . . . 42CAPACITY, COSTS, AND RISKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

TRENDS IN AIR POLLUTION CONTROL SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51OPERATOR TRAINING.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53OFF-SITE INCINERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Off-Site v. On-Site Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Co-Incineration or Co-Firing of Wastes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Regional Incineration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Chapter 5. Special Treatment Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59SHARPS MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Manufacturing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Mechanical/Chemical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Encapsulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Mail Shipment for Disposal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

SMALL GENERATOR MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61OTHER TREATMENT TECHNIQUES: SEWER USE AND SHREDDING . . . . . . . . . . . . . . . . . . . . . 62

Sewer Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Shredding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Chapter 6. Comparisons of Treatment Alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65CAPABILITIES AND RISKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65COSTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Appendix A. The Medical Waste Tracking Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Contents—Continued

BoxesBox Page

A. Management of Medical Low-Level Radioactive Waste (LLW) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16B. Disposables: Infection Control and Waste Management Implications . . . . . . . .......... . . . . . 20C. California and Its Dioxin Control Measure: A Case Study of One State’s Approach to

FiguresFigure Page

l. Schematic of One Hospital’s Proposed Segregation Categories and ComprehensiveMedical Waste Management Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... 23

3. Typical Sterilization Destruction Curve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 30

5. Mechanical/Chemical Disinfection Unit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356. Mobile Microwave Medical Waste Disinfection Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 37

8. Controlled Air Incinerator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............ . 459. Comparison of PCDD/PCDF Concentration in Medical and Municipal Wastes. . . . . . . . . . . . . . . . . . . 49

IO. Comparison of PCDD/PCDF Emissions From a Variety of Icinerators . . . . . . . . . . . . . . . . . . . . . . . . . 4911. Comparisons of Cadmium Emissions From a Variety of Incinerator s..... . . . . . . . . . . . . . . . . . . . . . . 50

TablesTable Pagel. Major Federal Agencies Addressing Medical Waste Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32. Types of Wastes Designated as Infectious by Various Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123. Percentages of Waste Types Produced at Different Medical/Health-Care Facilities in the

State of Washington . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... 144. Characteristics of Medical Waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175. Comparison of the Composition of Medical and Municipal Waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176. Emissions of Dioxins and Cadmium From Medical Waste Incinerators in California . . . . . . . . . . . . . . . 487. Performance Data of Medical Waste Incinerators With Pollution Control Equipment . . . . . . . . . . . . . . 528. Comparison of Treatment Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Introduction, Major Findings, and Policy Issues

Two years after the beach washups of medicalwastes in a hot summer,l preliminary results frominvestigations by Federal agencies into medicalwaste management issues are being reported.2 At thesame time, many State and local governments (107,139,110) and several private groups (77) haveundertaken efforts to better address the managementof medical wastes. Certainly, more is known aboutcurrent medical waste management practices thanprior to the passage of the Medical Waste TrackingAct (MWTA) in October 19883 (see app. A). Yet,much of the confusion and inconsistency associ-ated with medical waste policy persist. Basicinformation as well as consensus on some funda-mental management issues remain absent from theefforts to formulate a adequate national medicalwaste policy.

As current governmental studies and efforts arecompleted, it is clear that critical aspects of medicalwaste issues need to be addressed further:

Consensus on the definition of regulated medi-cal wastes must develop, based on the potentialhealth risks posed by these wastes (e.g., theability of a particular type of medical waste topose a risk of infectious disease transmissionbeyond that associated with municipal solidwaste).Basic, more precise information on the genera-tion (amounts and disposal methods) of medi-cal wastes, particularly by non hospital sources,is needed.Potential waste reduction and recycling opportu-nities to improve medical waste managementneed to be investigated, including considera-tion of product redesign to produce reusableand recyclable medical products where appro-priate, or to avoid use of problematic (e.g.,cadmium and lead) components in products.Appropriate workplace practices for occupa-tional groups in frequent contact with medicalwastes (e.g., health-care workers, refuse work-ers) need to be developed by relevant govern-

●

●

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mental agencies and adopted by employers tominimize the occupational hazards posed bythese wastes.Information on treatment technologies, inparticu-lar nonincineration alternatives, needs to bemore readily available to State and localregulators, to generators, and to the generalpublic.Air emission standards for medical wasteincinerators, expected to be completed in acouple of years by the Environmental Protec-tion Agency (EPA), are needed to create a morecertain regulatory climate. Procedures to estab-lish the safety and efficacy of new treatmenttechnologies are needed.Management options for small generators ofmedical waste (including households) must bedeveloped and information on their availabilityshould be more readily available.

Before a comprehensive approach to medicalwaste management can be pursued, gaps in informa-ion and research that limit resolution of these issuesmust be better addressed. Some of the necessarystudies, particularly those that better characterize thenature of health risks posed by medical wastes, willrequire significant commitments of time and fund-ing, e.g., for epidemiologic and longitudinal studies.

The Office of Technology Assessment (OTA), ina background paper released in October 1988, Issuesin Medical Waste Management, briefly examinedthe adequacy of current medical waste disposalpractices, the potential risks from such practices, andthe need for further Federal requirements for thehandling, treatment, storage, and disposal of medicalwastes. The focus of this OTA report is: 1) to placemedical waste problems in a broader waste reductionand materials management perspective, as is evolv-ing for municipal solid waste (MSW) and hazardouswaste; and 2) to address a number of outstandingissues on incineration and other medical wastetreatment technologies.

l~e causes and impacts of the beach washups of medical waste are discussed in a sep~ate effofi (11s).~amely, the studies of medical waste issues mandated by the Medical Waste Tracking Act to be completed by the Environmental Protection Agency

and the Agency for Toxic Substances and Disease Registry, as discussed below.3~e Me~~ Wwte T~a&@ Act is mended ~ new subti~e J to tie so~d waste Dispos~ Act and tie Resource Conservation and Recovery Act

(Public Law 89-272; 42 U.S.C. 6901 et seq.).

– l -

2 ● Finding the Rx for Managing Medical Wastes

Medical wastes are defined to include all the typesof wastes produced by hospitals, clinics, doctors’offices, and other medical and research facilities.4

These wastes include infectious, hazardous, radio-active, and other general wastes from these health-care and medical facilities. Infectious wastes are arelatively small portion of medical wastes, althougha high level of concern regarding their managementexists. 6 For purposes of this report, regulatedmedical wastes are those infectious, potentiallyinfectious, and special wastes designated by EPA assuch under MWTA (see app. A). Throughout thisreport, the regulated medical waste stream is theprimary focus and is usually referred to as suchunless another type of medical waste (e.g., low-levelradioactive, hazardous, etc.) is being discussed.

All medical wastes represent a small portion ofMSW. Estimates for medical waste, exclusive of thatgenerated from home health-care (for which reliablenational estimates do not exist), range from 0.3 to 2percent of the total municipal solid waste stream(130, 114).7 The amount of infectious waste gener-ated by medical facilities as a percentage of theirtotal waste stream varies widely depending on thetype of health-care facility, the definition of infec-tious waste used, and the standard operating proce-dures specified by it for designating and separatingwaste types. Most hospitals, however, designateabout 15 percent of their waste as infectious (95).

EPA reports that autoclaving (i.e., steam steriliza-tion) is utilized nationally to treat most infectiousmedical waste (141, 49, 139). However, medicalwaste incinerators continue to be a source of publicconcern, particularly because there are no nationalemission control standards for them (because theirsmall size exempts them from current standards).EPA is in the process of developing new sourceperformance standards (NSPS) for medical wasteincinerators, which are expected to be proposed in1992 (41; see ch. 4). Meanwhile, many States havedeveloped new regulations to control these sources(107). To date, even less regulatory development has

Photo credit: R. Guttman

Infectious wastes, although a relatively small portion of alltypes of medical wastes, are the principal focus of

regulatory concern.

occurred for autoclaves or other nonincinerationtreatment alternatives (see ch. 3).

Nearly 70 percent of the Nation’s hospitals useon-site incinerators. There is, however, great varia-tion in the type, nature, and use of these incinerators.Some are used only for pathological waste disposal;others are used for disposal of infectious andnoninfectious medical wastes.

Only a few States have reliable information on thenumber, types, and conditions of treatment unitsoperating in their States. The State of Washington,for example, in its recent survey of medical wastepractices, found that somewhere between 48 and 87percent of the incinerators operating in the Statewere doing so without emission control equipment(139). The State of California reports that most of its146 operating medical waste incinerators are small,uncontrolled units; 94 percent are on-site units(107). Recently, data has been reported that indicatesthat the rates of toxic emissions from medical wasteincinerators (without emission controls) exceedthose from modern MSW incinerators (106). Inter-estingly, the State of California also reports that amaximum of 60 percent of the waste burned in these

4Medic~ w~tes from households are generally considered to be part of the municipal solid waste stream. AS noted throughout this repo~ however,certain items such as syringes, which can be generated in significant quantities by households, may warrant separate and special management practices.Further, wastes similar to those identified as medicaI wastes may be generated by such facilities as police crime investigation units, mortuaries, veterinaryclinics, etc.

51t sho~d be noted mat ~ ~s context “&mdous” is a leg~ desi~tio~ not necess~y a m~sure of tie ac~ -d C)f a pMdCUkU WaSk

61t i5 fipo~t t. emp~~e tit not all medical waste is infectious. As EPA noted in 16 gui&nce document, defining infectious WMe aS W&Xt3

capable of producing an infectious disease requires consideration of factors necessay for induction of disease. These factors include: presence of apathogen of sufficient virulence, dose, portal of entry, and resistance of the host (122).

7J3pA es~ates that 2 to 3 million tons of infectious hospital waste is generated annually.

Introduction, Major Findings, and Policy Issues ● 3

incinerators is regulated medical waste, the remain-ing 40 percent being municipal waste (107).

EPA, the Centers for Disease Control (CDC), theOccupational Safety and Health Administration(OSHA), and other Federal agencies have issueddifferent, general guidelines for infectious andmedical waste management (see table 1). Differ-ences of opinion exist over the importance andimpact of variations between the definitions andrecommendations of these government agencies.Any remaining confusion over government posi-tions on these matters could be eliminated ifCongress designated a lead agency to coordinate andclarify the Federal Government positions on medicalwaste issues. As noted in OTA’s previous back-ground paper on medical waste, EPA is the agencywith the most comprehensive authority to provideFederal leadership on the management of medicalwastes (114).

OTA’s statement in that background paper stillapplies: “Currently, no Federal regulations existthat comprehensively address the handling, transpor-tation, treatment, and disposal of medical waste”(emphasis added; 114). This means that variationexists among the requirements that States andlocalities have devised for medical waste manage-

ment. In recent years, such variations have ledobservers to suggest that the Federal Governmentneeds to establish some baseline, uniform standardsand guidelines for medical waste management. Todate, the Federal Government has been reluctant toact without greater information on a number ofissues related to medical waste management (114).

Some of this information may come from studiesthat both the EPA and the Agency for ToxicSubstances and Disease Registry (ATSDR) arerequired to conduct under MWTA (sees. 11008 and11009). MWTA (sec. l1008(a)) requires EPA toevaluate and include in reports to Congress: genera-tor information (types, number, and size); on-siteand off-site management practices, including seweruse; types and amounts of medical wastes; costsassociated with the improper management of medi-cal waste and those from compliance with theregulatory requirements of MWTA demonstrationprogram; available and potential reduction, reuse,and management methods; implications of regula-tory exemptions of household and small quantitygenerators; guidelines for the management of medi-cal waste from households and small-quantity gener-ators; existing State and local controls; and theappropriateness of applying Subtitle C requirements

Table l—Major Federal Agencies Addressing Medical Waste Issues

Agency Authority Activity

U.S. Environmental ProtectionAgency (EPA)

Occupational Safety and HealthAdministration, U.S. Departmentof Labor (OSHA)

Centers for Disease Control, U.S.Department of Health and HumanServices (CDC)

Agency for Toxic Substances andDisease Registry, Public HealthService, U.S. Department ofHealth and Human Services(ATSDR)

Guidance and Regulatory a Issued Guide for Infectious Waste Management; issuedregulations to establish the Medical Waste TrackingProgram; establishing new source performance stan-dards for medical waste incinerators; completing stud-ies requested by the Medical Waste Tracking Act;authority under the Resource Conservation and Recov-ery Act to regulate the handling, storage, and transpor-tation of medical wastes.

Guidance and Regulatory b Issues advisory notices and workplace standards focusingon occupational exposure to infectious materials andwastes.

Guidance and Recommendations c Issues notices and advisories, sometimes jointly withOSHA, focusing on infection and control issues.

Study and Reviev c Completing study required by the Medical Waste TrackingAct, focusing on evaluating health effects associatedwith medical wastes.

aEpA’$ comprehensive autlmfity to regulate medical waste management is granted under the Resource Conservation and Recovery Act. The Agency alsohas special regulatory authority to administer a demonstration medical waste tracking program and is required to complete a number of studies related tomedical waste management under the Medical Waste Tracking Act (42 U.S.C. 6901 et seq.).

b@J+A~$ Pnmwy a~honty is granted under the ~upationa[ safety and Health Act (29 IJ.S.C. 651 et seq.). Guidelines or regulations only appiy tO priVd43

facilities, unless a State extends cmverage to employees of public facilities as well.CDCMM not have the authority to issue regulations.

SOURCE: Office of Technology Assessment, 1990.


(i.e., the hazardous waste provisions) of the Re-source Conservation and Recovery Act (RCRA) tomedical wastes.

EPA has concentrated its implementation effortsthus far on promulgating and implementing therequirements for the MWTA demonstration pro-gram. The regulations were promulgated ahead ofschedule in March 1989 and became effective inJune 1989 (Federal Register, Mar. 22, 1989). TheAgency and its contractor convened a meeting inNovember 1988 with health-care and waste indus-try, environmental, and various State and FederalGovernment representatives to discuss ways tocollect information on medical waste generation andmanagement practices as part of this effort (123).EPA’s first of three required reports to Congressunder the law, highlighting the efforts to address theissues under study, was delayed by more than a year.This delay was due, at least in part, to inaction by theOffice of Management and Budget (OMB) in itsreview of the report. The first report is expected toreview what EPA plans to study and focus on theproposed approach for a health hazard assessment(89).

ATSDR is required to report on such healtheffects of medical waste as: estimates of the numberof people annually infected or injured by medicalwastes (including sharps), including descriptions ofthe nature and seriousness of those incidents; andestimates of the number of cases traceable to medicalwaste of diseases that could be spread by impropermanagement of such wastes (in particular, hepatitisB virus (HBV), and immunodeficiency virus (HIV),or AIDS). Its report to Congress on the public healthimplications of medical waste is expected to bereleased on schedule on November 1, 1990.8

The EPA and ATSDR studies are limitedbecause existing information and data are inade-quate (134). Still needed are research, surveysand studies that generate new information andaddress existing data gaps.

To address these research needs is beyond thescope of this report, which is intended to provide aframework for considering medical waste manage-

ment issues and to assess in a preliminary way thepotential of various reduction and treatment meth-ods for medical waste.9 The report is divided into sixchapters: 1) applying a comprehensive waste man-agement strategy to medical waste and a brief reviewof Federal efforts undertaken to date; 2) exploringpretreatment approaches (e.g., waste reductions andrecycling options); 3) exploring nonincinerationmedical waste treatment technologies and emergingtreatment technologies; 4) examining current issuesregarding incineration of medical wastes; 5) discuss-ing special treatment issues, such as sharps (e.g.,needles, glass, etc.) management and small genera-tor issues; and 6) comparing various managementtreatment alternatives.

SUMMARY OF FINDINGSTwo of the critical findings of this study are

consistent with a comprehensive waste reductionand materials management approach to wastemanagement. First, treatment technologies willcontinue to be needed for waste management, butthey can be preceded and complemented byprevention and pretreatment efforts (i.e., reduc-tion and recycling). Second, while there is no onepreferred treatment method, source separationpractices (i.e., separating wastes based on thephysical, chemical, and infectious characteris-tics) are key to targeting particular materials/wastes for the most appropriate treatment method.

Other findings of this report include:

. The commercial viability of nonincinerationtreatment alternatives has increased in re-cent years due to the increased cost ofincineration, the difficulty associated withpermitting incinerators, and the perceiveddesirability of reducing dependence on incin-erators given concern over their emissions.Alternative treatment technologies such asautoclaving (steam sterilization) with com-paction, microwaving, and mechanical/chemi-cal disinfection are likely to be less capitalintensive and have fewer emission concernsthan incineration processes. Yet, further inves-tigation of treatment alternatives (e.g., health

8~e~e fi&g~, h~wever, ~ be ~ted by the Mme of the e,xisfig &M base ~d litera~e fiom Wtich & findings are drawn. The number Ofunreported occupational injury cases, the baseline health status of workers, and the significance of potential exposure routes not yet studied (e.g.,aerosolization of substances during treatmen~ etc.) are crucial unknowns which could strongly impact risk determinations of VfiOUS @aWenttechnologies.

%eatrnent methods throughout this report refer broadly to any management technique and processes intended to render the wastes suitable fordisposal. Treatment of medical wastes is intended both to render wastes noninfectious and to lead to environmentally sound disposal.


Photo credit: Extrufix, OrIando, Florida

The diversity of the medical waste stream indicates thatsource separation practices can help target particular

materials/wastes to the most appropriate managementmethod, based on the physical, chemical, and infectious

●

characteristics of that waste.

risks) and determination of appropriate per-formance standards is warranted, as well asconsideration of research and developmentfunding to encourage innovative technologies.

Current regulatory activity at all levels ofgovernment tends to encourage incinerationeither by focusing most of its activity onincineration and/or by identifying it as apreferred treatment method in regulations orguidelines with minimal attention to alterna-tives. Congress may alleviate concerns overthe difficulties associated with introducingalternative treatment technologies by direct-ing EPA to specify approval or certificationprocesses for treatment alternatives capableof rendering infectious medical wastes non-infectious. A program taking these factors intoaccount might help stimulate the development

of innovative and improved treatment proc-esses.Incineration remains and is likely to con-tinue to remain a primary treatment methodfor medical wastes for the foreseeable future.Advanced pollution control equipment is be-coming a standard part of many new inciner-ators. An important concern is the impactFederal regulation of air emissions from medi-cal waste incinerators will have when they arefinalized in 1991, since stringent regulationshave been already enacted by some States.New incinerators for a variety of reasons (asnoted above) are tending to be larger facili-ties that operate on a more continual basisthan facilities in the past. A number ofregional incinerators, either nonprofit/gen-erator or commercial ones, are being planned.Yet some medical waste generators prefer tocontinue managing their own waste in an effortto maintain greater control over their costs andliability. A number of factors weigh in favor ofor in opposition to on-site and off-site manage-ment, leaving the particular circumstances ofthe medical waste generator and the hostcommunity to be the main determinants for thetype of treatment selected.A fundamental policy issue of importancethat the Federal Government could addressis the extent to which medical wastes are tobe regulated on the basis of their potentialthreat to public health (i.e., infectious na-ture) and their aesthetic characteristics (i.e.,recognizability as a medically related item).That is, Congress could clarify whether thenonrecognizability criteria of MWTA shouldremain a part of future regulations by address-ing this issue either as part of the currentResource Conservation and Recovery Act (RCRA)reauthorization or as part of the evaluation ofMWTA upon its expiration in 1991.A need exists for further education about thenature of the risks posed by medical wastesand methods for their proper handling andmanagement for health-care workers, otherworkers at risk, and the general public.These efforts could be undertaken by either orboth the health-care community and the gov-ernment. Such efforts could include instructionfor health-care workers and housekeeping staffexposed to medical wastes and incinerator


operating training for workers responsible formedical waste management.

This brief study discusses what is known regardingvarious medical waste treatment technologies andrelated management issues. Possible directions forFederal policy and areas where further informationto facilitate policy development and improvedmanagement are suggested by the study’s findings.

POLICY ISSUES FORFEDERAL ACTION

The reauthorization process for RCRA pro-vides an opportunity to revisit the medical wasteissues first addressed by Congress in 1988. In1991, the completion of the MWTA demonstrationprogram will provide further opportunity to incorpo-rate what is learned from the program and from themandated studies by EPA and ATSDR into thedecision making process for any further Federalaction on medical wastes management.

One possible option regarding medical wasteissues for Congress to choose is to do nothing in thisarea once the MWTA demonstration program andagency studies are completed. EPA will set airemission standards for medical waste incineratorsand Congress could defer to the Agency, as it has inthe past, for any further policy action as considerednecessary. Given the general concern over EPA’spast reluctance to act on medical waste issues andcurrent efforts at improving waste managementpractices in the country coupled with concern overState variations in the regulation of medical wastes,this appears to bean unlikely course for Congress.

More likely, Congress will address at least someissues regarding medical waste management as partof the RCRA reauthorization, whatever action mayor may not be taken once MWTA expires. 10 Con-gress could move beyond the current approach tomedical waste management and define a morecomprehensive approach. A comprehensive ap-proach might incorporate medical waste into thetype of waste reduction and materials managementapproach suggested by OTA (1 16) for MSW. Suchan approach could, for example, include determi-nations on the definition of regulated medicalwastes; address waste reduction and recyclinggoals/objectives; encourage the development and

adoption of baseline, uniform standards for eachtype of treatment method; establish a protocol forapproving or certifying new treatment alterna-tives; and include medical wastes in State wastemanagement plans. In these plans, States could berequired to consider waste reduction options, recy-cling opportunities, capacity needs for treatment,and similar planning issues for medical waste, asthey would be required to do for MSW.

Within this more comprehensive approach tomedical waste management, or independent of it, anumber of other policy issues can be addressed.These include the following:

●

●

●

●

A

Reduction and recycling issues-Greater atten-tion to opportunities for toxicity and volumereduction and recycling of medical wasteswould complement the efforts suggested andbeing adopted throughout the country for MSW.Dissemination of information through the EPAclearinghouse and possibly research and devel-opment (R&D) funding, could bring attentionto these opportunities.Non-incineration treatment technologies—Further investigation of treatment alternativesis warranted, e.g., health risks; need for per-formance standards (e.g., waste loadings, tem-peratures); operator and maintenance proce-dures, etc.Incineration treatment issues—Monitoring andoperating requirements for medical waste incin-erators and operator training and certificationrequirements could be specified; standards forair emissions and ash management could beestablished.Small generator management-Information andassistance for households and other nonhospi-tal sources of medical wastes could be madeavailable through the clearinghouse for solidwaste, which RCRA already directs EPA toestablish and the Agency is currently develop-ing.

number of these issues will need to beaddressed by nongovernmental entities, such ashospitals and other generators of medical wastes,the manufacturers of medical supplies, and thewaste management industry. In particular, a hospi-tal or medical facility itself can best identifystandard operating procedures that affect waste

IONote tit ~ ~mber of b~S on “fi~uS ~Sp=~ of medic~ ~aSte m~agement ~ve been fi~oduced ~ con~ess, @ he focus Of activity iS ~elyto center on how medical waste issues are addressed in the reauthorization of RCRA.



Careful planning and a comprehensive approach to wastemanagement, which may include recycling efforts, are

likely to reap cost savings to a medical facility, as well asenvironmental benefits for its community.

segregation practices, safe handling of waste materi-als, and adoption of waste reduction, reuse, orrecycling practices.

Medical waste management is a small part of ahealth-care facility’s function, but careful plan-ning and a comprehensive approach to waste

management are likely to reap cost savings to thefacility, as well as environmental benefits for itscommunity. This type of planning would involveconsideration of purchasing practices, use of differ-ent types of products, methods of waste segregation,and selection of treatment option(s) based on consid-eration of the full range of available alternatives. Thebenefits of such efforts may include cost savings tothe facility as well as a reduction in the amount ofwaste requiring management.

Education efforts regarding the nature of therisks posed by medical wastes and methods fortheir proper handling and management can alsobe effectively undertaken by health-care providers-for health-care workers, other workers at risk,and the general public. These efforts can includeincinerator operating training and personal protec-tive equipment and instruction for housekeepingstaff exposed to medical wastes. The government,waste generators and others involved in medicalwaste management also can undertake such efforts(see ch. 4).

For example, the American Diabetes Associationhelps educate diabetic patients on the safe disposalof their syringes (4). The government also couldmake information and assistance for households andother nonhospital generators of medical wastes morereadily available. One possibility is to include sucha focus in the clearinghouse for solid waste beingestablished by EPA, as currently required by RCRA.The resources spent on various education effortswould improve understanding of how medicalwastes can properly be managed, their associatedrisks, and would facilitate adoption of improvedmanagement practices.

Other more specific issues for which policyclarification by Congress will be useful are whetherthe nonrecognizability criteria of MWTA will re-main a part of future regulations; whether shreddingrequirements should or will be adopted; and alsosome specific packaging, transportation, and mail-ing issues.1l Of these issues, a fundamental one ofcritical importance that the Federal Governmentcould address is the extent to which medicalwastes are to be regulated on the basis of their

1 IFOreX~ple, two bilk (s. 2393 and H.R. 3386) currently before Congress address the transportation of medical waSteS as it is Part of the bac@*gof waste. The legislation seeks to require the use of dedicated vehicles for some substances, such as medical wastes, to avoid the transportation of foodin vehicles used to haul such wastes. The Department of Transportation, however, does not want the authority to regulate backhauling (as the proposedlaw would grant them) and instead believes the EPA, Department of Agriculture, and the Food and Drug Administration could better take the lead indetermining the necessary standards.


potential threat to public health and their aes-thetic characteristics.

Considerable expense can be associated withmanaging wastes (e.g., certain IV tubing) that poselittle public health threat but are recognizable asmedical items. A health-care organization officialrecently mused something to the effect that medicalwaste is probably as much in need of an imageconsultant as it is in need of regulation. The adoptionof regulations that treat wastes purely for aestheticreasons reinforces a “bad image” for medicalwastes, or at least the notion that more of this wasteposes hazards than may be true. It may be that themost appropriate treatment criterion with respect tomedical waste is the ability of a treatment system torender wastes noninfectious.

Clarifying the definition of regulated medicalwastes to include only the waste types consideredinfectious based on objective criteria may facilitatespecial management of those wastes that pose thegreatest risk to human health without risking" over-regulation” (e.g., special management of wastes forprimarily aesthetic reasons). Concerns over such‘‘needless and expensive’ requirements are particu-larly heard from public officials and generators ofmedical wastes in rural areas or areas where medicalwastes have not been as much of a public concern asthey have in the Northeast and other coastal andmore densely populated areas. The potential impli-cations of national legislation on areas of the countryprimarily concerned with the infectious potential(and not appearance per se) of medical wastes needto be carefully considered and balanced against theneeds of coastal areas and more densely populatedareas. In these areas, the medical waste beachwashups and other waste related problems in recentyears create entirely different waste managementcircumstances.

Another important issue centers on addressingwhether a “level playing field” exists for all theavailable treatment alternatives. Congress mightfacilitate the introduction of new treatment technol-ogies through specification of certification or ap-proval processes for treatment alternatives capableof rendering infectious medical wastes noninfec-tious. The same testing will not be appropriate for alltreatment technologies and determining potentialrisks and identifying any necessary control measureswill also vary depending on the nature of thetreatment technology.

A protocol to evaluate new technologies byidentifying appropriate tests, establishing standardsto demonstrate effective microbial kill, establishingoperating parameters and evaluating potential riskscould be adopted. Veterans hospitals or otherFederal medical laboratories and facilities mightalso be possible pilot/test sites for new treatmenttechnologies. Funding for the research, develop-ment, and testing of alternatives would also encour-age innovation and improvement in medical wastemanagement.

It will be an important part of any programregarding the management of medical wastes toinclude a provision addressing how the adequacy ofvarious treatment alternatives (which in fact mightevolve in response to the regulatory program) will beconsidered. As noted, such a program could provideinterim approval or certification status and/or fund-ing for a pilot/test facility to facilitate gathering theinformation necessary to determine whether routineadoption of the technology would be acceptable.Such a program might help stimulate the develop-ment of improved treatment processes.

Chapter 1

Characterizing Medical Wastes and Applying aComprehensive Management Strategy

The Medical Waste Tracking Act (MWTA) of1988 represents an attempt by Congress to addressthe problems of beach washups and illegal disposalof medical wastes .1 A more comprehensive ap-proach to medical waste management, one consis-tent with the broader waste management strategyevolving nationally, could be formally established ifthe issue of medical wastes remains part of thecurrent RCRA reauthorization effort. Medicalwastes need to be put into a broader frame ofreference along with other wastes (e.g., municipaland industrial hazardous and nonhazardous wastes)if we are to establish appropriate levels of protectionfor humans and the environment. The relative risksposed by all these types of wastes must be consid-ered when determining appropriate managementmethods for them.

This chapter consists of a brief discussion of thecontext within which the current Federal approach towaste management for other hazardous and nonhaz-ardous wastes evolved and consideration of theimplications of a broader, more comprehensivewaste management strategy for medical waste.Appendix A to this report provides a short review ofMSVTA, the first major Federal effort to addressmedical wastes.

MEDICAL WASTE IN ACOMPREHENSIVE WASTEMANAGEMENT STRATEGY

The Resource Conservation and Recovery Act(RCRA),2 passed by Congress in 1976, is the majorFederal statute addressing management of the Na-tion’s wastes—hazardous, municipal, industrial, andother types of solid waste, including medical waste.3

EPA has authority under RCRA to regulate thehandling, storage, treatment, transportation, anddisposal of all of these wastes. Before passage ofMWTA, EPA’s activity regarding medical wasteissues was mostly limited to distribution of itsguidance document for the management of infec-tious wastes. Other medical wastes were consideredto be like any other solid waste and subject torelevant RCRA Subtitle D regulations (114).

OTA finds four key challenges which need to beresolved for medical waste management:

1.

2.

3.

4.

The

better defining/identifying infectious and othermedical wastes, to facilitate more consistentand adequate handling and treatment ofwastes;

better addressing the diversity of generators(e.g., home health care, small doctors’ offices,clinics, etc.) to minimize contradictory re-quirements and inequities they pose;

improving the segregation of wastes for theirproper treatment; and

identifying appropriate treatment alternatives.

very nature of these issues indicates that acomprehensive, flexible, yet cost-conscious ap-proach is needed for medical waste management.These challenges can be met by a broader approachto medical waste management that emphasizeswaste prevention efforts and management of differ-ent portions of the medical waste stream based ontheir physical, chemical, and biological (i.e., infec-tious) properties. Such a comprehensive approach towaste management is beginning to be applied tohazardous waste and more recently to municipalsolid waste (MSW).

ICongress alSO amended the Marine Protection Research and Sanctuaries Act (also known as the Ocean Dumping Act) h 1988 to fif=ase thepenalties for illegal disposal of medical wastes by public vessels (33 U.S.C. 1401 et seq.). See app. A and (115) for discussion of MWTA.

Zwbhc bW 94-580 (1976); 42 U.S.C. 6901 et seq. The Solid Waste Disposal Act of 1965 (Public Law 89-272; as amended by the Resource RecoveryAct of 1970, Public Law 91-512) was the law by which Congress first established a F~eral role in solid waste management. The most recent majorrevision of RCRA was by the Hazardous and Solid Waste Amendments of 1984 (Public Law 98-616), which did not address medical waste issues inany detail. RCRA is currently in the process of further revision and reauthorization.

30m (1 15) recenfly completed its assessment of municipal solid waste, of which the 1988 background paper on medical wastes was a Part. CurrenflY,OTA is completing a background paper on industrial solid (Subtitle D, RCRA) waste issues (expected to be rdeased in early 1991). Hazardous wasteissues have been addressed by several OTA reports (e.g., 112, 113).

It should be noted that the following discussion is based in part on ref. 137.

-9 -


Photo credit: L. Swanson

Beach washups containing medical debris, such assyringes, helped prompt passage of the MWTA.

Subsequent studies indicate the sources of most washupsto be related more directly to sewage treatment systems

operation than illicit waste management practices.

There is some consensus that at least portions ofthe medical waste stream can be treated like otherMSW. Indeed, in practice this appears to occur. TheCalifornia Air Resources Board reports, as notedabove, that typically 40 percent or more of the wasteburned by medical waste incinerators in their Stateis waste, comparable to MSW in nature (106, 108,29).4 Available evidence also seems to indicate thatmost medical waste poses no more public health orenvironmental hazard when properly handled thandoes MSW (109, 56, 107, 139). Yet, when medicalwaste is incinerated (or treated by some other means)its emissions may be hazardous if not properlycontrolled (as is the case with any other waste).Thus, basic policy determinations regarding man-agement approaches, and weighing risks and costs,etc., are common to any waste problem.

It is instructive to consider the current trends inhazardous waste and MSW treatment in which thereis a movement away from treatment methods thatmanage indiscriminately mixed wastes and towardsource separation programs that encourage manage-ment based on the properties of the materials in the

wastes (e.g., recyclability, ability to destroy orneutralize, etc.). OTA’s assessment of the MSWissue found that environmentally sound waste man-agement requires focusing on how the Nation usesmaterials from manufacturing through subsequentdistribution and disposal (116). On this basis, OTAconcluded that,

A clear national policy on MSW that addressesthe use of materials is essential for providing abroader context in which specific MSW programscan be developed and implemented. Waste preven-tion and materials management should be thefoundation of this policy.

The basic steps are: 1) characterizing the wastestream in light of categories used for differentalternative treatment options; 2) segregating wastesat the point of origin to facilitate management basedon their characteristics; and 3) examining theproduction of the waste, i.e., looking upstream toconsider possible opportunities for waste reduction(in either volume or toxicity) that may include use ofdifferent products which are reusable or recyclableor contain less problematic substances for wastetreatment.

For example, government agencies and/or thehealth-care industry could examine prospects forwaste reduction in health-care settings (see ch. 2).Although the growth in the volume of medicalwastes is not well documented, there is generalacknowledgment that the use of disposable inhealth care has increased significantly in the last twodecades. Clearly, in some cases the use of disposa-ble is important for infection control. Yet, thoseuses driven primarily by economies may need to bereassessed (see ch. 2).

From a management perspective, the presumptionheld by some regulators and members of interestgroups that incineration is the “preferred’ treatmentoption for medical wastes warrants closer examina-tion. Most of the recent regulatory activity formedical waste management at all levels of govern-ment tends to focus on incineration and does notusually include specific procedures for the regula-tory approval of nonincineration alternatives.

For example, the “treat and destroy or track”requirement of MWTA does not include a proc-ess with specific criteria for how the standard can

4B~~~d on ~~ me of ~omation, ~~~~ion data from medic~ and MSW facilities can be compar~, as long as the &pe and size of incinerator Orother technology and the mix of wastes is taken into account (see ch. 5).

Chapter 1-Characterizing Medical Wastes and Applying a Comprehensive Management Strategy ● 11

be met by various treatment alternatives, anddoes not specify how new non-incineration treat-ment alternatives can be introduced. A number ofsuch alternatives (e.g., several types of disinfectionunits) are commercially viable and warrant consider-ation (see ch. 3).

Further, a number of unanswered questions re-main regarding incineration, e.g., the nature ofemissions and proper controls, the nature andadequate treatment of ash residues, and the costcompared with alternative management methods(see ch. 4). Information on operating parameters,risks, and costs for various alternative treatmentmethods is also needed. As with the hazardous andsolid waste streams, a combination of managementoptions may prove optimal for managing medicalwaste once the material composition of its compo-nents is considered.

That is, landfilling, incineration, and othertreatment alternatives, as well as recycling andwaste reduction all may be viable managementoptions for medical waste—when it is consideredon a waste component basis. Ultimately, this mayhelp to control costs and minimize any hazardsassociated with medical waste management. This isone way, given the experience gained in regulatingother waste streams, that programs to managemedical wastes can be devised wisely and efficientlyin order to alleviate public concern, protect workers,and provide environmental protection.

WASTE CHARACTERISTICS ANDTYPES—TREATMENT

IMPLICATIONSExamining various treatment options underscores

the importance of considering the properties ofdifferent types of medical waste and matching themto the capabilities of the treatment technologies.Although the medical waste stream is hetero-geneous, the focus of concern is on the portion of thewaste stream termed ‘‘infectious, ’ and how thesewastes are classified (e.g., solid, hazardous, orspecial) and regulated. The regulated waste stream,

i.e., the medical wastes covered by MWTA, includesinfectious, potentially infectious, and some wastesidentified as requiring special handling. Most esti-mates are that 10 to 15 percent of medical wastesgenerated by hospitals are infectious, although thisfigure can range as high as 80 percent depending onthe generator’s definition. Determining which por-tion of medical waste is infectious remains at theheart of definitional issues. How infectious waste isdefined can greatly affect the cost of waste manage-ment, and ultimately the choice of disposal options(114).5

Currently, both aesthetic considerations andhealth risks posed by medical wastes can lead to theclassification of a medical waste as infectious and/orregulated and requiring special management. TheState of Washington has defined infectious wastebased on risk criteria, particularly the determinationof “infectious disease causation potential’ (139). Aconsensus on which medical waste warrantsspecial regulation and management might beforged if the definition of regulated medical wasteis based on the potential health risks associatedwith the waste (i.e., the ability of a particularmedical waste-given organism concentration,ability of the waste to penetrate skin, etc.—topose a risk beyond that associated with MSW totransmit infectious disease).

As noted, no consensus exists on the types ofmedical wastes that should be designated as infec-tious or that require special handling, althoughseveral categories of wastes are included in mostlists (114; also see table 2). Under MWTA (seebelow), EPA has listed seven types of medical waste(commonly and hereafter refer-red to as “regulatedwaste types’ to be tracked in the demonstrationprogram. These are:

1. microbiological wastes (cultures and stocks ofinfectious wastes and associated biologicalthat can cause disease in humans);

2. human blood and blood products (includingserum, plasma, and other blood components);

Ssome confusion was created over the Centers for Disease Control (cDC) universal precautions guidance issued in August 1987, tit suggestti titall patients be considered potentially infected with human immunodeficiency virus (HIV) (i.e., the virus which causes acquired immunodeficiencysyndrome, AIDS) and/or other blood-borne pathogens and that workers should adhere to rigorous infection-control procedures. In October 1987, CDCissued a joint advisory notice with the Department of Labor further addressing protection against occupational exposure to Hepatitis B (HBV) and HIV.After these advisories led to a great inflation of the amount of waste designated as infectious, the CDC issued a cltilcation in August 1988, indicatingto which types of secretions and circumstances its recommendations applied and that CDC did not intend for generators to alter waste mamgementprocedures, but only meant to protect health-care workers. In May 1989, the Occupational Safety and Health Administration (OSHA) of the U.S.Department of Labor issued a proposed job health standard for protecting health-care workers from blood-borne diseases.

Table 2—Types of Wastes Designated as Infectious by Various Entities

EPA/ PercentageWaste category MWTA EPA a CDC MA CA IL NY SC WI of hospitals

Microbiological c . . . . . . . . . . . . . . . . . . . . Yes Yes Yes Yes Yes Yes Yes Yes Yes 99.0Human blood and blood products . . . . . Yes Yes Yes Yes Nod Yes Yes Yes Yes 93.7Isolation wastes . . . . . . . . . . . . . . . . . . . . Yes Yes Optional e Yes Yes Yes Yes f Yes No 94.4Pathological wastes g . . . . . . . . . . . . . . . . Yes Yes Yes Yes Yes Yes Yes Yes Yes 95.6Contaminated sharps h . . . . . . . . . . . . . . Yes Yes Yes Yes Yes Yes Yes Yes Yes 98.6Contaminated animal carcasses,

body and bedding . . . . . . . . . . . . . . . . Yes Yes No Yes Yes Yes Yes Yes Yes 90.1Uncontaminated sharps. . . . . . . . . . . . . . Yes No No Yes No No Yes No No N/A

Other contaminated wastes:Miscellaneous laboratory wastes . . . . . . O p t i o n a l i N o Yes Yes Yes Yes f No Yes 88.8Surgery and autopsy wastes . . . . . . . . . O p t i o n a l i N o Yes Yes Yes Yes f No Yes 83.2 &91 .9,

respectivelyDialysis unit wastes . . . . . . . . . . . . . . . . O p t i o n a l i N o Yes Yes No Yes f No Yes 83.4Equipment . . . . . . . . . . . . . . . . . . . . . . . . . O p t i o n a l i N o Yes Yes Yes Yes f No Yes N/AAny other infectious waste . . . . . . . . . . . No No Yes Yes Yes Yes Yes Yes Varying

percentagesaB=~ on r=ommen~tions in EpA Gu&nce D~ument (U.S. En~ronmentai prot~tion Agency, Gujde for /nfectious Waste ~anagement, EPA/!X30-SW-86-01 4 (Washington, DC: May 1986);see discussion in U.S. Congress, Office of Technology Assessment, /ssues in Medica/ Waste Marragernent-/3ackground Paper, OTA-BP-O-49 (Washington, DC: U.S. Government Printing Office,October 1988).

bpercentage of hoSp~als&@n~ting thiS~aste ~ategory, according t. a survey completed for the Amefican Hospital Association. w, Rutala, W.W. Odette, and G. %fTW, “Management Of InfectiousWaste by U.S. Hospitals,” Journal of American Medicai Association 262:1635-1640, 1989.

csuch as-cultures and stocks of infectious agents.dHumm blo~ and blo~ pr~u~s that are proven to ~ntain pathogens arae subject to California’s inf~tious waste law and rWJJh3tiOM.

ecDC r~ommencls that this waste be treated according to hospital policy.fThe New York State Commissioner of Environmental Conservation may exclude this category.9Such as human body parts, tissues, fluids, and organs.hsuch ss syringes, needles, scalpel blades, and 91a=.iEpAJs 1 g86 gu~ance stat= that the decision to handle these wastes as infectious should be made by a responsible, authorized person or committee at the individual faCility.

SOURCE: Office of Technology Assessment, 1990; based on U.S. General Accounting Office, Medicaf Waste Regulation: Health and Environmental Risks Need To Be Fully Assessed,GAO/RCED-90-86 (Washington, DC: March 1990).

Chapter l--Characterizing Medical Wastes and Applying a Comprehensive Management Strategy ● 13

3.

4.

5.

6.

7.

pathological wastes of human origin (includ-ing tissues, organs, and body parts removedduring surgery or autopsy);contaminated animal wastes (i.e., animal car-casses, body parts, and bedding exposed toinfectious agents during medical research,pharmaceutical testing, or production of biologi-cals);isolation wastes (wastes associated with ani-mals or humans known to be infected withhighly communicable diseases);contaminated sharps (includes hypodermicneedles, scalpels, broken glass); anduncontaminated sharps.6

Other waste categories that EPA had to consider forinclusion in MWTA demonstration program are:wastes from surgery or autopsy that were in contactwith infectious agents (e.g., sponges, soiled dress-ings, drapes, surgical gloves, drainage sets); dialysiswastes that were in contact with blood; discardedmedical equipment and parts that were in contactwith infectious agents; and laboratory wastes thatwere in contact with infectious agents (e.g., labora-tory coats, slides and cover slips). EPA determinedthat potentially infectious items from these wastecategories are covered by the other seven regulatedwaste types. It is interesting to note that according toa recent survey sponsored by the American HospitalAssociation, the vast majority of the 441 randomlyselected hospitals designated six of the sevencategories above as infectious (the exception beingunused sharps) (95).

Wastes within each of these regulated waste typecategories can have different chemical (hazardous,radioactive, or nonhazardous) and physical (liquid,gas, or solid) characteristics that are important toconsider in selection of the most appropriate treat-ment method. Clearly, different types of medicalpractices by physicians, types of hospitals, and

different departments within a hospital generatedifferent types and quantities of the regulated wastetypes (123, 29) (see table 3). Therefore, it isreasonable to assume that just as hospital type andsize and occupancy rate are important determinantsof generation rates of medical wastes, they are alsokey factors affecting the chemical and physicalmake-up of the wastes. That is, general medical andsurgical hospitals will generate a different quantityand mix of wastes than psychiatric or other specialtyhospitals (e.g., chronic disease, orthopedic, andeye/ear/nose/throat hospitals).

Chemical Characteristics

Hazardous Constituents

Waste from a medical facility may containcytotoxic chemicals, laboratory solvents, toxic met-als, low-level radioactive waste, or waste contami-nated with human pathogenic microorganisms. Cy-totoxic chemicals are hazardous pharmaceuticalsused in chemotherapy, and seven such compoundsare on the RCRA ‘‘U’ list of hazardous waste.7 Thismeans that they cannot be disposed of in bulkquantities in medical waste incinerators without aRCRA hazardous waste incinerator permit. It is alsotrue that these RCRA hazardous wastes could not betreated by most nonincineration treatment methods.Yet, given that these substances are usually encoun-tered as “trace” contaminants, rather than “bulkwastes, ” they are not managed as RCRA hazardouswastes, and can legally be disposed of with othermedical wastes.

Laboratory solvents and other types of hazardouschemicals are commonly found in medical wastes,and many of these are also listed as hazardous wastesunder RCRA.8 Although these wastes should bemanaged separately from other medical wastes asRCRA hazardous wastes, like cytotoxic compounds,sometimes they are so intimately mixed with medi-

6c&e GAO (134) for ~ more complete discussion of tie EPA’s determinations for inclusion and Specification of the different wa.~tc tYPcs.

7~e~e ~e: c~o~bucil, cyclophosp~ide, duanarnyc~, melpha]~, mitomycm, stretozotocin, and uracil mustard. nesc CYtotoxic compoundsare a small fraction of all cytotoxic agents. The total amount of cytotoxic compounds incinerated is not known and little is known of the potential threatfrom cytotoxic emissions.

Indeed, data for cytotoxic emissions is lacking and conditions necessary to destroy cytotoxic compounds arc not known. A conservative assumptionis that 1,800 ‘F (1,260 K) would ensure complete destruction of cytotoxic compounds, although destruction is also dependent on rcsidcncc time andmixing (12, 41). As part of its testing program (at two incinerators) for developing standards for ncw medical waste incinerators, EPA is conducting teststo determine the destruction efficiency of the two test medical waste incinerators of hcxochlorobcn7zne as a surrogate for cytotoxic chemicals (the testswill be conducted at a secondary chamber temperature of 2,000 OF) (41).

8Hudous solven~ ~ic~]y fo~d in medic~ w~tc ~cludc: acetone, 2.butane], bu~l atcohol, Cyclohexane, dietiyl cticf, ethyl acetate, Cthylalcohol, formaldehyde, heptane, hexane, methyl alcohol, methyl cellosolve, pentane, petroleum ether, 2-propanol, scc-butyl alcohol, tert-butyl alcohol,tetrahydrofurau and xylene (12). Many of the chemicals used as laboratory solvents and all but the seven chcmotherapeutics listed as ha7adous wastecan be disposed of legally through the sewer system (141).

Table 3—Percentages of Waste Types Produced at Different Medical/Health-Care Facilities in the State of Washington

Type of facility

SurgeryAll cases Total Funeral Nursing Vet Lab centers Hospital Clinic Dental Research Medical

Wastes produced (*) ... , . . . . . . . . . . . 100% 1 00% 100 ”/0 1 00% 1 00% 100”/0 100”/0 100% 100% 10070 10070(350) (32) (43) (49) (25) (8) (51) (60) (32) (17) (33)

Wastes with excretions/secretions , ., 75 91 84 64 63 96 70Microbiological , ., . . . . . . . , . . . . . . . . . 42 0 16 41 44 25 92 57 3 65 42Human blood and blood products . . . . 56 88 23 2 88 38 96 63 44 53 64Animal blood and blood products . . . . 15 0 0 69 12 0 10 0 0 59 3Pathological . . . . . . . . . . . , ., ., . . . . . . 44 28 5 86 32 50 88 32 31 24 30Sharps . . . . . . . . . . . . . . . . . . . . . . . . . . 94 94 98 96 92 100 98 87 91 88 100Wastes from surgery . . . . . . . . . . . . . . 64 69 16 92 8 88 98 67 78 12 76Dialysis unit wastes ., . . . . . . . . . . . . . 7 19 0 0 0 0 25 5 0 6 3Contaminated animal carcasses/

bedding . . . . . . . . . . . . ., . . . . . . . . . 14 3 0 76 0 0 4 0 0 47 0Isolation patients’ wastes ., . . . . . . . . . 32 47 77 37 8 0 78 5 0 0 6Radioactive wastes ... , ., ., . . . . . . . . 15 0 0 0 40 0 49 10 0 53 9Chemotherapy wastes . . . . . . . . . . . . . 18 9 2 10 12 13 69 15 0 0 18None of the above ., . . . . . . . . . . . . . . 3 3 0 0 8 0 2 10 3 6 0

(*) percentages may not add to 100 percent because of multiple responses.

SOURCE: Washington State Department of Ecology, Solid and Hazardous Waste Program, “Report to the Legislature: Washington State Infectious Waste Project and Attachments” (Olympia, WA:Dec. 30, 1989).

Chapter 1-Characterizing Medical Wastes and Applying a Comprehensive Management Strategy ● 15

cal wastes that separation is impractical.9 Whenhazardous materials are mixed with infectiouswastes in this way, the hazardous portion needs to bethe component that is given primary considerationfor proper treatment. Some generators prefer atreatment method (e.g., incineration) that is practicalfor both hazardous and infectious materials so thatonly one treatment form is required. Alternatively,the infectious nature can sometimes by addressedthrough thorough disinfection before being sent forhazardous treatment to avoid exposure to infectiousagents during the handling process (43).

These substances may be precursors in the forma-tion of dioxins (dibenzo-p-dioxin, PCDD) andfurans (dibenzofuran, PCDF), suspected carcino-gens, when chlorine is present during incineration(12). Metals that can be toxic, such as lead,cadmium, chromium and mercury, are present inmedical waste. One study completed by the Univer-sity of California at Davis concluded that plastics inthe waste contributed most of the lead and cadmium(12). Although lead was found in many materials,plastics were the primary source. Both cadmium andlead are components in common pigments and areused as thermo- and photo-stabilizers in plastics,such as may be used to color red bags used forinfectious waste (12).

Low-Level Radioactive Wastes

Low-level radioactive wastes (LLW) are pro-duced in health-care settings from administeringradiopharmaceuticals and performing nuclear medi-cine procedures and radio-immunology procedures.In fact, medical and research facilities produce lessthan 5 percent of the total volume of LLW generatedin the United States (1 17). It should be noted thatunlike radioactive materials used in powerplants orthe production of weapons, medically useful radio-active tracers, which are extremely valuable indiagnostic procedures and medical research (e.g.,testing new drugs), usually have a very shorthalf-life (1 17). That is, typically, half of the material

decays to a nonradioactive form in hours to days.Hospitals usually do not store LLW with isotopeswith half-lives greater than 8 days given the signifi-cant amount of storage space this would involve(117, 73). Currently, there are only three disposalsites for storage of LLW in the United States.10 Thetemporary closure of two of these sites in 1979 set inmotion Federal efforts to encourage States to estab-lish more sites and spurred medical and health-carefacilities to devise a variety of new reduction andmanagement strategies for LLW (see box A).ll

Biological Characteristics

Pathogens in Wastes

Pathogens in medical wastes include a wide rangeof bacteria, viruses, and other microorganisms (e.g.,mycobacteria, yeasts, fungi, parasites, and rick-ettsia) that are sufficiently virulent to infect a humanbody if they are given an exposure route (e.g., apuncture or an open wound) (12,3).12 Clearly,pathogens are also present in MSW (e.g., contrib-uted by disposable diapers, sanitary napkins, tissues,etc.), although the likely higher concentrations ofpathogens in medical waste and the level of patho-genicity of organisms found in health-care institu-tions and their increased resistance to antibioticsmay make them a greater threat for those who handlethe material and may also introduce the possibilityof public health concerns (43).

The important issue is the viability of the patho-gens during treatment and disposal and their poten-tial to transmit disease. Some degree of pathogensurvival in an MSW landfill is expected, forexample, but the likelihood of pathogens migratingfrom a properly operated landfill is consideredextremely low, based on available research (110,138, 116). Even so, there have been few scientifi-cally designed experiments to measure for patho-gens, e.g., in leachate or waters downstream from alandfill (41).13

What is, radioactive tracers which are commonly used for diagnostic purposes arc commonly mixed with solvents during the extmctive proceduresand should be handled as hazardous waste, according to EPA (141).

l~~cse arc in Washington State, Nevada, and South Grolina. Not surprisingly, Lhesc States object to being the Nation’s o~y disposal sites.1 lcongres~ pass~ the ~w.~ve] Radloactivc Waste Pollcy Act in 1980 (later amended in 1985), which -es each State responsible for providing

disposal capacity for its own LLW and encourages States to form compacts (which can exclude wastes from nonmembership States) to provide disposalcapacity. Too little waste is generated to justify a need for a LLW disposal site in every State (see 117).

12M~i~~l ~z~tc~ and Msw can Contain such organisms as: staphylococcus aurcus, candida albica~, pseudomonas, clostidiurn perfringem,staphylococcus cpidermidis, and respiratory streptococci (12).

}~For Cx:lmplc, microorganisms such as Salmonella and Hepati~s VifUS can& carricd in water, and Can SUXWiVt3 Well (43).


Box A—Management of Medical Low-Level Radioactive Waste (LLW)

Medical LLW is treated in several ways, depending on the physical form of the waste (e.g., liquid or solid) andthe type and quantity of its radioactivity. The medical LLW with short-lived radionuclides (i.e., less than 8 days)in low concentrations is typically stored until its radioactivity is below detectable levels. The waste can then bedisposed of as nonradioactive waste. Certain liquid medical LLW that meets limits established by the U.S. NuclearRegulatory Commission (NRC) for radioactivity concentration and volubility in water can be disposed of throughthe sewer. Certain solid medical LLW (e.g., liquid scintillation counting media and biological) can be disposedof without regard to its radioactivity, where the radiological hazard is considered small, but the nonradiologicalhazards warrant special handling and disposal. 1 The NRC considers controlled incineration of low-activity medicalLLW to be adequate treatment because any radioactivity released during the burning is well below acceptedenvironmental levels. Medical LLW, which cannot be stored for decay, disposed to the sewer, or incinerated, istypically land disposed.2

The NRC distinguishes four classes of LLW: Class A Waste (contains low levels of radiation and requires noshielding to protect workers; decays in less than 100 years and represents about 97 percent of LLW); and Class B,Class C, and Greater Than Class C (all three of which require shielding and can remain harmful for 300 or moreyears). In addition, LLW that is mixed with hazardous waste is referred to as ‘‘mixed waste” (e.g., organic liquids,such as scintillation fluids used in diagnostic tests, comprise the largest volume of mixed LLW). Mixed LLW isregulated by both the NRC and the EPA; at this time there are no licensed facilities to accept mixed LLW (117).3

Since 1980, total LLW volumes have been reduced by 55 percent, and estimates for reducing medical LLWcould be 70 percent or higher ( 117, 140, 136). This reduction is due to efforts by generators to reduce volume, costs,and risks associated with LLW management. The waste min imization techniques include improved management(i.e., segregation of nonradioactive from radioactive waste), substitution of nonradioactive materials, andoperational practices to prevent materials from becoming contaminated (1 17, 24).4 Although volume reduction todate has already reduced the amount of LLW requiring disposal, the NRC and Agreement States have consideredreclassifying some LLW to a category for which no special handling or management would be required. Previously,public concern over potential health risks associated with any such reclassification has worked against adoption ofany national proposal to reclassify LLW in this way. Recently, however, the NRC announced a controversial newpolicy that deregulates certain low-level radioactive wastes considered nonhazardous. This so-called “belowregulatory concern” (BRC) waste would include such items as trace amounts of radioactive material and mildlycontaminated bodies of laboratory animals, which health-care and medical research laboratories could dispose ofwith municipal solid waste (135).

ITM IS, such waste woutd be managed as a hazardous waste if other components of the waste are hazardous or as medical waste if tiewaste is non-hazardous (1 17, 70, 24)

2Es~tes are that two lo-foot-deep trenches, each about the sue of a footbalt field, are required to meet the amount Of LLW from medi~and health-care settings annualty in the United States. However, the exact amount of medlcat LLW is not known (l). (See ref. 117 for a detaileddiscussion of these site requirements, the efforts to date to form compacts, and other issues regarding LLW management.)

3A excepuon of M5 Sutement is scmti~tion fluids. For the most part, these substances can be treated (e.g., ~c~erated) b~ause tieconcentration of radionuclides in them falls below limits set in the XRC’s Blome&cat Rule (10 CFR, Part 20.306). Other higher concentratedmedicat mixed wastes, however, are left with no treatment or disposal ophons.

d~teres~gly, medical LLW is one M= Of waste management for which the medicat profession has been encouraging governmentalaction to ensure the availability of disposat sites, and thereby the continued use of radioactwe isotopes. For example, the American College ofNuclear Physicians has ‘‘stIongly’ encouraged officials of all levels of government to aciue~e a timely resolution of the VW issues], stressingpublic safety, economy, and preservation of all the benefits society enjoys that depend on radioactive isotopes” (19).

A risk evaluation completed in King County, escapes of gases containing pathogens during load-Washington (Seattle area), concluded that reductionin the risks posed by medical waste will best beachieved by eliminating modes of transmissionbetween humans and the pathogens in the wastes(111). Pathogens are easily destroyed when exposedto the mean gas temperature and residence timesencountered in incineration. The main potentialroutes of exposure of concern, then, are through

ing, and pathogen survival in the ash or air emissionsdue to poor operating conditions (see discussion in134). To date few test results have been publisheddocumenting pathogen survival after incineration,and further study has been recommended (1 34). EPAis planning to address the issue of potential pathogensurvival in the incineration cycle in its current studyof medical waste incineration (33). The results of

Chapter l--Characterizing Medical Wastes and Applying a Comprehensive Management Strategy ● 17

Table 4-Characteristics of Medical Waste

Bulk density as fired Moisture content as fired Heating value as firedWaste component (Ib/cu.ft.) (weight percent) (Btu/lb)

Human anatomical ... , . . . . . . . . . . . . . . . . . . . . . . . . . 50-75 70-90 800-3,600Plastics , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-144 0-1 13,860-20,000Swabs, absorbents ., ., . . . . . . . . . . . . . . . . . . . . . . . . . 5-62 0-30 5,600-12,000Alcohol, disinfectants . . . . . . . . . . . . . . . . . . . . . . . . . . . 48-62 0-0.2 10,980-14,000Infected animals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-80 60-90 900-6,400Glass ... , .., , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175-225 0 0Bedding, shavings, paper, fecal matter . . . . . . . . . . . . . 20-46 10-50 4,000-8,100Gauze, pads, swabs, garments, paper, cellulose . . . . 5-62 0-30 5,600-12,000Sharps, needles ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450-500 0-1 0-60Fluids, residuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62-63 80-100 0-2,000

KEY: 1 Ib/cu.ft. = 16.03 kg/m3

1 Btu/lb = 2.324 J/g

SOURCE: T. Milburn, “Biomedical Waste Incineration BACT Application Considerations, ” Proceedings of the Third National Symposium on Infectious WasteManagement, Chicago, IL, April 1989, as cited in R. Barton, G. Hassel, W. Lanier, and W. Seeker, State of the Art Assessment of Medical WasteThermal Treatment EPA Contract 68-03-3365 and ARB Contract A832-155 (Irvine, CA: Energy & Environmental Research Corp., 1989).

this effort will be reported in the Agency’s finalreport to Congress, although EPA anticipates thatfurther studies on the issue beyond this effort maybewarranted (14 1).

Disinfection rates for nonincineration treatmentalternatives can also be high, if the treatment systemis properly designed and operated. A source ofgeneral concern and confusion is the extent to whichvarious treatment alternatives ‘‘disinfect’ medicalwastes. The efficacy of a treatment method shouldbe demonstrated by development of an appropriatebiological testing program. It appears reasonablethat the degree of disinfection not be required toexceed microbial and virulence levels that maygenerally be found in MSW (111).

Physical Characteristics

The basic physical forms of medical wastes (solid,liquid, and gas) should be taken into account for theirhandling and management. Segregation of wastes byhealth-care facilities into types based on thesephysical states is likely to occur, e.g., liquid wastes,non-sharp/solid wastes, sharp wastes (see tables 4and 5).

Both physical characteristics (e.g., heat value andmoisture content) of waste components and thebiological make-up and chemical (elemental) composi-tion of the waste are important determinants of themost appropriate treatment technology and haveimportant impacts for that treatment. Despite the factthat medical waste is heterogeneous in its physicaland chemical nature, the waste is rarely managedinitially as a mixture of all the wastes from thefacility. That is, it is likely that a medical facility will

Table 5-Comparison of the Composition ofMedical and Municipal Waste

Amount in waste,percent by weight

Medical Municipal HazardousWaste component waste waste wastea

Dry cellulosic solids . . . . . . . . . 45.1 54.2 0Wet cellulosic solids . . . . . . . . 18.0 12.2 0Plastics . . . . . . . . . . . . . . . . . . 14.2 7.4 12Rubber . . . . . . . . . . . . . . . . . . 0.7Solvents . . . . . . . . . . . . . . . . . . 58Noncombustibles . . . . . . . . . . 20.4 26.2Pathological . . . . . . . . . . . . . . . 1.6Heating value (Btu/lb) . . . . . . . 6,000 4,335 6,030aFOr a typICaI comrneraal incinerator accepting a broad range Of wastes.

1 Btu/lb = 2.324 J/g

SOURCE: D. Campbell, “Hospital Waste Management in Canada,” Pro-~wadings of the Nat]onal Workshops on Hospital Waste inciner-ation and Hospital Sterilization, U.S. Environmental ProtectionAgency, San Franciscx, CA, May 19843, as cited in R. Barton, G.Hassel, W, Lanler, and W. Seeker, State of the Arf Assessmentof Medical Waste Thermal Treatment, EPA Contract 68-03-3365 and ARB Contract A832-155 (Irvine, CA: Energy &Environmental Research Corp., 1989).

collect wastes from various departments separately(i.e., computer printouts are collected from theaccounting department; kitchen waste, patient waste,etc. are collected separately), although they may bemixed for treatment (e.g., incineration) (12, 139).

Given the important impact chemical characteris-tics of wastes can have on the effectiveness ofvarious treatment technologies to safely managemedical waste, it appears sensible to keep wastesseparate based on their physical and chemicalproperties, at least as carefully as possible intohazardous, solid, and regulated medical/infectiouswaste categories, to ensure the wastes receiveappropriate treatment/management. This will be truewhether incineration or nonincineration treatment


technologies are used. It will also facilitate efforts torecycle wastes when feasible and identify opportuni-ties for waste reduction.

EPA adopted as part of its regulations underMWTA (40 CFR Part 259) segregation requirementsto control and reduce costs for waste disposal andminimize worker exposure to certain medicalwastes. The Agency reports, however, that facilitiesin MWTA demonstration program base their segre-gation policies primarily on the basis of convenienceand barriers associated with reeducating their staff to

change management practices (141). A recent studycommissioned by the New York City Health &Hospitals Corp. and conducted by Waste Tech, findsthat facilities required to comply with MWTA couldreduce the cost and volume of their waste manage-ment through more careful segregation and reduc-tion practices (62, 63). Waste management compa-nies also report that segregation at the point ofgeneration is key to containing handling and treat-ment costs, as well as assisting in appropriaterecycling opportunities (43) (see ch. 4).

Chapter 2

Before Treatment: Waste Reduction and Recycling

Waste management concerns now confronting themedical waste generator are largely reflective of thegeneral movement toward minimizing the quantityof waste warranting disposal. Effective managementof medical waste incorporates a waste reduction andrecycling component where appropriate. These ac-tivities should be fostered via policy incentives.

This chapter explores the implications of applyinga waste prevention and materials management ap-proach (ch. 1) to medical wastes by considering“before treatment” approaches to controlling medi-cal wastes. This exploration includes a discussion ofcareful on-site planning, and waste reduction andrecycling opportunities in health-care facilities.

BEFORE-TREATMENTAPPROACHES

Lessons from the management of other wastestreams, notably hazardous waste and MSW, indi-cate that (as noted in ch. 1) a sound control strategyfor waste management follows the basic steps ofcharacterizing the waste stream in light of differenttreatment alternatives, segregating some wastes tofacilitate management based on these characteris-tics, and looking “upstream” to discover anyopportunities to reduce the volume and/or toxicity ofwaste. Achieving this strategy requires some form ofplanning to garner the necessary information forreduction and management decisions.

The value of on-site management plans or strate-gies appears to be gaining r e c o g n i t i o n a s m o r emedical and health-care facilities grapple with howto respond to increasingly complicated regulationsfor waste management (94). Waste audits of someform are becoming more common in hospitalsand other medical institutions. The advantages ofthese waste audits or more comprehensive plans fora facility include using the information they providenot only to devise a strategy for compliance withenvironmental requirements, but also to determinethe most cost-effective means to meet requirementswithout compromising the quality of patient careand to identify waste reduction, reuse, and recyclingactivities as well as other management options thatcould be adopted.

Every facility must tailor its own strategy basedon its characteristics, but several areas should beaddressed in any attempt to analyze waste options.First, the definition and segregation of wastesshould be examined because facility standard oper-ating procedures (SOPS) for waste segregation havea direct impact on type and cost of medical wastetreatment. For example, sometimes when a facilitydesignates “surgery waste” as infectious waste allwaste from that department is managed as infectiouswaste, some of which could be managed as nonin-fectious (e.g., paper from the administrative area).

Second, the types of products and packaging(e.g., for wastes) used in the facility and their impacton the waste stream can be considered, withoutcompromising infection control goals. For example,woven linens may be substituted for some applica-tions of disposal linens with little risk of increasedinfection potential; and, based on preliminary datafrom the New York City Medical Waste Study,considerable reduction in the volume of waste andsignificant cost savings (see box B) (62, 63, 94).Careful purchasing might help reduce the level oftoxic emissions from an incinerator. Finally, thetypes of on-site versus off-site disposal optionsavailable to a facility need to be considered fromhandling and management perspectives and theircosts and risks compared.

WASTE REDUCTIONSource reduction, or prevention, of waste is

defined by OTA as “activities that reduce thetoxicity or quantity of discarded products before theproducts are purchased, used, and discarded” (1 16).1

Source reduction can be achieved by: 1) manufactur-ers considering waste issues in designs of currentand planned medical and health-care products andtheir packaging; and 2) consumers of medical andhealth-care products (e.g., hospitals) directing theirpurchasing decisions, product use, and the discard-ing of products toward waste reduction goals. Thetwo fundamental characteristics of wastes that arethe focus of reduction efforts are: toxicity, i.e.,eliminating or finding benign substitutes for sub-stances that pose risks when they are discarded; and

IA basic distinction is made between prevention and management, the latter occurring after Waste is generated.

–19–

20 ● Finding the R X for Managing Medical Wastes

Box B—Disposables: Infection Control and Waste Management Implications

It appears that the use of disposable can be carefully tailored, from an infection control perspective, to thoseprocedures where disposable have the greatest benefit (e.g., isolation situations). Based on a literature search ofresearch to date, OTA found that handwashing is widely considered to be the most important barrier to transmissionof infections (119, 53, 59, 61). A clear understanding of modes of infection transmission and the factors that affectit can ensure that the most effective infection control practices are undertaken (53, 59,98, 105). Measures to controlinfections include handwashing, the use of sterile disposable items, and other measures (e.g., closed urinarydrainage, intravenous catheter care, nontouch dressing techniques, and proper care of respiratory equipment andperioperative chemoprophylaxis) (119, 120, 53).

In some cases, the benefits of isolation (in which typically disposable, nonwoven polypropylene gowns andnonsterile latex gloves are used) have been demonstrated for reducing the incidence of nosocomial bacterial andfungal infection, particularly in cases of prolonged (more than one week) intensive care for a patient (64). Yet, oftenthe sources of infections in hospitals are discovered to be related to misuse of medical equipment andperson-to-person transmissions. In one London hospital, the investigation of a number of incidents ofcross-infection with an antibiotic resistant infection (Klebsiella aerogenes) led to the conclusion that, ‘While manyunits practise [sic] almost ritual cleansing of selected equipment, and rely heavily on disposable, there are oftencircumstances when the misuse of simple ward equipment [in this case, contamination of portable suction apparatus]becomes an accepted routine with inevitable consequences” (37a).

Some infection control measures are proven and standard practices for every hospital, while others aresupported by less extensive studies, and some proposed measures are not supported by study data (e.g., floordisinfection). A disposable item maybe in any one of these categories regarding its value as an effective infectioncontrol measure depending on the particular item and its use. Studies have found, for example, that nonwovendisposable gown and drape fabrics were no better barriers to infection than reusable, woven, cotton gowns anddrapes; and, in point of fact, the protective value as well as the transmission potential of gowns, shoe covers, andeven masks has been questioned (50, 16, 59).1 Potential volume reduction of disposable linens and medicalapparatus could be considerable, perhaps between 30 to 60 percent depending on the specific health-care facility(63).

With other disposable items, e.g., some catheters and syringes (by diabetics), reuse is not a simple yes-or-noissue. Studies to date indicate that morbidity associated with reuse of cardiac catheters, for example, is low (46, 37,60). With regard to the reuse of disposable syringes, it appears both safe and practical for diabetics to use disposablesyringes and needles for more than one injection (4, 52, 23, 90, 46).2

Nonetheless, the practicality of reuse, given liability concerns and standard operating procedures for aparticular health-care facility, may preclude reuse of particular medical items at an institutional level.3 Certaindisposable items though are advantageous over reusable items for various reasons including controlling infection,saving labor costs for processing, and minimizing exposure to hazardous chemicals used in chemical sterilizationprocesses. The use (and reuse) of disposable can be considered on an item by item basis, in light of how they willbe used, including consideration of infection risks and other factors associated with those risks. Some institutionsare beginning to examine the opportunities for use of fewer disposable and other waste reduction options (seebelow).

lb my ~~e, one s~dy reports that linen poses a higher infection risk to laundry workers tin to patients (Zla).

21t should be noted that these studies focused on the reuse by the same patient, i.e., a diabetic, using the Same S@nge. Dhbetic pati~tswho used the same plastic disposable syringe (up to 7 days) were not found to develop infection at the site and little or no contamma“ tion of thesyringes was found (23, 90).

The American Diabetes Association (ADA) in its Position Statement on Insulin Administration states that although manufacturers ofdisposable syringes recommend that they be used only once, most insulin preparations have bactenostatic additives to inhibit growth of bacteriacommonly found on the sic@ and generally “it appears both safe and practical for the syringe to be reused if the patient so desires” (4). Thesyringes must be discarded when the needle is dull or if it becomes contaminated in some way. The ADA statement also discusses the importanceof such practices as good personal hygiene and proper handling of syringes (i.e., procedures to recap a syringe safely) by patients.

3The potential for ~cr~sed Habfity of a he~th-cme facility using nondisposables v. disposable for different medical apptiCatiOm ~been raised. OTA asked only one insurance company about this concern and was told that insurance companies insure for negligence anddistinguish between real and perceived risk in such a way that the use of disposable v. nondisposables would not usually matter horn a liabilityperspective. It was also noted that insurance companies do attempt to ensure that proper procedures are followed to help keep risks as low aspossible (15).

Chapter 2-Before Treatment: Waste Reduction and Recycling ● 21

quantity, i.e., changing the design or use of productsto minimize the amount of waste generated whenthey are discarded.

For waste reduction, reuse, or recycling to occurwithin a medical facility, a waste audit that empha-sizes characterization of the waste stream anddevelopment of a plan delineating necessary segre-gation techniques and education/training of theapproach to be taken to the employees of thehealth-care facility is necessary. Currently, mosthealth-care facilities resist waste segregation be-cause of its perceived inconvenience and the diffi-culty of ensuring staff compliance. The increasedcosts associated with new regulatory requirements,however, are creating an economic incentive forgreater waste segregation by health-care facilities.

From both volume and toxicity perspectives, theuse of plastics in society is a focus of wastemanagement concern. EPA’s recent report on plas-tics in MSW found that plastics production has hadan average annual growth of 10 percent for the last30 years (132). The report also noted that “sourcereduction and recycling are the best way to reducepotential environmental impacts from plasticwastes” and discusses a number of activities EPAwill undertake toward these ends. A higher percent-age of plastics is contained in medical wastes than inMSW, approximately 20 percent (by weight) inmedical wastes (and perhaps higher)2 and slightlyunder 10 percent (by weight) in MSW (1 14, 116).3The medical community is projected to consume 2.4billion pounds annually by 1994 (13).

As in general public use, plastics are utilized forboth products and packaging. While single-usedisposal plastic items are often preferable from aninfection control perspective, other forces havestimulated the use of these products. For instance, tofacilitate pricing patient procedures individually,disposable products are individually wrapped tomake bookkeeping easier both internally and forthird-party reimbursement. Certain internal prac-tices within health-care institutions reduce wasteeven if they were not initially developed for thispurpose. For instance, inventory programs that keeppackaging and corrugated cardboard boxes out of thehealth-care facility, and often times discouragesingle-item packaging, can have a positive effect.


Corrugated cardboard-including that used to speciallypackage regulated medical waste s-can comprise asignificant portion of a hospital’s waste stream. Somehospitals have purchased balers to facilitate handling

and marketing of reclaimed cardboard.

Procedural trays that are prepackaged by distributorsreduce individual packaging and put all necessaryproducts for a procedure within a single container.

The type of plastic used and its impact on wastetreatment is one example of how waste reductionefforts focused on reducing certain emissions canlink pretreatment and treatment management efforts.The higher concentrations of hydrogen chloride(HCl) in emissions, on average, from medical wasteincinerators compared with MSW incinerators maybe due to the higher levels of polyvinyl chloride(PVC) plastics in medical wastes. Almost all of thechlorine in these wastes is converted to HCl duringthe combustion process (assuming a high combus-tion efficiency). In this way, chlorinated plasticsmay contribute to the high emission rates of HCl and

%%e recent survey of New York City hospitaIs found 26 percent of medical waste to be plastics (63).3Ye. @ven tit ~edic~ waste is a ~m~ percen~ge of MSW, it is likely ~t me fofu/ rele~e of HC1 from m~ic~ wrote incineration is comparably

lower (despite the higher concentration). In a local are% however, it could be a signillcant source of such emissions.


possibly the formation of dioxins (particularly ifcombustion efficiency is low) (114).

PVC plastics were reported to account for 9.4percent of the weight of infectious wastes in onestudy of two Houston hospitals (cited in 139).4

Concerns over hydrogen chloride generationthrough on-site incineration, as well as off-site, havebegun to put pressure on the producers of plasticmedical products to switch from polyvinyl chlorideplastic to one that does not carry the same type ofenvironmental concerns, such as polyethylene (51,43). Unfortunately, because of certain physicalcharacteristics, the PVC plastic is more desirable incertain products. Increased efforts to find alternatematerials for products such as intravenous tubingshould be encouraged. For other products, such asslide holders, trays, and garbage bags, manufacturersmay be able to easily substitute materials (139, 43).

Sometimes there can be a direct tradeoff betweenthe potential environmental harm caused by onemanagement practice versus another. For example,the issue of whether using disposable or reusableitems is “better” can be difficult to determine. Itwill depend on which particular goal (e.g., infec-tion control, convenience/labor savings, cost sav-ings, safe waste management) is deemed mostimportant regarding the product’s use. Oneexample of where such a determination has to bemade regards the use of products and equipmentgenerating chlorofluorocarbon (CFC) emissions,which are used by the medical and health-careindustry to sterilize reusable items for patientprocedures.

The medical and health-care industry is responsi-ble for less than 4 percent of the total amount ofCFCs released to the atmosphere. Given the con-cerns over the association of CFCs with ozonedepletion and possible global warming effects, theAmerican Hospital Association has recommendedthat hospitals reduce consumption of all CFC-basedproducts and chemicals used for sterilization pur-poses. 5 This reduction can be achieved through theuse of disposable, but any significant growth in theuse of plastics containing CFCs might negate overallCFC reduction. It maybe that other solutions wouldavoid greater contributions to the medical and solid

waste streams, e.g., the greater use of steam steriliza-tion or other substitutions for CFC-dependent steri-lization systems, or use of non-CFC, recyclableplastics (76, 129).

The increased use of disposable in health-caresettings is widely acknowledged, if not well docu-mented. Battelle recently has undertaken a project,Medpak, to study the consumption, use, and disposalof medical products and packaging by health-carefacilities in order to assist health-care productcompanies to develop products, packages, andprocess concepts that would reduce the volume andcost of managing medical wastes by hospitals andother medical facilities (13).

The growth in the use of disposable in health-care settings is attributable to a number of converg-ing factors in recent decades. These include:

1.2.

3.

4.

One

increased concern over infection control;decreased available nursing staff (and a need toprovide more expedient treatment and moreconvenient clinical practices);increased cost of health-care labor (and con-cern over the time needed to handle andsterilize reusable items); andconsideration of disposable as part of thegeneral solid waste stream of the health-carefacility (with, in the past, resultant low cost forhandling and disposal) (94, 17).

widely held presumption is that the use ofdisposable is important from the perspective ofinfection control. Nosocomial (hospital-acquired)infections are a serious concern in U.S. hospitals,with 2 to 15 percent of all in-patients acquiring themand millions of dollars spent to control them (37).

Yet, infection control studies do not indicate aconstant and consistent reduction in nosocomialinfections where disposable replace reusableproducts. Other factors also come into play (seebox B). Competing concerns over the cost, andmore recently the waste implications, of usinglarge quantities of disposable in health-carefacilities are now being raised, particularly forproducts that do not have a direct effect oninfection control and patient care (e.g., disposa-ble telephones).

4~es of plastics in products ordered by hospitals include: polyvinyl chloride, polyethylene, polypropylene, polystyrene, and polyurethane (139).SH~th fisks t. employ=s proc.~sfig ~~pment via ethylene Ofide ~te~~tion also prompt~ con~ms. Often equipment sterilized by thiS IIMMIM,

however, cannot be steam sterilized because damage to the equipment would result.

Chapter 2-Before Treatment: Waste Reduction and Recycling . 23

RECYCLING AND SOURCESEPARATION PRACTICES

In addition to reduction efforts, source separationpractices (i.e., segregation of materials as they arediscarded based on their characteristics) that targetparticular materials/wastes for recycling and themost appropriate treatment method can lead to moreenvironmentally sound medical waste management.Source separation before incineration or any othertype of treatment has been shown to improve theoperation of MSW incinerators, and the same maybe true for medical waste treatment as well (1 16).Most health-care facilities segregate infectious andnoninfectious waste streams, but separation of otheritems for recycling may also facilitate managementefforts. Yet, any recycling efforts must also considerand address the potential of increased exposure towastes to health-care workers and waste handlersfrom such management efforts.

A number of hospitals are adopting recyclingprograms as part of their waste management pro-grams, although in the past little recycling hasoccurred by hospitals. A recent reported surveysponsored by the Greater Boston Chamber ofCommerce found that hospitals were discarding tonsof waste that could be reused or sold and were payingmore than other businesses to dispose of noninfec-tious, commercial solid waste. Hospitals in thismetropolitan area, including Massachusetts GeneralHospital and Beverly Hospital, however, have begunpaper recycling programs (9).

Some health-care facilities are planning anddeveloping comprehensive waste management pro-grams, of which recycling is an integral part. Forexample, Bayfront Medical Center(a518-bed acute-care community hospital) in St. Petersburg, Florida,has proposed a recycle-and-reclaim project in con-junction with its proposed waste-to-energy system(see figure 1). This system represents a comprehen-sive waste strategy designed to recycle materials aspossible, effectively render infectious medical wastenoninfectious, reduce the amount of waste going toa landfill, generate energy to power the hospital’slaundry, and reduce some of the risks and costsassociated with waste management (14).

Figure l—Schematic of One Hospital’s ProposedSegregation Categories and Comprehensive Medical

Waste Management Approach

Pharmacy &Patient care

Food Off Icelaboratory Housekeeping

&

services supplies medicalsupplies supplies

I

H o s p i t a l1

[Off Ice paper

Aluminum cans Green barRegulated Cardboard

Selected plastics Batteries medical &

Selected glasscomputer waste food waste

paper

I I

SOURCE: Bayfront Medical Center, St. Petersburg, FL.

Cardboard, food, and other general wastes cancomprise as much as 85 to 90 percent of a hospital’swaste stream, with pathological and infectiouswastes comprising the rest (29, 12).6 Some hospitalsare beginning to focus on the nonpatient sources ofwastes in their facility and target materials forrecycling. For example, corrugated cardboard, com-puter paper, cans and bottles, and other items (whichcan contribute metals, particulate, and volatiles toflue gas emissions from incinerators) can be segre-gated for recycling. Batteries and other non-combustible items that can contribute air emissionsof cadmium and lead from incinerators, or ifstate-of-the-art air pollution control equipment is inplace can affect the ash, can also be segregated formore appropriate management efforts.

A Department of Energy study of three MSWincinerators found that presorting not only reduceduncontrolled emissions significantly, but also led to

~s estimate is based on hospital survey information reported by Cross (30), see also Cross data cited in (12).


better ash burnout and thereby cut ash volume byhalf and reduced its toxicity as well. Boiler efficien-cies and increased disposal capacities also resulted(heat value increased by 25 percent with presorting)(109).7

The New York City Health & Hospitals Corp., aspart of the regional planning effort for medical waste(see ch. 4), has undertaken waste audits of areahealth-care facilities; when the results are compiledthey will set a target goal for reduction and recyclingefforts. These types of activities may become moretypically associated with efforts to establish treat-ment facilities.8 It appears that the emphasis will beon recycling cardboard and other nonpatient wastesin these New York hospitals (71, 67). Recycling ofcorrugated and high-grade papers may achieve up to20 percent waste reduction (62, 63). Yet, some itemsin the entrained regulated medical waste stream maybecome targets for reduction and recycling efforts aswell. For example, based on the preliminary evalua-tion of the waste audits, disposable linens were amajor component of this waste category (62, 63).9

An interesting finding is that the red bags and theshipping boxes themselves comprise the largestsingle component of the regulated waste stream(perhaps as much as 16 percent) (62, 63). Alternativeforms of packaging that will reduce the volume andweight of the waste stream, as well as potentiallysome toxic components, may be considered pro-vided they will ensure safe and adequate handling.For example, some reusable, versus disposable,sharp containers are available (62, 63).

The preliminary results of the New York Citymedical waste study indicate that the amount ofregulated medical waste escaping the MWTA sys-tem may be as high as the amount actually capturedby it. Further, the amount of nonregulated medicalwaste entrained in the regulated waste stream maybeabout 50 percent of the total captured medical waste(63). Importantly, weight, volume, and cost reduc-

tions are predicted to be achievable through bettersegregation, management, and accounting practicesat the department levels of hospitals (51). Educationis important to achieve the cooperation necessary toensure successful changes in such practices.

Improved waste segregation can reduce the amountof regulated medical waste requiring disposal by 30percent (43). Enlightened management practices canalso dramatically affect the volume of waste requir-ing treatment-and influence the cost associatedwith managing that waste. For example, the true costto dispose of medical wastes from different depart-ments can be included in costs charged on a patientbasis and become reimbursable under Medicare (seech. 6). Other management controls that can improveoptions for waste reduction and recycling includeinternal controls over unused products and materi-als, bulk purchasing, and adoption where feasible ofreusable products (e.g., food service items) (62, 63).

Beth Israel Hospital (a 1,000-bed major metropol-itan hospital) in New York City is one of the frosthospitals in that area to recently institute a recyclingprogram. l0 The initial program involved recyclingcorrugated cardboard and office paper (includingcomputer printouts and computer tab cards). Theprogram will be extended to include newspapers,magazines, bottles, and cans. The hospital expects torecover approximately 13 tons of computer printoutpaper and computer cards and 300 tons of corrugatedcardboard per year (28).11

Beth Israel purchased a baler to improve theability to market the corrugated cardboard. It wasexpected to quickly pay for itself, given the antici-pated savings in waste disposal costs of over$100,000 a year (based on avoided disposal costs)(28). Colorful collection folders given to workers fortheir desks, collection bins placed near photocopy-ing machines and related work stations, and postersand flyers explaining the goals and logistics of therecycling program are all part of the educational and

TMedic~ waste incin~ato~ burn a higher Btu value waste than municipal solid waste incinerators (10,000 Btu V. 5,000 Btu). Mtic~ waste itse~has been presorted and does not contain the material that one sees in solid waste that lowers Btu value, increases toxicity, etc. (43). Ag~ the importanceof good segregation practices is underscored.

8Effo~s such as ~ese could si@ficanfly r~uce tie Volwe of tic mea’s waste s~cam and will need to be taken into consideration when sizing anincinerator (or alternative treatment method) for the region.

sos~ fidicates fiat its proposed stand~d prohibits the use of reusable sh~s containers, but it nlay amend this provision if CommelMS on theproposal and evidence indicate that no added occupational hazard is associated with the use of reusable containers (55).

IOO~er hospi~ls ~ tie New York Ciw mea also have adopt~ recycling proms, These inc]ude: ~nox fiu Hospital, Lutheran Medical Center,Metropolitan Hospital Center, and Doctors’ Hospital (28).

1 l~e p~cipat~g ~eas of fie Hospi~l me: mamgement info~ation center, matel-ials m~gement, SUpply room for pathology, receiving forpathology, centrat supplies, pharmacy, housekeeping, storeroom.

Chapter 2-Before Treatment: Waste Reduction and Recycling . 25


Increasingly hospitals are adopting recycling programs to help reduce the volume of waste requiring disposal.

publicity efforts associated with the Beth IsraelRecycling Program (67).

The Iroquois Healthcare Consortium, located innortheastern New York, has implemented an ag-gressive effort to educate its 56 member facilitiesand assist them in developing and implementingcomprehensive recycling programs. The region’ssuccess stories include the Albany Medical Center,which currently recycles over 350,000 pounds ofcardboard, paper, glass, aluminum cans, and plasticannually. The region has also developed successfulprograms working closely with local government. InOtsego County, New York, the A.O. Fox Hospitaland Mary Imogene Bassett Hospital are two commu-nity hospitals that have worked closely with countyofficials to develop and implement an effectiveprogram now being used as a model in the develop-ment of the region’s recycling program (94).

In several areas of the country, commercial wastesfrom institutions such as health-care facilities areincluded in community recycling programs. In thesesituations, the special nature of the medical wastestream should be taken into account by localplanners (e.g., the lower percentage of paper content

in hospital wastes than in wastes from some othercommercial facilities). Again, health-care facilitieswill need to ensure proper worker education andtraining, necessary so that separation practices forrecycling will not pose increased hazards to workers.

Recycling efforts by hospitals have been inhib-ited in some cases by the lack of available marketsand in some cases by discrimination against dis-carded medical materials. For example, in New YorkState glass intravenous (IV) bottles are not acategory of regulated medical wastes, but hospitalsreport they are unable to successfully market theglass for recycling because it is perceived to beinfectious/medical waste (94).

This underscores the need for greater educationefforts and better understanding of the nature andactual public health risks posed by the variouscomponents of the medical waste stream. In part toaddress this need, the Iroquois Healthcare Consor-tium held a meeting sponsored by hospitals at theAlbany Medical Center in June 1990 to discussopportunities and existing programs for recyclingcertain materials from the medical waste stream(94).


Obviously, some items (e.g., most sharps) inhealth-care settings are not likely candidates forrecycling or reuse, but a surprising volume ofmaterials in health-care settings have reduction,recycling, and reuse potential. For example, a newcompany (a joint venture of Standard Textile Co.and Marriott Food & Service Management) wasrecently announced that will offer hospitals recycla-ble, protective, sterile surgical linen packs. Thecompany claims the specially designed barrier fabricproducts (e.g., surgical drapes and gowns) will behighly protective and safely recycled at a cost lowerthan disposable (69).

The importance of product packaging on the totalwaste stream can also be significant and a focus ofwaste reduction efforts. Health-care facilities canhold medical product manufacturers accountable forreductions in packaging and for constructing prod-ucts that use recycled materials and/or that arereusable or recyclable (65).

Some organizations encourage the recovery ofmedical items that would otherwise be discarded.For example, sometimes more than one disposable

kit is opened in order to use just a part of it for aprocedure, or items are opened and then not used.Rather than being discarded, sometimes these itemsare stored, desterilized (if necessary), and then sentoverseas for use there. Outmoded medical equip-ment that can still be used in other countries is alsosometimes sent (139, 84). (It should be noted that nogovernmental guidelines exist currently to ensurethe safety of these practices.)

An organization in Texas, the Medical Benevo-lence Foundation Presbyterian Medical MissionFund, is one such organization that collects equip-ment from medical facilities in the United States tosend to developing countries where it will be used(139). A network of surgical nurses supporting thistype of ‘recycling” is being organized in Oakland,California (84). The group, called RACORSE Net-work (Recycling, Allocation, and Conservation ofOperating Room Supplies & Equipment), hopes tofacilitate efforts to direct needed medical suppliesoverseas that would otherwise be discarded here.12

12~g~ ~pliatiom of ~S ~ctivi~ ~d its s~e~ me being reviewed by the group. The goal of RACORSE is to help tie tie practice Safer byestablishing recommended protocols (84).

Chapter 3

Non-incineration Treatment Technologies and Trends

Of the still unresolved issues regarding medicalwaste management, one of the most critical is whichtechnologies and controls are most appropriate fortreatment. 1 Clearly, the answer depends on theparticular circumstances of the medical waste gener-ator and the host community for the treatmentfacility. Factors such as the nature (quantity andtypes) of the medical waste, the availability ofpermitted landfill space, local air quality conditions,and other demographic and geographic factors (e.g.,urban v. rural locations) need to be considered whenselecting the most appropriate management strategy.Safety, reliability, and costs of alternative treatmentmethods and the regulatory certainty associated withtheir use also affect selection of treatment alterna-tives. Knowledge of various incineration and non-incineration alternatives can also facilitate adoptionof medical waste policies at all levels of government.

While some States and localities actively encour-age incineration as a preferred method of treatment,others have enacted moratoriums on incinerators tosuspend permitting until further information on thesafety of the option is available or new regulationsgoverning it are completed. Thus, incompletenessand uncertainty characterize regulatory activity formedical waste management.

The dilemma now facing New York State facili-ties, for example, can occur elsewhere dependingupon how a State adopts regulations. Facilities theremust make management decisions regarding whetherto upgrade existing on-site incinerators no later thanthe fall of 1990 in order to be able to meet New YorkState’s new air quality standards by January 1, 1992.At present many facilities are seeking treatmenttechnologies alternative to incineration; however, todate the State Health Department has not developedand implemented standards for the approval oftreatment alternatives. As a result, the State govern-ment is limiting the available treatment technologiesto the previously approved methods of incineration

and autoclaving. This delay in the evaluation andapproval of alternative technologies may preventmany New York State facilities from using them,including technology already approved in otherStates and/or technology which could be moreattractive from both financial and environmentalperspectives (94).

This chapter, based on available information,addresses the variety of available and emergingnon-incineration treatment alternatives, their techni-cal capabilities, and their risks and costs. First,treatment of medical wastes by autoclaving (i.e., aprocess of steam sterilization), the most frequentlyemployed alternative to incineration, is discussed.Then, a number of other alternative treatments areexamined: steam disinfection and compaction; mechani-cal/chemical disinfection; microwaving; irradiation;and other emerging treatment technologies. 2 Chap-ter 4 discusses various incineration options, includ-ing co-incineration and regional incineration, andpollution control issues, as well as risk and costimplications. A comparison of non-incineration andincineration treatment alternatives is included inchapter 6.

Increasingly, questions are raised about the avail-ability and performance of non-incineration treat-ment alternatives for medical wastes. While themajority of medical waste is autoclave or inciner-ated, some medical waste (treated or untreated) islandfilled, including some categories of infectiouswastes. The State of Washington found in its surveyof medical facilities that some infectious wastes areabout as frequently treated by autoclaving as byincineration (139). In addition, other treatmentmethods, including disposal into the sewer system,are not rare. It should be noted again that mosttreatment alternatives some form of solid wastedisposal, usually either incineration or landfilling,will be necessary.

IIt sho~d be not~ tit ~~tment in this repofl refers to a process to render wastes noninfectious, unless otherwise indicated, sucb as ~atment toreduce toxicity of wastes, or treatment to render wastes nonrecognizable.

z~s ~~pter relies on tie Om con~act repo~ ‘‘Medical Waste Treatment Tw~ologies,’ completed by Robert Spurg@ Spurgin & Associates,March 1990. See alSO (30) and (73). It should be noted tht mention of a specific company or treatment technology does not constitute endorsementof it by OTA. OTA tloes not endorse any specific application of the various incineration and nonincineration treatment alternatives.

–27-


The viability of alternative technologies hasincreased in recent years due to the increased costof incineration, the difficulty associated withpermitting incinerators, and the perceived desir-ability of reducing dependence on incineratorsgiven concerns over their emissions. A number ofStates (e.g., New Jersey, California, Washington)are attempting to encourage adoption of alternativetechnologies for such reasons. EPA is conductingseveral research projects to evaluate various wastetreatment technologies as required by MWTA (92).

The extent of detail contained in these EPAstudies is not known, but the Agency does report that‘‘most of the treatment technologies are as effective[as incineration] in rendering medical waste nonin-fectious” (141). In addition to the usually highercapital, maintenance, and operating costs of inciner-ation, EPA cites the public perception problems anduncertain regulatory climate associated with inciner-ation as disadvantages of incineration compared toalternative treatment technologies (141). Landfillavailability and other factors, however, will alsoinfluence a medical or health-care facility’s choiceof treatment technology.

Alternative treatment technologies are less capitalintensive and have fewer emission concerns thanincineration processes. Although it is important torecognize that oftentimes more than one treatmenttechnology may be needed to manage all compo-nents of the waste stream (e.g., incineration ofpathological wastes that cannot be autoclave).Further, the nature of emissions and efficacy of newtreatment technologies must be demonstrated.

AUTOCLAVINGHistorically, autoclaving or steam sterilization

has been used as a treatment method in laboratorysettings to sterilize microbiological laboratory cul-tures (104).3 The first commercial steam sterilizationprocess for medical infectious waste was introducedin California in 1978. As incineration requirementswere tightening in California, it became clear thatinsufficient off-site capacity existed to replace

closed on-site incinerators, which would not meetthe State air emission standards (see ch. 5).

Autoclaving is a process by which wastes areeither sterilized or disinfected prior to disposal in alandfill (114) (see figure 2).4 Autoclaving can be asterilization process if all microorganisms are ex-posed to the steam for a sufficient temperature/pressure/time period to assure their destruction. The routineachievement of sterilization can be monitored byplacing Bacillus stear other mophilus spores into thecenter of a load to be autoclave. If the sporessurvive, then the conditions for sterilization have notbeen achieved; if the spores are destroyed (i.e., failto grow in microbiological media after steamsterilization), then the conditions for sterilizationhave been achieved (given the practical limitationsof this routine test).

If the spores have not been destroyed during steamsterilization, then sterilization has not occurred.However, some level of disinfection of the wastewould likely have resulted. Unfortunately, the levelof disinfection cannot be routinely or practicallymeasured. Sterilization of infectious waste is gener-ally regarded as “overkill” for most waste disposalsituations. Disinfection of infectious waste is proba-bly a more reasonable goal for most infectiouswastes, though some appropriate and measurabledisinfection goal should be established (1 11).

Most steam sterilizers in use for treating infec-tious wastes are of the high-vacuum type (92). In theautoclaving process, bags of infectious waste areplaced in a chamber and steam is introduced for adetermin ed period of time (usually about 15 to 30minutes) and pressure. The use of pressure helpsreduce the required time for disinfection of medicalwastes, yet the amount of time required will still varydepending on the type and volume of waste (141).Steam temperatures are usually maintained at 250‘For slightly higher (to disinfect the waste morequickly and allow for shorter cycle times).

Autoclaving parameters, e.g., temperature andresidence/cycle time, are determinedby the factorsinfluencing the penetration of steam to the entire

sEthylene oxide and other gas sterikation processes are typically used to sterilize processes for medical equipmen~ but are dSO SOmebes used totreat wastes. EPA, however, does not recommend ethylene oxide for treating infectious wastes because of its toxicity and given that other treatmentoptions are available (122).

4st~~ation i5 a Pmwss tit des~oys ~ ~cmorg~5m5 (e.g., Pathogem). Disinfection is a process intended to reduce the n u m b e r o fmicroorganisms or pathogens as low a level as possible, at least below the level at which exposure to a susceptible host could not result in an infectiousdisease. Actual sterilization is not likely to be maintained once wastes leave the autoclave, m is true of incineration ash residue (see studies cited in 134);thus, disinfection is a more accurate term.

Chapter 3-Non-incineration Treatment Technologies and Trends ● 29

Figure 2—Autoclave

SOURCE: AMSCO, Erie, PA.

load and consequently the extent of pathogendestruction (114, 30) (see figure 3).5 Generally,complete pathogen destruction should occur ifsterilization is the goal of treatment (92; seediscussion in 114).

A major advantage of autoclaving is its ability toscale to various on-site and off-site treatmentrequirements, including the possibility of multipleunits that can be located close to the areas wherewastes are generated. Most health-care facilities donot use the largest available autoclaves and somecompanies are beginning to market smaller, tabletopunits for use by doctors’ offices and other small

generators (141). Autoclaving is considered appro-priate for treating most regulated medical wastes,except pathological wastes (see below). Commercialspore indicator kits provide easy and reliable qualitycontrol capabilities for autoclave systems if sterili-zation is the goal of treatment (141, 92).6

Capacity and Siting Issues

Browning-Ferris Industries (BFI), the largestoff-site waste management company for medicalwastes, has employed autoclaving since 1976. Otherlarge waste management companies and regionalwaste management firms use autoclaves as well(104). Indeed, one large waste management firm

ssee C)W’S back~o~d paper (1 14) on medic~ waste for a more complete description of the autoclaving process md Operadng P~eters.blf dis~ection is the goal of treatment, spore strip testing would not have a use.


Figure 3—Typical Sterilization Destruction Curve

‘F ‘C

250(1 27)

240(1 16)

220(104)

200(93]

180(82

160(71)-

140(60)-

120(49)

100(38)

Temperature

O 5 lb microbiological wastes

● 15 lb microbiological wastes

10 20 30 40 50 60 70 80 90

Time (rein)

SOURCE: William Rutala et al., “Decontamination of Microbiological Wasteby Steam Sterilization,” Applied Environment/ Microbiology,vol. 33, 1982.

reports that it is currently siting more autoclavesthan incinerators. Meanwhile, some hospitals con-tinue to use on-site autoclaves for treating their ownmedical waste. The demand for autoclaving appearsto be increasing across the Nation, as the rest of thecountry begins to experience the shift from heavyreliance on incineration and the increased need foroff-site medical waste treatment that emerged inCalifornia in the late 1970s.

A major advantage of autoclaving is the capacitya single unit can provide without the spatial require-ments associated with incineration systems. Thecapacity of an autoclave is a function of its size andthroughput. 7 For example, an autoclave capable ofdisinfecting 4,000 pounds per hour of medical wastemeasures 8 feet in diameter by 24 feet in length,which means it occupies about as much space as a500-pound-per-hour incinerator (104).

Autoclaving maybe limited in some applicationsbecause wastes that are only autoclave are stillrecognizable-unless they are then shredded orcompacted (see below).8 EPA points out that the‘‘recognizability’ of medical wastes is only an issuein States covered by MWTA and that most Stateshave not found it necessary or practical to adopt sucha requirement (141). The potentially high costs ofrequiring the nonrecognizability of treated wasteshave led some to question the wisdom of a require-ment to address solely an aesthetic concern.

In the past, landfill refusals of autoclave medicalwastes frequently occurred. A variety of reasonsaccount for these refusals, but usually they happenedbecause landfill operators could not easily identifywhether waste had been treated and disinfected.Efforts to use bags that change in some visible wayin response to autoclaving (e.g., that melt in theautoclaving process or have a strip that changescolor) apparently have met with mixed results (104).A nonrecognizability requirement is one solution tothis problem, albeit a potentially costly one.

Another solution is for commercial users to havetheir own private, permitted landfills for disposal.Informal discussions by OTA with a number ofhospital officials across the country indicate, how-ever, that few refusals occur if a hospital worksclosely with landfill operators to explain their wasteprocedures. The State of Washington reports fromits 1989 survey that 86 percent of the hospitalsresponding to the survey have not had a wastecollector or landfill refuse to accept its wastebecause of its potentially infectious nature (139).

For States under the MWTA program, wastesmust be treated and destroyed or rendered nonrecog-nizable to be exempt from the tracking program.This would necessitate that some form of shredding

7~e ~~e of tie autoclave loading hopper and the cycle time needed for disinfection% however, affect and limit autoclave ~ou@Put (63).8Histofic~ly, proble~tic operation has also been a factor leading some hospitals to abandon autoclavfig (1 14). Appmently, re~nt ~Provements

in the technology have minimiz ed some of these concerns. Proper operatio% however, is key to the effective functioning of any treatment technology.

Chapter 3--Non-incineration Treatment Technologies and Trends ● 31

be employed before shipping the autoclave wasteoff-site; otherwise use of the manifest form would berequired to meet the tracking requirements. Anoption for Congress is to amend MWTA (orrelated follow-ens) to allow verified autoclavedwastes to be exempt from manifesting. Thisessentially means modifying the nonrecognizablecriteria of the regulatory program.

Suitability for Different Medical Wastes andAssociated Risks

Some wastes are not suitable for autoclaving.‘‘ Suitability,’ however, is determined by bothtechnical and nontechnical factors. For example,particular pathological wastes are sometimes con-sidered unsuitable for autoclaving (principally foraesthetic reasons, i.e., they will not be renderednonrecognizable). 9 In any case, approximately 90percent of the regulated medical wastes generatedare suitable for autoclaving (104). Autoclaving isconsidered particularly appropriate for microbiolog-ical wastes (e.g., laboratory cultures). In contrast,autoclaves are not suitable for cytotoxic and othertoxic chemical wastes because of the hazardousnature of these wastes. In addition, contaminatedanimal bedding is not autoclave.

To the extent that autoclaving is used for only aportion of medical wastes, then it can be used as asupplement, more than a substitute for incineratingmedical wastes. Yet, if wastes are segregated fortreatment based on their chemical and physicalcharacteristics, it is likely that a smaller fraction ofwaste will require incineration. Additional segrega-tion of the items requiring incineration (or othertreatment) is not usually necessary since thesewastes are generated and/or managed separately .10

Documented health impacts from autoclaving donot exist. It is of critical importance that certainwastes, due to their either hazardous or pathological

nature, not be autoclave. For example, autoclavinghazardous materials such as antineoplastic agents,radioisotopes, solvents, or other toxic wastes couldlead to chemicals being volatilized by the steam andcould result in possible worker exposure betweenprocess cycles. If autoclaves are of a gravity-displacement type, steam “escapes” through an

outlet vent, most of which is condensed and drainedinto the sanitary sewer.11

Potentially, if the waste itself contains traceelements of formalin or other carcinogenic com-pounds, workers could be exposed to the aerosolizedcompounds if they come in contact with the ventingsteam (104). Once again, the importance of separat-ing waste materials for diversion to the mostappropriate treatment method is evident (e.g., in thiscase, hazardous materials to a hazardous wastetreatment option). Further study of emissions fromautoclaves is warranted based on the fact thatinfectious wastes may contain significant levels ofcytotoxic compounds or low level radioactivewastes and concerns that the presence of suchsubstances could lead to emission problems.

A noticeable odor in the steam discharge, de-scribed by one knowledgeable observer as ‘‘muchlike styrofoam cups tossed in a campfire,” is notknown to be harmful (104). Odor-controlling tabletsthat can be added to each autoclave load areavailable. 12 The potential for problems with landfillleachate associated with autoclave waste is notknown, but in general the survival of viruses in solidwaste leachate does not seem to occur.13

Costs and Volume Reduction Issues

Autoclave units are generally not as costly ason-site or off-site incineration alternatives. Anautoclave unit will cost between $30,000 and$100,000 installed (depending on the size of theunit), with annual operating costs at about $0.05 to0.07 per pound plus labor, with an expected equip-

me phrase “pathological wastes” throughout this report refers to wastes of human origin (e.g., tissues, organs, body parts). Pathogens andpathogenetic wastes should be distinguished from pathological wastes (of human origin). Pathogens and pathogenetic wastes are components of themicrobiological waste type (see ch. 1).

~~or exmple, in most hospitis all tissue samples are transferred to pathology for amlysis before disposal and can be collected separately here forincineration.

ll~ese disch~ges t. he s~tw sewer system should be fiocuous ~ their impact although ~ ~dus~~ waste water discharge pefit may berequired by the local sewage distict authority (see ch. 5).

]@TA&d not dete~e Whether these table~ m~kthe odor orac~ly c~gethe chefis~, orwhether their effect makes a differencefrom a h~~health perspective.

13 See litera~e review ~d discussion by ~nberg (1 10), from w~ch the au~or concludes tit reseach hS not esmblished a relationship betweenlandfill leachate and solid waste and disease, and that obtaining evidence of such a relationship is difficult and further research is necessary. Also seerefs. 138, 103, 44.


ment lifetime of 10 to 15 years. Landfill costs mustalso be taken into account, but overall this treatmentoption appears less expensive than incineration andmanagement of its ash residue (if it has to be sent toa hazardous waste landfill). The State of Californiaconcluded from its preliminary cost data that auto-claving and other non-incineration alternatives maybe more economical for some small medical facili-ties than retrofitting existing incinerators to meettheir newly proposed air emission control measure(108).

If autoclave waste is not subsequently com-pacted or shredded, there is no significant volumereduction. Yet, given that medical waste representssuch a small percentage of the solid waste stream, itdoes not pose a significant contribution to landfillcapacity problems experienced in some areas of thecountry (and landfill waste cost is usually chargedon a weight rather than a volume basis). Forexample, California reports that if all on-site incin-erators are abandoned for alternative treatmentmethods, the medical waste requiring landfillingwould only represent 0.03 percent of the wastecurrently handled at MSW landfills in the State(108).

AUTOCLAVING ANDCOMPACTION

High-vacuum steam sterilization combined withthe compaction of treated waste began in Californiain 1978 and is increasingly being used in theNortheast and Mid-Atlantic areas of the country. Asof May 1990, over 100 units are in operation. Thistreatment process combines an autoclave with astationary compaction unit intended to handle theregulated medical waste as well as the solid wastefrom a health-care facility (see figure 4). The systemis designed to be used as an on-site treatmentalternative (104, 48, 30).14

The high-vacuum autoclave removes air, whichacts as a steam displacement barrier, and therebyshortens the time for the steam to achieve thenecessary operating temperature (approximately 284°F) and permeate the entire waste load. This meansthat exposure to the waste is faster and the cycle timeis reduced, which is estimated to be between 40 and50 minutes from loading to loading (104).

The disinfected waste is then hydraulically fedinto the solid waste hopper, where it is compactedwith general refuse from the facility and automati-cally fed into the refuse bin or trailer for hauling toa solid waste facility. Operators are not exposed tothe treated medical wastes, reducing the risk ofexposure to sharps, fluids, or other waste items. Aswith most autoclaves, no separate fuel source isusually needed since live steam from existing boilersin the facility’s physical plant can usually power thesystem (104). The compaction process achieves a 60percent reduction of volume of the waste, and higherlevels of up to 80 can be achieved if corrugatedcardboard and other recyclable materials are sepa-rated from the waste to be compacted and landfilled.

The system is increasingly being adopted on theeast coast, even in States covered by MWTA (wherethe autoclaved/compacted waste must be tracked).In New York State, however, the two restrictionsassociated with compacted, autoclave waste havelimited the application and acceptance of thisalternative. First, the New York State Department ofHealth is requiring that the sharps treated in autoclave/compaction units, such as the San-i-pak units, mustbe in compaction-resistant containers to preventspillage and/or exposure to sharps when the com-pacted waste is placed in the landfill. Second, the‘‘recognizability’ of the compacted waste hasresulted in refusal by many local landfills to acceptthe waste (94). As noted above, however, in otherareas of the country such refusals appear lessdifficult to overcome with explanation and demon-stration of the process to landfill operators.

The capital costs are approximately $115,000 to$130,000 for equipment suitable for a 400 bedhospital, with estimates of $35,000 to $60,000 forsite preparation (including utilities, slab, drainage,etc.) (48, 94). Operating costs, according to the solemanufacturer, San-i-pak, range from $0.03 perpound when the solid waste disposal costs are $300per pull (haul) to $0.10 per pound when pull costsrun as high as $1,600. Fuel costs are stated to be$0.003 per pound of steam used (47). The operatingcost estimate includes this steam and electricity cost,as well as repairs and maintenance, the capitalizedcost of the equipment, labor, and bags (48). Thesystems have an expected lifetime of 15 years(similar to that of most incinerators). The operating

laFour sizes of the autoclave and compaction unit are available which will accommodate 1,3,7, or 16 autoclave bags, m=s~ appm~ately 38x44inches each in a given cycle. Some limitti attemp~ have been made for a commercial off-site use of the technology; such use, however, does not appearas practical as the on-site application for which the unit was designed (104).


Figure 4—Autoclave and Compaction Unit

Sterilizerload door(for medicalwastes)

Compactorload door(for othersolidwastes)

(roll-off)interface

Time and

Compactortemperature

controlchart recorder

panel/

Sterilizer

/controlpanel

Ratchet I

jack “eye” Gauges

connector

SOURCE: San-i-pak Pacific, Inc., Tracy, CA.

cost includes hauling costs for infectious and generalwastes, and specially hauled wastes, i.e., chemother-apeutic, radioactive, and pathological wastes (esti-mated to be less than 1 percent of a facility’s totalwaste).

MECHANICAL/CHEMICALDISINFECTION

Chemical agents such as chlorine have been usedas disinfectants for medical products for some time,although the application to large volumes of infec-tious wastes generated by hospitals and laboratoriesis more recent (104). This type of technology, whichhas been available since the mid- 1980s, is referred toas “mechanical/chemical’ because of mechanicalmaceration and chemical disinfection (a result offorcing a reaction that occurs to volatilize wastematerial and expose all of the pathogens to a

chemical disinfectant in a controlled environment);the residue is discharged to the sewer system.15

Chemical disinfection processes, according toEPA, are most appropriate for liquid wastes, al-though they can be used to treat solid wastes (122).The appropriateness of the process for pathologicalwastes is not clear (92). A number of factors shouldbe considered regarding the effective use of chemi-cal disinfection, including: the types and biology ofmicroorganisms in the wastes; degree of contamina-tion; type of disinfectant used (usually sodiumhypochlorite, commonly known as chlorine bleach)and its concentration and quantity; the contact time;mixing requirements; etc. (122). As with othertreatment alternatives, efficacy of the method needsto be demonstrated through the development of abiological testing program and monitoring on aperiodic basis using appropriate indicators in orderfor the system to be adopted and used on a routine

ls~s me of system is also sometimes referred to as “hydropulptig” (see 30).

34 Ž Finding the Rx for Managing Medical Wastes

basis. Test results reported to date find the process,using chlorine bleach, to be an effective disinfectantfor medical wastes contaminated wi th vege tab lebacteria and viruses, but less effective againstspore-formin g bacteria (92).16 No standard protocolhas been developed to evaluate the efficacy of thesystem and to assist in developing standard operat-ing procedures for it (92).

Maceration of the medical waste, involving high-speed hammermill blades and/or shredders, requiresuse of copious amounts of water. To keep the unitfrom overheating as well as to disinfect the waste,water is introduced along with the disinfectant(usually chlorine-based) during the maceration phase.The simultaneous volatilization and introduction ofthe disinfectant is designed to render the wastesnoninfectious. The introduction of water creates aliquid waste, which is discharged to the sewer.17

This means an industrial waste water dischargepermit from the local sewage district may berequired.

According to Research Triangle Institute’s (RTI)contractor report to EPA, “Once the proper operat-ing parameters such as the flow rates for water andchlorine solutions are established the device issimple to operate and requires little training” (92).The nonrecognizable nature of the byproduct of themechanical/chemical treatment process and its abil-ity to treat liquid medical waste before dischargingit to the sewer system are important factors account-ing for the favorable market response to thistreatment alternative. The waste treated by theprocess is rendered nonrecognizable by the shred-ding and pulverizing phases, which are primarily fortreatment efficiency but act to destroy the waste aswell (104).18 This means that the waste meets thenonrecognizability criteria of MWTA and would nothave to be tracked under its manifest system.

Increased concern over the practice of discharginguntreated liquids (e.g., blood and other body fluids)into the sewer system also makes the mechanical/chemical process with its discharge of treated

liquids an attractive alternative. Yet, it is not clearthat this system would reduce any risks that mightexist as a result of direct discharges in a facility ofblood and body fluids into the sewer system (see ch.5). Further, the sewage system contains countlesshuman pathogens from the vast quantity of humanbody waste. Liquid medical waste comprises only aminor fraction of this overall waste flow. Microbio-logically, there is little difference between bloodwaste and fecal/urine waste (except that fecal wasteswould be expected to have a far greater number ofhuman pathogens) (11 1).

The process is designed for on-site use withpossible applications to a variety of medical andhealth-care settings (see figure 5). The frost companyto manufacture such a system (Medical SafeTec.,Inc.) currently offers three machines, one for largerapplications and the other two for laboratory set-tings. A similar system was designed by a companyfor application in the funeral industry. This companyalso has a clinical machine for sharps and plans tooffer over 200 separate machines for a wide varietyof health-care applications. While the one companyis offering a system that would require a largefacility to purchase one unit, the other company ismarketing smaller machines for use throughout thehospital (104).

States such as California and New Jersey, whichare open to innovative technology for medical wastegenerally, are a responsive market for this alterna-tive. Some large generators converted to this system,rather than replacing or retrofitting existing incin-erators (104). Currently, about 40 of the smallerunits are in use, primarily for sharps management.These systems can treat pathological waste (e.g.,formalin-fixed tissue samples) and most other medi-cal wastes. 19 The system is powered electrically withstandard electrical requirements. Sewer connectionis mandatory, and, as noted, a local discharge permitmay be necessary. Concern has been raised over thelevel of metals, organics, and other contaminantsthat may be in the sewage discharge (5).

IGHward and ocwpation~ risk from tie handling, storage, and use of chlorine have been suggested as a potential disadvantage of ~s tec~olog’y(94).

17Repofiedly, systems that shred and disinfect medical wastes that will not require use of copious amounts of water or a sewer dkchge are beingdeveloped (63). One such process will combine conventional shredding technology with the use of special red bags. These red bags have a small seamthat envelops a few grams of formulated powder (a water-activated disinfectant). Treated material is “only slightly moist, no longerrecognizable. . disinfected and volume-rcxiuced” (78).

18A pres~~~g system which is part of the large hammermill, breaks up the waste materials before the ha.mmermill pulverims hem.

lg~e EPA s~tes, however, that these units are not normally recommended for patiOIOgicd waste ~es (141).

Chapter 3-Non-incineration Treatment Technologies and Trends .35

Figure 5-Mechanical/Chemical Disinfection Unit

Negative pressureMepa filter system blower

1

SOURCE: Medical SafeTec, Inc., Indianapolis, IN.

The percentage of dissolved solids in the dis-charge into the sewer is high (up to 10,000 ppm v.300 ppm for residential users), but the manufacturerstates that changes necessary to reduce the level tothat of other points of discharges are now feasible(104). Even so, the liquid effluent contains highconcentrations of substances, e.g., chlorine, that mayrequire pretreatment before being discharged to themunicipal sewer system. It would appear that localpermit levels for sewage discharges would have tobe met.20

Solidwaste

collectioncart

\

designed to control emissions and force air througha series of prefilters and a chlorine-resistant falterbefore discharging it to the atmosphere (141, 5). Theuse of chlorine and the potential impact on sewagedischarges is also raised as a concern with thechemical disinfection process. Further study of theseissues is needed, possibly as part of EPA’s currentresearch on alternative treatment methods.

There are no air quality regulations that arerelevant. Although it is not clear there is a need forany air regulations, given that no known air emis-sions problems have been encountered, little hasbeen reported about the nature of the emissions.There is some concern over the potential forproducing volatile chemicals and/or microbes dur-ing the shredding process, although the system is

The mechanical nature of the equipment, with somany moving parts, means it could require a highlevel of maintenance. This also means there is morepotential occupational exposure. The manufacturersnote that no injuries involving equipment repair ormaintenance have been reported.21 As with anautoclave unit, the space needed for a mechanical/chemical unit is not large and the capacity is thenmainly a factor of the throughput rate for the unit.The smaller units require an area approximately 10

20R~ (92) ~Wo~ tit ~a~te ~eatment effluent from the Medical S~eT& tit has been tested according to the specitlcations published under theClean Water Act for pollutant analysis (40 CFR, Part 136).

21Ye~ ~S ~th o~er ~eatment ~ternatives, it is not clear how fr~uently a~idents are reported (given mncerns OVer pOteIl~ hpiiCtS 011 kMIKZIIICe

pre miums, etc.).

36 ● Finding the &for Managing Medical Wastes

feet by 9 feet and the units with additional capacitywould require areas of 11 feet by 10 feet.

Capital costs are approximately between $40,000and $50,000 (equipment and installation) for thesmaller units and approximately $350,000 for thelarger sized unit. Operating costs are reported to be$0.06 per pound of waste per hour of treatment(104).

MICROWAVEThe application of microwave technology to

disinfect medical waste was introduced in Europeseveral years ago. The technology is from WestGermany and just recently is being marketed in theUnited States (34). The units can be on-site ormobile facilities. The first on-site installation was inNorth Carolina in March 1990. A second commer-cial system began operation shortly after this inCalifornia as a supplemental technology to anexisting regional incinerator (104, 34).

Powered by electricity, the unit shreds the wastein a controlled environment; the waste then entersthe chamber for exposure to the microwaves (seefigure 6). The disinfection process takes placethrough microwave heating, which occurs inside thewaste material (unlike other thermal treatmentmethods which heat wastes externally) and wettingand shredding the waste to facilitate heating andsteam penetration of the waste. The material isdischarged to a storage bin for ultimate disposal.

Computerized controls, as with most other treat-ment technologies, are used to ensure the minimumparameters for disinfection and proper function ofthe equipment. Fire and temperature conditionsnecessary for waste sterilization are the same asthose for autoclaving (92). Studies conducted inGermany by the Institute of Hygiene, University ofGottingen concluded that the process treated ma-terial to a lower level of bacteria content thanordinary household wastes (as reported by ref. 35).Performance tests at a unit operating in the UnitedStates, using a Bacillus subtilis microbiologicalspore test indicator, found the wastes to be treatedunder conditions to render it sterilized (35). Re-search Triangle Institute reports that although themethod is essentially a steam sterilization method, itis necessary to confirm that conditions required forsteam sterilization exist in the microwave process(92).

Photo credit: Vetco Sanitec Corp.,Combustion Engineering, Stamford, CT

Microwave units can be installed on-site or be used asmobile units. Mobile units could facilitate collection of

regulated medical wastes from home health-care settings,doctor offices, and other small generators of medical

wastes. This type of mobile microwave unit has been usedin Berlin, West Germany for several years.

As with autoclaving, approximately 90 percent ofmedical wastes can be treated by this method (it isnot recommended for pathological wastes). The useof electricity averages about $0.02 per pound.Energy use is reportedly lower than that of anincinerator (35). The shredding process results in avolume reduction of 80 percent prior to disposal.Treated wastes are suitable for disposal in a solidwaste landfill. Given that the process is used inEurope with no reported emission problems, itsacceptance is anticipated in the United States (35,104).

The microwave system is designed to be operatedby unskilled labor. All adjustments in wastes levelsand time are preprogrammed into the system (92).Operating and maintenance costs are reported to beapproximately $0.10 or $0.07 per hour, dependingon whether the system is operated 8 hours or 10hours a day, respectively. Capital costs are about$500,000 for a unit (35). It appears that health risksassociated with the unit would primarily be associ-ated with the maintenance of the shredder compo-nent of the system. Potential operator exposure tovolatized chemicals during loading or cleaning/maintenance should be examined, h o w e v e r .

IRRADIATIONA common practice is to treat medical products

with radiation for sterilization purposes (104). Thehigh cost of cobalt used in the process and highoperating costs have discouraged commercial ven-tures from using the technology for medical wastemanagement. In February 1990, however, the first


Figure 6—Mobile Microwave Medical Waste Disinfection Unit\

u

12

o11

II 1‘%31 0)

o- 13

1.2.

3.

4.

5.

6.

7.

8.

9.

Process scheme of a mobile microwave-disinfection unit

Feeding hopper

Feeding crank

Shredder

Connecting hopperwith inspection window

Level sensors

Main conveyor auger

Microwave generators

Temperature holding section

Discharge conveyor auger

SOURCE: Vetco Sanitec Corp., Combustion Engineering, Stamford, CT.

commercial medical waste irradiation facility wasopened in Arkansas, and additional facilities areplanned in California and New Jersey. Questionshave been raised about the actual process of radiat-ing the material and achieving adequate disinfection(104) (see figure 7). Garoma radiation sterilizesinfectious waste by penetrating the waste andinactivating microbial contaminants. T h e i o n i z i n gradiation hydrolyzes the water molecules within the

10.

11.

12.

13.

14.

15.

16.

17.

Temperature sensors

Filter system, 2-stage

Water tank with pumpand spraying connection

Steam generator

Steam connection

Hydraulic aggregate

Room heater

Container

micro organisms and these intermediate hydrolysisproducts interact with the gamma radiation andbiological compounds, are broken down and arerendered noninfectious. The company pursuing thistreatment technology emphasizes that the waste willnot be disposed of as solid waste. Rather, it isshredded, rendering it nonrecognizable, and isshipped to a cement kiln where it is burned as fuel(104).22 Eventually, one such operator of a system

~t should be noted that concerns have also been raised about the practice of burning wastes in cement kilns, which typically are not subject to airemission standards (other than the new source performance standard (NSPS) for particulate matter emissions). The assumption is that these kilns operateat such high temperatures that wastes used as fuels are destroyed without producing harmful emissions. This is an unsettled regulatory issue. It is true,however, that any cement kiln burning MSW would be subject to air emissions standards for MSW incinerators as proposed by EPA in December 1989.


Figure 7—irradiation Unit

Cobalt 60 radiation chamber

Infectious waste

SOURCE: Technology Process, Inc.

plans to separate the plastic waste and sell the treatedplastic residues for recycling (92, 101).

The process is highly predictable, according toRTI’s analysis (92). Verification of the conditionsfor disinfection involves using Bacillus pumilis as atest indicator organism. According to RTI, nostudies specifically addressing the efficacy of gammairradiation of medical waste for disinfection (92). Inaddition, film is placed between every few boxes toquantify the amount of radiation each box receives(104).

Again, this treatment method is not recommendedby EPA for pathological wastes. The capacity ofthese units is a factor of the throughput rate. Theunits are an off-site alternative and can manage alltypes of waste, except pathological wastes. Theapproximate operating cost could be $0.15 per

Treated waste

pound. Potential risks of this alternative treatmenttechnology are primarily associated with the possi-bility of radiation exposure to workers.23

OTHER POTENTIALTREATMENT TECHNOLOGIESOther technologies with potential application to

medical waste management are in a conceptual orexperimental stage in their development. Several arementioned here to illustrate the variety of attemptsto develop treatment alternatives for medical wastes.

One technology that has recently been announcedas available and capable of thermally destroyingbiomedical wastes uses an electric molten glassfurnace. At least with other waste types, the wastesare fed into the furnace and are subjected to intenseheat (2,300 ‘F) and air and water vapor. The result

~Worker~ ~pma@ ~ese systems ~~~d ~ve to be @ained according to tie IfJ ~ ‘‘S~nd~ds for Protection Ag&t Radiation” [email protected] would need to be highly trained to ensure the efficient and safe operation of the process.

Chapter 3--IVon-incineration Treatment Technologies and Trends ● 39

is the vaporization or oxidation of some wastes anda inert stable glass residue (87).

Electrohydraulic disinfection and pulse-powertechnology were created as disinfection systems forcontaminated liquids. Their uses are not widespread,although the concept of applying the technology tomedical waste disinfection has been suggested. Itappears that the perceived high cost of this technol-ogy is a major reason it has not yet been developed.The process involves the use of pulsed plasma ofelectrical discharges in water, using ultravioletradiation, hydrogen, hydroxil, ozone and shockwaves to act as disinfectants. One application ofpulse power technology does not require the use ofradioisotopes (104).

Future application of plasma torch technology tomedical wastes (and other hazardous wastes) hasbeen suggested (42, 39, 31). A “pyroxidize,” asmall pyrolysis on-site laboratory waste disposalunit, is being developed (92). Another recentlyannounced potential treatment technology is anelectrocatalytic oxidation system (38).

Adaptations of existing technologies have beensuggested, for example, a sterilization/dry grindingmethod (30). This system would combine an auto-clave system with dry grinding/shredding in ahammermill to achieve both volume reduction andnonrecognizability of the wastes. Projected costs forthis hypothetical alternative treatment are $0.08 perpound (30). It is not clear whether the increasedmaintenance cost usually associated with shreddersis taken into consideration in these calculations. Onereason frequently given for the limited application todate of shredders is that they require a high level ofmaintenance. Thermal inactivation or dry heatsterilization, reportedly sometimes used for bothsolid and liquid medical wastes, also could possiblybe used in conjunction with a shredder or compactor(although it is not considered as efficient as steamdisinfection) (73).

SUMMARYSeveral non-incineration alternative treatment

technologies for medical wastes are commerciallyavailable, others are at a conceptual or developmen-tal stage. Autoclaves, autoclave/compaction units,mechanical/chemical units, and most recently mi-crowaving and irradiation treatment alternatives arein use in medical facilities across the Nation. Mostof these units are on-site treatment alternatives and

most appear less costly than incineration. Many ofthe alternatives will achieve significant volumereduction (of 60 percent or more) of the medicalwaste and all can render wastes nonrecognizable (ifa compactor or shredder is added). Weight reductionmay or may not occur, particularly if water is addedduring the treatment process. In fact, some of thesetreatment alternatives can add to the weight ofwaste, given their use of water. These alternativesappear to have fewer emissions concerns (althoughthese warrant further study) than incinerators. Mostof these alternatives do not appear appropriate forpathological wastes.

Health risks associated with these technologieshave not been thoroughly investigated. Furtherexamination of potential health risks is warranted(particularly for the newest applications, e.g., micro-wave and irradiation). When any waste treatmentalternative is considered, any new or additionalemployee exposures that could result from utiliz-ing the new method should be identified andevaluated.

Before adopting a medical waste managementstrategy, medical waste generators must first knowthe applicable regulatory requirements and thenassess the capabilities, costs, and associated healthand environmental risks of various treatment tech-nologies as applied to their facility in order to adoptthe most appropriate technology for their needs. It islikely that the emergence of these non-incinerationalternative treatment methods will reduce but noteliminate the current level of dependence on inciner-ation for medical wastes. Many of these alternativescan be viewed as supplementing the use of incinera-tion for treating medical wastes. Pathological wastesare the one type of regulated medical wastes forwhich incineration remains the preferred treatmentalternative (122, 92).

It appears most prudent for any regulatory pro-gram for medical waste to avoid directly or indi-rectly encouraging a particular type or application oftreatment technologies. Rather, flexibility for thegenerators to meet their management needs andcomply with regulatory requirements will allow foradoption of the most appropriate treatment optionsand help ensure safe management of medical wastes.

Government agencies, particularly EPA, couldfacilitate the evaluation and adoption of newtreatment alternatives by developing a programfor demonstrating the efficacy of a treatment


method. A general protocol for the certification ofapproval of any type of waste treatment technology(e.g., hazardous, solid, medical) could be establishedwith adjustments made for developing appropriatetesting programs (e.g., biological testing of medicaltreatment methods).

Interim approval status might be given while testprotocols and results are developed and/or pilotprojects, perhaps at veterans’ hospitals or othergovernment facilities could be used. Monitoringnew facilities on aperiodic basis, perhaps with somesupporting funding, could facilitate developing ap-

propriate operating parameters and specifications. Aprogram similar to the Superfund Innovative Tech-nology Evaluation Program has been suggested as amodel for a program evaluating new medical wastetechnologies (31, 124).

Such efforts could help ensure that governmentregulatory activity does not create barriers forevaluation and adoption of new technologies. Animportant task for State and Federal regulators thenis to rid the current regulatory system of inconsisten-cies and ambiguities and enable the “market” tomove ahead with optimum management solutions.

Chapter 4

Incineration Treatment Issues and Trends

Incineration of medical wastes remains a preva-lent treatment method in the United States. l It is alsothe treatment technology most often used for medi-cal wastes in other Western countries (57, 58). Theadvantages of incinerating medical wastes, are thoseassociated with the incineration of any type of waste:significant volume reduction (by about 90 percent),assured destruction, sterilization, weight reduction,and the ability to manage most types of wastes withlittle processing before treatment.2 The disadvan-tages include potential pollution risks associatedwith incineration processes and increased costsassociated with controlling pollution emissions (114,116).3

In some European countries it appears thatregional off-site incineration facilities have beenencouraged to optimize the economical applicationof advanced pollution control technologies (57). Inthe United States, incineration continues to occuron-site in smaller units, most of which have few orno pollution controls. As some States adopt morestringent air standards for medical waste incine-rators, 90 percent or more of these existing units canbe expected to retire when these new standards gointo effect within the next several years (e.g., NewYork State, California) (12). New on-site as well asoff-site units can be designed to meet stringentemission control standards, and some older, on-sitefacilities can be retrofitted with air emission controls(if sufficient space and the economics make thispractical). Retrofitting can include modifying theincinerator, adding or changing pollution controldevices, or both.

While new regional facilities are being estab-lished and other new on-site facilities are operatingin the United States, it is also likely that incinerationwill be supplemented by other treatment technolo-gies. Nearly 80 percent of the hospitals in Californiause alternatives to on-site incineration (49). Severalinterrelated factors account for the likely decreaseddependence on incineration:

1.

2.

3.

4.

the increased cost of incineration due toincreased equipment needs to meet new emis-sion standards and permit requirements;siting and permitting difficulties associatedwith locating new incineration facilities;regulatory uncertainty associated with incinera-tion requirements at the local, State, andnational levels of government; andthe increasing availability of nonincinerationalternatives for treatment of medical wastes.

In fact, increasing concern over incineration ingeneral and particularly for medical waste hasresulted, in some States, in indirect regulatoryencouragement for developing alternative treatmenttechnologies.

More specifically, the regulatory emphasis byStates has been on operation requirements forincreasing temperature, residence times, and com-bustion efficiency to foster destruction of toxiccompounds in the combustion process in order topreclude their release to the atmosphere. The re-quired temperatures are tending to be set increas-ingly higher than necessary to destroy pathogens.According to EPA, the incinerator conditions neededto destroy gas stream pathogens emitted from themedical wastes are a function of temperature,residence time, and good mixing to preclude ‘pock-ets’ of gases (which do not reach the requiredtemperature). Based on limited available data, attypical residence times, temperatures (for the secon-dary chamber) necessary for pathogen destructionare 1,600 ‘F or more. Most existing regulationsusually require temperatures of 1,800 or 2,000 ‘F,higher than the temperature probably needed forpathogen destruction, but considered necessary tocontrol other emissions such as volatile organics(e.g., chemotherapy agents) (41).

Incineration technology continues to evolve, andmore sophisticated pollution control equipment isbecoming available. Another source of concern,

IMost of ~ese~c~erators are of tie controlled-air type (see below and 114). This type of incinerator is popub.rfor medicd wastes because it mica.llYis more fuel-efficient and has lower particulate emissions than other smaller, modular combustion systems and its solid hearth can vapor-combust liquidwastes and ensure that needles are rendered noninfectious.

2A]tiough separation of noncombustibles and items with problematic constituents improves maintenance and possibly air emissio~.30nce other ~mtment me~ods (e.g., ~utoclaving) me more ~oroughly s~died, however, ~creased coscs to ensure tieir enviromnenti safety may

also occur. Nonetheless, most nonincineration altermtives are less capital-intensive than incineration.

- 4 1 –

42 ● Findingh the Rx for Managing Medical Wastes

however, is the potentially hazardous nature ofincinerator ash. As air pollution control equipmentbecomes increasingly effective in removing particu-late matter and toxic substances from flue gases, thepotential toxicity of fly ash collected from theequipment is likely to increase.4 Effective destruc-tion of toxic substances during combustion (i.e., ofsome organic chemicals, as opposed to metals)would minimize the presence of those substances influe gases; this would reduce the amount requiringremoval by pollution control equipment and therebyreduce subsequent concentrations in fly ash residuescollected from the equipment. The toxic materialscaptured in the fly ash are usually disposed of in alandfill. 5 Limited data available on the constituentnature of medical waste incinerator ash indicates itcan contain a number of hazardous substances (e.g.,heavy metals; and dioxins and furans in fly ash) (asreported in 114) (54a).

The presence of a toxic substance in ash does notnecessarily mean it presents an environmental haz-ard. This depends, for example, on its volubility andhow it is managed (e.g., whether conditions willallow leaching or gaseous emissions that lead toinhalation or ingestion of the substance) (116). Inthis light, the nature and management of ash frommedical waste incinerators requires careful consid-eration. To date, little information is available aboutits nature and potential hazards.6 EPA, as part of itsNSPS test program, will be collecting and analyzingboth bottom ash and fly ash samples for dioxins andheavy metals.

This chapter reviews: 1) the regulatory trendsdriving the market and development of incinerationoptions; 2) capacity, cost, and risk issues associated

with incineration; 3) current trends in the selectionof air pollution control systems; and 4) prospects forco-firing medical waste with other waste types andfor regional incineration.

REGULATORY TRENDS ANDMEDICAL WASTEINCINERATION

Currently, trends in medical waste managementare primarily being driven by State regulation,particularly of air emissions, of medical wasteincinerators. At the Federal level, the Clean Air Act,which is being re-authorized, is a source of concernto the medical waste incineration industry.7 Lessattention has been paid to the regulation of incinera-tor ash from medical waste incinerators. IncreasedState and/or Federal regulation of ash disposal couldincrease insurance (due to potential RCRA and“Superfund” liabilities if it is considered hazard-ous) and other operating costs for managing the ash(presumably off-site at a specially controlledlandfill). s

The Waste Combustion Equipment Institute (WCEI)testified before the Senate Committee on the Envi-ronment and Public Works that the proposed CleanAir bill would inappropriately apply standards forlarge MSW incinerators to incinerators of differenttypes and for different wastes, such as medicalwastes (45). At the same time, EPA is in the processof formulating its new source performance standards(NSPS) for medical waste incinerators under itsexisting authority in the Clean Air Act. They areexpected to be proposed in 1992. Some NSPS andother types of Federal standards have been estab-lished for MSW.9 The Agency initially considered

4F1Y ash is comp~s~ of fight p~icles that me either carried off the grate by turbulence, or that condense ~d fOrm ~ tie flue gas ~ the bofler sYstem.Bottom ashis the residue from combustion (ash) that accumulates on or falls through the grate of the incinerator. Most volatile metals (e.g., lead, mercury,cadmium) are concentrated in fly as& whereas other types of less volatile metals (e.g., al uminu chromium iron) are concentrated in bottom ash (1 16).

sc~en~y, ~ the sate rewlates an ash tes~g pro-, the material should be tested, and if it is h~dous it sho~d be sent to a ~ardous wastefacility. See OTA (1 16) for a discussion of the current unresolved state of ash regulation at the national level.

GAItiou~ Wrote wmgaen~ rnc. indicates that its testing of medical waste incinerator ash det ermined that the quality of the ash is similar to MSWincinerator ash (43). See OTA (1 16) for a discussion of the nature and management of MSW incinerator ash. Quberand DrUIU (66) report that EP toxicilytests at one facility with advanced pollution control equipment have tested the ash and found it to be nonhazardous.

~SCA 7401 et seq.8See OTA, 1989 (1 16) for a more de~led ~scussion of MSW ~c~emtor ash ~d possible m~gement ad r@atory scendos. presumably,

medical waste incinerator ash, which has been found to be more hazardous than MSW ash in some cases, would be regulated in a similar way as MSWincinerator ash (54a).

9CWenfly, at me Federal 1evel, NSPS for p~ic~ate matter and opaci~ ~ssions ~ set for MSW ~ctierators. MSW incinerators dSO must meetthe mercury standard which is regulated as a hazardous air pollutant and the national ambient air quality standards [set for such pollutants as nitrogenoxides and carbon monoxide (1 16)]. The revised NSPS for MSW incinerators, proposed by EPA on Dec. 20, 1989, would cover acid gases,dioxins/furans, nitrogen oxides, carbon monoxide, and metal emissions and revises the particulate matter and opacity standards to more stringent levels(41). In additio~ emission guidelines for existing MSW incinerators were also proposed in the Federal Register on Dec. 20, 1989.

Chapter Incineration Treatment Issues and Trends ● 43

including medical waste incinerators in their pro-posed air emission standards for all incineratorsburning more than 50 percent MSW on November30, 1989. Those proposed standards would haveapplied to most medical waste incinerators andrequired a 90 percent reduction in air emissionsthrough emissions limits, operating standards, andsome source separation and recycling requirements.Apparently, at this time EPA is considering a lowersize cutoff for the MSW NSPS standard, whichwould essentially exclude medical waste incinerat-ing. Instead, a specific NSPS for medical wasteincinerators would be adopted (41).

At the State level, over half the States havechanged their requirements for medical waste man-agement within the last 2 years (107). Most of thisregulatory activity focuses on setting stricter air

emission standards for medical waste incinerators.Currently, the standard-setting process for air emis-sions from medical waste incinerators in Californiais attracting considerable attention (see box C). TheCalifornia Air Resources Board (CARB) is propos-ing regulations for medical waste incinerators thatwould require reducing emissions of dioxins by 99percent or to 10 nanograms per kilogram. There is nocadmium requirement, but local air districts arerecommended to evaluate the need for such stan-dards on a case-by-case basis.

Originally, the proposal required the use of a dryscrubber/baghouse combination for air pollutioncontrol equipment, as the best available controltechnology (BACT), to achieve the desired removalrates. Any other technology that could document thenecessary reductions in dioxins could also be

Box California and Its Dioxin Control Measure: A Case Study of One State’s Approachto Regulation of Air Toxics and Medical Waste Incinerators

On July 12, 1990, a proposed “air toxic control measure” (ATCM) requiring a 99 percent reduction in dioxinsor control to a level no greater than 10 rig/kg of medical waste burned was adopted by the State of California.1 Itis the culmination of an effort begun when the California Air Resources Board (CARB) identified dioxins as toxicair contaminants in July 1986.2 CARB is required to evaluate the need for and the appropriate degree of control fora compound that is identified as a toxic air contaminant (106, 108).

Through a formal risk management process, medical waste incinerators were found to have the greatestindividual risk potential of all dioxins sources the State identified. This, combined with the facts that most of theincinerators are uncontrolled and located in residential areas and that emission test results from eight test facilitiesfound that they were also sources of other pollutants (e.g., cadmium, benzene, polycyclic aromatic hydrocarbons,lead, mercury, nitrogen oxides, sulfur dioxide, particulate matter, and hydrochloric acid), led CARB to give medicalwaste incinerators the highest priority for the dioxin ATCM (106, 108).

CARB identified 146 facilities that incinerate medical wastes in the State of California. Of these, 137 areon-site facilities incinerating 28 percent of the total amount of medical waste incinerated, and 9 are off-site, regionalfacilities incinerating the remaining 72 percent of the medical waste incinerated. The on-site incinerators aretypically located at a medical facility and mainly incinerate general solid waste (70 to 95 percent by weight of thetotal amount of waste incinerated), similar to MSW, with infectious and pathological waste (5 to 30 percent byweight of the waste incinerated). The incinerator may generate steam and hot water, but the only current air emissionregulation is a particulate matter emission standard set by the local air pollution control district (49, 106, 108).

Regional incinerators in California are located to serve many medical facilities and incinerate only pathologicaland infectious wastes. These facilities have particulate matter and HCl emissions regulated by the local air pollutioncontrol districts and the Department of Health Services (49, 106, 108). These regional facilities manage nearly 75percent of the infectious waste incinerated in the State (8,700 tons per year of the 12,105 tons per year of infectious

l~ter tie a&ptiOn of the CARB control measure, local air pollution control districts have 120 days to propose ad 6 monti to adopta regulation at least as stringent as that adopted by CARB (106, 108).

2~cordfig to Califofia law, a tOXiC fi conti~t “an air pollutant which may cause or contribute to an increase in mortality oran increase in serious illness, or which may pose a present or potential hazard to human health’ (California Health and Safety Code Section39655).

Continued on next page


wastes incinerated). The amount medical waste currently incinerated represents about 0.05 percent of the totalgeneral waste produced in California annually (49, 106, 108).

CARB emissions testing of eight California medical waste incinerators served as the basis for developing theATCM. The emission rate for dioxins from these eight facilities ranged from 0.0003 to 14,140 rig/kg of wasteburned. A multipathway risk assessment (which considered exposure to inhalation, dirt ingestion, dermalabsorption, and mother’s milk) estimated that the risk for dioxin is 1 to 246 chances of developing cancer permillion, with the lower end of the range reflecting controlled facilities. Based on these findings, CARB identifiedcontrol equipment that could reduce dioxin emissions by 99 percent or to 10 rig/kg and determined that wastedisposal alternatives to incineration are available (106, 108). The proposed control measure is expected to reducethe maximum individual risk by 90 to 99 percent, to 1 to 3 chances of developing cancer per million (49, 106, 108).

The proposed ATCM for dioxin of 99 percent reduction of dioxins or reduction to a level no greater than 10rig/kg of waste burned is considered to be BACT (the best available control technology). Although CARB firstidentified a dry scrubber and baghouse air pollution control system as the most effective in reducing dioxinemissions, it later tested and reported that a well-designed incinerator equipped with a Venturi wet scrubberachieved the 99 percent reduction (i.e., the proposed emission limit for dioxins). The proposed control measure alsoincludes requirements to ensure combustion efficiency to minimize dioxin formation, These include a minimumtemperature of 1,4000 °F in the primary chamber of a multiple chamber unit and a minimum temperature of 1,800°Fin the secondary chamber of a multiple chamber unit or the primary chamber of a single chamber unit, with a onesecond gas residence time (106, 108).

In addition, a maximum temperature for flue gas at the outlet of the air pollution control equipment is specifiedas 300°F (unless an alternative temperature achieves equal or greater control). The control measure also specifiesrequirements regarding continuous record keeping for the operation of equipment and maintenance; reportingviolations, malfunctions, or upset conditions; annual source testing; operator training; and mandatory air districtpermits (106, 108).

The proposed measure became effective July 1991, and the compliance timetable is for installation of BACT15 months after the local air district’s adoption or to cease operation 6 months after the district’s adoption. Thedioxin control measure is expected to increase waste treatment costs by approximately $0.10 to $0.35 per poundover current incinerator costs. In addition to the reduction in the risk to 1 to 3 chances of developing cancer permillion, the control measure is expected to produce other net environmental benefits (106, 108).

considered for permitting (e.g., wet scrubber sys- the wastes they burn may be most appropriate.10

terns). This provision was modified, however, to MSW incinerators tend to be large, mass-burnState performance standards (e.g., a 99 percentreduction requirement) without regard to the specifictechnology necessary to meet them. The proposedfinal standard became effective on July 12, 1990.Reported test results from one facility show a 99percent reduction and 10 rig/kg achievable with awell-operated incinerator equipped with a high-efficiency Venturi (wet) scrubber (107).

Given the large number of medical waste inciner-ators (on-site and off-site) operating in the country,separate regulation taking into account the specialcharacteristics of these incinerators and the nature of

incinerators (i.e., waste is burned as-it is received,not processed or sorted), which are typically one-chamber combustion systems operating under con-ditions of excess air. Most medical wastes areburned in excess air or controlled air incinerators(sometimes referred to as starved air incinerators),which burn waste in two or more chambers underconditions of either excess oxygen or a deficiency ofair, respectively (1 14, 45, 30, 40) (see figure 8).11

As with MSW incineration, a trend may beemerging for medical waste incineration to recoverenergy and include front-end waste separation and

lo~e exact number of medic~ waste incinerators operating in the country is not known with certainty. The State of California, Xti 10 percent ofthe U.S. population, reports 146 medical waste incinerators (49).

I IEpA finds, based on information gathered in ~States, that approximately 40 percent of total number of incinerators are ones operating underexcess air conditions and 35 percent are starved air units. These excess air incinerators are probably small incinerators used for pathologicrd wastes andhave limited or no air pollution control equipment. They are probably not required to meet most air quality standards due to their size unless they arein a State (e.g., New York California) tbat has recently adopted new air quality standards (141).


Figure 8-Controlled Air Incinerator

To boiler

I I Secondarychamber

Fossil fuel

I burner/

● /

Primarychamber

II

Ashdischarge ram I

Ash sump

Ash quench

SOURCE: U.S. Environmental Protection Agency, Industrial Incinerators, EPA-450/3-80-013 (Washington, DC: May 1980).

recycling efforts. Such efforts, along with designingthe incinerator to account for the nature of thewastes, affect incinerator performance. A recentstudy of the performance of hospital incineratorsconcluded that while performance-related problemsand emission exceedance problems can be caused bypoor equipment design, they are “more likelycaused by the incineration of wastes different, intype or mixture, than originally anticipated” for thesystem (81). Accurate waste analysis and designingthe incinerator to accommodate that waste feed willhelp avoid waste-related operational problems.

In any case, the absence of controls at the Federallevel and the variation of controls at the State levelcreate a highly uncertain and complicated regulatoryclimate for those who make, sell, and use medicalwaste incinerators. Siting and permitting medical

waste incinerators in most areas of the country havebecome as problematic as siting any type of wastefacility. Public resistance to siting some medicalwaste facilities focuses on potentially hazardous airemissions (e.g., dioxins, furans, HCl, cadmium andlead emissions) and the disposal of potentiallyhazardous ash residue (e.g., cadmium and leadcontent). Pollution control equipment and engineer-ing solutions are being applied to control theseemission and residue problems (e.g., scrubber equip-ment to control particulate and HC1 emissions andhigher combustion temperatures and retention timesin the secondary chamber of incinerators of one totwo seconds at 1,800‘F to control organics) as wellas efforts to separate materials for recycling, includ-ing such items as batteries, which contribute to thelevel of metals in the ash.


CAPACITY, COSTS, AND RISKS

Capacity

The advent of stricter environmental controls forincinerators and the prospect of the resulting closureof many existing facilities has fueled concerns overwhether adequate incineration capacity for medicalwastes is available nationally. This discussion willfocus on capacity issues, which are driving trends intechnology and permitting, and will indirectly (qual-itatively) identify the general level to which acapacity problem exists in this country.

It is extremely difficult to determine existingincineration capacity (or demand/need for capacity)on a national basis given the differences betweenon-site and off-site incinerator capacity parametersand the fact that the amount of medical waste(including nonhospital sources) requiring treatmentis not definitively known (104). It does appear,however, that the demand for capacity has outpacedits availability in some regions of the country,especially where new, more stringent State require-ments lead to the closure of existing facilities andnewer facilities are not readily available (given thelengthy permitting process and the persistent sitingproblems).

The capacity problem is most likely to arise whenon-site incinerators shut down because they can nolonger meet regulations, when management prac-tices (e.g., universal precautions widely applied)increase the amount of waste requiring incineration,or when increasing numbers of nonhospital genera-tors enter the market. If a large number of on-siteincinerators cease operation, for whatever reasons,in the same geographic region, a ‘‘capacity crunch’can occur (104). This capacity deficit can result ineither accelerated permitting or increased export(transfer) to other regions. In California, new re-gional incinerators are being permitted, which willprovide surplus capacity for medical waste, nolonger burned on-site (49). In New York State,increased out-of-State shipment is anticipated atleast in the short-term after new regulations takeeffect (94).

Increasingly, older, on-site units are being re-placed either with larger, on-site units that can beregional (accepting medical wastes from nearbyclinics and nursing homes) and/or co-incinerate thefacility’s medical and solid wastes, or with off-siteregional incineration. The customer base for re-gional incinerators continues to grow. Substantialgrowth in this industry is projected.12 Interestingly,although total on-site and off-site capacity may beadequate to meet disposal needs, the regionalmarkets determine the fluctuations in availablecapacity in a given area. That is, the variedgeneration rates (in part related to regulatory trendsand shifts in management practices), the reluctanceof major regional incineration and autoclavingoperating companies to make capacity available tocompetitors when the need arises, and regionalregulatory trends create an unstable level of treat-ment capacity (104)0

The Southeast (centered in and around SouthCarolina), lower Midwest (centered in and aroundOklahoma), and the Ohio Valley area now appear tohave excess capacity for medical waste. Indeed,these areas have been magnets for the waste fromother parts of the country where capacity has becomesaturated. Wastes from locations on both coasts havebeen transported great distances to facilities in theseareas.

The uncertain outcome of the pending changes inthe Clean Air Act has slowed the pace of permitapplications in a number of States. In the Northeast,constraints on capacity have been driven by suchfactors as permit difficulties (e.g., the (now expired)moratorium on incineration activity in Pennsylva-nia). In other areas, there may be permit activity(e.g., Texas, Illinois), but there is a lag between thetime when additional incineration and/or alternativetreatment capacity will be available in those marketsand the immediate capacity needs (104). This cannecessitate exporting medical waste out of the areafor treatment, at least until new treatment capacity isavailable. In some areas, a “capacity crunch” isbeing met by arrangements with local MSW incine-rators to accept medical wastes (68; see below). TheState of California, when adopting new air emissionstandards for medical waste incinerators, examinedthe potential for a capacity shortfall. They concluded

12~e Swe iS tie for tie entire ~e&c~ ~a~te ~Mgement indus@y. ~cording to one study, me c~enfly estimated $750 mdfion medical wasteindustry will expand to $1.5 billion by 1991 and grow to nearly to $5 billion by 1994 (cited in 75). Other studies project revenues to be even higher,reaching $10.7 billion by 1991, with expenditures estimated to grow from $970 million to $2.9 billion by 1991 (cited in 74).


that upgraded or new incinerators, or other treatmentalternatives, could be permitted within the timeframebefore existing facilities would be required to shutdown. Further, the relatively low volume of medicalwaste incinerated could be landfilled at existingfacilities with little impact on their capacity accord-ing to CAB.

Changes in regulation of a waste stream can resultin short-term shortfalls of permitted treatment ca-pacity (e.g., the shortages of permitted MSW landfillcapacity experienced in some areas of the country asStates adopt more stringent landfill regulations,leading to closure of many existing facilities). Itappears that such temporary shortfalls of permittedcapacity can occur for medical wastes. Yet, ifadoption of new regulations is coordinated withcareful planning and expedient permitting, suchshortfalls may be averted.

costs

The variable nature of the equipment design, size,and add-on pollution control equipment make itimpractical to identify the typical cost of treatingmedical waste by incineration (104, 54).13 Incinera-tion costs can vary by more than 500 percent, andOTA’s contractors independently identified widecost ranges from $0.07 per pound to over $0.50 perpound (104, 54). The California Air ResourcesBoard estimates that uncontrolled incineration costsare about $0.15 per pound and controlled incinera-tion costs about $0.50 per pound (108). It isgenerally believed that incineration is a more costlyalternative than most nonincineration treatmentalternatives; some estimates find autoclaving to be30 percent of the cost of incineration (104).

CARB also calculated the estimated cost toretrofit existing facilities to meet its proposedstandards to be an increase of $0.16 per pound ofwaste burned. If on-site incinerators are shut downand off-site incineration is used, costs are estimatedto increase by $0.35 per pound. If steam sterilizationis used, on-site, a $0.10 per pound cost is estimated,and if incinerators are shut down and off-site steam

sterilization is used, a cost of $0.17 per pound isexpected (108).

Risks

Relative health risks associated with the combus-tion of medical wastes continue to be debated as dataremains limited. A thorough examination of healthand environmental risks posed by different pollut-ants is beyond the scope of this effort; these risks areaddressed elsewhere (116, 66, 12, 108). The inten-tion here is to identify those pollutants of primaryconcern in medical waste incineration because oftheir potential human health and environmentalimpacts.

These pollutants include dioxins and furans (someof which are thought to be carcinogens), pathogens(entities with infection potential), metals (e.g.,cadmium, a neurotoxic chemical and thought to bea probable human carcinogen), acid gases (e.g.,hydrogen chloride (HC1), nitrogen oxides, and sulfurdioxides), which can cause acute effects such as eyeand respiratory irritation, can contribute to acid rain,and may enhance the toxic effects of heavy metals),and particulate emissions (which can absorb heavymetals and organics and 1odge in human lungs, andserve as irritants possibly responsible for chronichealth effects). Their presence in either air emissionsor ash residue is a concern.14

A large data base for dioxins and furans and theirpotential carcinogenicity makes them a particularsource of concern. It is presumed by regulators thatcontrolling emissions of these organics will controlemissions of other organics (PAHs), cadmium, andperhaps particulate matter and HC1.15 Emissions ofthese organic compounds from medical waste inci-nerators have been noted (see table 6 and figures 9,10, and 11). Barton et al., in a study for the EPA andCARB, hypothesize that dioxin and furan formationcan be minimized by controlling particle and traceorganic emission levels within the combustion zone,minimizing the time particles are held at tempera-tures that maximize dioxins and furan formation andmaximizing the destruction of precursors (both

13EPA, as p~of its Nsps Pqram form~ic~ waste incinerators, is evaluating the capital and operating costs of various W pollution control devi~sand incinerators; the preliminary results are expected in late 1990.

Idsee OTA, 1989 (1 16) for a discussion of fisks associated with MSW incinerator air emissions ~d ash residues, which maY be simil~ to ~“seassociated with some forms of medical waste incineration.

15~@ scrubber systems (i.e., acid gas remov~ plUS particulate removal), high removal of particulate matter gene~lY me~s ‘i@ ‘emovd ‘f ‘ea~metals (except possibly mercury) and moderate to high control of dioxins~~s (~d other semi-volatile organics). It appears that particulate mattercontrol is the key to controlling the pollutants noted here, because they me converted to a solid (particulate) form to facilitate their removal from thegas (20).


Table 6-Emissions of Dioxins and Cadmium FromMedical Waste Incinerators in California

Percent of total waste Percentincinerated v. percent statewide waste Percent dioxinsof statewide dioxins burned a emittedemissions in California: (%) (%)

119 Onsite incineratorsControlled units:

1. Multiple chamber . . . 21.4 1.32. Excess-air . . . . . . . . . 0.07 0.03

Uncontrolled units:1. Multiple chamber . . . 25.3 21.02. Excess-air c . . . . . . . . . 9.9 36.3

Subtotal . . . . . . . . . . . 56.7 58.6

9 Off-site incineratorsControlled units:

1. Multiple chamber . . . 31.1 2.5Uncontrolled units:

1. Excess-air . . . . . . . . . 10.3 38.9

Subtotal . . . . . . . . . . . 43.4 41.4

Total . . . . . . . . . . . . 100.0 100.0

Percent of total waste Percent Percentincinerated v. percent statewide waste cadmiumof statewide cadmium burned a emittedemissions in California: (%) (%)

119 Onsite IncineratorsControlled units:

1. Multiple chamber . . . 21.42. Excess-air . . . . . . . . . 0.07

Uncontrolled units:1. Multiple chamber . . . 25.32. Excess-air c . . . . . . . . . 9.9

Subtotal . . . . . . . . . . . 56.7

9 Off-site incineratorsControlled units:

1. Multiple chamber . . . 31.1Uncontrolled units:

1. Excess-air . . . . . . . . . 10.3

Subtotal . . . . . . . . . . . 43.4

Total . . . . . . . . . . . . 100.0

15.70.1

32.213.8

61.8

23.4

14.9

38.3

100.0aFrom table X-3.bFrom table XII-8.qncludes types not specified.‘From table X11-1 O.SOURCE: State of California Air Resourees Board, Technica/ Support

Document to Proposed Dioxins and Cadmium Control MeasureforMedica/ Waste hwirterators, prepared by Toxic Air Contami-nant Control Branch, Stationary Source Division, California AirResources Board (Sacramento, CA: May 23, 1990).

vapor and particle bound) within the incinerator(12). They also note that to control dioxins from theflue gas with low-temperature fine particle controlmerely transfers the dioxins from the air to the ash(12).16 Yet, metals will not be controlled by these

measures; only add-on pollution control equipmentor front-end source separation will reduce emissionsof metals (41).

As part of its standard-setting process, Californiaundertook what to date is probably the mostcomprehensive health risk assessment of medicalwaste incineration. CARB worked closely with theCalifornia Department of Health Services to developa multipathway health risk assessment model toassess the potential acute, chronic and cancer healtheffects from exposure to pollutants emitted frommedical waste incinerators, MSW incinerators, fos-sil fuel combustion, and hazardous waste incine-rators. For dioxins the multiple pathways used toestimate potential risks are: inhalation, dermalabsorption, soil ingestion, and mother’s milk for thefrost year of an infant’s life (108). Other routes, suchas produce (leafy vegetable) ingestion, can increasethe risk relative to inhalation, but were not feasibleto consider in this effort. Further studies to supple-ment the California studies could address this andother exposure routes.

The results of the California risk assessmentestimate for dioxins that the risk factor ranges from1 to 246 in a million of developing cancer forcontinuous daily exposure for 70 years to an airborneconcentration of one picogram per cubic meter oftotal dioxins. For cadmium, the estimate is that therisk factor ranges from less than 1 to 15 in a millionfor continuous daily exposure for 70 years to anambient air concentration of one nanogram per cubicmeter (108).

CARB also reported results for potential chronicnoncancer effects from exposure to pollutants emit-ted from the eight hospitals it tested and reported aswell on the significance of emissions with thepotential to cause chronic health effects. The mostsignificant noncancer effects might come from iron,manganese, and lead. Five facilities were identifiedas having the potential to cause acute effects inexposed individuals from HCl emissions (108). Yet,the use of the risk assessment and its findings havebeen problematic in California, and further workneeds to be completed in this area.

Beyond disputes over the actual health risks posedby incineration, it appears that effective, availabletechnology will be able to reduce risks to whatever

16~e ~t~c~ent @on&@ of dio~/&m t. solids, i.e., the ash, is such tit their removal by leaching in a Iantifl is not considered significant.Thus, concentrating the dioxins/furans in residue allows for their control by landfiiling (20).

Chapter 4-Incineration Treatment Issues and Trends ● 49

Figure 9-Comparison of PCDD/PCDF Concentration in Medical and Municipal Wastes

c

100

10

Medical waste Municipal waste

SOURCE: R. Barton, G. Hassel, W. Lanier, and W. Seeker, State of the Art Assessment of Medical Waste Thermal Treatment, EPA Contract 68-03-3365 andARB Contract A832-155 (Irvine, CA: Energy& Environmental Research Corp., 1989).

Figure 10—Comparison of PCDD/PCDF Emissions From a Variety of Incinerators

Emitted PCDD/PCDF concentrations Medical

Municipal waste incineratorswaste

incinerators

12000 I

6000

Hazardouswaste

incinerator

ESP - Electrostatic precipitatorDI - Dry sorbent injectionFF - Fabric filterSD - Spray drierV - Venturi scrubberCYC - CycloneDS - Dry scrubberWS - Wet scrubber

*Note that ng/Ncm represents measurements normalized to standard concentration of 12% C02

SOURCE: R. Barton, G. Hassel, W. Lanier, and W. Seeker, State of the Art Assessment of Medical Waste Thermal Treatment, EPA Contract 68-03-3365 andARB ContractA832-155 (Irvine, CA: Energy& Environmental Research Corp., 1989).


Figure n-Comparisons of Cadmium Emissions From a Variety of IncineratorsCadmium

Municipal solid waste

Medical Hazardous

waste waste

- (,0 [

u

0.1

0.01

0001

0.0001

ESP = Electrostatic precipitatorDI = Dry sorbent InjectionFF = Fabric filterSD = Spray drierV = Venturi scrubberCYC = CycloneDS = Dry scrubberWS = Wet scrubberIWS = Ionizing wet scrubberWSH = Water spray humidifierPBS = Packed bed scrubber

A = Data not availableD = Metal below detection Iimit

dscf . dry standard cubic foot; 1 gr/dscf = 2.290 g/Ncm

SOURCE: R. Barton, G. Hassel, W. Lanier, and W. Seeker, State of the Art Assessment of Medical Waste Thermal Treatment, EPA Contract 68-03-365 andARB Contract A832-155 (Irvine, CA: Energy& Environmental Research Corp., 1989).


levels are defined by standards.17 CARB, for exam-ple, reports that tests demonstrate high efficiencyVenturi wet scrubber systems, as well as dryscrubber systems, at well-designed and operatedincinerators can reduce risks to acceptable levels,defined by their standards to one to three chances ina million (49, 108). It should be noted though that theheterogeneous nature of the medical waste streammakes it nearly impossible to conclude with cer-tainty what the emission levels of certain substanceswill be in any given unit. For example, two hospitalswith similar incineration systems can have highlydifferent emission test results largely due to thedifferences in their waste streams and chargingmethods (104).

TRENDS IN AIR POLLUTIONCONTROL SYSTEMS

Until a few years ago when the first major studyof emissions from hospital incinerators was com-pleted and some localities set more stringent airemission standards, air pollution equipment associ-ated with these incinerators was minimal (126).Today, some form of scrubbing system is considereda standard part of many new incineration systems,although most medical waste incinerators remainuncontrolled and pollution control equipment is notnecessarily a standard part of medical waste inciner-ation systems (41). Pollution control devices cur-rently in use on medical waste incinerators includewet or dry acid gas scrubbers (to remove/neutralizeacid gases, etc.), baghouses (fabric falters) or electro-static precipitators (to remove airborne particulatematter), hybrid dry/wet scrubbers, and afterburners(sometimes used on excess air combustors to reducetoxic organic gases).

A fairly common list of toxic compounds andcriteria pollutants to be controlled has evolvedthrough the development of regulations and thepermitting process. These substances are: particu-late, hydrogen chloride, sulfur dioxide, carbonmonoxide, nitrogen oxides, dioxins, furans, mer-cury, arsenic, cadmium, chromium, nickel, zinc, andlead (104) (see table 7).

The selection of air pollution control systemsinvolves choosing between a wet or a dry scrubbersystem. A scrubber is an emission control device thatadds alkaline reagents to react with and neutralizeacid gases, with the resultant products collected formanagement of residue. For a dry scrubber this isusually done through the use of a baghouse (fabricfalter) to trap solid particles (dust), while for a wetscrubber byproducts are discharged as a slurry,possibly requiring treatment before discharge to thesewer. In the future, depending on the type ofscrubber used and the sewage discharge standards inan area, wastewater treatment may also become amore common feature of medical waste incinerationsystems. This could add significantly to the capitalcost of an incineration system utilizing wet scrub-bing (e.g., a wastewater treatment system can cost$150,000 (8)). However, a condensing wet scrubbersystem with zero liquid discharge, a technology usedfor hazardous waste incineration, is being adaptedfor application to medical waste incineration. Itappears that this could be an efficient and costeffective system for controlling emissions frommedical waste incinerators (2).

These scrubber systems can control dioxin andfuran emissions as well as particulate emissionsbecause dioxins and furans in flue gases condenseonto fly ash particles if the gases are cooled enough.They are then removed by the scrubber or particulatecontrol system (1 16). In MSW incinerators, thecombination of a dry scrubber and baghouse canremove 97 to 99 percent of total dioxins present inpostcombustion flue gases (1 16).

As noted, the proposed regulations in Californiafirst identified a dry scrubber as BACT18 Theincineration industry reported, however, that the dryscrubber/baghouse combination is not suitable forall medical waste incinerators, although this appearsto be primarily based on cost considerations. As onestudy concluded, “Venturi [wet] scrubbers, due totheir lower capital costs and greater flexibility, arethe best choice for smaller and medium size hospitalincinerators’ and dry scrubbers, while ‘‘not as pop-ular or as proven in the field, ” are cost competitivefor larger facilities (12 tons per day or more) (26).

17This is me ~ess ZtiO risk is re@red, which no technology---or waste management praCtiCC-Can ac~eve.

lsc~ifornia used EPA data on dry scrubbers used for MSW incinerators (usually a spray atomizer-baghouse system) to medicd w*te incin~ators.Medical waste incinerators which do use dry scrubbers usually have dry inj@ion baghouse systems with injection of a dry alkaline substance into theflue gas, which reacts with pollutants and is then captured in the baghouse (41).


Table 7—Performance Data of Medical Waste Incinerators With Pollution Control Equipment

“Typical”average of Lowest

Emission measured three samples reported Units of measurement

1.

2.

3.

4.

5.

6.

8.9.

10.11.12.13.14.15.16.17.

Particulate including Method 5 impinger catch, 0.028 0.018without CHEAF installed 69.2 44.5

89.0Particulate including Method 5 impinger catch, 0.014 0.008with CHEAF installed

HCI (hydrogen chloride)

SO2 (sulfur dioxide)

CO (carbon monoxide)

HF (hydrogen fluoride)

As (arsenic)Be (beryllium)Cd (cadmium)Cr (chromium)Ni (nickel)Pb (lead)Hg (mercury)TCDD equivalent (dioxins)TCDF equivalent (furans)

34.6 19.897.3

9.2 0.9815.0 1.699.3

4.0 0.3111.4 0.8992.118.8 8.7

Note: Worst case reported is 68 ppm (voI) dry basis @770020.08 Not detected0.094 —

95.6 —<0.05 —<0.25 —

1.02 0.960.045 0.030.112 0.06

10.74 5.822.96 1.860.0311 0.02640.1088 0.0967

Total TCDD & TCDF as TCDD equivalent 0.1399 0.1231Opacity 2 0

Grain/sdcf @7%02mg/Nm 3 dry @7% O2

% RemovalGrain/sdcf@7?4002mg/Nm 3 dry @7% O2

% Removalppm (voI) dry basis @7% O2

mg/Nm 3 dry @7%O 2

% Removalppm (voI) dry basis@7Y002mg/Nm 3 dry@7% O 2

% Removalppm (voI) dry basis @7% O2

ppm (voI) dry basis @7% O2

mg/Nm 3 dry @7% O2

% Removalmg/Nm 3 dry@ 7Y002fg/Nm 3 dry@ 7% O2

fg/Nm 3 dry@ 7% O2

fg/Nm 3 dry @7%O 2

fg/Nm 3 dry@ 7Y002fg/Nm 3 dry@ 7?4002fg/Nm 3 dry@ 7%O 2

fg/Nm 3 dry@ 7%02fg/Nm 3 dry@ 7%O 2

fg/Nm 3 dry@ 7%O 2

Percent

NOTE: These data were collected from over 20 installations of medical waste incinerators with scrubbers in the United States in the period from Jan. 1,1988through Apr. 1, 1990. They do not necessarily represent the best performance which can be achieved, but do represent “typical” performance whichcan be expected from the equipment and systems reviewed by the study. Some data are supported by over 100 separate samplings, while some(including the detailed metals and dioxin information) are based on only one or two installations with three samplings each. Nm 3 representsnormalization of measurements to standard 70/. 02 conditions. 1fg=10 -15 grams.

SOURCE: Anderson 2000 Inc., Technical Description, Performance Information, Material Balance and Flowsheet Data, Typical Guarantees and TurnkeyInstalled Pricing for a 16.2 MM BTU/HR (1700#/HR) State-of-the-Art Medical Waste Incinerator With Wet Scrubber Emission Controls, Document#1-5670-W (Peachtree City, GA: Anderson 2000 Inc., 1990).

EPA reports that there are no technical reasonswhy a dry injection system or a spray dryer systemcannot be applied to medical waste incinerators (41).Reports that the baghouse in medical waste incinera-tor applications is susceptible to corrosion becauseof the intermittent operation, which can result inholes in the bag, should not occur if the system isproperly designed and operated (41, 49). Further, dryscrubbers do not have any associated waste waterproblems.

Wet scrubbers can remove about 95 to 99 percentof HC1 and 85 to 95 percent of sulfur dioxideemissions in MSW incinerator applications (116,45). Wet scrubbers can achieve 90 percent HClremoval with plain water in medical waste incine-

rators, but lime slurries or caustic soda solutions canresult in 99 percent or better hydrochloric acidremoval (139, 126). The California Air ResourcesBoard reports 85 percent particulate removal, 99percent hydrogen chloride removal and O to 75percent cadmium removal by wet scrubber systemsfor a medical waste incinerator (108). Reheating theflue gases may be necessary to ensure adequatedispersion from the stack and compliance withambient air quality regulations, although it is notclear that any medical waste incinerators have had todo this (41).19

The WCEI maintains that advanced (versus con-ventional Venturi) wet scrubbing systems can attainhigh removal efficiencies for fine particulate, acid

ls7’hat is, wet scrubbing COOLS tie flue gases to the water sateration temperature which can be as low as 120 OF. AS a result, plumes leaving the s@ckdo not rise very high which can increase ground level concentrations of pollutants (1 16).

Chapter 4--Incineration Treatment Issues and Trends ● 53

gases and heavy metals at substantially lowermaintenance costs than the dry scrubber/baghousecombinations (45). The industry anticipates thatsoon (possibly within a year) the zero discharge wetscrubber systems will be available (45, 2, 104). Yet,wet scrubbers in current use can require a highenergy input to collect fine particulate, can sufferproblems of corrosion and erosion problems andreentrainment of particulate, and may produce avisible steam plume. Insoluble gaseous organics arenot controlled and permits for some local sewerdistricts may be necessary prior to wastewaterdischarge (126, 139).

Removal of HC1 and sulfur dioxides in one dryscrubber system for a MSW incinerator were re-ported to be 90 and 70 percent, respectively (1 16). Itis not clear how comparable these results are to thosethat could result from medical waste units. TheCalifornia Air Resources Board reports 99 percentparticulate removal, 85 to 95 percent HC1 removal,and 99 percent cadmium removal by a dry scrubberwith a baghouse system for a medical waste incine-rators (108).

Again, the type of waste burned in a unit and thesize and type of incinerator unit are key factors indetermining how appropriate a particular applica-tion of pollution control will be. In the types ofmodular incinerators used for most medical wasteincineration, it appears from the California reportthat dry scrubbers with fabric filters are effective incontrolling particulate, cadmium, and dioxin emis-sions (49). EPA is testing inlet and outlet emissionsfor both a wet and a dry scrubber system todetermine their performance in controlling metalsand dioxins as part of their NSPS testing program formedical waste incinerators (41).

In the past, manufacturers and users have pre-ferred wet scrubbing systems (104). EPA reports thatthe current trend for large, new medical wasteincinerators, at least in the States with more restric-tive air standards, favors dry injection/baghousesystems (41). It appears that more testing of both wetand dry scrubbing systems and other pollutioncontrol technologies is needed to determine the besttreatment technology for a particular setting. Indeed,some companies are experimenting with dry/wet

hybrids which are ‘‘customized’ versions of thesesystems to presumably best meet a particular facil-ity’s needs (56, 104).20

It should also be noted that presorting waste toremove non-combustibles and substances known tocontribute toxic compounds (see ch. 2) and allow forcompleteness of combustion (i.e., minimizing car-bon monoxide and hydrocarbon emissions) areimportant factors affecting air pollutant emissionsfrom incinerators. In fact, these factors can beconsidered complementary approaches for control-ling emissions via applications of air pollutioncontrol technologies (1 16). Additionally, well-trained operators can monitor and control combus-tion efficiency to limit combustor emissions.

OPERATOR TRAININGFundamental to the proper operation of incine-

rators are trained operators. In addition, satisfactoryequipment (e.g., proper design, controls and instru-mentation, etc.) plus regular maintenance and repairare key components affecting performance (1 14). Itis widely suspected that operators of medical wasteincinerators are not routinely receiving proper train-ing, and this, in part, explains why many incineratorsperform poorly.

Recently, a number of efforts have been under-taken and/or completed that will facilitate operatortraining and improved operating practices. EPA haspublished a two-volume hospital incinerator trainingcourse and a handbook on the operation andmaintenance of hospital medical waste incinerators(127, 131). The stated purpose of the volumes is toprovide the operator ‘‘with a basic understanding ofthe principles of incineration and air pollutioncontrol” (127). The presumption is that site-specific, hands-on training of operators will alsooccur.21

Some States (e.g., New York) have recentlyadopted requirements for certification of operators(94). The American Society of Mechanical Engi-neers is also developing an operator’s certificationprogram (6). The Waste Combustion EquipmentInstitute endorses the development of a nationaloperator training and certification program (45).Most of these programs suggest various levels of

Wests of one facility with a hybrid dry/wet scrubber systcm reportedly met lhc stnngcnt Swedish dioxin cmission limit Icvcls (66).

211t is ~tmc.t@ t. note tit al~Ou@ wo~kcr safety issues arc dlscusscd in tic EPA course, Ihc imp~rtancc of front-end separation of recyclable or

noncombustible materials are not covcrcd, and issues related to ash management arc addressed only briefly.

54 ● Finding the Rx for Managing Medical Wastes —

training and competence for operators to achievecertification. In addition, privately published hand-books are also available to facilitate operator train-ing (e.g., 32).

OFF-SITE INCINERATION

Off-Site v. On-Site Treatment

There was speculation after the passage of MWTAabout whether the exemption from tracking require-ments for wastes treated on-site (which meet thespecified regulatory requirements) would encourageuse of on-site incineration. This may not occur,given that other conditions (e.g., increased expenseand/or space limitations to expand existing facilities,limited on-site expertise in waste management, etc.)may provide strong incentives for off-site treatment.It was in light of these conditions, which existwidely, that the prospect of an increased number ofregional incinerators or other types of regionaltreatment facilities has also been predicted in recentyears. It is not clear whether there is a trend formore off-site or continued on-site incineration.

A trend toward more off-site incineration mayoccur if changing requirements for waste manage-ment make it more advantageous for medicalfacilities than on-site incineration. Yet, health-carefacilities still tend to favor on-site treatment becausethey have control over the ultimate disposal and canthereby limit their liability more easily. In addition,properly designed, operated, and maintained on-sitefacilities can meet emission standards and provide aviable waste disposal option.

At a minimum, it appears that present circum-stances will stimulate cooperative planning effortson a regional basis, whatever type of on-site oroff-site treatment technology or management strat-egy is actually adopted.

22 The two basic types ofoff-site incineration options are: co-incineration ofmedical wastes with other types of waste (e.g.,MSW) or regional incineration facilities dedicatedto medical wastes.

Co-Incineration or Co-Firing of Wastes

To date, most off-site incineration has been inunits dedicated only to burning medical wastes.Usually, capacity at off-site facilities is at such apremium that companies do not want to use theincinerators for nonmedical wastes. Yet, severalMSW incineration systems, operated by differentcompanies, do accept or are considering acceptingmedical wastes because they have excess capacityand/or the potential revenue from these sources ismuch higher than from MS W (104).23 In fact, someMSW facilities have marketed their ability toincinerate medical wastes (e.g., locations in SouthCarolina and Oklahoma).

From a technical perspective, MSW mass-burnincineration systems are presumed adequate torender medical wastes noninfectious (although nodata on this was found) and their pollution controlequipment should effectively control toxic com-pounds contained in it.24 Concerns have been raisedabout the ability of some MSW incinerators (e.g.,water-wall types) that may not attach a sufficientlyhigh temperature throughout the chamber to ensurepathogen destruction in infectious medical wastes(45).

The number of co-incineration efforts is not highfor a variety of reasons, including: 1) public concernover the ‘‘importation of medical waste fromnon-local areas; 2) employee concern over potentialexposure to medical wastes in the workplace; and 3)mechanical considerations, such as the handlingsystem for MSW (in which ‘‘red bags’ can beruptured when a crane lifts them from the pit to thefeeder of the incinerator, risking worker exposure)and the roller grate system in MSW facilities, whichcannot control the movement of certain items well,such as needles and syringes (104).

More recent attempts at co-incineration of MSWand medical wastes attempt to address these issuesby having a separate feed system that lifts intactmedical waste packages into a dedicated medicalwaste hopper for the incinerator. Such systems areused in some on-site applications of incineration aswell, particularly in a facility where heat is recov-

zzlt ,SI1ou Id bc no[cd W;lt rcgion:ll, commercial autoclave units ;dso exist in some mcas and arc being proposed in other areas.

z~[n ~lost ~:L~cs, MSW tipping fees at inclncmtors arc much Iowcr than medical wa.st~’ fees ( 104).

~Dl fficultlcs, Prim:lrlly related t. grc:ilcr Occupatlona] risk, ;lss~~latcd with ~ttcnlp(s I() nl;inflgc mc~ic~l W;LS[C at refuse-derived fuel faci]ilics have

been reported (10). Questions have also been raised about the ability of MSW incincratom 10 handle nccdlcs and liquid wastes (given their grate design)and the possibility for greater pathogen survival given the typically cooler water walls assocmtcd with MS W (heat rccovcry) chambers (41).

Chapter G-incineration Treatment Issues and Trends . 55

ered. Another strategy is to use dedicated incine-rators for medical wastes at sites permitted for MS Wincineration (104). Sweden and the Federal Republicof Germany take a similar approach. In addition topermitting the use of high-volume MSW incine-rators for medical waste, these governments allowco-locating infectious waste incinerators with MSWincinerators and channeling their flue gases throughthe high efficiency air pollution control equipmentof the larger incinerator (57).

A variation of co-incineration is a demonstrationproject sponsored by the Department of Energy-Morgantown Energy Technology Center and Penn-sylvania Energy Development Authority whichco-fires medical waste with coal in a circulatingfluidized bed with steam recovery (27). Suggestionshave also been made that medical waste regionalfacilities configured as hazardous waste incinerators(which burn at extremely high temperatures) couldbe efficient enough to cofire hazardous or other“problem wastes” with medical wastes. Wastetypes suggested for co-incineration with medicalwastes include: household hazardous waste, scraptires, and some commercial waste (66). To date nosuch co-incineration facility exists.

There are plans for a hazardous waste (rotary kilnincinerator) facility in California to burn medical aswell as hazardous waste. This facility is in the permitprocess and has an expected start date in 1992 (104).In some European countries, MSW and medicalwaste facilities are sometimes designed as hazard-ous waste incinerators (57).25

Regional Incineration

Regional facilities for medical waste managementmay be privately owned and/or operated, or may becooperatively owned and/or operated by a number ofgenerators. It is also conceivable that, as with MSWincineration, some of these facilities might be run bya municipality or by a municipality in conjunctionwith a private company and/or a number of genera-tors (31). Regional incineration of medical waste ona commercial basis began in earnest in 1986, whenthe demand for services was high, capacity wasscarce, and permit requirements for air emissionscontrols were simple and uniform (104).

In the four short years since then, the aggressivepursuit of permits and development of facilities bywaste management companies have made greatercapacity available, even though the regulatory cli-mate for permitting such incineration has becomecomplicated and variable. Indeed, the more compli-cated regulatory situation for incineration of medicalwastes is one reason the demand for off-site treat-ment has remained high. At this point, hospitals andlarge generators in at least two metropolitan areas,Baltimore and New York City, are cooperativelyplanning a regional facility, usually as part of abroader planning effort for a regional waste manage-ment strategy. This section discusses these differentapproaches to off-site, regional incineration ofmedical waste: commercial (privately run) regionalincineration and generator-run regional incineration.

Commercial Regional Incineration

The two largest waste management companies inthe United States, Waste Management, Inc. andBrowning-Ferris Industries, have aggressively de-veloped medical waste incineration sites on anational basis; a number of other smaller companies(e.g., Medigen, Atwoods, and Incendere) have donethe same on a more regional basis (104). As theconditions for permitting these facilities have be-come more problematic, closer scrutiny is beinggiven to the size, type, and location of the regionalsites. The waste management industry has called fora ‘ ‘leveling of the playing field, ” i.e., for uniformperformance standards on a national basis in orderthat companies operating in more than one State willhave similar requirements to meet. In addition,on-site and off-site incinerators would be subject tothe same requirements; a state of affairs which canfavor a larger scale operation (104).

Permitting is a long, difficult process for anyfacility—an-site or off-site—whether it be for medi-cal wastes, MSW, hazardous wastes, or low-levelradioactive wastes. Yet, for medical waste incinera-tion, it is probably more difficult to permit an off-sitethan an on-site facility, although the on-site facilitymight operate quite similarly to the off-site facility(e.g., accept wastes from other generators). On-siteincineration has the benefit of possible waste heatutilization and reduced transportation of waste.Indeed, some waste companies have attempted tolocate on the site of a hospital or large generator.

MA f;lcl[lfy LIIa[ buns MSW :{nd mcdlc~ WaSkX In Stroud, Oklabom~ is ah equipped m a way Shih 10 a hz=dous waste facili~.


Three significant hurdles in the siting and permittingof off-site, commercial incinerators are: addressingpublic concerns over potential risks posed byincineration, meeting zoning permit requirementsand addressing transportation issues (e.g., the ‘ ‘im-portation’ of wastes for the facility).26

The lengthy and difficult nature of the permittingprocess has had a dramatic impact on the economicsassociated with the construction of a regionalmedical waste incinerator. Permitting a site can takeup to two years or more to complete beforeconstruction of a facility. This can encourage theconstruction of larger facilities or multiple facilitieson a site.

Other factors can favor siting smaller units. Forexample, some communities are willing to accept asmaller facility that will manage their own commu-nity’s or local region’s medical waste, but areopposed to a facility that acts like a magnet for theimportation of wastes from great distances. Also,depending on the service needs of an area, havingseveral facilities rather than one large unit willprovide convenient backup capacity when a unit isdown for maintenance or repairs (104). It appearsthat a mixture of large and small facilities will beconstructed depending upon the type of companyoperating each, the scope of intended service, andreceptivity of the local community (104). It is likelythat the developmental trend of regional incinerationfacilities for medical waste incinerators will mirrorsomewhat the ups and downs of the regulatoryclimate, at least until that becomes more uniform andcertain in nature.

Nonprofit/Generator Regional Incineration

Although the number of cooperative arrange-ments between hospitals and other medical wastegenerators within regions is not as high as somemight have predicted a few years ago, several sucharrangements are being developed in different areasof the country. Examples include: the Baltimore areamedical waste project; the Greater New YorkHospital Association plans for a facility for metro-politan New York, and the facility planned by theNassau-Suffolk Regional Council on Long Island,New York.

The Baltimore regional facility is designed some-what like a utility, A number of factors led to theparticular regional approach taken in this area.Hospitals were responding to a dramaticallychanged climate for medical waste managementbrought on by the media coverage of washups ofsyringes in the Baltimore area and related publicconcern, new State and local regulations that re-sulted, and consequent concerns over the viability ofpresent management practices by various facilities(given, for example, a newly instituted ban ofmedical wastes by a local MSW incinerator, amoratorium in one county on incinerator construc-tion, etc.).

The Maryland Hospital Association at the requestof its members then solicited bids for a long-termsolution to the medical waste management needs ofthe area hospitals (25).27 These efforts were soonre-directed when a newly organized corporation, theMedical Waste Associates (MWA), presented aproposal to develop a privately-owned medicalwaste disposal facility. Eventually, to secure a freedcost for financing the facility, ‘‘tax exempt’ statuswas obtained for the $24 million bond issue. Thecentral features of the arrangements between MWAand the individual hospitals are that participatinggenerator facilities will sign ‘ ‘put or pay’ contracts(i.e., each hospital agrees to pay for the disposal ofa minimum number of tons of waste per year) for 20years (with renewal options every 4 years), andMWA will charge a flat rate of $300/ton ($0.15/pound) for their disposal privilege. A rebate arrange-ment exists to share the profits of ‘excess’ capacitysold to others, and MWA will pay the ‘‘founding’hospitals 50 percent of any net profits earned fromcogeneration activities (e.g., sale of byproducts suchas steam, ash, etc.) (25).

The facility will have a 160-tons-per-day capacityin two incineration units; 120 tons are reserved forthe participating hospitals. This facility will acceptonly medical wastes, including wastes from officesof doctors on the staffs of a participating hospital.Hospitals find it attractive that the facility willaccept nonsegregated medical wastes, but this fea-ture and the ‘‘put or pay’ nature of the contractcreate little incentive for reduction and recycling

~sl%bhc concern over the siting of medcal waste facilities and the importance of public involvement in the permitting and siting processes are topicsbeyond the scope of this effort. Public concerns and the impacts of participation are net dissimilar to those expressed for MSW facilities that are discussedin OTA, 1989, see especially, chapter 8 (1 16).

27Cmley ~d Born (25) provide a more detailed account of the development of the Baltimore rewond medic~ wrote facfli~.


efforts. There are 31 hospitals in the region to beserviced by the facility (as restricted by a special cityordinance). Construction began on the facility in thespring of 1990; it is expected to open in 1991.

The Greater New York Hospital Association hasformed a cooperative to build a state-of-the-artfacility to service the participating hospitals in themetropolitan New York area. Citizen and environ-mental interests, unions, waste companies, and cityand State officials, as well as the generator interests,are involved in the planning of this facility as part oftheir development of a broader medical wastemanagement plan. The New York City Health &Hospitals Corp. initiated a related but separate effortfor a comprehensive waste management study toevaluate the potential of waste reduction and recy-cling opportunities for area hospitals before deter-mining the most appropriate type of regional incin-erator. The Natural Resources Defense Councilhosted an initial meeting of interested parties in theirNew York office, November 30, 1989, to discusssome of the initial study plans for developing theregional medical waste management plan.

This plan also sets targets to reduce the volume ofmedical waste, explores toxicity reduction efforts,and identifies feasible recycling opportunities forhospitals. A critical feature of the planning isensuring that the sizing of regional incineratorfacilities factors in the impacts that reduction andrecycling efforts might have on capacity needs in anarea.

The Nassau-Suffolk Hospital Council, Inc. repre-sents 22 nonprofit hospitals on Long Island, NewYork and also has been in the process of establishinga nonprofit corporation for a regional disposalfacility, This regional planning effort, as with themetropolitan New York effort, includes efforts toimplement reduction and recycling services in thehospitals. At this point, the council has adopted aninterim strategy that involves use of autoclave/compaction units (see ch. 3) by the hospitals on-siteand then shipment to several existing communityMSW incinerators with excess capacity. A regionalmedical waste incinerator is still planned for thefuture, and sites for it are being investigated now(68).

Community involvement in the development ofplans such as these is key to their acceptability. Forexample, the disinfection of wastes prior to shipment

to the off-site incinerator can allay communityconcern over the transportation of the wastes. Theentire load of waste (which is mixed in the compac-tion process with nonregulated medical wastes) ismanifested to meet the requirements of MWTA. Asnoted above, there are no technical reasons topreclude the burning of medical waste in MSWincinerators. The pollution equipment on a state-of-the-art facility should adequately control emissionsfrom the medical wastes. Adjustments can be madeto facilitate safe handling of the wastes to minimizeworker contact and any risks associated with expo-sure. In the case of the Long Island hospitals,pathological wastes and sharps will not be sent to theMSW incinerators, but instead sent to an upgradedhospital incinerator. This interim plan allows theclosure of 11 older incinerators, which would notmeet New Yorkin 1992 (68).

State new standards taking effect

SUMMARY

Incineration of medical waste is likely to remain,at least for the next decade, the cornerstone ofmanagement methods for medical wastes in muchthe same way landfilling is for MSW managementefforts. Yet, as has already occurred with MSWmanagement, this necessary and appropriate treat-ment option for certain wastes can be effectivelysupplemented by other treatment technologies (e.g.,autoclaving, chemical/mechanical disinfection, etc.).The size, type, and nature of pollution controlequipment will continue to change as the regulatoryissues evolve. There is general agreement amongregulators and the regulated community that devel-opment of uniform regulatory standards for airemissions and site permitting would help stabilizethe regulatory climate for medical waste manage-ment and assist in the further identification andassessment of risks associated with incineration. Inaddition, regulatory determinations r e g a r d i n g t h emanagement of incinerator ash are necessary toaccurately project costs for ash management andfacilitate decision making by health-care facilitiesregarding the attractiveness of the incinerationalternative on the basis of costs.

Chapter 5

Special Treatment Issues

A number of management issues associated withpackaging, handling, and disposal practices inter-face with decisions regarding treatment methods formedical waste. This chapter examines m a n a g e m e n tdevelopments for a number of such treatment issues:sharps management, small generator management,sewer use, and shredding.

SHARPS MANAGEMENT

Special attention is given to the management ofsharps (e.g., hypodermic needles and syringes; alsoscalpels, broken glass, etc.) because of both theoccupational and general public risks they pose.Sharps, specifically syringes, are generated by bothhouseholds (e.g., in-home health-care) and health-care facilities. They are therefore part of both thegeneral MSW and medical waste stream. In Wash-ington State’s survey of occupational exposure ofwaste industry workers to infectious waste (with 438of the 940 workers surveyed responding), 21 percentof the respondents reported having sustained aneedlestick injury on the job from both medical andresidential sources (139).1 The ATSDR, based on itsliterature survey and study, estimates that 500 to7,300 medical waste-related sharp injuries occurannually to solid waste workers (93). Surveys ofhealth-care workers, including housekeeping staff,usually indicate much higher incidence of needle-stick injuries .2 Sharps cause concern not onlybecause of their infectious potential, but also be-cause of the direct prick or stab type of injury thatcan result from them (114; see also 96). It is in partfor this reason that EPA included unused sharps inits definition of regulated waste types under MWTA.

Most of the concern over the management ofsharps has focused on the packaging of used sharps,the integrity of which is critical to containing thesharps during their collection, storage, and transpor-tation to the treatment or disposal site. Currently,puncture-resistant containers are the preferred han-

dling package for sharps (122, 118, 120, 121). Yet,a number of new techniques for containing sharps,particularly needles and syringes, continue to emerge(e.g., encapsulation).

Education of health-care and refuse workers, aswell as the general public, about the proper disposalof sharps will facilitate their safe handling andmanagement. Segregation of sharps and their sepa-rate collection and management without compactionis key to reducing the risk of injury associated withtheir management. In King County, Washington(Seattle area), there is a local requirement that allsharps be segregated and disposed of in leakproof,impermeable plastic containers with tight lids forseparate, uncompacted collection and transportationto a landfill. This management strategy greatlyreduces the risk of human contact with the sharpsand the potential of needlestick injuries (111).

Manufacturing

Some of the efforts to ensure the safer handling ofsharps have been made at the manufacturing stage.The attempt by manufacturers of sharps is toincorporate into the syringe a mechanism which willrender it “nonsharp’ immediately after it has beenused. One method for achieving this is a sheatharound the barrel of the syringe that will slide uparound the needle when used while the barrel part isheld. This makes it impossible for a needlestickinjury to occur and the end product can be disposedof in a bag with other regulated waste items (unlessthe facility’s protocol dictates otherwise) (104).These syringes are costly, however, restricting theiruse to date to high-risk areas of health care. Theirpotential as a feasible and practical method ofprotection in the home health-care setting seemsapparent, although this application has not yetoccurred, presumably due to their higher cost (104).Tests of the performance and reliability of thesesyringes were not identified by OTA.

lhte~s~ly, 32 percent of the respondents reported direct contact with waste blood on their clothing or shoes and l’g percent repofled Mvingreceived occupationrd cuts and scratches (139). Needlestick injuries while prevalent are not necessarily the most common type of occupational hazardfor waste workers (e.g., back strain and other types of injuries are more prevalent).

@ne survey by a local union of the Service Employees Intermtional Union (the Nation’s Iargest health-care union) of its hospital workers in the SanFrancisco area, found that 62 percent reported accidental needlestick injuries on the job (100; see also 91).

–59–


Mechanical/Chemical

Although grinding, clipping, and other practicesare no longer used for sharps management, primarilydue to their potential for worker injury or exposurethrough aerosolization of microorganisms duringthe procedure, new techniques have appeared, e.g.,chemical treatment and shredding of sharps. Theprimary alternative method of sharps managementof this sort is the mechanical/chemical disinfectionprocess discussed in chapter 3. In another processthe needle part of the syringe is placed in a box whileholding the barrel part. The needle completes anelectrical circuit that melts it and leaves only thebarrel in need of disposal. This process is a bit timeconsuming given the individual treatment of eachsharp, but it does probably meet the “treated anddestroyed” criteria of MWTA (141). Again, it maybe a process for which the appgenerator settings is most practica

Encapsulation

Another process introduced with

ication to small(104).

in the last coupleof years that is experiencing some success isencapsulation of sharps. This process involves use ofa phenolic solution to disinfect sharps and thenintroduction of an oxidizing agent as a catalyst toencapsulate the waste in a polymer matrix, i.e., asolid block-like material. This material can then bedisposed of as solid waste without risk to theworkers handling it (114, 104). It does not, however,meet the ‘‘treated and destroyed’ criteria of MWTAregulations (141).

This system is also expensive, currently four tofive times higher than the cost of comparablecontainers for sharps (104). This factor makes itsapplication for high-volume generators largely im-practical, but the process could facilitate handlingsharps for the small generators and home health caresince it both disinfects and immobilizes the sharps,allowing for their disposal with other solid waste.

Some States (such as California, where smallgenerators are required to manage their medicalwastes in an approved reamer) have endorsed theprocess and in some cases permitted its use as analternative treatment technology. Until more Statesendorse this process, it is unlikely that it will gainwidespread adoption (104).

Concern has been expressed over potential im-pacts of these blocks of encapsulated sharps to thesolid waste stream, in particular over what signifi-cance (if any) incinerating them with other wasteswould have. Where landfilling of the “blocks” isnot allowed, the encapsulated sharps are in somecases shipped via the United Parcel Service (UPS) toa manufacturer of the process in Georgia (see below)(104).

Mail Shipment for Disposal

The mail shipment of wastes for disposal is anincreasingly common practice. As noted above,encapsulated sharps are sometimes shipped by UPS.Apparently, they are one of the few types of wastethat nonpostal shipping companies will acceptbecause they are rendered noninfectious prior toshipment.

A number of companies now operating werecreated primarily to cater to the needs of small orrural generators for viable disposal options. Theyoperate out of several States and accept wasteshipments from generators and then transport thewastes to treatment facilities. A contractor to OTAidentified such operations in four States: Indiana,New Jersey, Oklahoma, and Texas (104). One ofthese firms claims over 30,000 clients nationwideand transfers the material to an incinerator in yetanother State (104).

Most States authorizing waste by mail mandatethat their State requirements be met, even if thewaste is being mailed out of the State. For example,California authorizes out-of-state shipment only ifthe waste is rendered noninfectious prior to disposal.International shipment is allowed also if the waste istreated frost in-state (104). Under MWTA, genera-tors in States covered by the demonstration programare allowed through an exemption in the regulationsto ship medical waste sharps through the mail,provided they meet the specified packaging require-ments (40 CFR 259). This exemption is intended toencourage small quantity generators (e.g., doctors’offices) to dispose of medical wastes properly (141).

For the most part, most of the medical wastesshipped are sharps. Some tissues and laboratoryspecimens are mailed to laboratories for diagnosticpurposes. Historically, laboratory samples, etiologicagents, and other medical items have been shippedthrough the postal service. Some basic postalpackaging requirements exist and the practices have

Chapter Special Treatment Issues ● 61

been the subject of congressional hearings (e.g., 54Federal Register 1197(.)).

Concerns have been raised not only about thepotential hazard or at least negative perceptionassociated with handling medical wastes and house-hold mail through the same postal system, but alsoover the operation of these waste mail companiesthat essentially operate as transfer stations (104).The scope of current regulation does not cover suchoperations. These practices warrant further investi-gation, particularly over the adequacy of currentregulations governing the shipment of wastesthrough the mail and the desirability of such systemsfor small generators and rural health-care facilities.

SMALL GENERATOR -MANAGEMENT

The amount of medical wastes generated nation-ally from non-hospital settings is not known (al-though EPA will reportedly be including suchestimates in its first report to Congress). These smallgenerators include such sources of medical wastesas: home health-care patients, doctors’ offices (in-cluding dental and veterinarian), and rural health-care settings. Although some States are includingsome small generators of medical wastes, such asdoctor and dental offices, in their regulatory pro-grams for medical wastes, most exclude households.

The equity of including some and not all genera-tors of medical wastes under regulations is hotlydebated. 3 It is widely recognized that the same typesof controls are not feasible for both large and smallgenerators. The focus of the debate is over wheretodraw the regulatory line between generators to beincluded or excluded from regulation and over howlarge the gulf should be between the level of scrutinyand degree of requirements for large versus smallsources of medical wastes.

In the area of medical waste policy, the demandfor a comprehensive scope for controls is beinggrappled with from the beginning of regulatoryefforts. EPA issued guidelines for home health-care

disposal shortly after it promulgated its standards forMWTA (130). Other guidelines are being developedand discussed in response to the increased attentionto wastes from these sources and their infectiouspotential (102; see also 82, 83).

The need for developing feasible and economicaltreatment and disposal options for small generatorsis widely acknowledged. Few advocate includinghouseholds under medical waste regulations, butconcerns over solid waste worker safety are real. Theneed for viable disposal options for rural hospitals,small laboratories, and different types of doctors’offices are also real. Some technologies have alreadybeen adapted for nonhospital sources. For example,for a number of years a mobile sterilization systemhas been used in Berlin, West Germany, to collectdoctor office and nursing home medical wastes.There are plans by a hospital council on Long Island,New York, to attempt to bring this technology to theUnited States (68).

For small generators, the most promising of theemerging treatment methods discussed in this reportare the nonincineration treatment methods and thenewer management methods for sharps. Theseoptions may provide safe and economically feasibleon-site treatment alternatives for small generators.Off-site incineration is also an option, since somemedical waste companies will contract to pick upand transport to their incinerator medical wastesfrom doctor and dental offices and other smallgenerator sources.

Careful and creative management strategies willbe key to ensuring effective handling and treatmentof these wastes. Limited information and assistanceare available to households, small and rural hospi-tals, and other smaller generators to help them deviseeffective medical waste management plans andsystems. Education efforts are clearly important butto date are limited to an EPA brochure for house-holds, to be distributed by health-care providers orothers (130).

qclemly, mWlatiom are usually adopted not beeause they are permived as “fair,’ but rather beeause they are necessary to achieve some social oreconomic goal of the greater public. That regulations be “rea.somble” maybe dif.fkult to define, but a legitimate standard by which to judge them. Inmost areas of environmental policy, regulatory attention is first focused on the largest generators of the problem. Later, refinements are made to theregulations and their scope broadened to include other signit3cant sources.


OTHER TREATMENT TECHNIQUES:SEWER USE AND SHREDDING

Sewer Use

Certain medical wastes can be legally dischargedto sewers. These wastes include blood and bloodproducts, ground-up solid infectious wastes (e.g.,body parts and organs), and other liquid and orsemi-liquid infectious wastes. Reportedly, about 23percent of hospitals dispose of blood and body fluidsto sewers and about 14 percent grind solid infectiouswastes and discharge them to sewers using a grindersimilar to that used for in-sink home garbagegrinding (91). The State of Washington surveyfound that 49 percent of the hospitals surveyedreported pouring blood into the sewer system (139).

EPA (122), in its guidance manual for infectiouswaste management, identified sewers as an accepta-ble treatment option for blood and blood products ifsecondary treatment is available (i.e., occurs at thesewage treatment plant).4 Secondary treatment sys-tems, however, are designed to microbiologicallybreakdown and remove organic constituents inwastewater and are not designed to disinfect wastewater. At a primary or secondary municipal treat-ment facility, wastewater disinfection occurs as thelast step, usually by chlorination, prior to release tothe environment (11 1).

While there is little concern over the ability ofsewage treatment plants to handle liquid medicalwastes adequately, the absence of treatment at thepoint of discharge (i.e., at the facility) has promptedsome concern.5 Medical staff and plumbers riskoccupational exposure if there is a sewage backup(104, 91). At least one such incident reportedlyoccurred in 1987 at the Los Angeles County-University of Southern California Medical Centerwhen a pipe in the basement burst and dumpedpossibly contaminated blood and fluids on workers(five of whom filed a lawsuit against the facility).6

This type of incident is an example of a plumbingproblem and concern over potential worker exposurefrom these types of accidents should be distin-

Photo credit: Vetco Sanitec Corp., Combustion Engineering,Stamford, CT

Shredded medical waste meets the nonrecognizabilityrequirement of MWTA. Shredders can be used for

untreated wastes or be incorporated into the use ofvarious treatment technologies. Shown here are contents

of microwaved and shredded medical wastes.

guished from the issue of health-care facilitiesdischarging body fluids to the sewage system.

Another aspect of sewage disposal that is muchlarger than the medical waste issue and its contribu-tion to the flow of wastes to the sewers is potentialproblems associated with combined sewer over-flows (CSOs), i.e., where sanitary and storm sewersare combined. In these situations when it rainsuntreated sewage and any wastes discharged tosewers may be discharged directly to waterways,because the sewage treatment plant cannot accom-modate the increased flow of waste water. In NewYork City, for example, there are over 500 CSOpoints and for some as little as a quarter of an inchof rain can lead to the release of untreated sewage(134).7

Shredding

The nonrecognizability requirement of MWTAregulations has focused attention on methods todestroy treated waste, notably shredding, to meetthis requirement. Currently, there are no criteria(voluntary or mandatory) on the degree of shredding

Asteam stefitiation and incineration are, however, the two recommended treatment methods (122).5~s is me pfic~mly when ~~eated ~sc~ged liquids can @-pass me ~eatment facifity h areas Mm combined sewer OV@OWS.

6@~nn v. Court of ~s Angeles, Case No. C669760, L.A. Superior COWI of tie State of C~Ofia.7cs0s were ~fact ~plicated as amajor so~ce respo~ible for tie beach washups c)f rne&Cal wastes fi the SllIMIl er of 1988. Investigations concluded

that syringes discharged to the sewers, primarily from I.V. drug users and diabetics, were directly discharged to waterways in heavy rains and then otherweather patterns made the likelihood of washups containing these wastes high (137).

Chapter 5--Special Treatment Issues . 63

required to achieve nonrecognizability. This lackmay account for the apparent reluctance to applyshredding technology to emerging treatment meth-ods.8 The necessity for criteria or standards for thisand other treatment and destruction methods willperhaps best be evaluated after the completion ofMWTA demonstration program.

Yet other factors, such as the difficulty existingshredding systems have with the heterogeneity ofthe medical waste stream and the high maintenance

associated with shredders, may account for theirlimited application to date. It may be that improve-ments and refinements to shredding technologieswill occur, particularly if the nonrecognizabilitycriterion is more widely incorporated into medicalwaste regulations, and the use of shredders isincreased. In any case, disinfection of infectiousmedical wastes before shredding to minimize poten-tial aerosolization of pathogens is desirable.

%teresfigly, mere are specific shredding standards for document destruction by the Department of Defense for confidentiality (1~).

Chapter 6

Comparisons of Treatment Alternatives

However great the achievements of reduction andrecycling efforts, there will continue to be a need foreffective treatment and disposal for wastes thatcannot be recycled. Although incineration remains,and is likely to continue to remain, a primarytreatment method for medical wastes for the foresee-able future, a number of other treatment alternativesare available and will supplement incinerationtechnology. As concerns over the cost, safety, andpermitting/siting of incineration facilities continue,so too will the favorable climate for emergingnonincineration technologies. New variations ofautoclave, mechanical/chemical, radiation, and mi-crowave treatment methods are now commerciallyviable. Other emerging technologies are in thetesting or even conceptual stages. Currently, Statesplay the critical role in evaluating and approvingalternative treatment technologies. Inconsistenciesexist among the States and increasingly Federalguidance on evaluation and approval of treatmentalternatives is suggested as necessary and desirable(e.g., suggestions of participants at the OTA MedicalWaste Workshop, 1990).

An important given when comparing alternativesis that whatever treatment alternative is used, someform of additional solid waste disposal must occur.In all cases, ultimately, some degree of dependencyon landfills remains. For medical waste incineration,the ash becomes a waste product requiring landfill-ing. For autoclaving, microwaving, and irradiationeither incineration and/or landfilling is necessary.The residue from the chemical/mechanical treatmentalternative will be discharged to the sewer orlandfilled. The difficulty of landfilling even treatedmedical wastes, given refusals by some landfilloperators, remains a significant obstacle for man-agement in some areas of the country. Interstateshipment and international exportation of solidwaste, including medical wastes, is an emergingenvironmental and political issue nationally (1 16).

Valid comparisons of various treatment alter-natives for medical wastes are problematic be-cause different types of treatment goals areserved by different technologies (e.g., the goal canbe treatment to render wastes noninfectious; ornoninfectious and nontoxic; or noninfectiousnonrecognizable, and/or nontoxic). This means

that different techniques may be appropriate fordifferent waste types. Treatment alternatives willdiffer in the nature of the emissions that warranttest protocols, control measures and operatingparameters specific to each technology.

Obviously, costs and risks associated with thealternatives will vary. Further, a number ofconsiderations concerning liabilities and costsinfluence generator decisions about on-site ver-sus off-site treatment. Treatment alternatives aremore easily scaled to various types and sizes offacilities. Comparisons between off-site and on-site applications of various alternatives can alsobe problematic. With all of these differences,clearly, comparisons of the treatment technolo-gies must be made carefully. Such comparisonsare imprecise, but helpful in highlighting thevarious features and considerations associatedwith the alternative treatment technologies.

CAPABILITIES AND RISKSTable 8 compares the various treatment technolo-

gies discussed in chapters 3 and 4. All of thesetreatment alternatives can effectively managemost infectious wastes; the only ones that areusually used to treat pathological waste are theincineration and mechanical/chemical disinfec-tion systems. Depending on the type of incineratorand the nature of its controls, incineration is the onetreatment alternative that could manage all of ahealth-care facility’s wastes, i.e., pathological andother infectious, hazardous (possibly, depending onthe design and controls of the incinerator), adminis-trative, food, and other non-patient wastes.

From other perspectives, nonincineration al-ternatives may have advantages over incinera-tion. In general, there are more serious emissionsconcerns associated with incineration than mostalternatives. Yet, it is true that because incinerationis a more established technology, emission concernshave been more clearly identified. The human healthand environmental risks may be presumed to be lessfrom nonincineration treatment alternatives but ad-ditional study, particularly of water effluents fromsome of the systems, is necessary. Generally, healthrisks associated with the various treatment technolo-

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Table 8—Comparison of Treatment Technologies

Costs (approximate) d

“Regulated medical Operating or per poundwastes” appropriate for charges (not including Capital (equipmenttreatment method to render Volume reduction labor; depreciation; profit/ and installation)

Treatment technology wastes non-infectious (%) return) ($/lb./hr.) ($ K)

Steam autoclave . . . . . . . . All, except pathological o $0.05-$0.07 $100 K (on-site)Autoclave with

compaction . . . . . . . . . . Ail, except pathological 60-80% $0.03-$0.10 $100 KMechanical/chemical . . . . . All 60-907. $0.06 $40-350 KMicrowave

(with shredder) . . . . . . . All a 60-907. $0.07-$0.10 b $500 KIrradiation

(with grinder) . . . . . . . . . All, except pathological 60-90% $0.15 Not availableincineration . . . . . . . . . . . . All c 90-95% $0.07-$0.50 $1,000 K (on-site)apathologi~l ~a~te~ are usu~ly nottreat~ by rnicrowavedue to esthetic reasons, Cytotoxical Orothertoxic Chemicals cannot IM adequately treated to dUCe

their hazardous nature.b[n~~ing an energy cost of $0.07/kWh.cAlthough separation of noncombustibles ad items with problematic ~nstituents improves combustion efficiency (See ch. 3).dReiiable Cmt information is difficult to obtain and verify. Further, valid comparisons are difficult to m~e given the different circumstances under which VariOUS

technologies operate (e.g., amount of waste treated and its effect on costs, etc.)

SOURCE: Office of Technology Assessment, 1990.

gies have not been thoroughly studied. Presumably,pollution controls could adequately control pollut-ants of concern for both nonincineration and inciner-ation alternatives. Of course, the more pollutioncontrols necessary, generally, the more expensivethe treatment.

The concerneconomic statejeopardized by

COSTSthat the already generally precariousof the health-care industry could befurther regulation of medical waste

management warrant s examination. Presently, theexact amount a health-care facility spends onmedical waste management is often not known withcertainty even by the facility’s management. Theadditional cost that new controls, alternative treat-ment technologies, or management practices mightentail can not be accurately assessed unless currentcosts can be understood with some certainty.

Available cost estimates for various treatmenttechnologies indicate that on-site incinerationcan be comparable or significantly higher in coststhan other on-site alternatives (30; 104). Whilecosts for on-site alternatives can be estimated fairlyconstantly, the same is not true for off-site alterna-tives. OTA contractors found from informal discus-sions with generators of medical wastes and opera-tors of medical waste services throughout thecountry that the price charged for any type of off-sitetreatment is never determined solely on the basis ofcosts, but rather by ‘‘what the market will bear. ’Given that it is a highly competitive industry, this

does not necessarily mean that off-site waste facili-ties reap an unusually high profit, but, as noted inchapter 3, the medical waste industry is healthy.

It appears that hospitals and other health-carefacilities eligible to receive Medicare reimburse-ment can theoretically be reimbursed for someon-site medical waste management costs. Althoughthere is no specific category for waste managementreporting, some percentage of capital costs and someoperating costs could be covered (54). In the State ofNew York the eligibility of health-care facilities forMedicare reimbursements for some on-site medicalwaste costs (and regional utilization of an on-sitehospital treatment facility) is explicitly addressed bythe Department of Health (85). Although no hospi-tals have been known to request Medicare reim-bursement to date, it was part of the New York Statelegislative debate over increasing the reimburse-ment rates for hospitals (80).

Other types of grants offered by some Stateenergy offices, such as those that will cover someportion of the capital costs for waste-to-energyfacilities, may also reduce a facility’s share of costsfor this type of incineration (31). For example, inNew York State, a proposed Environmental bondissue, which will be on the ballot in November 1990,will provide $50 million in State assistance forregulated medical waste projects. The grant programwould be administered by the State Department ofHealth and would provide funding for up to 50percent of the project costs. To be eligible, a facilitymust participate in a waste audit and must develop

Chapter 6-Comparisons of Treatment Alternatives and Policy Issues for Federal Action . 67

a plan for recycling, product reuse, and wastereduction (94).

The volume of waste handled by a treatment unitand its effect on the operating cost of the unit ishighly variable, but generally costs are lower foron-site incineration and nonincineration alterna-tives. The capital costs associated with incinerationare significantly higher than those for most alterna-tive treatment technologies. Yet, heat recovery (and,as noted, programs that will reimburse up to half thecapital costs for waste-to-energy facilities) andefficient operation (e.g., including recycling inconjunction with incineration) may reduce incinera-tion costs to the facility and result in a morefavorable cost comparison of incineration to theother technologies (31). Nonetheless, the potentiallyhigh cost of disposal of incinerator ash, if it isclassified as a hazardous waste, is also a potentialsignificant cost factor associated with incinerationthat must be considered. Other factors that affectcosts, such as reduced cost of transportation, reduceddisposal costs, and reduced liability, are relevant toa decision to manage wastes on-site v. off-site.

Costs, even so, are only one of a number of factors(e.g., nonrecognizability, liability, and ability torender wastes non-infectious) that health-care facili-ties consider when deciding what type of treatmentalternative to use and whether to manage wasteson-site or off-site. Clearly, a facility may be able toreduce its costs and liability and have greater controlby managing wastes on-site; however, on-site man-agement also represents a major institutional com-mitment of resources to waste management, which

is not the primary function of the health-care facility.As has been noted throughout this report, a numberof factors favor off-site treatment as well.

Ultimately, each generating facility must weighthe various factors and determine which wastereduction and management alternatives are mostappropriate for its circumstances. Public policiesshould recognize and not preclude the variablesolutions necessary to meet individual generators’waste management needs. In addition, medicalwaste policies shouldsort of protocols toreliability and safetytives.

help through the use of somereduce uncertainty over theof various treatment alterna-

It remains to be seen what direction Congress andFederal agencies, and the medical and health-careindustry and community will define for medicalwaste management. It will be important, though, thatany legislative or regulatory activity acknowledgesand appropriately addresses the variety of manage-ment issues and available treatment technologiesdiscussed in this report. Experiences with manage-ment of other components of our society’s wastesindicate that effective waste management is basedon a recognition that there are a variety of viablemanagement options available and appropriate tomeet particular site-specific circumstances, andprevention or reduction and recycling efforts areincluded in these options. Adopting a more compre-hensive approach to medical waste policy may offerthe greatest prospect for adoption of a program thatwill ensure the safe, cost-effective management ofmedical wastes.

Appendix A

The Medical Waste Tracking Act

MWTA establishes a demonstration tracking system(Sections 11001-11003) and, as noted in the introduction,directs EPA and ATSDR to undertake studies of certainmedical waste management issues (see box D).1 Unlikeany other environmental law, MWTA was designed tostructure a process for gathering sufficient information toevaluate the nature and risks posed by a waste, so thatCongress could then reevaluate and identify whether anyfurther policy action is warranted. The intent of the law isto develop a basis for determining, after the completion ofthe demonstration program and the government-mandated studies, whether and in what ways the FederalGovernment should regulate medical wastes.

MWTA specifically applies to the Great Lakes Statesand Connecticut, New Jersey, and New York (Section11001). All of the Great Lakes States were given theoption to decline to participate in the demonstrationprogram (and any other State was given the opportunityto participate); and Connecticut, New Jersey, and NewYork could petition out if their State had a program at leastas stringent as that of the Federal Government.2 None ofthe Great Lake States chose to participate, while none ofthe other three States petitioned out. Thus, MWTAapplies only to New York, New Jersey, Connecticut, andalso to Rhode Island and Puerto Rico, which voluntarilyentered the program. Louisiana and the District ofColumbia voluntarily joined the program, but laterpetitioned out of it.

MWTA defines medical waste as “. . . any solid wastewhich is generated in the diagnosis, treatment, or immuni-zation of human beings or animals, in research pertainingthereto, or in the production or testing of biologicals. ”3

Section 1004(40) of RCRA, as amended by MWTA,notes further that medical waste “does not include anyhazardous waste identified or listed under Subtitle C orany household waste as defined in regulations underSubtitle C.’ Any solid waste mixed with a regulated (i.e.,listed) medical waste (see below) is also a regulated wasteunder MWTA. As noted earlier, special regulations existfor the management of LLW (see box A).4 MWTAregulations do require tracking of LLW medical waste,unless it is mixed with hazardous wastes that would be

regulated under RCRA Subtitle C (40 CFR 259).5 Itshould also be noted that domestic sewage is not includedin the RCRA definition of solid waste (Section 1004(27)).

It is possible that the EPA definition of regulatedmedical wastes, codified as part of MWTA, might becomemore widely used and help forge consensus on thecategories of wastes designated as infectious. Thesecategories are now frequently referred to as “regulatedmedical wastes. Box D outlines the major features of thetracking program established by MWTA.

EPA cost estimates, although provided to EPA by theregulated community, are considered low by some wasteindustry officials and regulated sources (141). Theseestimates are that the cost to comply with MWTA willincrease disposal of regulated medical wastes by approxi-mately $0.08/pound on average; with average annualcompliance costs per facility range, according to EPA,from about $3,750 for hospitals to about $70 for dentists(Fed. Reg., vol. 54, No. 56, Mar. 24, 1989). According tothe preliminary results of the New York City medicalwaste study, while the per pound cost of medical wastedisposal has remained relatively stable since MWTApassed, overall waste management has become highlycostly. For example, ‘‘a typical 500-bed acute-carehospital in New York City has experienced a 400 percentcost increase in waste disposal as a result of MWTA”with an actual cost ‘‘in excess of $400,000 per year forsuch a hospital” (63). This could result from poorsegregation practices at certain facilities and/or to short-ages of personnel for such tasks.

Upon completion of the demonstration program, EPAand the participating States will review the generatorreports and evaluate the program, including the impactsof the program on management practices and the costs ofcomplying with the tracking regulations. As noted above,EPA’s report to Congress on the program is due inSeptember 1991.

The importance of MWTA demonstration trackingprogram to abating medical waste problems is not clear;if a more comprehensive regulatory program is adopted inthe future, the contribution of a tracking system to the

1’I’MS discussion is based in part on that contained in (137); see tdSO (36), (86), and (22).Zbdependently, a ntier of actions have been undertaken by States to address medical waste problems (e.g., New York Stite and New Jersey

cooperatively adopted a tracking system in August 1988 (before passage of the MWTA)). Also, the New York Bight FIoatables Action Plan, amulti-agency effort led by EPA Region II, is part of the New York Bight Restoration Phin and addresses some medical waste handling procedures inthe New York Bight area.

3~ere is a difference beWeen ~.s defition of “medic,~ waste” in tie MWTA ad wastes iden~ied as “re@ated med.icd wastes” (S= ch. 1).4~e ~w.~vel Radioactive Wrote policy Act of 1980 ~d fie ~w-~vel Radioactive Waste policy Amendments Act of 1985 (1 17).5~w medi~ ~mte, upon radioactive d~ay, wo~d still ~ve to be @ack~ as re@at~ medic~ waste, disposed of ~OU@ @ sewer syStelQ Or

treated and destroyed onsite, or tracked as a hazardous waste.

-69–


Box D—The Medical Waste Tracking Program

EPA established the 2-year pilot Federal tracking program authorized by MWTA by publishing its “Standards for theTracking and Management of Medical Waste; Interim Final Rule and Request for Comments ‘‘ in the Federal Register in March1989, which took effect in June 1989.1 The tracking system for medical wastes designates recordkeeping requirements forfacilities that generate over 50 pounds a month of medical waste and requires the use of a four-part form for any off-she shipmentof medical wastes. EPA and the State must be notified if a generator does not receive a copy of the manifest form from the finaldestination facility. Generators of medical waste that produce less than 50 pounds are subject to the same handling requirements,except instead of using the tracking form they must maintain a log (i.e., as a reporting requirement).

EPA has authority to assess civil penalties of up to $25,000 per day for each violation, criminalpenalties of up to $50,000per day per violation, and jail terms of up to 5 years may be imposed in States implementing the tracking system (sec. 11005).States have the authority to conduct inspections and take enforcement actions as well. The MSWTA does not specify whether theEPA or the States has lead enforcement authority and the EPA regulations do not specify enforcement roles, but the Agencyprepared an enforcement strategy which encourages State implementation. Flexibility is given to the States to develop a varietyof approaches to compliance and enforcement (134). EPA restricts its role to encouraging voluntary compliance through itsvarious education efforts and by providing States with guidance and assistance when needed (e.g., when a violation involveswastes from or transported to a nonparticipating State).

EPA, also as part of the MWTA demonstration program, issued requirements that generators of waste must follow beforemedical wastes leave the site to be shipped to authorized treatment or disposal facilities. Under the demonstration program,generators include institutional and commercial sources of wastes in the participating States and territories. Of course, anytreatment facilities accepting regulated medical wastes may be subject to other Federal, State, and local laws and regulations.The MWTA does not consider residential sources of medical waste to be regulated generator sources, nor does it address problemswith the disposal of wastes associated with illegal drug use. EPA issued guidance information on proper home medical wastedisposal and states in its pamphlet describing the MWTA that drug enforcement, Clean Water Act programs, and citizen littercontrol projects will help eliminate ‘‘flagrant dumping of wastes. ’ (130)

According to the MWTA requirements, generators must separate regulated medical wastes from general refuse, meet storagerequirements (if such wastes are stored before treatment), and package regulated wastes in labelled, rigid, leak-resistantcontainers. In addition, special separation and packaging requirements are specified for both sharps and fluids. To help ensurethat packages retain their integrity during handling and transportation, secondary packaging (i.e., a rigid outer container) isgenerally required for shipping. This secondary packaging can be reused if thoroughly cleaned. The package labels must identifythe content, generator, and transporter of the wastes.

Medical wastes incinerated on-site, or treated by other methods (e.g., some type of disinfection unit) that meet bothregulatory criteria of treatment and destruction (i.e., waste is ‘‘processed by a means to reduce levels of infectious agents” andwaste is “no longer generally recognizable as medical waste”), do not need to be tracked under the demonstration program, butinstead generators must submit a report to EPA. The position of the EPA is that if the biological and physical hazard of the waste,as well as their ‘visually offensive nature, “ is altered they can be managed according to regulations applicable to solid waste.The required report must be a summary of the volumes and types of medical waste treated on-site during the first 6-month periodof the program; a second report covers the 13 to 18 months of the program.

I since this tie, the Agency has issued a number of guides for the public, generators and transporters about tie Fede~ ~ program(128).

improved management of medical waste will need to beevaluated independently. GAO (134) has evaluated theefforts to date of the EPA and States to implementMWTA. For this reason, their implementation activity isnot evaluated here. Apparently, despite early controversyover the listing of wastes by the Agency to be tracked andconcerns over compliance costs, as well as the initial typeof confusion usually associated with new regulatoryprograms, the implementation of MWTA demonstrationprogram has been rather smooth. EPA reports that mostof the early violations were minor in nature (e.g., errors incompleting manifest forms, etc.), although fines havebeen levied against responsible parties for such violationsas incomplete record keeping and failing to lock storageareas (88).

A number of issues that EPA and ATSDR are requiredby MWTA to address (e.g., health effects of medicalwaste, generation information, cost implications, small-quantity generator issues) also is not discussed exten-sively in this study. The focus of this effort is on availableand emerging management methods, including wastereduction and recycling possibilities. This emphasis onthe evaluation of treatment technologies is intended toalleviate immediate concerns over the nature, availability,and tradeoffs of various treatment methods and tostimulate a broader consideration of management alterna-tives for medical waste than is currently typical.

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