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Comparison of infectious waste management in European hospitals
Journal of Hospital Infection (2003) 55, 260–268
www.elsevierhealth.com/journals/jhin
Comparison of infectious waste management in European hospitals ¨hlich*, M. Scherrer, F.D. Daschner M. Mu Institute for Environmental Medicine and Hospital Epidemiology, Freiburg University Hospital, Hugstetter Str. 55, 79106 Freiburg, Germany Received 28 January 2003; accepted 5 August 2003
KEYWORDS Infectious waste; Definition of waste types; Waste management; Waste treatment; Europe
Summary A research project sponsored by the EC-LIFE programme was conducted to compare waste management in five different European hospitals. A comparison of the regulations governing current waste management revealed different strategies for defining infectious hospital waste. The differences in the infrastructure were examined and the consequences for waste segregation and disposal were discussed under economic and ecological aspects. In this context the definition of infectious waste is very important. Q 2003 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction Waste is more than just rubbish to be disposed of and forgotten about. This fact is reflected in the increasing number of different waste disposal regulations1 – 7 and in the continuous development of waste segregation and treatment systems.8 – 11 Although there are still pronounced differences in the practical design of disposal systems, in most countries there is a growing awareness that the enormous volumes of waste generated not only result in huge disposal costs, but also that there is still a great deal of energy and re-usable material in waste which should not be carelessly discarded and ignored. In the assessment of hospital waste, the focus lies mainly on the biological hazards caused by *Corresponding author. Tel.: þ 49-761-270-5436; fax: þ 49761-270-5440. E-mail address: [email protected]
bacteria.12 – 16 In particular, the fact that biological systems are capable of reproducing themselves is considered to be very unpleasant. So far, the question of the extent to which hospital waste represents a suitable medium for the reproduction of bacteria has not been answered conclusively. However, studies on the bacterial content of hospital waste appear to indicate that it is not a very good culture medium for pathogens and disease transmission; so far, it has not been possible to provide a conclusive answer to the question as to whether, or at what point, any existing pathogens are transmitted from waste to humans. Empirical data show that it is mainly in intermediate animal hosts where pathogens, if allowed to multiply, can cause problems. But whether there are any differences in this respect between hospital waste and other waste remains unclear. Modern disposal technology, whether properly managed landfills or incinerator units, provide a great deal of protection.
0195-6701/$ - see front matter Q 2003 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2003.08.017
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Methods
Results
The project described here investigated waste management policies in five hospitals in five different European countries. The project, which was funded by the EU Commission LIFE 96 programme (LIFE96/ENV/D/10) examined disposal practices, the applicable regulations, available infrastructure, climate conditions and the organization of waste collection and disposal in the hospitals. Regulations and guidance documents, relevant to waste management, were collected and compared. The results were summarized in a questionnaire on regulations pertaining to waste management. The influences on actual waste management practice were discussed in workshops with all the partners. To obtain an overview of waste management practice in each hospital, the Freiburg team developed a second questionnaire on waste disposal infrastructure and management. Waste management practice in each hospital was examined to confirm the results of the questionnaires. Existing waste disposal practice was discussed with local partners and experts. Local infrastructure for waste disposal also formed part of the survey. An analysis of waste was undertaken to obtain more detailed information about waste composition and waste segregation. Workshops were held to compare disposal practice in the different hospitals, the influence of legal stipulations and available local infrastructure. Among the issues addressed was the question of how different waste types are defined in the individual countries, how much leeway the definitions allow for optimized disposal practice in hospitals, and the reasons for existing differences and similarities. Basic considerations, such as the health and safety of patients and personnel,17 – 20 or ethical concerns have been addressed in the discussion of the differences between the hospitals included in the project. A high level of safety can be attained in a number of ways. Thus, besides considering the definition of waste materials, the study included handling, level of staff knowledge and the available infrastructure. The hospitals participating in the project were divided into two main groups and comprised large university hospitals with 1300 to 2100 beds (Freiburg, Nottingham and Grenoble) and smaller regional hospitals with 500 to 600 beds (Foril, Sabadell). The differences in the scope of the medical services provided or the hospitals’ research facilities did not influence the project, because the focus lay on internal medicine and surgical wards, all of which were present in the hospitals surveyed.
Classification of medical wastes from hospitals Rules and regulations pertaining to the current practice for the definition and disposal of healthcare waste vary widely in the countries surveyed. Specific legislation on hospital waste is only in place and enforced in Catalonia. With the exception of Italy, in all other countries classification and disposal of hospital waste is regulated by ordinances. In Italy, no specific rules exist, and the general law covering waste management provides only a very rough definition of hospital waste. Official guidance documents for hospital waste management are available in Grenoble, Nottingham, Sabadell and Freiburg. Infectious waste definitions vary widely. Contamination of materials with defined pathogens as a basis of classification as infectious waste is used in Freiburg and Sabadell (see Appendix, Notes 1 and 2). The other hospitals classify waste according to their source and/or the activities that produce them (see Appendix, Notes 3 and 4). Risk factors are not specified in greater detail. The European waste catalogue provides for a category of waste from hospitals, which, in terms of infection prevention, does not require any special precautionary measures (EWC: 180104). This means that waste, which is identified as having originated in hospital, is no longer automatically categorized as requiring special treatment. During discussions in the project, a ‘no risk healthcare waste’ category was generally approved. Eliminating ‘sharp objects’ as a separate category of waste, as presented in the European waste catalogue (EWC: 180101), was generally welcomed, as too was the definition of a separate category for cytostatic agents (EWC: 180108).
Disposal practice The amount of waste disposed off as infectious or hospital-specific differs widely in the hospitals surveyed. At Sabadell and Freiburg 3 – 4% of the total amount of waste generated is classified as infectious waste, in contrast to 28% at Grenoble, 40% at Nottingham and 51% at Forlı` (Figure 1). In three hospitals (Italy, Spain and Germany), infectious waste is collected in waste bins made of rigid material; these bins are used both for internal and external transport. The waste is only collected in plastic bags in areas where very little waste is generated (Spain, Germany). At Forlı`, reusable
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taken to another hospital, where it is sterilized in an autoclave and shredded. Following this process, waste disposal is as with conventional domestic waste. At Forlı` and Freiburg the waste is taken to a chemical waste incineration plant, where it is incinerated at approximately 1200 8C. Grenoble uses a domestic waste incinerator (800 8C) with a separate feed system for infectious waste. The transport distances necessary for waste disposal range from 4 km at Grenoble to several 100 km at Freiburg; this also increases the cost of disposal. Figure 1 Quantity distribution between domestic and hospital-specific waste. ( ) HS waste; ( ) D waste.
Cost of waste disposal in the different hospitals
metal containers lined with bin bags are used. These containers are closed at the point of collection and emptied directly into the furnace of the incineration plant, which is located on the city outskirts. Conversely, Grenoble and Nottingham use plastic bags for waste collection, which, when filled, are stored intermediately in wheeled waste containers. The wheeled containers are used for internal and external transport. Different colour codes are used by each hospital to mark the bins. Grenoble uses white bags with red stripes, Nottingham uses yellow bags with black labels, Freiburg uses black bags or black plastic containers with red covers while in Sabadell red bags or black plastic containers are used. In most cases, the source of the waste can only be determined from the internal transport route. However, this often ends in the intermediate storage area, which different work areas use. Only in Nottingham are the bags sealed with sticky tape denoting the work area. According to the definitions used at Grenoble, Forlı` and Nottingham, all waste generated by patients is considered to be infectious and is disposed of accordingly. At Freiburg and Sabadell, however, collecting infectious waste is restricted to defined areas agreed upon by the department of hospital hygiene or, the waste management team, respectively. These include all areas where patients are treated who have a disease, illness or condition covered by the definitions for infectious waste (see Appendix, Notes 1 and 2). Thus, these hospitals also run patient-care areas where no waste is generated that fits the classification criteria for infectious waste. With the exception of Sabadell, which has no incineration plant, the infectious waste of the hospitals participating in the project is normally sent for incineration. At Sabadell, the waste is
As the costs of the different disposal routes are a very important factor in the evaluation, the disposal costs incurred by the project hospitals are dealt with in greater detail at this point. Figure 2 shows the costs per tonne for the disposal of domestic-type waste (D waste) and of hospitalspecific and/or infectious waste (HS waste). As expected, dumping the D waste is the most cost-effective solution. The landfill charges in Sabadell near Barcelona are remarkably low. In Freiburg, dumping charges are only fractionally lower than the incineration costs in Forlı` and Nottingham. As the choice between domestic waste incineration and dumping usually depends on local conditions for the disposal of municipal domestic waste, most hospitals have no option. The enormous difference in costs between HS waste and D waste is remarkable in every hospital. This difference is particularly noticeable in Barcelona, where almost 70 tonnes of D waste can be disposed of for the price of 1 tonne of HS waste. In
Figure 2 Disposal costs for domestic-type waste ( ) D waste; and hospital specific waste ( ) HS waste.
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contrast, the difference between D waste and HS waste is smallest in Grenoble. At Forlı`, the disposal costs for HS waste also include transport charges within the hospital and the costs for containers and other equipment, because it is included in the service of the disposal firm.
Disposal of sharp objects One particular feature of the Freiburg system is the disposal of sharp objects at the local dump. The containers for disposal of sharp objects are collected and transported separately from the D waste, because compaction of this type of waste must be avoided. At the landfill site these objects are also deposited in an area that is not as densely compacted as the D waste area. Because of the separate treatment required, the landfill charges for this type of waste are also higher than for D waste. This system is based on the classification of sharp objects as a waste category that requires special care and attention in its handling inside the hospital, but which can be classed as D waste outside the hospital. The structure of the European waste catalogue also fails to classify sharp objects as hazardous waste, but other project hospitals classify them as dangerous waste requiring disposal accordingly.
Discussion Definitions of infectious waste A central issue concerning hospital waste disposal is the assessment of the real and potential risks emanating from waste with the focus on the risk of infection. This is reflected in the different definitions developed by the individual countries. In general, two strategies are applied for definition of infectious waste: Catalonia (Spain) and Germany largely apply a narrow pathogen-related definition of waste management. In the other countries, waste is classified in terms of its source and the activity producing it. The risks are not specified in greater detail. Medical knowledge of disease transmission or the suspicion that they may cause certain infectious diseases suffice to define waste as infectious. Examples are used in the regulations to provide closer descriptions of waste types, but as the descriptions are incomplete or inconclusive, it is left to the hospitals to interpret and implement the definitions.
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More accurate definitions are therefore left to the hospitals themselves. Because it is difficult for hospitals to decide which wastes are infectious and which are not, there is an undesirable tendency to classify all waste as HS (infectious). This problem is further exacerbated by the attitude of the public, which assumes hospital-specific waste poses a high risk.
Disposal practice A comparison of disposal practice in the hospitals participating in the project showed three basic approaches to deal with the classification of HS: material composition and/or contamination, source and activity whereby it was produced. In practice, a mixture of these criteria is normally applied with different focal points in the evaluation of these criteria. In waste classified as infectious, contamination with organic material originating from a patient is decisive. However, in practice, assessing contamination is very difficult, with the effect that the site or the activity is determined as a second best option. Activity If the activities producing the waste are taken as a measure of infectiousness, and if it is stipulated that all waste originating from patient care should be classified as potentially dangerous, containers for HS should be placed wherever patients are nursed or treated. However, as domestic type waste is also generated in patient-care areas, this system usually involves placing two containers next to each other. This means that the staff have the added difficulty of correctly classifying and sorting the waste. In the experience of this project, this procedure usually results in a greater volume of hospital-specific (infectious) waste as shown in Figure 1 by the example of Forlı`. Adequate staff training and clear information material are necessary for proper waste segregation. The success of the system used should be reviewed and discussed with the staff at regular intervals. Source of waste From the point of view of easier orientation for personnel, it is advisable to determine the sites and locations where infectious waste may and may not be expected and to provide the appropriate waste collection bins. This avoids the problem of incorrect sorting mentioned above, but it also means that more wastes are classified as HS (infectious). Waste management in Nottingham is organized in this way (Figure 1). An inherent problem in this system is
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that of training personnel in such a way that there is no confusion when placing and emptying the containers. This is why the waste types to be collected at the collection points should be identifiable independently of the waste containers, e.g. by a sign on the wall. Material and/or contamination If the focus lies on evaluation of the material and/or contamination, blood and body fluids will be the main source of problems during proper sorting. If waste is always classed as infectious when it comes into contact with blood, secretions or excretions, it will be very difficult to assign areas where no infectious waste is expected and where, as a consequence, a container does not need to be provided for this waste category. This is why it is necessary to define clear contamination assessment criteria that enables personnel to sort and assign the waste quickly and without complication. At Freiburg University Hospital, the issue of waste containers used for infectious waste is controlled by the Department of Hygiene and is subject to strict criteria (patients with defined diseases and defined material and/or contamination with material containing bacteria), so that wards that have no patients with infectious diseases normally have no collection containers for infectious waste.21 – 22 There are also other defined areas such as the dialysis unit, the blood bank or the operating theatres, where larger quantities of blood, body fluids or tissue are generated, and where infectious waste is continuously collected. Sorting by material and/or degree of contamination is only possible if the definitions show a clear distinction between the different types of waste. If the definition of HS waste relates not to known risks, but to suspected risks, hospitals will find it relatively difficult to draw clear demarcation lines. The best approach in this case may be to determine what waste from patient treatment areas can be safely disposed of as domestic waste. Again, staff training and information is essential for successful waste segregation. The above focal points for the disposal of HS waste constitute a relatively far-reaching abstraction, which is not practised ‘in its purest form’ in any of the hospitals. They merely constitute different approaches to implementing the definitions of waste, with the appropriate consequences for the quantity of the different waste categories (Figure 1). They also account for the external legislative measures that hospitals face and that are intended to ensure that no risk emanates from hospital waste.
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Disposal safety In some cases comparison of disposal practices at the point of collection showed surprisingly few differences between D waste and HS waste. Both waste types are collected in plastic bags and lifted into waste containers for immediate storage. Assuming that no one in the community will come into contact with the waste much of this waste could also undergo disposal as D waste. Therefore it would be helpful to examine in greater detail at what points along the disposal route problems with infectious agents might arise. This would reduce risk and the cost of disposal.
Cost of waste disposal To illustrate the economic consequences of waste segregation for the individual hospitals, the effects of classifying the waste into D waste and HS waste on the overall costs for hospital waste disposal were compared. The difference in costs that would result if the same distribution system were applied to other hospitals were computed on the basis of both extremes i.e. in respect of quantity of HS waste (Barcelona: 2.7%; Forlı`: 50.8%). Separating waste into HS waste and D waste, as practised in Barcelona, would result in savings of between e200,000 and e290,000 per year in hospitals with a higher proportion of HS waste. Figure 3 shows the present segregation in comparison with the distribution pattern in Barcelona. Conversely, if the Sabadell hospital had the same percentage quantity of HS waste as Forlı`, the cost would be unmanageable. On the basis of their present HS waste disposal charges, the cost of waste disposal would rise by more than e1,000,000
Figure 3 Hypothetical disposal costs for waste segregation as practised in Barcelona. ( ) D waste 1998; ( ) D waste 97.3% (as in Barcelona); ( ) HS waste 1998; ( ) HS waste 2.7% (as in Barcelona); ( ) difference.
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per year at this hospital. Freiburg would also have to spend an extra e800,000 on waste disposal if the proportion of HS waste and D waste were identical to that at Forlı`. These sample calculations are designed to show the impact that the segregation of waste has on the cost of waste disposal.
External waste treatment Unfortunately, as yet there are no scientific data on whether the discharging of HS waste into the waste bunker of the incineration plant and simultaneous feeding with D waste poses any health risks to personnel and members of the community. As the HS waste in the examples shown is only placed in bags, which are then dumped in the reusable transport containers, it is to be expected that they will burst open when the containers are emptied into the waste bunker. More detailed scientific investigations are also urgently needed to verify whether there are any good reasons for high temperature incineration of HS waste. Extreme temperature stability is known of a limited number of cytostatic agents that could conceivably escape through the chimney. Therefore it is necessary to collect this waste type separately and dispose of it as chemical waste. A temperature of 800 8C is adequate to kill pathogenic micro-organisms. Burning HS waste in D waste incineration plants, as already practised at Grenoble, might also be an interesting future option for others. Trials involving this disposal route are now taking place in England. A high-quality flue gas cleaning system must be used, regardless of the incineration temperature, because volatile exhaust gas components can also form dioxins after burning.23 Particularly when compared with the enormous expense of incinerating HS waste at high temperature, which is often associated with long transport routes to suitable plants, local pre-treatment
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appears to offer a very reasonable alternative. This may be of particular interest in countries with a high proportion of HS waste. Furthermore, local pre-treatment does not require the expensive packaging prescribed for road transport of hazardous goods. Proof that the method of pre-treatment is successful and safe must be provided. In Germany, the Robert Koch Institute has issued a list of approved disinfection methods, including waste disinfection.24
Evaluation of current waste disposal practice In discussions between the project partners, it transpired that it is difficult at present to find a common denominator for defining HS waste, because estimation of the risks, particularly those involving the health and safety of personnel, still vary widely. However, it proved easier to find a common standpoint with respect to the waste disposal routes employed outside the hospitals. An outline of the agreements reached on waste disposal is given in Table I. One important question that arose was why there is so little information on the risks involved in waste disposal. In the 1980s investigations conducted in Germany and Austria on the pathogenic spectrum in hospital waste raised the question as to whether, in terms of hygiene, assumptions of the levels of potential risk were realistic. The outcome of these studies is that in Germany one is oriented toward known risks, and this in turn has resulted in a drastic drop in the quantities disposed of as infectious waste. Unfortunately, there are few concomitant studies showing that these waste management strategies increase risk to personnel. One approach for the future might involve emphasizing the risk to personnel and carrying out more detailed scientific research in this direction. Recently, the UK Environmental Agency published an interesting
Table I Proposals for assigning the different waste types to various disposal routes Type of waste Domestic-type waste Hospital-specific waste Infectious waste
Cytostatic agents Sharp-edged objects
Remarks Without hospital-specific waste Without risks of infection (a) After waste treatment to eliminate any risk of infection (e.g. disinfection) (b) Without waste treatment (a) Traces of contamination (b) Severe contamination Pierce-proof, labelled containers
Proposal for disposal route As municipal domestic wastes As 1, but without direct contact (a) As 2 (b) Incineration like domestic waste (a) As 2 (b) High temperature incineration Dumping or incineration like domestic waste
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study on this topic, in which hazards are ranked according to the severity and the likelihood.25 This paper has highlighted the problems of assigning and sorting waste. There is also the problem that there are differences in ones approach to how risk is assessed in different countries, which means they select and sort waste differently. It remains to be determined whether the safety levels necessary for handling normal domestic waste cater sufficiently for the needs of most hospital waste, which, today, is still classified as potentially infectious.
Appendix Note 1: Definition of infectious waste in Germany7 FREIBURG: Group C: Waste which, from the point of view of infection prevention, requires special supervision and care during disposal inside and outside the public health sector (so-called infectious, contagious or highly contagious waste): Waste requiring treatment in accordance with § l0a Federal Epidemic Law. This applies, if the waste is contaminated with the pathogens of infectious diseases requiring registration and if the spread of the disease is therefore to be expected. The necessity for additional requirements (e.g. separate collection, disinfection) is defined by the nature of the pathogens involved i.e. in respect of their contagiousness, survival capability and transmission routes, the extent and the nature of the contamination, and the waste quantity. Waste belonging to this group can cause the following diseases: Cholera, diphtheria, leprosy, tularaemia, anthrax, typhoid, paratyphoid, virus-induced haemorrhagic fevers, plague, brucellosis, smallpox, meningitis/encephalitis, poliomyelitis, Q-fever, dysentery, farcy, rabies, tuberculosis, viral hepatitis. Wastes of this type can, for instance, be generated in infection wards, dialysis wards and dialysis centres with yellow dialysis, pathology departments, blood banks and doctors’ surgeries and in veterinary surgeries and hospitals. This is usually waste generated during the treatment of patients, e.g. material contaminated with secretions or excretions containing pathogens; packaging materials are normally not included. This waste also includes microbiological cultures generated in hygiene institutes, microbiology,
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virology, or medical laboratories and in doctors’ surgeries.
Note 2: Definition of infectious waste in Catalonia (Spain)26 SABADELL (BARCELONA) Group III: Non-specific waste from the public health sector is waste which must be handled, collected, transported and disposed of within and without the hospitals with due regard to preventive and protective measures because it constitutes a fundamental risk for employees and for public health These materials include: liquid blood and blood products, needles and sharp objects, live and attenuated vaccines, body parts (with the exception of corpses and identifiable human body parts from miscarriages, mutilations and surgical operations), infectious laboratory cultures, infectious animal waste and any kind of waste material from the public health sector likely to cause infections with the following diseases: (infectious material named in the brackets) Haemorrhagic fevers caused by viruses: Congolese red fever, Lassa fever, Marburg, Ebola, Junin, Machupo, Arbo-virus, Absettarow, Hanzalova, Hypr, Kumlinge, Kiasanur-Forest disease, Omsk fever, Russian spring-summer encephalitis (any kind of human secretions, excrements, etc.); Brucellosis (pus); Diphtheria (diphtheria of the respiratory system: respiratory secretions, diphtheria of the skin: skin secretions); Cholera (excrements); Creutzfeld-Jacob disease (excretions); Glanders (skin secretions); Tularaemia (tularaemia of the lung: respiratory secretions, tularaemia of the skin: skin secretions); Anthrax (skin anthrax: pus, lung anthrax: skin secretions); Plague (bubonic plague: pus, pneumonic plague: respiratory secretions); Rabies (respiratory secretions); Q-fever (respiratory secretions); Active tuberculosis (respiratory secretions).
Note 3: Definition of infectious waste in UK NOTTINGHAM Ordinance on waste requiring supervision 1992 (SI 1992/588) Hospital waste is: a.
any waste consisting in whole or in part of the following components: human or animal tissue,
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b.
blood or other body fluids, excretions, drugs or other pharmaceutical products, swabs or dressings, syringes, needles or other sharp instruments hazardous for persons coming into contact with such waste unless it has been first safely treated. Also: any other waste from treatment, care, dental medicine, veterinary medicine, pharmacies or similar facilities, the examination, treatment, teaching or research, blood donations which can cause infections in persons coming into contact with it.
In Nottingham, hospital-specific waste is subdivided into five sub-categories, although all waste types are incinerated together externally. Group A: Contains the following components: identifiable human tissue*, blood, animal carcases and tissue from centres of veterinary medicine, hospitals and laboratories. Soiled surgical dressings, swabs and similar polluted waste. Other waste, for instance from patients with infectious diseases, except those belonging to Group B– E. Group B: Used syringe needles, cartridges, broken glass and other contaminated sharp objects or instruments to be disposed of. Group C: Microbial cultures and potentially infected waste from pathology and other clinical or research laboratories. Group D: Drugs and other pharmaceutical products. Group E: Items used for the disposal of urine, stool or other bodily secretions or excretions and which do not belong to Group A. These include used disposable bedpans or bedpan linings, incontinence drawsheets, urine bags and urine bottles.**
Note 4: Definition of infectious waste in France GRENOBLE: French ordinance No. 97-1048 6/11/1997 on the disposal of body parts and infectious waste from the public health sector. ArtR.44-1: Waste from the public health sector is waste originating from the diagnosis, monitoring and prevention, curative or palliative activities in the area of veterinary and human medicine. Waste subsumed under the above ordinance are waste
* All identifiable human tissue, whether infected or not, must be incinerated. ** If the risk assessment shows that there is no risk of infection, waste of Group E is not counted among the clinical waste.
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materials which: 1. constitute a risk of infection by containing viable micro-organisms or their toxins of which it is known or reasonably suspected that, by virtue of their nature, their quantity or their metabolism, they may cause diseases in humans or living organisms. 2. even if not infectious, but belonging to one of the following categories: sharp objects and materials destined for disposal, irrespective of whether they have come in contact with a biological product; blood products beyond the use-by date for therapeutic use; visually identifiable human body parts.
Waste from teaching, research and industrial production in veterinary and human medicine, also waste from pathology departments if they have the above properties under 1 and 2, belong to waste from the public health sector and are subject to this ordinance.
References 1. Analysis of Priority Waste Streams. Healthcare Waste. Information Document, Commission of the European Communities December 1993. 2. Moritz JM. Current legislation governing clinical waste disposal. J Hosp Infect 1995;30:521—530. 3. Generalitat de Catalunya. Guia de Gestio ´ Intracentre de Residus Sanitaris, Direccio ´ General de Salut Pu ´blica, 1994. 4. Health and Safety Commission, Safe disposal of clinical waste, 2nd ed. Suffolk: HSE Books; 1999. 5. Liberti L, Tursi A, Costantino N, Ferrara L, Nuzzo G, Optimization of infectious hospital waste management in Italy. Part I: Waste production and characterization study. Waste Manag Res 1994;12:373—385. 6. Ministe `re de l’emploi et de la solidarite ´: Elimination des de ´chets d’activite ´s de soins a ` risques: Guides techniques. Paris, 1999. 7. La ¨nderarbeitsgemeinschaft Abfall. Merkblatt u ¨ber die Vermeidung und die Entsorgung von Abfa ¨llen aus o ¨ffentlichen und privaten Einrichtungen des Gesundheitswesens, (Instructions concerning the Avoidance and Disposal of Waste Generated by Public and Private Health Service Institutions, published by the State Working Party on Waste [LAGA]) Bundesgesundhbl 35: 30—38. 8. Bundesgesundheitsamt. Richtlinie des Bundesgesundheitsamtes und der Deutschen Gesellschaft fu ¨r Krankenhaushygiene: Pru ¨ fung von Abfalldesinfektionsverfahren auf Wirksamkeit. Fassung vom 1.2.1993. BGBI 1993—02. 9. NHS Estates: Clinical waste disposal/treatment technologies (alternatives to incineration), Health technical memorandum HTM 2075, Stationery Office, 1998. 10. Basel Convention. Technical guideline on the environmentally sound management of biomedical and healthcare waste (Y1,Y2,Y3). Draft, 03/99.
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11. Pru ¨ss A, Giroult E, Rushbrook P, editors. Safe management of wastes from health-care activities. Geneva: WHO; 1999. 12. Collins CH, Kennedy DA. The microbiological hazards of municipal and clinical wastes. J Appl Bacteriol 1992;73:1—6. 13. Health and Safety Commission Advisory Committee on Dangerous Pathogens, Categorisation of biological agents according to hazard and categories of containment. Suffolk: HSE Books; 1995. ¨ ber die mikrobielle 14. Kalnowski G, Wiegand H, Ru ¨den H. U Kontamination von Abfa ¨llen aus dem Krankenhaus. Zbl Bakt Hyg B 1983;178:364—379. 15. Reinthaler FE. Bewertung von sogenannten ‘infektio ¨sen Abfa ¨llen’ und Empfehlungen fu ¨r die Entsorgung. Hyg Med 1994;19:463—470. 16. Rutala WA, Odette RL, Samsa GP. Management of infectious waste by US hospitals. JAMA 1989;262:1635—1640. 17. Audit Commission. Getting sorted: the safe and economic management of hospital waste, 1997. 18. NIOSH. Guidelines for protecting the safety and health of health care workers. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, Division of Standards Development and Technology Transfer, September 1988.
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19. NIOSH: Selecting, evaluating, and using sharps disposal containers, U.S. Department of Health and Human Services, CDC, NIOSH, 1998. 20. Health Services Advisory Committee. The management of health and safety in the health services. Suffolk: HSE Books, 1994. 21. Daschner F. Umweltschutz in Klinik und Praxis. Berlin: Springer; 1994. 22. Scherrer M, Daschner F. Infektio ¨sen Abfall verringern und kostengu ¨nstig entsorgen. Das Krankenhaus 1991;3:131—133. 23. Buekens A, Stieglitz L, Huang H, Cornelis E. Formation of dioxin in industrial combustors and pyrometallurgical plants. Environ Engng Sci 1998;15:29—36. 24. Robert-Koch-Institut, Liste der vom Robert Koch-Institut gepru ¨ften und anerkannten Desinfektionsmittel und—verfahren. Bundesgesundheitsblatt 2003;46:72—95. 25. Environment Agency: risk assessment for handling and disposal of clinical waste, RD Report P4-073/TR, 2002, 1—119. 26. Departament de Preside `ncia. DECRET 27/1999, de 9 de febrer, de la gestio ´ dels residus sanitaris. Diari Oficial de al Generalitat de Catalunya. Nu ´m 2828—16.02.1999.
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Comparison of infectious waste management in European hospitals ¨hlich*, M. Scherrer, F.D. Daschner M. Mu Institute for Environmental Medicine and Hospital Epidemiology, Freiburg University Hospital, Hugstetter Str. 55, 79106 Freiburg, Germany Received 28 January 2003; accepted 5 August 2003
KEYWORDS Infectious waste; Definition of waste types; Waste management; Waste treatment; Europe
Summary A research project sponsored by the EC-LIFE programme was conducted to compare waste management in five different European hospitals. A comparison of the regulations governing current waste management revealed different strategies for defining infectious hospital waste. The differences in the infrastructure were examined and the consequences for waste segregation and disposal were discussed under economic and ecological aspects. In this context the definition of infectious waste is very important. Q 2003 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction Waste is more than just rubbish to be disposed of and forgotten about. This fact is reflected in the increasing number of different waste disposal regulations1 – 7 and in the continuous development of waste segregation and treatment systems.8 – 11 Although there are still pronounced differences in the practical design of disposal systems, in most countries there is a growing awareness that the enormous volumes of waste generated not only result in huge disposal costs, but also that there is still a great deal of energy and re-usable material in waste which should not be carelessly discarded and ignored. In the assessment of hospital waste, the focus lies mainly on the biological hazards caused by *Corresponding author. Tel.: þ 49-761-270-5436; fax: þ 49761-270-5440. E-mail address: [email protected]
bacteria.12 – 16 In particular, the fact that biological systems are capable of reproducing themselves is considered to be very unpleasant. So far, the question of the extent to which hospital waste represents a suitable medium for the reproduction of bacteria has not been answered conclusively. However, studies on the bacterial content of hospital waste appear to indicate that it is not a very good culture medium for pathogens and disease transmission; so far, it has not been possible to provide a conclusive answer to the question as to whether, or at what point, any existing pathogens are transmitted from waste to humans. Empirical data show that it is mainly in intermediate animal hosts where pathogens, if allowed to multiply, can cause problems. But whether there are any differences in this respect between hospital waste and other waste remains unclear. Modern disposal technology, whether properly managed landfills or incinerator units, provide a great deal of protection.
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Methods
Results
The project described here investigated waste management policies in five hospitals in five different European countries. The project, which was funded by the EU Commission LIFE 96 programme (LIFE96/ENV/D/10) examined disposal practices, the applicable regulations, available infrastructure, climate conditions and the organization of waste collection and disposal in the hospitals. Regulations and guidance documents, relevant to waste management, were collected and compared. The results were summarized in a questionnaire on regulations pertaining to waste management. The influences on actual waste management practice were discussed in workshops with all the partners. To obtain an overview of waste management practice in each hospital, the Freiburg team developed a second questionnaire on waste disposal infrastructure and management. Waste management practice in each hospital was examined to confirm the results of the questionnaires. Existing waste disposal practice was discussed with local partners and experts. Local infrastructure for waste disposal also formed part of the survey. An analysis of waste was undertaken to obtain more detailed information about waste composition and waste segregation. Workshops were held to compare disposal practice in the different hospitals, the influence of legal stipulations and available local infrastructure. Among the issues addressed was the question of how different waste types are defined in the individual countries, how much leeway the definitions allow for optimized disposal practice in hospitals, and the reasons for existing differences and similarities. Basic considerations, such as the health and safety of patients and personnel,17 – 20 or ethical concerns have been addressed in the discussion of the differences between the hospitals included in the project. A high level of safety can be attained in a number of ways. Thus, besides considering the definition of waste materials, the study included handling, level of staff knowledge and the available infrastructure. The hospitals participating in the project were divided into two main groups and comprised large university hospitals with 1300 to 2100 beds (Freiburg, Nottingham and Grenoble) and smaller regional hospitals with 500 to 600 beds (Foril, Sabadell). The differences in the scope of the medical services provided or the hospitals’ research facilities did not influence the project, because the focus lay on internal medicine and surgical wards, all of which were present in the hospitals surveyed.
Classification of medical wastes from hospitals Rules and regulations pertaining to the current practice for the definition and disposal of healthcare waste vary widely in the countries surveyed. Specific legislation on hospital waste is only in place and enforced in Catalonia. With the exception of Italy, in all other countries classification and disposal of hospital waste is regulated by ordinances. In Italy, no specific rules exist, and the general law covering waste management provides only a very rough definition of hospital waste. Official guidance documents for hospital waste management are available in Grenoble, Nottingham, Sabadell and Freiburg. Infectious waste definitions vary widely. Contamination of materials with defined pathogens as a basis of classification as infectious waste is used in Freiburg and Sabadell (see Appendix, Notes 1 and 2). The other hospitals classify waste according to their source and/or the activities that produce them (see Appendix, Notes 3 and 4). Risk factors are not specified in greater detail. The European waste catalogue provides for a category of waste from hospitals, which, in terms of infection prevention, does not require any special precautionary measures (EWC: 180104). This means that waste, which is identified as having originated in hospital, is no longer automatically categorized as requiring special treatment. During discussions in the project, a ‘no risk healthcare waste’ category was generally approved. Eliminating ‘sharp objects’ as a separate category of waste, as presented in the European waste catalogue (EWC: 180101), was generally welcomed, as too was the definition of a separate category for cytostatic agents (EWC: 180108).
Disposal practice The amount of waste disposed off as infectious or hospital-specific differs widely in the hospitals surveyed. At Sabadell and Freiburg 3 – 4% of the total amount of waste generated is classified as infectious waste, in contrast to 28% at Grenoble, 40% at Nottingham and 51% at Forlı` (Figure 1). In three hospitals (Italy, Spain and Germany), infectious waste is collected in waste bins made of rigid material; these bins are used both for internal and external transport. The waste is only collected in plastic bags in areas where very little waste is generated (Spain, Germany). At Forlı`, reusable
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taken to another hospital, where it is sterilized in an autoclave and shredded. Following this process, waste disposal is as with conventional domestic waste. At Forlı` and Freiburg the waste is taken to a chemical waste incineration plant, where it is incinerated at approximately 1200 8C. Grenoble uses a domestic waste incinerator (800 8C) with a separate feed system for infectious waste. The transport distances necessary for waste disposal range from 4 km at Grenoble to several 100 km at Freiburg; this also increases the cost of disposal. Figure 1 Quantity distribution between domestic and hospital-specific waste. ( ) HS waste; ( ) D waste.
Cost of waste disposal in the different hospitals
metal containers lined with bin bags are used. These containers are closed at the point of collection and emptied directly into the furnace of the incineration plant, which is located on the city outskirts. Conversely, Grenoble and Nottingham use plastic bags for waste collection, which, when filled, are stored intermediately in wheeled waste containers. The wheeled containers are used for internal and external transport. Different colour codes are used by each hospital to mark the bins. Grenoble uses white bags with red stripes, Nottingham uses yellow bags with black labels, Freiburg uses black bags or black plastic containers with red covers while in Sabadell red bags or black plastic containers are used. In most cases, the source of the waste can only be determined from the internal transport route. However, this often ends in the intermediate storage area, which different work areas use. Only in Nottingham are the bags sealed with sticky tape denoting the work area. According to the definitions used at Grenoble, Forlı` and Nottingham, all waste generated by patients is considered to be infectious and is disposed of accordingly. At Freiburg and Sabadell, however, collecting infectious waste is restricted to defined areas agreed upon by the department of hospital hygiene or, the waste management team, respectively. These include all areas where patients are treated who have a disease, illness or condition covered by the definitions for infectious waste (see Appendix, Notes 1 and 2). Thus, these hospitals also run patient-care areas where no waste is generated that fits the classification criteria for infectious waste. With the exception of Sabadell, which has no incineration plant, the infectious waste of the hospitals participating in the project is normally sent for incineration. At Sabadell, the waste is
As the costs of the different disposal routes are a very important factor in the evaluation, the disposal costs incurred by the project hospitals are dealt with in greater detail at this point. Figure 2 shows the costs per tonne for the disposal of domestic-type waste (D waste) and of hospitalspecific and/or infectious waste (HS waste). As expected, dumping the D waste is the most cost-effective solution. The landfill charges in Sabadell near Barcelona are remarkably low. In Freiburg, dumping charges are only fractionally lower than the incineration costs in Forlı` and Nottingham. As the choice between domestic waste incineration and dumping usually depends on local conditions for the disposal of municipal domestic waste, most hospitals have no option. The enormous difference in costs between HS waste and D waste is remarkable in every hospital. This difference is particularly noticeable in Barcelona, where almost 70 tonnes of D waste can be disposed of for the price of 1 tonne of HS waste. In
Figure 2 Disposal costs for domestic-type waste ( ) D waste; and hospital specific waste ( ) HS waste.
Infectious waste management in European hospitals
contrast, the difference between D waste and HS waste is smallest in Grenoble. At Forlı`, the disposal costs for HS waste also include transport charges within the hospital and the costs for containers and other equipment, because it is included in the service of the disposal firm.
Disposal of sharp objects One particular feature of the Freiburg system is the disposal of sharp objects at the local dump. The containers for disposal of sharp objects are collected and transported separately from the D waste, because compaction of this type of waste must be avoided. At the landfill site these objects are also deposited in an area that is not as densely compacted as the D waste area. Because of the separate treatment required, the landfill charges for this type of waste are also higher than for D waste. This system is based on the classification of sharp objects as a waste category that requires special care and attention in its handling inside the hospital, but which can be classed as D waste outside the hospital. The structure of the European waste catalogue also fails to classify sharp objects as hazardous waste, but other project hospitals classify them as dangerous waste requiring disposal accordingly.
Discussion Definitions of infectious waste A central issue concerning hospital waste disposal is the assessment of the real and potential risks emanating from waste with the focus on the risk of infection. This is reflected in the different definitions developed by the individual countries. In general, two strategies are applied for definition of infectious waste: Catalonia (Spain) and Germany largely apply a narrow pathogen-related definition of waste management. In the other countries, waste is classified in terms of its source and the activity producing it. The risks are not specified in greater detail. Medical knowledge of disease transmission or the suspicion that they may cause certain infectious diseases suffice to define waste as infectious. Examples are used in the regulations to provide closer descriptions of waste types, but as the descriptions are incomplete or inconclusive, it is left to the hospitals to interpret and implement the definitions.
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More accurate definitions are therefore left to the hospitals themselves. Because it is difficult for hospitals to decide which wastes are infectious and which are not, there is an undesirable tendency to classify all waste as HS (infectious). This problem is further exacerbated by the attitude of the public, which assumes hospital-specific waste poses a high risk.
Disposal practice A comparison of disposal practice in the hospitals participating in the project showed three basic approaches to deal with the classification of HS: material composition and/or contamination, source and activity whereby it was produced. In practice, a mixture of these criteria is normally applied with different focal points in the evaluation of these criteria. In waste classified as infectious, contamination with organic material originating from a patient is decisive. However, in practice, assessing contamination is very difficult, with the effect that the site or the activity is determined as a second best option. Activity If the activities producing the waste are taken as a measure of infectiousness, and if it is stipulated that all waste originating from patient care should be classified as potentially dangerous, containers for HS should be placed wherever patients are nursed or treated. However, as domestic type waste is also generated in patient-care areas, this system usually involves placing two containers next to each other. This means that the staff have the added difficulty of correctly classifying and sorting the waste. In the experience of this project, this procedure usually results in a greater volume of hospital-specific (infectious) waste as shown in Figure 1 by the example of Forlı`. Adequate staff training and clear information material are necessary for proper waste segregation. The success of the system used should be reviewed and discussed with the staff at regular intervals. Source of waste From the point of view of easier orientation for personnel, it is advisable to determine the sites and locations where infectious waste may and may not be expected and to provide the appropriate waste collection bins. This avoids the problem of incorrect sorting mentioned above, but it also means that more wastes are classified as HS (infectious). Waste management in Nottingham is organized in this way (Figure 1). An inherent problem in this system is
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that of training personnel in such a way that there is no confusion when placing and emptying the containers. This is why the waste types to be collected at the collection points should be identifiable independently of the waste containers, e.g. by a sign on the wall. Material and/or contamination If the focus lies on evaluation of the material and/or contamination, blood and body fluids will be the main source of problems during proper sorting. If waste is always classed as infectious when it comes into contact with blood, secretions or excretions, it will be very difficult to assign areas where no infectious waste is expected and where, as a consequence, a container does not need to be provided for this waste category. This is why it is necessary to define clear contamination assessment criteria that enables personnel to sort and assign the waste quickly and without complication. At Freiburg University Hospital, the issue of waste containers used for infectious waste is controlled by the Department of Hygiene and is subject to strict criteria (patients with defined diseases and defined material and/or contamination with material containing bacteria), so that wards that have no patients with infectious diseases normally have no collection containers for infectious waste.21 – 22 There are also other defined areas such as the dialysis unit, the blood bank or the operating theatres, where larger quantities of blood, body fluids or tissue are generated, and where infectious waste is continuously collected. Sorting by material and/or degree of contamination is only possible if the definitions show a clear distinction between the different types of waste. If the definition of HS waste relates not to known risks, but to suspected risks, hospitals will find it relatively difficult to draw clear demarcation lines. The best approach in this case may be to determine what waste from patient treatment areas can be safely disposed of as domestic waste. Again, staff training and information is essential for successful waste segregation. The above focal points for the disposal of HS waste constitute a relatively far-reaching abstraction, which is not practised ‘in its purest form’ in any of the hospitals. They merely constitute different approaches to implementing the definitions of waste, with the appropriate consequences for the quantity of the different waste categories (Figure 1). They also account for the external legislative measures that hospitals face and that are intended to ensure that no risk emanates from hospital waste.
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Disposal safety In some cases comparison of disposal practices at the point of collection showed surprisingly few differences between D waste and HS waste. Both waste types are collected in plastic bags and lifted into waste containers for immediate storage. Assuming that no one in the community will come into contact with the waste much of this waste could also undergo disposal as D waste. Therefore it would be helpful to examine in greater detail at what points along the disposal route problems with infectious agents might arise. This would reduce risk and the cost of disposal.
Cost of waste disposal To illustrate the economic consequences of waste segregation for the individual hospitals, the effects of classifying the waste into D waste and HS waste on the overall costs for hospital waste disposal were compared. The difference in costs that would result if the same distribution system were applied to other hospitals were computed on the basis of both extremes i.e. in respect of quantity of HS waste (Barcelona: 2.7%; Forlı`: 50.8%). Separating waste into HS waste and D waste, as practised in Barcelona, would result in savings of between e200,000 and e290,000 per year in hospitals with a higher proportion of HS waste. Figure 3 shows the present segregation in comparison with the distribution pattern in Barcelona. Conversely, if the Sabadell hospital had the same percentage quantity of HS waste as Forlı`, the cost would be unmanageable. On the basis of their present HS waste disposal charges, the cost of waste disposal would rise by more than e1,000,000
Figure 3 Hypothetical disposal costs for waste segregation as practised in Barcelona. ( ) D waste 1998; ( ) D waste 97.3% (as in Barcelona); ( ) HS waste 1998; ( ) HS waste 2.7% (as in Barcelona); ( ) difference.
Infectious waste management in European hospitals
per year at this hospital. Freiburg would also have to spend an extra e800,000 on waste disposal if the proportion of HS waste and D waste were identical to that at Forlı`. These sample calculations are designed to show the impact that the segregation of waste has on the cost of waste disposal.
External waste treatment Unfortunately, as yet there are no scientific data on whether the discharging of HS waste into the waste bunker of the incineration plant and simultaneous feeding with D waste poses any health risks to personnel and members of the community. As the HS waste in the examples shown is only placed in bags, which are then dumped in the reusable transport containers, it is to be expected that they will burst open when the containers are emptied into the waste bunker. More detailed scientific investigations are also urgently needed to verify whether there are any good reasons for high temperature incineration of HS waste. Extreme temperature stability is known of a limited number of cytostatic agents that could conceivably escape through the chimney. Therefore it is necessary to collect this waste type separately and dispose of it as chemical waste. A temperature of 800 8C is adequate to kill pathogenic micro-organisms. Burning HS waste in D waste incineration plants, as already practised at Grenoble, might also be an interesting future option for others. Trials involving this disposal route are now taking place in England. A high-quality flue gas cleaning system must be used, regardless of the incineration temperature, because volatile exhaust gas components can also form dioxins after burning.23 Particularly when compared with the enormous expense of incinerating HS waste at high temperature, which is often associated with long transport routes to suitable plants, local pre-treatment
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appears to offer a very reasonable alternative. This may be of particular interest in countries with a high proportion of HS waste. Furthermore, local pre-treatment does not require the expensive packaging prescribed for road transport of hazardous goods. Proof that the method of pre-treatment is successful and safe must be provided. In Germany, the Robert Koch Institute has issued a list of approved disinfection methods, including waste disinfection.24
Evaluation of current waste disposal practice In discussions between the project partners, it transpired that it is difficult at present to find a common denominator for defining HS waste, because estimation of the risks, particularly those involving the health and safety of personnel, still vary widely. However, it proved easier to find a common standpoint with respect to the waste disposal routes employed outside the hospitals. An outline of the agreements reached on waste disposal is given in Table I. One important question that arose was why there is so little information on the risks involved in waste disposal. In the 1980s investigations conducted in Germany and Austria on the pathogenic spectrum in hospital waste raised the question as to whether, in terms of hygiene, assumptions of the levels of potential risk were realistic. The outcome of these studies is that in Germany one is oriented toward known risks, and this in turn has resulted in a drastic drop in the quantities disposed of as infectious waste. Unfortunately, there are few concomitant studies showing that these waste management strategies increase risk to personnel. One approach for the future might involve emphasizing the risk to personnel and carrying out more detailed scientific research in this direction. Recently, the UK Environmental Agency published an interesting
Table I Proposals for assigning the different waste types to various disposal routes Type of waste Domestic-type waste Hospital-specific waste Infectious waste
Cytostatic agents Sharp-edged objects
Remarks Without hospital-specific waste Without risks of infection (a) After waste treatment to eliminate any risk of infection (e.g. disinfection) (b) Without waste treatment (a) Traces of contamination (b) Severe contamination Pierce-proof, labelled containers
Proposal for disposal route As municipal domestic wastes As 1, but without direct contact (a) As 2 (b) Incineration like domestic waste (a) As 2 (b) High temperature incineration Dumping or incineration like domestic waste
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study on this topic, in which hazards are ranked according to the severity and the likelihood.25 This paper has highlighted the problems of assigning and sorting waste. There is also the problem that there are differences in ones approach to how risk is assessed in different countries, which means they select and sort waste differently. It remains to be determined whether the safety levels necessary for handling normal domestic waste cater sufficiently for the needs of most hospital waste, which, today, is still classified as potentially infectious.
Appendix Note 1: Definition of infectious waste in Germany7 FREIBURG: Group C: Waste which, from the point of view of infection prevention, requires special supervision and care during disposal inside and outside the public health sector (so-called infectious, contagious or highly contagious waste): Waste requiring treatment in accordance with § l0a Federal Epidemic Law. This applies, if the waste is contaminated with the pathogens of infectious diseases requiring registration and if the spread of the disease is therefore to be expected. The necessity for additional requirements (e.g. separate collection, disinfection) is defined by the nature of the pathogens involved i.e. in respect of their contagiousness, survival capability and transmission routes, the extent and the nature of the contamination, and the waste quantity. Waste belonging to this group can cause the following diseases: Cholera, diphtheria, leprosy, tularaemia, anthrax, typhoid, paratyphoid, virus-induced haemorrhagic fevers, plague, brucellosis, smallpox, meningitis/encephalitis, poliomyelitis, Q-fever, dysentery, farcy, rabies, tuberculosis, viral hepatitis. Wastes of this type can, for instance, be generated in infection wards, dialysis wards and dialysis centres with yellow dialysis, pathology departments, blood banks and doctors’ surgeries and in veterinary surgeries and hospitals. This is usually waste generated during the treatment of patients, e.g. material contaminated with secretions or excretions containing pathogens; packaging materials are normally not included. This waste also includes microbiological cultures generated in hygiene institutes, microbiology,
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virology, or medical laboratories and in doctors’ surgeries.
Note 2: Definition of infectious waste in Catalonia (Spain)26 SABADELL (BARCELONA) Group III: Non-specific waste from the public health sector is waste which must be handled, collected, transported and disposed of within and without the hospitals with due regard to preventive and protective measures because it constitutes a fundamental risk for employees and for public health These materials include: liquid blood and blood products, needles and sharp objects, live and attenuated vaccines, body parts (with the exception of corpses and identifiable human body parts from miscarriages, mutilations and surgical operations), infectious laboratory cultures, infectious animal waste and any kind of waste material from the public health sector likely to cause infections with the following diseases: (infectious material named in the brackets) Haemorrhagic fevers caused by viruses: Congolese red fever, Lassa fever, Marburg, Ebola, Junin, Machupo, Arbo-virus, Absettarow, Hanzalova, Hypr, Kumlinge, Kiasanur-Forest disease, Omsk fever, Russian spring-summer encephalitis (any kind of human secretions, excrements, etc.); Brucellosis (pus); Diphtheria (diphtheria of the respiratory system: respiratory secretions, diphtheria of the skin: skin secretions); Cholera (excrements); Creutzfeld-Jacob disease (excretions); Glanders (skin secretions); Tularaemia (tularaemia of the lung: respiratory secretions, tularaemia of the skin: skin secretions); Anthrax (skin anthrax: pus, lung anthrax: skin secretions); Plague (bubonic plague: pus, pneumonic plague: respiratory secretions); Rabies (respiratory secretions); Q-fever (respiratory secretions); Active tuberculosis (respiratory secretions).
Note 3: Definition of infectious waste in UK NOTTINGHAM Ordinance on waste requiring supervision 1992 (SI 1992/588) Hospital waste is: a.
any waste consisting in whole or in part of the following components: human or animal tissue,
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b.
blood or other body fluids, excretions, drugs or other pharmaceutical products, swabs or dressings, syringes, needles or other sharp instruments hazardous for persons coming into contact with such waste unless it has been first safely treated. Also: any other waste from treatment, care, dental medicine, veterinary medicine, pharmacies or similar facilities, the examination, treatment, teaching or research, blood donations which can cause infections in persons coming into contact with it.
In Nottingham, hospital-specific waste is subdivided into five sub-categories, although all waste types are incinerated together externally. Group A: Contains the following components: identifiable human tissue*, blood, animal carcases and tissue from centres of veterinary medicine, hospitals and laboratories. Soiled surgical dressings, swabs and similar polluted waste. Other waste, for instance from patients with infectious diseases, except those belonging to Group B– E. Group B: Used syringe needles, cartridges, broken glass and other contaminated sharp objects or instruments to be disposed of. Group C: Microbial cultures and potentially infected waste from pathology and other clinical or research laboratories. Group D: Drugs and other pharmaceutical products. Group E: Items used for the disposal of urine, stool or other bodily secretions or excretions and which do not belong to Group A. These include used disposable bedpans or bedpan linings, incontinence drawsheets, urine bags and urine bottles.**
Note 4: Definition of infectious waste in France GRENOBLE: French ordinance No. 97-1048 6/11/1997 on the disposal of body parts and infectious waste from the public health sector. ArtR.44-1: Waste from the public health sector is waste originating from the diagnosis, monitoring and prevention, curative or palliative activities in the area of veterinary and human medicine. Waste subsumed under the above ordinance are waste
* All identifiable human tissue, whether infected or not, must be incinerated. ** If the risk assessment shows that there is no risk of infection, waste of Group E is not counted among the clinical waste.
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materials which: 1. constitute a risk of infection by containing viable micro-organisms or their toxins of which it is known or reasonably suspected that, by virtue of their nature, their quantity or their metabolism, they may cause diseases in humans or living organisms. 2. even if not infectious, but belonging to one of the following categories: sharp objects and materials destined for disposal, irrespective of whether they have come in contact with a biological product; blood products beyond the use-by date for therapeutic use; visually identifiable human body parts.
Waste from teaching, research and industrial production in veterinary and human medicine, also waste from pathology departments if they have the above properties under 1 and 2, belong to waste from the public health sector and are subject to this ordinance.
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