Hospital Infection Control

Waste management

What specific organisms pose a risk for patients by/in waste management?

The production of waste is inherent in the performance of healthcare all over the world. As a corollary, healthcare waste management is an inevitable part of healthcare provision. By some estimates, healthcare facilities in the United States alone produce more than 4 million tons of waste every year.

Disposing of this waste consumes approximately 10-20% of the average facility's operating budget annually; and, the majority of healthcare facility staff is involved in waste production and management in some capacity.

Just as healthcare waste passes through many hands, from patient to practitioner, to procurement and disposal staff, the risk of infection from contaminated waste passes along in each step from its initial creation to ultimate disposal.

Many of these infections are blood borne viruses, and include human immunodeficiency virus (HIV), hepatitis B, and hepatitis C.

While these three infections are commonly associated with healthcare waste, multi-drug resistant bacterial organisms such as methicillin resistant staphylococcus aureus (MRSA), extended-spectrum beta-lactamase (ESBL) organisms, and Pseudomonas aeruginosa, among others, are also virulent infectious agents that can contaminate medical waste.

Constant vigilance and strategic programs to deal with infectious medical waste are necessary to mitigate the impact of these infections on patients, staff, and the community.

What is the impact of such infections if not prevented?

Failure to develop concrete policies for the handling of medical waste and infectious waste in particular can lead to disastrous consequences. Ignoring the importance of waste management not only makes a healthcare facility more dangerous for its current patients but also sets in motion a cycle of infection outside its walls.

Four major groups are at risk for exposure to poorly managed medical waste: current patients, practitioners, waste procurement staff, and the public.

Risks for patients

Patients are frequently the victims of poor waste management practices. For example, one global study of waste management found evidence that approximately 30% of injections administered in one country were performed with previously used equipment.

This represents a significant risk for the spread of serious infections, given that injectable medications and vaccinations are some of the most common medical procedures performed.

Needles are not the only potential vectors, however. Re-using sharp equipment of any kind can spread infection between patients or between practitioner and patient.

Risks for medical practitioners

Similarly, improper handling of contaminated waste can pose a hazard to medical practitioners (and by extension their future patients).

In one survey of medical interns, only 17.6% used puncture-resistant containers to dispose of needles and other sharp objects, and only 4.3% regularly avoided recapping needles.

Failure to follow safety practices when dealing with infectious medical waste such as needles, sutures, or scissors not only puts the medical practitioner at risk for acquiring a lethal infection but also increases the chances that he or she may pass that infection on to a future patient or to his or her family members.

Additionally, improperly handled medical waste poses a hazard for waste procurement staff.

Risks for waste procurement staff

The individuals who collect and dispose of healthcare waste are often at great risk of being exposed to infectious agents.

In one review of medical waste handlers in the developed world, it is noted that nearly 100% of workers experience contamination of their clothing with blood splashes within 4 hours of starting a shift; similarly, workers experienced complete saturation of all clothing layers with blood or body fluids approximately once every 150 hours worked.

Additionally, clinical waste staff around the globe is generally poorly trained not only in infection control procedures but also on the importance of preventing infections in themselves.

For example, one study of healthcare waste collectors revealed that they frequently re-opened packaged waste to re-segregate it, did not always wash their hands after removing gloves, and frequently did not utilize face masks. Additionally, examination of these waste handlers revealed relatively high rates of hepatitis B, pulmonary tuberculosis, and enteric pathogen infections.

These infection rates were not directly compared to the national population baseline in this particular study, so the attributable risk of being a waste handler is unknown.

Regardless, the article describes the high-risk practices employed by the handlers, so the potential for acquiring these infections through improperly handled waste is very high in this group.

Ultimately, the consequences of poor training for waste handlers can affect not only the handlers themselves but also the population at large.

Risks for the public

The ultimate disposition of medical waste after it leaves a healthcare facility can often pose serious infection risks to the public.

While some countries have complex waste management systems that involve the chemical and mechanical sterilization and/or destruction of infectious waste, many regions of the world have significantly limited resources to deal with dangerous medical waste.

Due to these limited resources, waste handlers in these areas are often forced to find less-than-ideal methods of disposal.

For example, used needles are often buried in simple pits in the ground. If such disposal is necessary, careful site selection can decrease the likelihood that they will be accidentally uncovered and injure individuals. Often, however, waste disposers are poorly trained and have little oversight. This can lead to dangerous consequences.

In one review, frequent episodes of improper dumping of medical waste were cited, including placing infectious material into general municipal waste where it later injured scavengers. Similarly, a mass exposure event occurred in another country where needles were dumped onto children’s soccer fields, leading to dozens of needle-stick injuries.

It is unknown how many of these children ultimately contracted HIV or hepatitis B because of poor follow-up. Incidents such as these likely go unnoticed on a regular basis around the world and pose a grave and serious threat to public health where they occur.

Improper handling and disposal of healthcare waste enhances the cycle of infection for many of these lethal agents. The spread of HIV, hepatitis B and C, and multi-drug resistant organisms through waste objects multiplies the impact of these infectious agents as they spread from patient to practitioner to waste handler and ultimately, back to the public.

Careful strategic planning is required in order to minimize the infectious potential of healthcare waste.

What are the key methods to minimize transmission of infection to patients by/in waste management?

When developing a strategy for minimizing the infectious potential of healthcare waste materials, the most important consideration should be the methods by which staff and waste management personnel will be trained to implement and monitor the facility's waste management plan.

Other important factors include the size, complexity, and financial resources available to the healthcare facility.

The size and complexity of the facility will often determine the volume of waste, and in particular infectious waste, that it creates. Financial resources will often determine the means by which that waste is disposed of.

Regardless of these factors, there are certain key principles of healthcare waste management that can be enacted regardless of size or resources. Several of these principles are derived from the World Health Organization's online guide to "Healthcare waste management."

Key methods

1. Train all staff:

  • Educate practitioners on the proper use and disposal of medical waste and waste workers on proper personal protection and disposal methods.

  • Have a set of policies and protocols for how waste management should be handled and ensure appropriate supervision of all staff so that the policies are implemented.

2. Segregate waste:

  • Keep sharps (needles, scalpels, scissors, etc.,), non-contaminated waste (common municipal waste such as food, paper products, etc.,), and contaminated waste (items other than sharps soiled with blood, body fluids, etc.,) in separate, clearly marked, containers from the point of waste creation to disposal.

  • If properly segregated, non-contaminated waste is not dangerous and can be disposed of using conventional waste management methods.

3. Properly utilize one-time use and multiple-use items:

  • Needles and surgical gloves should be disposed of after one use.

  • Multiple-use items should be fully sterilized (not just cleaned) before being re-used on another patient.

4. Keep an open dialogue with your community:

  • Consult with local community leaders about acceptable methods of waste disposal.

  • Consider what methods of medical waste disposal would have the least impact on the environment but also sufficiently minimize residual infectious material.

While these four key principles are by no means an exhaustive treaty on how to implement an effective waste management strategy, they are important core themes around which an institution can create a set of plans, protocols, and policies. In many cases these ideas are supported by evidence to suggest that they are effective at reducing the risks of disease transmission by healthcare waste.

What data support current recommendations with respect to hospital waste management?

Segregating overall waste production into its component parts is generally considered one of the most important and basic steps in developing an effective waste management program.

Many case studies from around the globe, however, indicate that this is generally not done properly. Even in complex academic institutions, compliance with waste segregation can be poor without consistent monitoring and correction.

Ensuring that waste is properly segregated into categories such as "infectious," "sharps," and "non-infectious" can provide multiple benefits; "sharp" and "infectious" wastes are often called "regulated medical waste (RMW)."

First, this allows the easy identification of potentially infectious or dangerous materials for waste workers. Secondly, dividing the infectious wastes and sharps from more common wastes can significantly reduce the amount of healthcare facility waste that must be specially treated.

For example, practicing consistent segregation of material that needs to be incinerated from that which does not can significantly decrease the amount and type of environmental air pollutants produced by waste incineration.

Proper segregation can have economic advantages as well. Primarily, disposing of infectious waste, if done properly, is more complex and costly than dispositioning non-infectious waste. Taking steps to properly segregate waste generated in the healthcare environment can significantly reduce the costs required to properly dispose of infectious waste.

In one large hospital, a rigorous waste management policy that emphasized the appropriate segregation of medical waste into the contaminated, non-contaminated, and sharps categories was implemented and resulted in a greater than 80% reduction in waste disposal costs.

For that hospital, the savings equated to $1.95 (US) per patient-day and a decrease from 8.1 pounds of RMW per patient-day to 1.3 pounds per patient-day.

Given that many healthcare facilities around the globe practice in limited resource environments, taking steps to reduce the amount of infectious waste products that require destruction is a relatively simple method of making sure scarce resources are not misallocated.

Some types of infectious waste products are complicated to handle, either because they are difficult to sterilize and destroy or because re-using them is economically beneficial.

Needles, surgical gloves, and metal instruments often fall into this category. These devices are often re-used around the world, especially in limited resource environments, because they are expensive to replace and difficult to destroy once contaminated.

Certain instruments are designed to be used multiple times and so long as proper sterilization techniques are utilized in between patient contacts, this can be a safe and economical way of handling this type of medical "waste."

In fact, re-using certain items as intended can significantly decrease the overall volume of medical waste a facility generates, reducing disposal costs overall as well. Needles and surgical gloves, despite being reused in many facilities around the world, should almost never be utilized more than one time before being disposed of properly. Surgical gloves are difficult to truly sterilize post-use and treating them with chemical cleaners does not guarantee the absence of pathogenic organisms.

Despite the significant danger of spreading infections, re-using hypodermic needles for injecting medications and vaccinations is a common practice worldwide.

These types of practices are thought, via modeling studies, to directly cause approximately 8-16 million cases of hepatitis B, 2.3-4.7 million cases of hepatitis C, and 80,000-160,000 cases of HIV every year. This is especially concerning given that many of these unnecessary infections are likely occurring in children who are being vaccinated with contaminated equipment.

In dealing with healthcare waste, devices must be utilized properly, whether one-time or multiple-use, in order to minimize the risk of infection to patients and providers.

One of the primary methods of ensuring both proper handling of healthcare waste and minimization of improper re-use of materials is to ensure that all staff is properly trained and educated. Many studies have shown that hospital staffs frequently have serious knowledge deficits regarding hospital waste management and the risks involved with improper waste handling.

One survey of physicians in a large region revealed that while most of them had significant knowledge about the infectious risks of medical waste, especially compared to other staff members, 0% of them understood that there are differences between different types of medical waste. This same survey also indicated that the physicians in the region did not feel it was their responsibility to manage healthcare waste or be involved in how it is disposed.

A similar theme is likely present in many regions of the world. Education about the risks involved in dealing with hospital waste must reach all levels of a healthcare organization, from the physicians, nurses, and other clinical practitioners to the direct waste handlers.

Indeed, at many facilities, less than 10% of hospital staffs have a thorough understanding of the risks of handling healthcare waste or about the differences between standard waste and medical waste.

Including extensive staff training at all levels of a healthcare organization and creating a culture of accountability are some of the most important elements in developing a strategic plan for minimizing the risks of infectious waste and ensuring proper use of waste disposal resources.

Rigorous community engagement should also be part of any healthcare waste management plan. While there are few data in this area, it stands to reason that discussing a waste management plan with local leaders would be prudent. This is especially important if local laws and regulations are absent or provide minimal guidance for how medical waste should be handled.

For example, community members may prefer that incineration of medical waste be carried out in specific locations or may have suggestions as to the safest areas to bury medical waste. Furthermore, community engagement is an important method of educating the populace regarding the risks of handling medical waste. This should increase the likelihood that if contaminated waste is discovered accidentally, it would be left undisturbed.

How can the safety of waste management be monitored? At what frequency?

Every healthcare waste management plan must include a component of self-analysis and monitoring in order for it to be effective. Variations in resources, size, and complexity require each institution to individualize the processes it will utilize in monitoring the safety and implementation of the waste management plan.

While there are limited data on the best practices for ensuring the safety of waste management, principles harnessed for monitoring other facets of healthcare, such as reducing healthcare-associated infections, provide models for best practices.

Like most other interventions in healthcare, safety begins by first promoting awareness of the importance of appropriate waste management among all levels of staff. Healthcare workers cannot be expected to consistently comply with a waste management program if the dangers of non-compliance and the purpose of the plan are not clear.

Secondly, as outlined above, staff must be adequately trained on the specifics of the institution's waste policies and given the opportunity to practice the skills required in order to implement the plan.

A staff that is aware and well-trained is more likely to feel invested in the waste management plan and therefore more likely not only follow the plan but also to use peer-support to ensure that the institutional culture is consistent with the safe handling and disposal of healthcare wastes.

Ultimately then, feedback is likely one of the most important tools to ensure the safety of healthcare waste management. This principle has been demonstrated both in the realm of healthcare-associated infections and specifically in waste management. Specifically, monitoring and then providing feedback on certain complex behaviors such as how waste is segregated and disposed of may produce improved compliance.

For example, in one study involving the monitoring of hand-hygiene (a similarly complex behavior) at a tertiary-care center, health care workers were noted to increase their compliance with appropriate hand-hygiene practices after receiving feedback both via the official channels of unit-level supervisors and directly via staff-targeted educational posters.

Similarly, a large teaching hospital noted significant improvements in its healthcare waste segregation practices simply by utilizing monitors who observed the waste practices of a unit and then providing this information back to unit leaders. In order to provide this feedback, the institutions in these studies utilized trained persons to observe and report the hygiene practices being studied.

While the hospital in the first study on hand-hygiene utilized "infection control professionals," the second study demonstrates the utility of undergraduate medical students as observers. Because resources and the availability of staff to monitor the safety of healthcare waste management are highly variable across institutions, hospitals and clinics may need to develop creative strategies to recruit and train monitors.

Regardless of the specific details of a program's observation and monitoring practices, providing simple feedback at the staff and leadership levels is likely the easiest and most cost-effective method for ensuring the safe handling of healthcare waste.

A discussion of monitoring healthcare waste management at the national level, including the use of regulatory agencies and legislative initiatives, is beyond the scope of this chapter but does and should play a vital role in the implementation of an institution's healthcare waste management plan.

What are the controversies related to hospital management of waste?

The major controversies related to healthcare waste management stem almost exclusively from the environmental and safety impacts of ultimate waste disposal.

Many authors and policy makers express significant concerns about the environmental, particularly atmospheric, damage caused by the broad-based incineration of medical waste. Similarly, the storage or burial of un-destroyed waste can pose a safety hazard to local populations not only in the form of direct exposure but also contamination of water supplies and soil.

While it is generally recognized that incineration and improper storage represent dangers to the environment, the controversy lies in how to minimize the impact. This can be particularly challenging in low resource environments, in places without significant healthcare infrastructure, or in countries where advanced waste treatment technologies are unavailable.

Often, these types of regions cannot benefit from economies of scale such as centralized waste storage and disposal afforded to more developed areas. Additionally, even in well-developed areas of the world, financial and political conflict surrounding the introduction of new technologies and methods can delay the implementation of more safe and effective healthcare waste management.

What data support each side of the controversies?

While the data supporting the health risks, as exampled above, are far from complete, they clearly indicate that inappropriate disposition of medical waste can lead to significant transmission of infectious agents.

Incineration significantly reduces the infectious potential of medical waste; however, the practice is known to lead to the production of dangerous toxic chemicals. While there are no comprehensive data to delineate the global environmental risks of incineration, it is a low-cost and pervasive method of waste destruction.

Case studies demonstrate that harmful by-products of medical waste incineration, such as dioxin and other similar compounds, are released into the atmosphere during incineration and ultimately deposited in the soil of the area surrounding the incinerator facility. Indeed, it is estimated that the incineration of medical waste is one of the largest sources of dioxin in the environment.

This chemical has been linked to many disorders and is classified as a human carcinogen by the World Health Organization. Additionally, mercury, a dangerous neurotoxin is routinely released by incineration of healthcare waste.

As financial resources allow and technology advances, the adoption of waste disposal methods that do not involve incineration of materials will be important in sustaining our global environment while also reducing the risk of infectious disease transmission by untreated waste.

What guidelines are currently in place?

The World Health Organization has taken a major role in developing guidelines for minimizing both the infectious potential and environmental hazards associated with healthcare waste disposal with the development of the manual entitled "Safe Management of Wastes from Health-Care Activities".

Specifically, chapter 8 of the manual provides a relatively detailed guide on some of key practices to employ and avoid when dealing with healthcare waste. The chapter provides guidance not only on the specifics of various methods of incineration, landfill disposal, and sterilization but also steps to take to produce maximum safety and minimal environmental impact even in low-resource environments.


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