Emergency Preparedness

October 16, 2011

Emergency Preparedness: Reconsidering On-site Disposal Options
By Alice P. Jacobsohn
When hospital and emergency responders are asked about emergency preparedness, the talk immediately turns to the possibility of a surge in the number of patients affected by disasters external to their facilities such as earthquakes, terrorist attacks, or epidemics. 

Some responders consider the management of patients when the hospital is located in a disaster area and becomes damaged such as flooding or loss of electricity caused by a hurricane. Often, patient care is where emergency preparedness stops. With the recent Ebola outbreak, we are finding very little preparedness for highly infectious waste, struggling with gaps in available disposal technology.

“There is a range of preparedness at hospitals, but we need to pre-designate facilities to handle specialized diseases,” said Darrell Henry, Executive Director, Healthcare Coalition for Emergency Preparedness, Washington, DC. He added, “These centers should have on-site sterilization technology.”

Henry is not alone in emphasizing on-site treatment options. The World Health Organization issued guidance in December 2014, stating, “It is not recommended to transport untreated infectious waste and therefore all waste should be treated on-site” (Ebola virus disease – Key questions and answers concerning healthcare waste).

According to the Centers for Disease Control and Prevention (CDC), as of February 13, 2015, there are 55 hospitals prepared to handle Ebola patients. These are located in 18 states and Washington, DC. The minimum requirements for this designation include securing the services of a waste management company capable of managing and transporting Category A waste, the classification adopted by the U.S. Department of Transportation (DOT) that includes Ebola waste. The designation requirements do not mention on-site disposal technology capabilities, although this is an option.

For most hospital decision-makers focused on keeping their institution’s in the black, spending resources on emergency preparedness lacks the appeal of robotic operating rooms and the latest technology to zap away cancer cells. Even when considering emergency preparedness, waste disposal options take second seat to the costs of isolation rooms and training of doctors and nurses.

Why should a hospital invest in emergency response and infectious waste disposal especially when there have been so few cases of Ebola or any other exotic diseases recently in the United States?

Henry responded, “While the daily risk is low, the potential is very high.” People do not select a hospital because of the facility’s waste disposal operations, but Henry says, “If people lose confidence in a hospital, they won’t get treated. We need to avoid creating a public health crisis.”

The situation at Texas Health Presbyterian Hospital in Dallas last October when two nurses became ill after treating an Ebola patient and where waste was shipped to a Port Arthur, Texas incinerator 325 miles away, raises the concern about public confidence and waste disposal options. According to hospital officials, Bellevue Hospital in New York City spent about $100,000 a day on waste disposal from one patient. This is compared to national disposal averages of between 18 and 50 cents per pound of medical waste with two to eight pounds per patient generated daily.

Henry’s coalition recommends a different approach to justifying emergency preparedness with on-site disposal methods. He said, “You have to look at the cost-benefit analysis and integrate emergency preparedness with daily operations.” This approach is different because rather than look at how to fund an emergency system that may never be needed, a hospital is spending the money required to manage the waste it generates every day and ensuring that the daily program can address a spike in loads should an emergency occur.

When the medical waste disposal company at Emory University Hospital in Atlanta last fall refused to accept Ebola-contaminated waste, the hospital borrowed a large, high-pressure autoclave from its university to treat the 40 bags of Ebola waste generated each day. Nebraska Medical Center in Omaha is likely the most prepared facility with an on-site biocontainment unit, but even after sending the waste through its autoclave, that waste was re-bagged and managed as regulated medical waste.

Why are on-site disposal methods lacking?

The first time that infectious waste was formally recognized as a waste stream was in 1978, when the U.S. Congress through Subtitle C of the Resource Conservation and Recovery Act included “infectious” as a criterion to consider for hazardous waste regulation. However, when the U.S. Environmental Protection Agency (EPA) developed the associated regulations in 1980, infectious waste management was not included. After medical waste washed up on New Jersey beaches in the early 1980s, Congress passed the Medical Waste Tracking Act creating a pilot program for regulation of infectious waste. The pilot program ended in 1991 with EPA deciding not to regulate. In the meantime, in 1987, the CDC issued recommendations on infectious waste management in its universal precautions guidance. By 1989, 84 percent of states were regulating medical waste. Other agencies such as the Occupational Safety and Health Administration and the DOT also began regulating medical waste in the 1980s.

Because of all these agencies’ activities regarding medical waste management, hospitals began seeking treatment and disposal options. At that time, very few off-site options were available. Therefore, hospitals installed incinerators, the available disposal method in the 1980s. A report to Congress by the Office of Technology Assessment, found that in 1988, 80 percent of hospital medical waste was incinerated.

This all changed when Congress passed the Clean Air Act over health concerns from air emissions. The law required EPA to regulate major pollutant sources, including medical waste incinerators. In 1997, when EPA promulgated final standards, the agency reported that 2,400 incinerators existed. In 2009, when EPA issued new standards, only 22 commercial incinerators were left and most of these were not located on-site at hospitals.

“Many hospitals tried to upgrade their incinerators to comply with the new requirements,” said Arthur McCoy, Senior Vice President, San-I-Pak World Health Systems, Tracy, California. He added, “Hospitals spent millions of dollars and their incinerators still failed to meet the standards so they became gun shy about spending more money for on-site treatment. The incinerators were removed and transporters were hired as an interim measure, but then transporting became permanent.”

Today, only 20 percent of hospitals house on-site options and many of these are not large enough to handle the volumes of waste from Ebola patients. The other 80 percent of hospitals contract with a medical waste hauling company to carry containerized waste to state-permitted disposal facilities. Ninety-five percent of medical waste is autoclaved, but this number is changing with other technologies on the market. These include ozone systems, plasma arc methods, pyrolysis, microwaves, chemical treatments, and electron-beam technology.

In an ozone disposal system waste is shredded and then treated with high levels of ozone killing the pathogens. Ozone is considered a natural sterilization agent. The process does not involve heat. Hancock Regional Hospital in Greenfield, Indiana is operating an ozone system, as is Union Hospital in Terre Haute, Indiana. Other commercial units are located in Aurora, Colorado and Indio, California.

In plasma arc technology instead of burning the waste like an incinerator, the waste is heated to a much higher temperature such that the waste melts and then vaporizes. This is done by an electrical device known as a plasma arc, which is a kind of super-hot torch made by passing gas through an electrical spark. The technology has mostly been used for metal cutting and treating sewage sludge.

Pyrolysis is a gasification process that uses heat in the absence of oxygen. Unlike traditional incineration, the flame never touches the waste and no outside air is added to the chamber, thus the waste does not combust and create air emissions and particulate matter. Several units are operational in the U.S. in California and Hawaii. A company from the United Kingdom sent a unit to West Africa to help manage Ebola waste.

Microwaves refers to electromagnetic energy having a frequency higher than 1 gigahertz (billions of cycles per second), corresponding to wavelengths shorter than 30 centimeters. Waste is shredded and high temperature steam is added and then the waste is subjected to electromagnetic energy destroying the pathogens. A number of units are commercially available in the U.S. The first unit was installed in 1990 at Forsyth Memorial Hospital in Winston-Salem, North Carolina.

Chemical treatments are mostly used as disinfectants on hard surfaces. Some of the Ebola waste management guidance, issued by state and federal agencies, recommend adding bleach to medical waste going off-site as a means of reducing risk. A commercial-size medical waste disposal unit was installed at Blue Mountain Hospital in Salt Lake City, Utah.

Electron-beam processing involves exposing the waste to a stream of high energy (fast) electrons that are attracted back to positive ions, causing a chemical reaction that kills the infectious substances. An electron-beam system is located at the Laboratories for Pollution Control Technologies at the University of Miami, in Florida, and in partnership with Jackson Memorial Medical Center.

Most of the 55 designated Ebola centers use off-site treatment. “I do know that waste disposal for Ebola-related cases, suspected or otherwise, is done off-site,” stated Lorna Wong, Director, Media Relations and News Office, in describing the process for the University of Chicago Medicine and Biological Sciences Center, Chicago, Illinois. According to the New York Department of Environmental Conservation, all of the designated New York City hospitals have off-site disposal arrangements.

Most of the outsourced services for hospital medical waste management are for Category B or regulated medical waste and do not cover Category A materials. For hospitals that have commercial-size on-site disposal technology, the majority made purchase decisions based on managing Category B waste. For those states issuing their own disposal facility guidance or regulations, separate permission is often required to accept Category A waste. Regardless of regulatory requirements and on-site or off-site arrangements, disposal technology should be tested to manage Category A waste if the equipment will be used for that purpose.

Since the first cases of Ebola patients in the U.S., the DOT issued an advisory on transportation requirements associated with Ebola waste. The advisory directs the regulated community to existing regulations for Category A materials that require more stringent packaging than regulated medical waste. These regulations apply to transport in non-bulk packaging. To date, only ten companies have received a special permit for transporting Ebola-contaminated waste in large packaging. Some of these permits will expire at the end of March 2015 if not renewed.

“I believe that on-site treatment will increase in the future because it is cheaper to manage waste that way,” said McCoy. He added, “I don’t say that on-site is better because I am a vendor. We have shown that on-site disposal is 70 percent cheaper than off-site disposal. I encourage any hospital looking at options to visit a hospital with an on-site system to see for themselves.”

McCoy described what a hospital should do to make a decision on waste management. He indicated, “The first step in the process is to perform a complete survey of the hospital for all waste streams -- solid, medical, and hazardous. This survey includes measuring upfront capital investment, labor, utilities, maintenance, consumables such as autoclave bags and liners, and landfill costs. Step two is a survey of the area, engineering work, to see how the technology will fit into the hospital’s space. And step three is to design a unit to fit the space and the needs of the hospital.”

These steps imply a careful analysis of material handling systems at a hospital both to reduce the total waste generated and to minimize the risk of exposure. McCoy and Henry agree that risk of liability is a huge factor in a hospital’s decision. “A hospital never relinquishes its liability for medical waste even when outsourcing,” said Henry. This is in reference to federal transportation regulations that hold the shipper or generator responsible until the final disposal site accepts the waste. “A hospital can reduce its risk by eliminating artificial transfer to a transporter with on-site management,” said McCoy.

The initial confusion and subsequent progress made on the management of Ebola-contaminated waste should serve as a wake-up call for hospitals to reassess their waste disposal options. Since EPA shut down most of the hospital waste incinerators, emerging diseases have increased, creating a gap in our knowledge of best practices for waste management. The available medical waste disposal technologies may be effective, but were originally designed to manage normal, daily loads. Many of these technologies will work well as part of an integrated waste management system that considers all hospital waste streams.

Alice P. Jacobsohn is a government relations leader and attorney with a focus on assisting industry in understanding regulatory requirements, participating in the legislative and regulatory process, and positioning themselves for growth. She can be reached atalicej5251@gmail.com.