Regulated Medical Waste – What is it and Why Should We Care?

An Introduction to Regulated Medical Waste

Think about the last time you went to a hospital. Did you ever notice the plethora of trash cans, sharps containers, and special waste bins? Have you ever thought about how much waste is generated by our hospitals? Well, it turns out that our nation’s hospitals generate approximately 6,600 tons of waste per day! That’s a little over 2.49 MILLION tons a year! Surprising isn’t it? Contrary to what many believe, most medical waste isn’t infectious or dangerous at all. As a matter of fact, approximately 80% of that solid waste is non-hazardous, and like most solid non-hazardous waste, it can be recycled, composted, or diverted from a landfill or incineration. Regulated medical waste, on the other hand, must be disposed of properly for the safety of society.

So what is regulated medical waste?

According to the EPA, the Medical Waste tracking Act of 1988 defines medical waste as “any solid waste that is generated in the diagnosis, treatment, or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals.”

A simpler way of thinking about it is that regulated medical waste is anything contaminated by blood, body fluids or other potentially infectious materials that poses a risk of transmitting infections.

Regulated medical waste must be disposed of in certain ways. And for most hospitals, that translates to incineration. However, the problem is that a lot of the waste that ends up in incinerators shouldn’t be there in the first place. Studies show that of all the waste generated by hospitals, no more than 15% should theoretically be RMW. Sadly, many hospitals are ending up with a lot more than that.

Incineration sounds safe–what’s the big deal?

Incineration might destroy the potentially harmful agents in RMW, but it’s at a tremendous cost (both financially and environmentally). Not only does disposal of RMW costs hospitals up to 10 times the amount compared to “normal” waste, it also produces toxic air emissions, toxic ash residue, and creates novel toxic compounds.  Thsee air emissions affect local communities and may even affect those hundreds, if not thousands of miles away, while Ash residue ends up in landfills where the pollutants can leach into the groundwater.  Even worse, burning of RMW can create novel toxic compounds such as dioxins which have been classified by the International Agency for Research on Cancer (IARC), an arm of the World Health Organization (WHO), as a known human carcinogen.  In fact, the EPA identified medical waste incineration as the 3rd largest known source of dioxin in air emissions and a contributor of approximately 10% of the mercury emissions to the environment.

A brief aside on Dioxin:

Dioxin (the compound found in Agent Orange) is one of the most toxic chemicals known. Exposure in humans occurs through the ingestion of foods, mostly meat and dairy products. This happens when cattle and dairy cows eat feed crops  that were contaminated by airborne dioxins that settle onto soil and plants. A scary thought is that dioxin has also been found to affect children in utero, and has been linked to birth defects, disrupted sexual development, and damage to the immune system.

If not incineration, then what alternatives?

Fortunately, the human endeavor to find alternative methods to incineration are ongoing, and some are already commercially available. I will only enumerate the different technologies below:

• steam sterilization in autoclaves
• post-treatment shredder or grinder
• microwave treatment
• alkaline hydrolysis
• dry heat treatment

 So what can we do to help minimize RMW?

As always, the best action is prevention through education. And that applies to waste as much as anything else. For healthcare professionals, that means understanding where waste is coming from and how it is being disposed. Organizations such as Practice Greenhealth have developed tools for health facilities to track their waste to better understand waste management practices.  But tracking isn’t enough. Education is paramount. I have personally seen countless times staff throwing non-hazardous waste in hazardous waste bins. Does this mean that staff members don’t care about the environment? Of course not. It’s simply a reflection of the lack of education surrounding RMW. I was surprised to see that many physicians, nurses, and even custodial staff did not realize the impact of their actions.

Those not directly in healthcare can make a difference too. Next time you’re in a doctor’s office or a hospital and you see a staff member or other healthcare professional about to throw something non-hazardous into a hazardous bin, ask them about it. We are all stewards of the environment. We should all take the opportunity to teach and learn from each other. After all, those in healthcare are there for a reason–to help heal, and what better way to do that than to prevent the introduction of toxins into the environment.

Medications in Our Water Supply! Part I

In March of 2008, the Associated Press had released information showing that 28 out of 35 US watersheds tested had detectable levels of numerous drugs. Although the detectable levels tested were in parts per billion, the astonishing finding was that there were so many different compounds. In fact, in a preceeding study conducted by the United States Geological Service in 2002, it was shown that 80% of the samples obtained from 139 streams contained numerous widely used drugs! Here are just a few of them:

17-α Ethynyl Estradiol

This is a a synthetic estrogen present in oral contraceptives and is potentially responsible for the feminization of male fish. In fact, an article in Scientific American (June, 2009) stated that “estrogen exposure reduces a fish’s ability to produce proteins that help it ward off disease and pointed to a possible link between the occurrence of intersex fish…male fish carrying immature female egg cells in their testes.”

Acetaminophen

Also known to us as Tylenol, Acetaminophen has been widely used for pain relief among other things. Surprisingly, detectable levels of this drug have been found in 24% of tested waterways.

Other Steroids and Hormones

Other steriods as well has hormones and hormone-mimicking agents such as nonylphenol were found in 16% of tested waterways. Although the effects of these hormones and hormone-mimicking agents are still largely unstudied, one has to wonder if they are also having a negative impact on the fish populations in many of our waterways.

Diltiazem

Less known to the public, diltiazem is part of a group of drugs called calcium channel blockers used for the treatment of high blood pressure, angina, and some types of heart arrhythmias. Diltiazem works as a strong vasodilator–it increases blood flow and decreases the heart rate.

Codeine

Many people have at one time or another used codeine as part of a mixed preparation with acetaminophen or in cough syrup. It is a alkaloid found in opium and is a controlled substance due to its potential for being habit-forming. Codeine has several indications for use including  cough, diarrhea, pain, and IBS. Given its wide use, it is no surprise that it has been found in numerous waterways as well.

Antibiotics and Antimicrobials

This is perhaps another one of those categories of drugs that has received widespread media coverage given the increased occurence of antibiotic resistance. A variety of antibiotics including ampicillin, tetracycline, penicillin and erythromycin have been found in testable amounts in numerous waterways. Not surprisingly, wild Geese resistant to these antibiotics have been found.

Ibuprofen

Ibuprofen is a commonly used drug for the treatment of pain. It has been found in 10% of sampled waterways.

Detectable levels? So what?

Although many can argue that there is a difference between detectable and therapeutic or toxic levels, the fact remains that our waterways are being contaminated by “foreign” agents. We would be remiss to simply push this alarming fact aside and ignore the potential for slow accumulation in aquatic life. To be so bold as to say that since there have been no described human effects, there should be nothing to fear is short-sighted and foolish. Additive effects of pollutants, and the concept of increased bioconcentration as we move up the food chain have already been seen in other toxic compounds such as mercury. For example, mercury poisoning from fish is a well-described phenomenon. In fact, famous actor Jeremy Piven (Old School and Entourage) suffered from mercury poisoning following a high-fish diet that forced him to cancel working on the Broadway revival, “Speed-the-Plow.”

Ok, so we have contaminated waters. How did it happen?

As with any problem, the important question to address is how did it start in the first place. There are three main routes by which these contaminants enter our environment.

1. Excretion

As the name implies, drugs are excreted by the body in two main forms: urine and feces. Excretion of most drugs is primarily through urination, and comprises a continual low-level addition to the environment by many people.

2. Bathing

Many drugs are applied directly to the skin. These drugs are not completely absorbed, and are simply washed off during the process of bathing. Additionally, some drugs can be excreted in sweat and are also washed off during bathing. Again, this represents a continuous low-level contribution to environmental contamination.

3. Disposal

The final method of contamination is the direct disposal of drugs via toilets and trash. Although disposal is not a continuous source of contamination, it is episodic, and can be a significant source if disposed in large volumes by many people.

Now that we understand how we contaminate our waters, we should go back to the reason why this happens in the first place: mass prescriptions and improper consumption of medications. As a rising physician, I have seen countless examples of patients receiving medications such as antibiotics or pain relievers for conditions that cannot be appropriately treated through such means. Additionally, I have noticed a sense of undue dependence on the part of patients to medications that is simply astonishing. People expect medications to heal when in fact, many times they are better off without them. I am not saying in any way that people should not have access to medications, however, I do believe that the justified use of medications should be advised.

Another reason is that many people do not finish their prescriptions, or choose to buy them in large quantities. I have been guitly of this myself. A simple trip to a nearby wholesale retailer will prove my point–Tylenol is sold in large bottles in quantities exceeding 300 pills. The same goes for a variety of different drugs.  If we are to minimize our waste, then we must be more responsible about consuming what we need and not running after the cheapest deal. Large drug companies should also be more aware of this phenomenon and certain actions should be taken to minimize the sale of wholesale drugs. 

  So what can we do to minimize the problem?

I will discuss ways to reduce our environmental impact in my next blog. Stay tuned!