A pilot survey of the U.S. medical waste industry to determine training needs for safely handling highly infectious waste

Risk Management for Whole-Process Safe Disposal of Medical Waste: Progress and Challenges

Over the past decade, the global outbreaks of SARS, influenza A (H1N1), COVID-19, and other major infectious diseases have exposed the insufficient capacity for emergency disposal of medical waste in numerous countries and regions. Particularly during epidemics of major infectious diseases, medical waste exhibits new characteristics such as accelerated growth rate, heightened risk level, and more stringent disposal requirements. Consequently, there is an urgent need for advanced theoretical approaches that can perceive, predict, evaluate, and control risks associated with safe disposal throughout the entire process in a timely, accurate, efficient, and comprehensive manner. This article provides a systematic review of relevant research on collection, storage, transportation, and disposal of medical waste throughout its entirety to illustrate the current state of safe disposal practices. Building upon this foundation and leveraging emerging information technologies like Internet of Things (IoT), cloud computing, big data analytics, and artificial intelligence (AI), we deeply contemplate future research directions with an aim to minimize risks across all stages of medical waste disposal while offering valuable references and decision support to further advance safe disposal practices.

Use of semi-permeable bag materials to facilitate on-site treatment of biological agent-contaminated waste

Clean up following the wide-area release of a persistent biological agent has the potential to generate significant waste. Waste containing residual levels of biological contaminants may require off-site shipment under the U.S. Department of Transportation's (US DOT) solid waste regulations for Category A infectious agents, which has packaging and size limitations that do not accommodate large quantities. Treating the waste on-site to inactivate the bio-contaminants could alleviate the need for Category A shipping and open the possibility for categorizing the waste as conventional solid waste with similar shipping requirements as municipal garbage. To collect and package waste for on-site treatment, a semi-permeable nonwoven-based fabric was developed. The fabric was designed to contain residual bio-contaminants while providing sufficient permeability for penetration by a gaseous decontamination agent. The nonwoven fabric was tested in two bench-scale experiments. First, decontamination efficacy and gas permeability were evaluated by placing test coupons inoculated with spores of a Bacillus anthracis surrogate inside the nonwoven material. After chlorine dioxide fumigation, the coupons were analyzed for spore viability and results showed a ≥6 Log reduction on all test materials except glass. Second, filters cut from the nonwoven material were tested in parallel with commercially available cellulose acetate filters having a known pore size (0.45 μm) and results demonstrate that the two materials have similar permeability characteristics. Overall, results suggest that the nonwoven material could be used to package waste at the point of generation and then moved to a nearby staging area where it could be fumigated to inactivate bio-contaminants.

Anti-cancer drug waste disposal practices and wastewater management in hospitals: A Lebanese survey

INTRODUCTION

To achieve continuous environmental sustainability and protect the population's health, healthcare waste (in liquid or solid form) needs appropriate management and suitable treatment strategies before its final disposal in the environment in order to reduce its adverse impacts. This study aims to identify disparities in the waste management of anti-cancer drugs and the wastewater generated in Lebanese hospitals.

METHODS

Three questionnaires were designed to evaluate the level of knowledge, awareness and experience of hospital personnel regardless of their job levels. Data was collected in December 2019 from three departments of each participating hospital: pharmacy, oncology and maintenance departments. A descriptive analysis was conducted to summarise the survey results.

RESULTS

The results revealed a lack of transparency and awareness of the participants, with a high frequency of 'prefer not to say' responses when asked about the disposal methods of anti-cancer drugs and with only 5.7% of the participants in the pharmacy department sharing their disposal procedures. The same perception was deduced regarding hospitals' wastewater treatment, where responses were often contradicting, preventing making assumptions about the fate of hospital wastewater.

CONCLUSION

The results of this survey support the need to establish a more comprehensive waste management programme in Lebanon that would be maintained through regular training and supervision.

Characterization of perceived biohazard exposures, personal protective equipment, and training resources among a sample of formal U.S. solid waste workers: A pilot study

In the United States, the majority of waste workers work with solid waste. In solid waste operations, collection, sorting, and disposal can lead to elevated biohazard exposures (e.g., bioaerosols, bloodborne and other pathogens, human and animal excreta). This cross-sectional pilot study aimed to characterize solid waste worker perception of biohazard exposures, as well as worker preparedness and available resources (e.g., access to personal protective equipment, level of training) to address potential biohazard exposures. Three sites were surveyed: (1) a family-owned, small-scale waste disposal facility, (2) a county-level, recycling-only facility, and (3) an industrial-sized, large-scale facility that contains a hauling and landfill division. Survey items characterized occupational biohazards, resources to mitigate and manage those biohazards, and worker perceptions of biohazard exposures. Descriptive statistics were generated. The majority of workers did not report regularly coming into contact with blood, feces, and bodily fluids (79%). As such, less than one-fifth were extremely concerned about potential illness from biological exposures (19%). Yet, most workers surveyed (71%) reported an accidental laceration/cut that would potentially expose workers to biohazards. This study highlights the need for additional research on knowledge of exposure pathways and perceptions of the severity of exposure among this occupational group.

Transport of High-Risk Infectious Substances: Packaging for the Transport of Category A Infectious Specimens in Spain

Infectious specimens and materials with pathogens included in Category A of the European Agreement concerning the International Carriage of Dangerous Goods by Road (ADR) must be transported following Packing Instruction P620. A triple packaging system must include leakproof receptacles and impact-resistant packaging to preserve the integrity of the samples and prevent the release of their content in any event during transport. ADR Packing Instruction P620 indicates that the primary receptacle or secondary packaging must withstand, without leakage, an internal pressure not less than 95 kPa at temperatures ranging from -40 °C to +55 °C. This study analyzes various packaging systems available in the Spanish market for the transportation of infectious samples to determine if they comply with the overpressure test, the most difficult to meet according to Packing Instruction P620. Five packaging systems were selected in this study. None of the secondary packaging tested showed adequate characteristics to withstand the pressure leakproof test. In this case, a primary receptacle (containing the sample directly) capable of withstanding an internal pressure of 95 kPa without leakage must be used (for example: test tubes with screw caps). However, manufacturer or distributor specifications are not always clear or readily available in this regard. Health, laboratory, and carrier personnel should be aware of the ADR regulation and packaging characteristics for safe and secure handling and transportation of high-risk Category A infectious materials.

Best practices of highly infectious decedent management: Consensus recommendations from an international expert workshop

With the increasing number of highly infectious disease incidents, outbreaks, and pandemics in our society (e.g., Ebola virus disease, Lassa fever, coronavirus diseases), the need for consensus and best practices on highly infectious decedent management is critical. In January 2020, a workshop of subject matter experts from across the world convened to discuss highly infectious live patient transport and highly infectious decedent management best practices. This commentary focuses on the highly infectious decedent management component of the workshop. The absence of guidance or disparate guidance on highly infectious decedent management can increase occupational safety and health risks for death care sector workers. To address this issue, the authorship presents these consensus recommendations on best practices in highly infectious decedent management, including discussion of what is considered a highly infectious decedent; scalability and storage for casualty events; integration of key stakeholders; infection control and facility considerations; transport; care and autopsy; psychological, ethical, and cultural considerations as well as multi-national care perspectives. These consensus recommendations are not intended to be exhaustive but rather to underscore this overlooked area and serve as a starting point for much-needed conversations.

Clinical Laboratory Biosafety Gaps: Lessons Learned from Past Outbreaks Reveal a Path to a Safer Future

Patient care and public health require timely, reliable laboratory testing. However, clinical laboratory professionals rarely know whether patient specimens contain infectious agents, making ensuring biosafety while performing testing procedures challenging. The importance of biosafety in clinical laboratories was highlighted during the 2014 Ebola outbreak, where concerns about biosafety resulted in delayed diagnoses and contributed to patient deaths. This review is a collaboration between subject matter experts from large and small laboratories and the federal government to evaluate the capability of clinical laboratories to manage biosafety risks and safely test patient specimens. We discuss the complexity of clinical laboratories, including anatomic pathology, and describe how applying current biosafety guidance may be difficult as these guidelines, largely based on practices in research laboratories, do not always correspond to the unique clinical laboratory environments and their specialized equipment and processes. We retrospectively describe the biosafety gaps and opportunities for improvement in the areas of risk assessment and management; automated and manual laboratory disciplines; specimen collection, processing, and storage; test utilization; equipment and instrumentation safety; disinfection practices; personal protective equipment; waste management; laboratory personnel training and competency assessment; accreditation processes; and ethical guidance. Also addressed are the unique biosafety challenges successfully handled by a Texas community hospital clinical laboratory that performed testing for patients with Ebola without a formal biocontainment unit. The gaps in knowledge and practices identified in previous and ongoing outbreaks demonstrate the need for collaborative, comprehensive solutions to improve clinical laboratory biosafety and to better combat future emerging infectious disease outbreaks.

Preparing your intensive care unit for the COVID-19 pandemic: practical considerations and strategies

The coronavirus disease 2019 (COVID-19) has rapidly evolved into a worldwide pandemic. Preparing intensive care units (ICU) is an integral part of any pandemic response. In this review, we discuss the key principles and strategies for ICU preparedness. We also describe our initial outbreak measures and share some of the challenges faced. To achieve sustainable ICU services, we propose the need to 1) prepare and implement rapid identification and isolation protocols, and a surge in ICU bed capacity; (2) provide a sustainable workforce with a focus on infection control; (3) ensure adequate supplies to equip ICUs and protect healthcare workers; and (4) maintain quality clinical management, as well as effective communication.

Medical waste management at three hospitals in Jenin district, Palestine

Medical wastes are considered hazardous because they may possess infectious agents and can cause unsafe effects on the environment and human health. This study is to analyze and evaluate the current status of medical waste management at Jenin's district in light of medical waste control regulations recommended by the World Health Organization. The results demonstrated that the average hazardous healthcare waste generation rate ranges from 0.54 to 1.82 kg/bed/day with a weighted average of 0.78 kg/bed/day. There was no established waste segregation of healthcare waste types in all hospitals, and these wastes were finally disposed of in a centralized municipal sanitary landfill, namely Zahrat Al-Finjan. The results suggest that there is a need for activation and enforcement of medical waste laws. This can be achieved through cooperation among key actors: Ministry of Health, Environmental Quality Authority, Ministry of Local Government, and Non-Governmental Organizations working in related fields. Additional remediation measures proposed to tackle the problematic areas of medical waste management in Jenin's district hospitals are addressed. Some recommendations to minimize potential health and environmental risks of medical waste are also introduced.

Medical waste generation and management in medical clinics in South of Iran

Medical wastes account for around 1–2% of urban wastes, which are very important in terms of health. In this regard, they are very important and can jeopardize human health. The aim of this study was to determine the qualitative and quantitative characteristics of the wastes in medical clinics in the south of Iran and in order to present suitable management solutions. First, 14 medical clinics were chosen and 24 samples were taken from each clinic (two samples per month) with a total 336 samples. Considering the special properties and the risk potential, the wastes generated in medical clinics were categorized as infections and special waste groups. In terms of properties, they were classified as pseudo-household, infectious, sharp, pharmaceutical, and paper wastes. Once the samples were collected, they were weighed and the results were analyzed by SPSS. The results indicated that in terms of quantity, the waste generated in the first and second groups was 8550.377 and 8053.71 kg/year, respectively. Furthermore, most of the wastes generated in the first and second groups accounted for pseudo-household (80.7%) and infectious (72.77%) wastes, respectively. Due to presence of the specialty of pathology laboratory in the second group, the quantity of infectious waste has increased. Therefore, for proper management of medical wastes in the studied clinics, the clinics of the studied study should implement and apply the rules of waste management properly. Furthermore, training physicians and employees in clinics about reducing, recycling, and collecting wastes in a separate form in clinics should be done in priority.

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In this study, the classification of Basel convention and World Health Organization was considered as the basis of waste classification.

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The results indicated that in the first group of the studied clinics, the order of the waste quantity was as follows: pseudo-household > infectious > sharp > paper.

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Due to large amounts of hazardous infectious wastes in the second group of the studied medical clinics, it necessitates proper management of collection and disposal of these wastes.

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Results can be used to improve the management of waste generation practices in medical clinics with high risk and special wastes potential.

Determining training and education needs pertaining to highly infectious disease preparedness and response: A gap analysis survey of US emergency medical services practitioners

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Gap-analysis survey concerning HID preparedness among U.S. EMS was conducted.

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Knowledge deficits for exposure routes of notable select HIDs were identified.

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Results indicate practitioners could gain from updated HID training and education.

Background

The Ebola virus disease outbreak highlighted the lack of consistent guidelines and training for workers outside of hospital settings. Specifically, emergency medical services (EMS) workers, who are frequently the first professionals to evaluate patients, often do not have advanced notice of patient diagnosis, and have limited time in their national curricula devoted to highly infectious disease (HID) identification and containment. All of these can place them at increased risk. To explore the depth of US EMS practitioners' HID training and education, a pilot gap analysis survey was distributed to determine where the aforementioned can be bolstered to increase occupational safety.

Methods

Electronic surveys were distributed to EMS organization members. The survey collected respondent willingness to encounter HID scenarios; current policies and procedures; and levels of knowledge, training, and available resources to address HIDs.

Results

A total of 2,165 surveys were initiated and collected. Eighty percent of frontline personnel were aware that their agency had an HID standard operating guideline. Almost 85% of respondents correctly marked routes of exposure for select HIDs. More than half of respondents indicated no maximum shift times in personal protective equipment.

Discussion

This research suggests EMS practitioners could benefit from enhanced industry-specific education, training, and planning on HID mitigation and management.

Conclusion

Strengthening EMS preparedness in response to suspected or confirmed HID cases may not only improve patient outcomes, but also worker and community safety.