TB bugs, other virulent pathogens go out with the trash, critics charge
Lack of regs means many labs don’t decontaminate before they dump
Many laboratories in the United States licensed to handle TB cultures and other highly virulent pathogens are disposing of their wastes without decontaminating them first, experts say.
Such practices were tied to a 1997 outbreak of TB that occurred among workers in a Washington state biomedical waste-disposal facility, investigators say. The same situation could easily happen again, some experts contend, unless states pass regulations to force clinical laboratories and other waste generators to decontaminate infectious wastes on site.
At present, South Carolina is the only state that requires laboratories to treat biomedical wastes before disposing of them, says Ira Salkin, PhD, director of the medical waste program at the New York State Department of Health’s Wads worth Center in Albany. "In other words, in 49 states, a generator [of biomedical wastes] has the right either to treat TB cultures on site — or not to," Salking explains. "Basically, the trouble is [that] what happens to garbage is very low on most people’s priority list."
He predicts that sometime in the next four to 12 months, a regulation will take effect in New York state requiring on-site decontamination of TB and other Biosafety Level 3 and 4 wastes. (In every state, federal regulations require that Biosafety Level 5 wastes, such as ebola virus, be destroyed before their disposal.)
There is an urgent need for other states to implement a regulation similar to what may go into effect soon in New York, Salkin and others contend.
"We’re talking about TB cultures that have been grown in extremely high concentrations and which may be resistant to one, two, even three or more frontline drugs," says Eugene Cole, DrPH, MPH, director of DynCorps Health Research Services in Raleigh, NC, and an expert on infectious waste disposal. "All states ought to require TB waste to be treated before it leaves the facilities. It’s simply the prudent thing to do."
In New York, an unpublished survey of clinical laboratories found that "the majority" do not first treat biomedical waste before disposing of it, says Salkin. In Washington state, where three workers at a disposal facility fell ill with TB within the same six-month period (one with a multidrug-resistant strain of TB), a similar survey found that of 44 laboratories licensed to handle TB, 20 were sending out their TB wastes untreated — to one of the state’s two biomedical waste-disposal facilities or, in one instance, to a landfill.1 (See related story, p. 47.)
Throughout the nation, there are 682,400 medical waste-generating facilities, according to 1994 data from the Environmental Protection Agency. Each year, those facilities generate 3.36 million tons of waste, including 504,000 tons of infectious waste.
Ten years ago, most facilities took care of the problem by incinerating infectious wastes on site, says Wayne Turnberg, public health advisor to the Washington State Department of Health and author of a book on biomedical waste disposal.2
But since passage of the federal Clean Air Act of 1990, the situation has changed; in every state, most on-site incinerators have been shut down. At the same time, says Salkin, the health care industry, feeling the pinch of tightened economic constraints, has begun cutting corners, often by unplugging autoclaves once used to decontaminate infectious wastes and laying off technicians once paid to run them.
$1.5-billion industry mostly unregulated
The result has been the rapid growth of a highly competitive, $1.5 billion-a-year industry dedicated to taking out the biomedical garbage. "We now have a nation that’s sending its medical waste to these regional treatment facilities," adds Turnberg, "and there’s not a whole lot of attention paid to how the facilities are run."
True, a patchwork of laws and regulations governs various aspects of the biomedical waste-disposal industry. A new Department of Transportation (DOT) regulation, for example, requires waste generators to wrap all Biosafety Level 3 and 4 wastes destined for off-site disposal in a sturdy, absorbent type of special packaging called PG-2. The packaging is specially designed to protect against spills and falls, says Salkin.
That DOT regulation is neither well-known to waste generators nor well-enforced, Salkin says. Nor, he adds, is it enough: "In a perfect world, maybe it would be, but what happens when a truck or a semi overturns, and suddenly you’ve got live MTB all over the place? It’s always better to send out a dead pathogen than a live pathogen, properly packaged."
Cole says the greatest day-to-day danger lies not in isolated accidents that may occur during transport, but in the ongoing perils the wastes pose to the workers whose job it is to load and unload the stuff.
"These [disposal] facilities typically transport waste in large containers that are reusable," Cole says. "Sometimes the waste is boxed or bagged; other times it’s loose. A number of times I’ve seen workers at these places pop the lid off a 32-gallon container and dump the contents into another container. As they draw the container back, you can see fluids dripping and blood flying through the air."
Nor does the protective gear always provide adequate protection that workplace regulations require workers to wear, Cole adds. "I remember watching one guy unloading stuff with his face shield up. I watched until I couldn’t stand it any longer, then I asked him, Say, shouldn’t you be wearing your face shield while you do that?’" Cole says the worker grinned ruefully and replied: "Yeah, I probably should. But after a few minutes, the face shield gets so splattered I can’t see through it."
Soon, the stakes will rise even higher as more and more labs begin working with bio-warfare agents such as anthrax, Cole asserts. "Laboratories will have to have the ability to maintain and identify these organisms; we’ll need to maintain stock cultures of them. What will happen to all those test tubes and agar plates?"
If and when New York state passes the regulation Cole and Salkin want to see in place, Cole hopes the effect will be to induce other states to implement similar regulations. Until then, Cole says he’d like to see professional associations push harder for on-site decontamination of TB and certain other virulent pathogens (such as vancomycin-resistant staphylococcus aureus). Abiding by recommendations from the Centers for Disease Control and Prevention and the National Institutes of Health could, perhaps, become part of the accreditation process for labs, he adds.
In the meantime, labs that don’t decontaminate biomedical wastes could find themselves held legally liable, Cole warns. "It’s like with chemical hazardous waste — if you generate it, it’s a cradle-to-grave responsibility."
References
1. KL Cairns, K Johnson, C Diamond, et al. Biomedical waste disposal practices of laboratories processing Mycobacterium tuberculosis specimens, Washington State, 1997. Abstract and poster presentation at the International Union Against Tuberculosis and Lung Disease, North American chapter conference. Chicago; 1999.
2. Turnberg WL. Risk Assessment Policy and Management. New York City: John Wiley and Sons Inc.; 1996.
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