Needle in a Waste Stack

New York City garbage, once hauled by many small, family run carters, has just a few handlers these days. With the Fresh Kills landfill on Staten Island winding down toward closure by the end of 2001, city municipal solid waste (MSW) often is heading to out-of-state landfills. These changes are bringing some unexpected questions - and increased scrutiny - of regulated medical waste (RMW) handling to the forefront.

Now, New York City authorities are considering exactly where, when and how RMW should be identified and handled. And they obviously are not alone. These questions are being addressed in many states.

According to a Feb. 22, 1999 New York Times article, there have been recent inspections of solid waste loads across eight states and the District of Columbia. Medical waste found mixed with Brooklyn garbage at a Virginia landfill in Charles City County sparked a news conference in which Gov. James S. Gilmore displayed the used syringes, bandages, etc. and vowed to seek fines against the hauler, Waste Management Inc. (WMI), Houston.

RMW, which can include needles (sharps), plastic tubing and bandages, comes from health care facilities, colleges, universities and pharmaceutical companies. It always has been a complicated matter because solid waste handlers don't necessarily recognize RMW when they see it. Interstate transportation regulations and the lack of a national medical waste definition contribute to the problem - one man's MSW may be another's RMW.

Mixed Loads WMI hauls perhaps the largest percentage of New York City waste. At New York's Varick Avenue Transfer Station, WMI workers pull out recyclables to reduce costs and load sizes. Workers also occasionally have found other items, such as RMW.

Whether an item is RMW or simply looks like it, the results are often fines or negative publicity - or both - for health care facilities. In 1998, the New York Department of Sanitation's Environmental Enforcement Unit (EEU) reported about 16 cases of improper medical waste removal. "It's not a heinous problem, but it needs to be addressed," says Tom McMann, EEU captain.

Although medical waste disposal has improved since the 1980s, questionable practices still exist, he says, pointing to doctors and dentists who may try to conceal RMW in loads of MSW. "Regular sanitation workers get stuck with needles every year," he says. The situation is more difficult for EEU to enforce because it has a staff of only six, down from more than 30 in the 1980s.

If a hospital generates tons of waste a day, it's inevitable that solid waste handlers will find something that should not be there, according to a hospital consultant, who adds that a needle also may be present in garbage because a patient or a drug addict put it there.

In addition, transfer station workers have questioned exactly what waste constitutes RMW. They have called state authorities to report medical waste that looks questionable - such as urine specimens or tubing. However, such items are not infectious, and it is legal to toss them in the garbage.

"We have found that there may not be employees at these [transfer station] facilities who are trained to identify RMW," says Alan Woodard, a Department of Environmental Conservation (DEC) environmental program specialist.

McMann traces the increased transfer station scrutiny to a 1997 garbage spill in Virginia. WMI agreed to pay a $125,000 fine after one of its trucks headed from the Bronx to a Virginia landfill crashed at the Chesapeake Bay Bridge Tunnel, spilling items such as intravenous bags and tubing, adult diapers and surgical gowns.

The state alleged that the waste was shipped illegally to Virginia in trucks not approved to carry hazardous materials. As part of the settlement, WMI admitted no wrongdoing, but agreed to pay a $70,000 penalty to the Virginia Environmental Emergency Response Fund and to spend $55,000 to produce two training videos on Virginia medical waste disposal laws.

Since then, WMI workers have scrutinized discarded hospital waste more carefully. Regardless of the type of waste, if garbage companies find anything questionable, they can call the state's sanitation department, the state Department of Health (DOH) or DEC.

A hospital consultant contends that some New York facilities are getting around the problem by using smaller vendors rather than giant haulers like WMI. Thus, the waste simply is not subject to inspection at transfer stations.

New York officials doubt this is the case. Although some hospital waste perhaps is going to smaller haulers, in general, less RMW is showing up, Woodard says.

"We've had a number of incidents, but those numbers have fallen off, largely because the hospitals appear to be doing a very good job now of segregating, taking that RMW out of the waste stream," he says.

Indeed, New York City's hospital waste appears to have decreased in recent months. The Varick Avenue facility is handling 125 tons per day (tpd) of hospital waste, down from 500 tpd. About 60 tpd to 70 tpd recently have been diverted to a Bronx facility, says Jose Rodriguez, health and safety manager for WMI of New York.

"We were getting MSW at Varick - we wanted to accommodate the hospital waste at a different location," Rodriguez says. The amount of hospital waste WMI has received is down, he says, noting that the reasons for the decrease are unclear.

Pinpointing the Source Reduced RMW is not necessarily a recent event. In general, hospital waste has decreased substantially over the past 10 years, says Wally Jordan, president of Waste Energy Technologies Inc. (Waste Tech), Prairieville, La. In 1991, Waste Tech wrote New York City's medical waste management plan, which the City Council adopted as part of its comprehensive waste management plan. The company now is conducting a new study for the city, evaluating how facilities have implemented the recommendations.

Preliminary data suggest that RMW has decreased as a proportion of the city's total waste stream. In the beginning of the 1990s, it accounted for less than 3 percent of the city's waste stream.

"It certainly has decreased in terms of net quantities - there are fewer hospital beds than 10 years ago," Jordan says. In addition, hospitals are more cost conscious and more health care is provided at home or in different clinics.

However, even at less than 3 percent, medical waste still represents a significant amount when considering that New York City landfills or ships for export approximately 160,000 tpd. And every time an "incident" occurs that involves medical waste, it creates a media-ready event, Jordan says.

"Hospitals are an easy target," he says, adding that he is unsure why health care facilities are automatically assumed to be the source of all RMW. "There may be 10,000 home health care patients in one neighborhood and one hospital."

There are other tenuous home-related ways RMW can be defined. "Let's say I cut myself working on the lawn mower, I staunch the blood and toss the bandage in the trash," Jordan says. "It's at home, so it's not RMW. But if I go to the hospital for treatment, it's RMW."

Nationwide, household-generated waste is exempt from most regulations, Woodard says. "States are recognizing it's a problem. We have a couple of laws in place that hopefully are dealing with that issue."

One such measure requires hospitals to accept sharps that have been used at home. However, this program relies on the accessibility of the facility and the willingness of citizens to bring in RMW.

Nevertheless, waste inspections shouldn't occur at transfer stations because it often is impossible to determine how an item was used, Jordan says. Even sharps, usually considered RMW, may have some ambiguity about them.

Under New York state medical waste regulations, syringes that have not come in contact with infectious agents may be treated as non-RMW. These are generally syringes that feed into IV tubing and have no contact with patients.

"I have been working on medical waste issues for more than 10 years in New York City, and I would be hesitant to inspect a compactor and identify RMW," Jordan says.

Furthermore, once waste is collected and compacted, its appearance will change. It's hard to say how a needle was used. An item may contain traces of betadine, a red fluid, that when compressed might mix with saline, and then take on a different appearance, Jordan says. "We're dealing with the appearance of waste rather than the true nature of the problem."

If RMW is inspected at transfer stations and landfills based on appearance, hospital waste will acquire a whole new definition and increase handling and disposal costs extraordinarily, he adds.

It Takes Education In the past year, DOH has stepped up inspections of city hospital procedures, arguing that the place to determine RMW is at the point of generation. The aim is to take the direction of education rather than regulatory compliance.

"We want to see hospital procedures and assist them in improving their waste stream management," says Ira Salkin, clinical director of DOH's clinical labor evaluation program.

The agency has inspected New York hospitals since 1966, and as part of its quality assurance program, the state issues permits to all clinical laboratories, tissue banks and other medical facilities.

Some could argue that keeping RMW out of MSW always will be impossible - all it takes is one person's error in one hospital.

The Greater New York Hospital Association (GNYHA), which works with area hospitals, acknowledges that the situation may never be perfect, says Susan Waltman, general counsel. "We've renewed with our members the need to be careful," she says, noting the association is not aware of medical waste incidents with any of its members.

Corinne McGowan, assistant general counsel, is in charge of GNYHA's Regulated Medical Waste Task Force, which brings people from different institutions together.

"We are talking about having a variety of programs to educate transfer station workers, as well as looking at alternative methods of treating waste," she says.

WMI trains workers on handling and identifying RMW, chemical waste and the like, Rodriguez says. The company uses documents, including the Occupational Safety and Health Administration's Bloodborne Pathogens Standard and information from the New York DOH and DEC.

In the past, city agencies including GNYHA, have considered developing a single transfer station for medical waste. But there are no plans for such a facility because of financing issues. It also is unnecessary, Rodriguez says.

"If you have employees who are properly trained, it can be handled at different locations," he says. "It should start at the hospital, with people trained to recognize RMW.

"When it comes to our transfer station, we treat it just like any other waste," he continues. "We have to do a visual inspection and if it doesn't pass, we just reject it."