Don't Get Stuck On Medical Waste

Mark Taitz

Q: What has a bunch of arms, a bunch of legs and weighs more than a billion pounds?

A: The medical waste generated every year by the country's health care providers.

And this is just the "regulated" medical waste (RMW) that, with some minor exceptions, gets treated before it goes into a landfill or waste-to-energy plant. Of the 160 million tons of solid waste generated nationally each year, three million are classified by the U.S. Environmental Protection Agency (EPA), Washington, D.C. as "other," according to its 1995 Waste Characterization Report.

Think about this: If just one-half of one percent of that three million tons is medical waste, the country's solid waste industry would be dealing with more than 30 million pounds of infectious waste annually in the municipal solid waste (MSW) stream.

Yes, treatment and disposal of these wastes are expensive and can threaten your employees' health. However, medical waste should be viewed as more than just a pain in the neck. By analyzing how industry trends affect your customer base, you can capitalize on the opportunities it presents.

First, you must know what RMWs are. Unfortunately, you will discover that the definitions are varied, and the answer you receive depends on the organization you ask and on the state where you operate. For example, EPA defines RMW only as it pertains to treatment, specifically through incineration, and not as it applies to identification, segregation, transportation, handling or storage.

However, this was not the case in 1988, when Congress enacted the Medical Waste Tracking Act (MWTA), which defined medical wastes as:

* cultures and stocks of infectious agents;

* human blood and blood products;

* human pathological wastes, including those from surgery and autopsy;

* contaminated animal carcasses from medical research;

* wastes from patients isolated with highly communicable diseases; and

* all used sharps, such as needles and scalpels, and certain unused ones.

The act also specified the procedures for handling, packaging, labeling, transporting and manifesting. However, the MWTA was only a two-year demonstration program which expired in 1991. Currently, EPA is considering defining medical waste only as it relates to pending medical waste incinerator regulations, re-quired by the Clean Air Act of 1990, and due to be finalized this July.

In comments on the proposed rules, EPA noted its inclination to adopt New York State's definition which includes all of the categories mentioned previously with the exception of isolation waste.

Another government agency, the U.S. Department of Transportation (DOT), Washington, D.C., in its Hazardous Materials (HM) 181 rule, de-fines RMW as a waste or reusable material which contains an infectious substance and is generated in:

* the diagnosis, treatment or immunization of humans or animals;

* research pertaining to the diagnosis, treatment or immunization of hu-mans or animals; or

* the production or testing of biological products.

This rule gives guidance to medical waste transporters on how to package, label, mark and manifest waste as well as how to train personnel.

If you ask the Occupational Safety and Health Administration, Washington D.C., it would refer you to its Bloodborne Pathogen Rule which uses a category-based definition and recommends that all human blood and certain body fluids be treated "as if known to be infectious for HIV, HBV and other bloodborne pathogens."

It also requires that employers whose employees may be exposed to bloodborne pathogens in their normal activities have a formal exposure control plan in place, which includes:

* providing information and training upon initial employee assignment to tasks where occupational exposure may occur and continue annual training;

* providing personal protective equipment, handwashing facilities, engineering and work practice controls; and

* offering hazard communication.

To complicate matters, at least 47 states have enacted medical waste regulations, each with slightly different definitions, transportation requirements and acceptable treatment methods. In fact, except where the DOT is involved, states determine all issues related to medical waste definition, transport and treatment.

Health And Environmental Issues Almost 700,000 RMW generators exist in the nation, including hospitals, labs, physicians and dentists. Although representing only about 1 percent of the generators, hospitals are estimated to produce up to 90 percent of the RMW.

The disease-causing potential of this type of waste is the principal concern. Those at greatest risk are healthcare providers, housekeeping staff, law enforcement professionals, solid waste workers and MSW/medical waste transport, treatment and disposal facility employees.

Despite highly-publicized incidents involving improper medical waste disposal in the '80s, there were few documented exposures of individuals. Rather, these events' closed beaches along the East Coast which raised public awareness and resulted in local, state and federal legislation.

These, in turn spurred laws and guidelines to direct healthcare providers to handle their medical wastes in a manner that would protect their employees, sanitation workers and the public from exposure. For example, items such as pathological waste, cultures and stocks of etiologic agents, blood/body fluids, sharps and contaminated animal wastes must be disposed of with special handling, packaging, treatment and manifesting.

It is ironic that medical waste isn't a significant environmental threat except from the impacts that might result from its disinfection - such as air emissions from medical waste incinerators.

Handling Medical Wastes Several years ago, a hospital epidemiology publication noted that household waste bacterial counts were considerably higher than those found in hospital wastes.

Workers who encounter medical waste should know that many combined factors contribute to disease transmission from the waste to the handler. Specifically, a viable, disease-causing organism of sufficient strength, quantity and virulence must be present, along with a means of release and a place to enter, such as through breathing, or punctured or broken skin.

Unless all of these factors are present, no disease can be transmitted. Training in proper handling techniques should be provided if workers are normally exposed to such hazards (see "What To Do In A Medical Emer-gency on page 50").

Business Opportunities Medical waste collection, transport and treatment/disposal currently is a $1 billion industry, with a 3 percent anticipated annual growth rate, ac-cording to a recent study.

The report also states that 43.3 percent of medical waste was treated on-site in 1996 - a figure it predicted would decline to 33 percent over the next five years. Simultaneously, incineration - now estimated to be treating 65 percent of medical waste - is predicted to decline by 25 percent, losing market share to autoclave, microwave and other alternatives.

At the beginning of 1996, there were are approximately 1,000 li-censed medical waste transporters operating nationwide. Of these, 180 hauled more than 50 percent of the waste that is sent off-site for treatment. However, the medical waste industry is consolidating.

There are 115 regional treatment centers that use incineration, autoclaving or microwaving technologies for treating RMW. Pricing for service has decreased dramatically since the mid-'80s, when a dollar-per-pound and above was common.

Now, pricing has leveled off at 18cents to 25cents per pound for large-quantity generators; 25cents and 40cents per pound for medium-quantity generators, and 50cents to $1 per pound for small-quantity generators with prices varying depending on region and competition.

Although volumes will increase, the report noted, growth will be slowed as waste minimization efforts begin. Industry mergers, consolidations and acquisitions are indicators of a maturing, stabilizing market and the shakeout of weaker competitors is expected to continue over the next five years, with fierce pricing competition persisting among the major players.

Further galvanization of public opinion toward environmentally-safe medical waste disposal and regulatory considerations are viewed as primary factors influencing general industry growth.

Over the next five years, the following factors will drive the market: new regulations; stricter enforcement of current regulations; publicity about mismanaged waste; public pressures and population age and size.

With this in mind, the best opportunities for growth within the medical waste industry seem to be, according to the report:

* innovative solutions, specifically incineration alternatives;

* treatment technology development;

* service to small facilities;

* vertical service integration to include disposable supplies, consulting services and hazardous wastes;

* regional disposal facilities; and

* consulting services related to waste management and strategic planning for hospitals, including waste audits.

Treatment Measures such as the Clean Water Act and the Clean Air Act require that treatment and disposal be performed with minimal negative environmental impact - emphasizing potentially harmful air emissions, such as hydro-chloric acid, mercury, carbon monoxide and dioxins, and on liquid discharges, such as chlorine.

The selection of a proper medical waste treatment technology varies. Currently, there are as many as 50 different alternative treatment system manufacturers in addition to the dozens of incineration and autoclave systems manufacturers.

Larry Doucet of Doucet and Main-ka, Peekskill, N.Y., has developed seven guidelines that can be used to compare technology:

* demonstrated performance;

* technical and performance criteria;

* vendor qualifications;

* environmental and permitting issues;

* occupational health and safety;

* facility infrastructure requirements; and

* economics.

According to Doucet, available alternatives fall into the general categories of mechanical, thermal, chemical, irradiation and biological processes, with each having different strengths and weaknesses.

Once you recognize that potentially infectious medical wastes are regularly present in your solid waste streams, you can capitalize on this niche market by providing value-added, vertically-integrated services for your healthcare customers.

And, you can help to eliminate exposure for your employees and all those handling medical waste by providing proper training and protective gear.

In the event of a spill or emergency involving medical waste clean up, the Medical Waste Institute (MWI), Washington D.C., recommends:

* Use Universal Precautions. Assume that all materials are potentially infectious and never handle them with bare hands.

* Don personal protective equipment with a Frazier air permeability of less than 1.0.

* Contain liquids by applying sorbent material around the spill's perimeter to prevent spreading.

* Spray contaminated areas with a hypochlorite solution (11/45 solution of household bleach in water) and let stand for 30 minutes.

* Add additional sorbent, allowing all liquid to be absorbed.

* Remove sorbent and waste with a shovel and broom. Place all sorbent materials, broken containers and spilled material in double red bags and appropriate biohazard container.

* Clean and disinfect reusable items before disrobing.

* Remove all protective gear and place disposable items in double red bags.

The Institute also recommends that personnel responding to infectious substances releases must have the required blood-borne pathogens training as referenced in CFR ss1910.1030.

For more information, contact MWI at 4301 Connecticut Ave., Ste. 300, Washington, D.C. 20008. (800) 424-2869.