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Environmental solutionsnews Covering infection prevention, medical waste management & sustainable practices

VOL. NO. 41 VOL. XIII XII NO.

www.HealthcareEnvironmentalSolutions.com

SPRING 2016 2017 WINTER

Dispelling the Stigma of Trash Generated by Healthcare Providers

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By Katherine West, RN, BSN, MSEd

aste generated by healthcare providers is known by many names: medical waste, infectious waste, biohazardous waste and others. Management and disposal regulations have been issued by states throughout the country, many of which contain very detailed and cumbersome requirements for healthcare providers. Because of this, most people assume there’s considerable risk associated with medical waste if it’s not properly handled or disposed of. The very existence of these regulations suggests there’s risk, but is that really the case? Concern over medical waste began in 1987, when syringes and other medical waste washed ashore onto beaches in New Jersey and New York. Beaches were closed and thousands of vacationers stayed away. Due to misleading media reports, the general public became concerned over the possibility of contracting a bloodborne pathogen and there was a substantial loss of revenue for vendors and states. Concern about dangerous emissions from the incineration of medical waste was also generated, which created substantial pressure for governments to “do something.” Statutes and regulations dealing with medical waste were promulgated by most states over the next several years. Although this

government action calmed the public outrage, the fact is that the legal landscape we’ve been left with is disproportionate to the risk involved.

Addressing and Defining Waste

n addition to state regulations, there are three Iissues: federal agencies that address medical waste the Environmental Protection Agency (EPA), the Occupational Safety and Health Administration (OSHA), and the Centers for Disease Control and Prevention (CDC). The CDC doesn’t have regulatory authority, but it issues notices and advisories that often are issued jointly with OSHA, focusing on infection control issues.1 Waste generated in hospitals and other healthcare settings that falls under the heading of “medical waste” is actually a very small percentage of the overall waste generated (about 15%), but concern about risks associated with this waste is high due to the prevalence of extensive regulations. When discussing waste generated through the provision of healthcare, different terms are used, and there’s no universally accepted definition used in state regulations that govern the definition, collection, handling and disposal of healthcare waste. For example, in New York and Rhode Island, the term used is “regulated medical

Continued on page 3

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Dispelling the Stigma of Trash Generated by Healthcare Providers Continued from page 1

waste.” In Colorado, Nevada and Nebraska, the term used is “infectious waste.” In Connecticut, Florida, Georgia, Maine and Washington, the term used is “biomedical waste.”2 OSHA published a definition of medical waste in its Bloodborne Pathogen Standard, 29 CFR 1910.1030, and it’s Compliance Directive for this regulation, CPL 02-02.069: “Liquid or semi-liquid blood or OPIM (other potentially infectious material); items contaminated with blood or OPIM and which would release substances in a liquid or semi-liquid state if compressed; items that are caked with dried blood or OPIM and are capable of releasing these materials during handling; contaminated sharps; pathological and microbiological wastes containing blood or OPIM.”3 In summary, sharps are medical waste and any item that’s “dripping, pourable or squeezable” with blood or OPIM, or is caked with dried blood, is medical waste. The EPA definition includes, but isn’t limited to, bloodsoaked bandages, culture dishes and other glassware, discarded surgical gloves and surgical

healthcare

Environmental solutionsnews Covering Infection prevention, medical waste management & sustainable practices

PUBLICATION STAFF Publisher / Editor Rick Downing Contributing Editors / Writers Katherine West, RN, BSN, MSEd Sandy Woodthorpe Production & Layout Barb Fontanelle • Christine Pavelka Advertising Sales Rick Downing Subscription / Circulation Donna Downing Editorial, Circulation & Advertising Office 6075 Hopkins Road, Mentor, OH 44060 Ph: 440-257-6453 • Fax: 440-257-6459 Email: downassoc2@oh.rr.com Subscription information, call 440-257-6453. Healthcare Environmental Solutions news (ISSN #1557‑6388) is published quarterly by Downing & Associates. Reproductions or transmission in whole or in part, without written permission of the publisher, is prohibited. Annual subscription rate U.S. is $19.95. Outside of the U.S. add $10.00 ($29.95). Contact our main office, or mail-in the subscription form with payment. ©

instruments, discarded needles used to give shots or draw blood, removed body organs, and discarded lancets.”4 The federal definitions serve as a guide, but each state sets its own definition to which OSHA defers. But the various definitions make it clear not everything used for patient care or that has some blood on it meets the definition of medical waste. How something is commonly defined in a regulation doesn’t mean it requires special handling and disposal in all states. For example, the medical waste regulation in Ohio lists sharps as medical waste but states that for small generators of waste (less than 50 pounds/ month) “sharps can be disposed of as solid waste in the landfill if they are placed into a rigid, puncture-resistant, leak resistant, and closed tightly to prevent loss of contents.”5 In North Carolina, an item must contain at least 20 mL of blood to be considered a potential hazard.6 In Illinois, the regulations passed in 1993 are titled Potential Infectious Medical Waste and state the regulation is the result of medical items washing up on the beaches. The wording clearly recognizes the issue isn’t sciencesupported. Illinois defines body fluids as “liquid emanating or derived from humans.” 7 So, not everything generated in patient care is red bag waste. In Nevada, the regulations state, “Concerning the health risks associated with medical waste, studies show that it does not contain any greater quantity, or different types, of microbiological agents than does residential waste.” There’s also evidence to show untreated medical waste can be safely disposed in properly operated municipal waste landfills. Regulations don’t always require treatment of medical waste—disposal in a permitted landfill according to approved practices is acceptable.8

Sharps

ll state definitions list sharps as medical A waste. This is appropriate since sharps such as needles, scalpels and even lancets have been documented to pose a risk for disease transmission in healthcare settings. In numerous studies, sharps injuries have been noted to be the primary risk for exposures among healthcare personnel. Sharps injuries make up about 80% of reported healthcare worker exposures.9,10 In 2000, the U.S. Congress passed the Needlestick Safety and Prevention Act requiring the use of sharp safe devices. This law instructed OSHA to update its bloodborne pathogen regulations to require the use of needle-safe devices.11 This has reduced the incident rate of sharps injuries to healthcare workers by more than 50%. Needlesafe devices must be disposed of as spring 2017

healthcare waste even though they’re designed to prevent another person being stuck by the sharp after use. It’s clear sharps may pose a potential risk for exposure, and therefore sharps are defined as a waste requiring special handling. But is this warranted? In 1987, concerns were raised regarding the opportunity for public exposure when children in Indianapolis, were found playing with needles and vials discarded in a trash bin by a medical office. A search of the literature shows no instances of public illness as a result of exposures such as this one. As the home health industry grows, concerns rise over the increasing quantities of medical waste found in residential waste. However, studies show that this waste doesn’t contain any greater quantity, or different types of microbiological agents, than regular residential waste.11 It is important to note that medical waste and sharps coming from households are exempt from regulation in all states. Contaminated sharps used in the provision of healthcare have been shown to pose a risk for disease transmission. But, what the science shows is that organisms die out and don’t survive in a dose to cause disease transmission.

Scientific Support

o studies really lack documentation of D medical waste posing a health risk? This question was perhaps best answered in a position paper published in 1992 by the Society for Hospital Epidemiology of American (SHEA).12 Here, we have experts in the field of infections and prevention of infection directly addressing the issue of risk. In this paper, SHEA made note of the fact that the quantity and volume of medical waste coming ashore on the beaches was relatively small. Actually, about 90% was plastic, glass and other debris.12 A key factor that’s missing in this discussion is whether medical waste can transmit an infectious disease. This brings into focus the factors necessary for disease transmission: dose of the organism, presence of a pathogen, virulence of the pathogen, host resistance and, the key element, mode of entry. Bloodborne diseases require blood-to-blood contact. The CDC and the EPA only consider waste to be infectious if it contains a sufficient number of pathogenic organisms to cause illness. Thus, the CDC and EPA list the following as waste: microbiological, pathological, animal, blood and sharps. In other words, not everything needs to go in a red bag! Most of what’s used in EMS is traditional trash—not red bag waste. Generally speaking, gloves that aren’t dripping with blood are trash. A 2x2 with some blood is trash. Bag-mask devices, IV bags and IV tubing are all trash.

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Healthcare Environmental Solutions news

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Dispelling the Stigma of Trash Generated by Healthcare Providers Continued from page 3

This information demonstrates the importance of knowing your state definitions. Medical items washing up on the beaches is an aesthetic issue and raises an economic cost, but risk for transmission of disease is “nonexistent” according to the SHEA document. The report states: “The theoretical estimate that the factors for infection to occur in a sequence and a person will develop HIV infection from a needle on the beach is 1 in 15 billion to 1 in 390 trillion.”12–14 Eight countries conducted studies that showed household waste was more microbial contaminated than hospital waste.15 Another study similarly showed the concentration of organisms in hospital waste was less than that of household waste.16 What about occupational exposure to medical waste? Multiple studies document the risk for disease transmission from a fresh sharps injury during the provision of patient care. However, to date, there’s no evidence that a waste worker, sanitary sewer worker or a member of the public has ever acquired an infection from medical waste.1 It would appear that regulations and concern over medical waste came about by the rush to address public concern rather than looking to the science to determine whether or not legislation on this issue was warranted. Fear superseded science and education. Today, there’s a more concerted effort to have science lead the way in healthcare. This is termed “evidence-based practice” and focuses on science to support laws before they’re passed.

Why it Matters

any departments have to contract for pickup and disposal of medical M waste at a significant cost. More and more medical facilities will no longer accept EMS-generated medical waste because of the additional cost to the facility, especially when much of what’s currently being placed into red bags isn’t truly medical waste by their state definition. State medical waste regulations, especially the definitions, should be in each department’s exposure control plan and need to be incorporated into training for all department members. Knowing the definition of medical waste in your state is important. Many dollars can be saved in cost for medical waste disposal if you’re aware of what is and isn’t considered waste. Understanding true risk versus perceived risk will assist in lowering apprehension levels among members of the department. Regulations remain regulations and whether they’re science-based or not, departments must still be in compliance. KATHERINE H. WEST, BSN, MSEd, has been working in the field of infection control since 1975. She lectures both nationally and internationally on this topic. She publishes books, Training materials and articles on infection control related issues. She has served as a consultant to the Centers for Disease Control and the National Institute of Occupational Safety & Health. She has served as an education specialist for the National Institutes of Health and authored the Infectious Disease Handbook for Emergency Care Personnel, now in its third edition Katherine is also a consultant to the US Public Health Service, Federal Occupational Health. Ms. West was voted a “Hero in Infection Control & Prevention” for 2006 for her work in the field of infection control & EMS. This honor was from the Association for Professionals in Infection Control & Epidemiology(APIC). She is a recipient of a Meritorious Service Award from the International Association of Fire Chiefs – EMS Section. This article was reprinted with permission from the April 2015 issue of JEMS (Journal of Emergency Medical Services) www.jems.com.

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Healthcare Environmental Solutions news Continued from previous page

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References 1.

U.S. Congress, Office of Technology Assessment: Finding the Rx for managing medical wastes. U.S. Government Printing Office, Washington, D.C., 1990.

Pollution Prevention and Compliance Assistance Information for the Healthcare Industry. (n.d.) Types of regulated medical waste. Healthcare Environmental Resource Center. Retrieved Feb. 9, 2015, from www.hercenter.org/rmw/rmwtypes.cfm.

Henshaw JL. (Nov. 27, 2001.) Enforcement procedures for the occupational exposure to bloodborne pathogens. U.S. Department of Labor. Retrieved Feb. 9, 2015, from www.osha. gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=2570.

U.S. Environmental Protection Agency. (Nov. 15, 2012.) Wastes—Non-Hazardous Waste— Industrial Waste. Retrieved Feb. 9, 2015, from www.epa.gov/osw/nonhaz/industrial/medical.

Ohio Revised Code Chapter 3734.

North Carolina Division of Waste Management, Section 1200 rules: Medical waste management rules.

35 Illinois Administrative Code 1420.102.

Nevada Administrative Code 444.662.

Occupational Safety and Health Administration. (n.d.) Bloodborne pathogens and needlestick prevention. U.S. Department of Labor. Retrieved Feb. 9, 2015, from www.osha. gov/SLTC/bloodborne-pathogens/evaluation.html.

10.

International Healthcare Workers Safety Center. (January 2013.) University of Virginia Health System. Retrieved Feb. 9, 2015, from www.healthsystem.virginia.edu/pub/epinet/ about_epinet.htm.

11.

Needlestick Safety and Prevention Act, H.R. 5178, Public Law 106–430.

12.

Rutala WA, Mayhall CG. Medical waste. Infect Control Hosp Epidemiol. 1992;13(1):38–48.

13.

Rutala WA, Weber DJ. Infectious waste—mismatch between science and policy. N Engl J Med. 1991;325(8):578–82.

14.

Agency for Toxic Substances and Disease Registry. The public health implications of medical waste: A report to Congress. [white paper]. U.S. Department of Health and Human Services: Washington, D.C., 1990.

15.

Pahren HR. Microorganisms in municipal solid waste and public health implications. CRC Critical Reviews in Environmental Control. 1987;17(3):187–228.

16.

Jager E, Xander L, Ruden H. [Medical waste. 1. Microbiologic studies of wastes of various specialties at a large and small hospital in comparison to housekeeping waste]. Zentralbl Hyg Umweltmed. 1989;188(3–4):343–364.

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A Look Back at 2016 for the Healthcare Waste Management Sector The Healthcare Waste Institute, part of the National Waste & Recycling Association, serves its members by acting as a resource for technical and regulatory guidance. The Healthcare Waste Institute worked on a number of issues in 2016 to improve the management of healthcare waste. The following is an overview of some of the topic areas the Association has focused on during the past year.

Washing Reusable Containers Guidance

he Healthcare Waste Institute finalized a voluntary guidance for washing reusable containers in June 2016. The use of reusable containers for both sharps and regulated medical waste has increased in the past few years. Yet, currently, no standards exist for thoroughly cleaning reusable waste collection containers in healthcare. Nor are there any national regulations covering this. As a result, these guidelines were developed so that the industry could exercise and maintain best practices for cleaning reusable containers intended for the collection and transport of regulated medical waste (RMW) or infectious waste. The voluntary guidance represents the minimum standards for cleaning reusable containers. They were not intended to replace other regulations or guidance. Also, the guidance was not intended to address containers for chemotherapy or pharmaceutical wastes. Three cleaning methods, each which include a wash and disinfectant stage, are described for cleaning reusable containers. The methods were written in a manner designed to thoroughly clean the containers while simultaneously protecting the longevity of the containers. In addition to cleaning containers, the guide suggests validating the effectiveness of the process and provides other considerations that facilities should consider when washing reusable containers. A copy of the guidance is available for download at: https://wasterecycling. org/members/interest-groups/healthcare-waste-institute.

Regulatory Efforts

umerous efforts were made to follow up on the latest regulatory changes that could affect the industry. Over the past year, comments were submitted by the Healthcare Waste Institute, on behalf of its members. Listed below is a summary of those comments: ●● State of Washington, Department of Ecology The Healthcare Waste Institute provided comments on draft amendments to the Dangerous Waste Regulations by the State of Washington Department of Ecology (Ecology). The proposed regulations were written in anticipation of the Environmental Protection Agency’s (EPA) proposed Management Standards for Hazardous Waste Pharmaceuticals (Pharmaceutical Rule). To be consistent with EPA’s rule we recommended that Ecology delay finalizing their regulations until after the EPA’s Pharmaceutical Rule is released. Other comments were offered on specific rule sections. ●● State of South Carolina, Department of Health & Environmental Control The Healthcare Waste Institute provided comments on changes proposed by South Carolina’s Departemnt of Health and Environmental Control. Numerous comments were offered. Some of the comments were: clarifying certain definitions such as products of conception and infectious wastes; clarifying generator requirements; establishing container labeling responsibilities; recommending alternative timelines for compliance; suggesting consistency with PHMSA on manifest requirements.

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●● State of Texas, Health Care Quality Section The State of Texas Health Care Quality Section proposed a rule requiring that the final disposition of fetal tissue be interment. The Healthcare Waste Institute requested that the Texas Department of State Health Services (DHS) consider language that would specify that this requirement to segregate the material be on the generator at the source. Further, we requested that inadvertent disposal not in compliance with this requirement would not be the fault of the healthcare waste service providers or the final disposal facility. We proposed alternative language for the rule. ●● State of New York, Department of Environmental Conservation The Healthcare Waste Institute provided numerous comments to the State of New York’s Department of Environmental Conservation when it proposed overhauling its regulations governing regulated medical waste. For example, just as with the South Carolina rules, the Healthcare Waste Institute recommended that the state’s rules be written to be consistent with PHMSA. Overlapping and inconsistent regulatory requirements drive unnecessarily complicate compliance by the industry.

Category A Waste Planning Guidance

n addition, the Healthcare Waste Institute continued to work with the Occupational Safety and Health Administration’s Office of Emergency Management and Preparedness on its proposed guidance on Category A waste. Numerous federal agencies shared information about appropriately managing Category A waste during the Ebola crisis. As a result, many stakeholders were confused about handling Category A waste. Now that the crisis is past, OSHA has taken the lead in herding the other federal agencies to contribute to the development of a draft guidance. Healthcare Waste Institute provided feedback to streamline the document and add clarity. Given the change in administration, it is unclear when the document is expected to be finalized, but it is hoped that it will be before the next crisis strikes.

Standards for Hazard Communication

n March 2016, the Healthcare Waste Institute updated its Guide to U.S. Occupational Safety & Health Administration Standards. This document includes information on hazard communication and was updated to include harmonized classification and labeling requirements. The updated document is available to members at the Healthcare Waste Institute members only website.

Membership

f you are interested in participating in the Healthcare Waste Institute, information about joining can be found at: https:// wasterecycling.org/members/interest-groups/healthcare-wasteinstitute.

News Briefs

Australian and US Studies Emphasize Care Bundles for ICU Infection Control

ummit, NJ – A broad-based strategy is most effective for controlling infections in the intensive care unit (ICU), according to papers published in the October 2106 issue of Neurocritical Care. Researchers at Overlook Medical Center in Summit, New Jersey and Royal Brisbane and Women’s Hospital and the University of Queensland in Australia have shown that bacterial infection rates in the ICU can be reduced with a “care bundle” approach. In Australia, a team headed by Rob Boots, Associate Professor and Deputy Director of the Department of Intensive Care Medicine at University of Queensland reviewed the effectiveness of documented ICU infection control techniques. The team’s conclusions emphasized regular hand washing, use of alcoholic hand rubs and sprays and restrictions on clothing and jewelry. In addition, adherence to infection control-related administrative practices, including surveillance and checklists, formal audits, clinical indicators, and benchmarking was suggested. On the clinical side, the team said that ensuring a patient’s pulmonary health is strong as possible before surgery and subsequent transfer to the ICU, as well as keeping the patient’s ICU stay as short as possible, also helped hold down infection rates, as well as costs. The three-year Overlook study reviewed documentation of ventilatorassociated events, catheter-related urinary tract infections, and catheterrelated blood stream infections in stroke patients who were being treated in the hospital’s ICU. Pneumonia, urinary tract infection, and bacteremia rates were running at 26 percent, the research team found.

The Overlook team decided to experiment with a new treatment variable – they brought equipment, such as CT scanners, to the patients instead of the other way around. Transporting patients through hallways and elevators jostles IV, catheter and ventilator tubes, providing routes of entry for bacteria, they noted. “We saw a correlation between the number of transports and the number of infections,” stated Dr. John J. Halperin, Chair of the Department of Neurosciences at Overlook in a TapInto.com article. Use of the mobile CT scanner made a significant impact on patient health: •

Infections related to ventilator use were reduced by 48%

•

Catheter- related infections went down from 2-3 per month to zero, over a 6-month period.

•

Overall complication rates decreased by 55%.

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ICU length of stay was lowered by 1.5 days.

•

Risk-adjusted mortality dropped by 11%.

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Total hospital-acquired infections decreased by 53% over an 18 month period.

The Overlook study also found that catheter use was cut in half, contributing to lowering urinary tract infection rates.

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News Briefs

Colorado’s Annual Health Care Facility Infection Report: Mixed Results

enver, CO – The ninth annual Health Care Associated Infections Disclosure report, released this January by the Colorado Department of Public Health and Environment, shows mixed results for infection rates in Colorado health care facilities. The reported data is for the period from August 1, 2015 through July 31, 2016. Key findings include: •

Statewide infection rates for colon surgeries, hip replacements and abdominal hysterectomies performed in hospitals were better than national averages.

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For the past three years, statewide infection rates for breast surgeries performed in hospitals were worse than the national average.

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For the past three years, statewide infection rates for hernia repairs in ambulatory surgery centers were better than the national average.

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In the past two years, long-term acute care hospitals showed lower rates of central line-associated bloodstream infections compared to the national average.

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The statewide rate of central line-associated bloodstream infections in neonatal critical care units was worse than the national average.

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The statewide rate for Clostridium difficile in hospitals was worse than the national average.

•

More dialysis centers reported zero infections in 2014-15 and fewer reported infection rates worse than the national average.

“Reported infection rates can be influenced by many factors, such as surveillance techniques and patient health, in addition to infection control practices,” said Tamara Hoxworth, manager of the Health Facility Infection Surveillance unit at the department. “To reduce infections, we have created an infection prevention unit and are continuing to collaborate with partners such as the Colorado Hospital Association and Telligen, Colorado’s health care quality improvement organization, on efforts to reduce health care-associated infections.” Each year, the report shows infection rates in certain types of Colorado health care facilities compared to national standards for selected surgeries and medical procedures. The report compares the incidence of health care-associated infections at Colorado facilities to the national mean and shows whether each facility was the “same,” “better” or “worse” than the national standard.

New Mechanism Found for Fighting MRSA

hampaign, IL – A new understanding of two enzymes that activate in Staphylococcus aureus (S. aureus) infections could lead to groundbreaking treatment strategies, according to a paper published in PLOS Pathogens. Researchers at the University of Illinois and Newcastle University in the U.K. observed how the bacterium, S. Aureus, defends itself against the body’s immunity arsenal. S. aureus has a tendency to overcome the body’s responses, becoming virulent and hard to cure with antibiotics. In extreme cases, S. aureus can turn into the “superbug,” Methicillin-resistant S. aureus, or MRSA. The study was led by University of Illinois microbiology professor Thomas Kehl-Fie and Dr. Kevin Waldron, of Newcastle University Research Fellow. To survive, S. aureus needs manganese and iron, metals that are used by two enzymes that protect S. aureus from destruction by the body’s immune system. Scientists have long understood the role of one enzyme, superoxide dismutase, or SOD, and how manganese helps it to thrive. However, observing the function of the second enzyme – the one that uses iron or manganese – sheds light on how S. aureus resists treatment and multiplies. During infections, pathogens must overcome both host-imposed manganese starvation and the oxidative burst of immune cells. The research team found that, when starved of manganese by the body, S. aureus activated the SOD with iron instead of manganese, ensuring its critical bacterial defensive barrier was maintained. “The cambialistic SOD plays a key role in this bacterium’s ability to evade the immune defense,” Dr. Waldron said. “Importantly, we suspect similar enzymes may be present in other pathogenic bacteria. Therefore, it could be possible to target this system with drugs for future antibacterial therapies.” The study was supported by operating grants for the National Institutes of Health, as well as several nonprofit fellowships and scholarships. 8

HEALTHCARE ENVIRONMENTAL SOLUTIONS news

spring 2017

Chicago University Maps Hospital Infection Zones

hicago, IL – Plotting the location of microorganisms and their genetic material within a given ecological niche is known as mapping a microbiome – and that is what some researchers at the University of Chicago have done, reports a DigitalJournal.com article. The Chicago endeavor is part of a large initiative called the Hospital Microbiome Project which was launched following a 2012 Sloan Foundation workshop attended by experts from diverse scientific fields including building engineers, medical practitioners, and microbial ecologists. For the Chicago phase of the study, sterile swab samples were taken from the University of Chicago’s new hospital pavilion, including 10 patient rooms, two nursing stations, nursing staffs, water and air sampling, both daily and weekly for a year. In each patient room, samples were taken from the floor, bedrail, outgoing air filter, cold water supply/ faucet, and glove box. Duplicate swabs of nasal, hand, and inguinal fold samples were taken from each patient. From the nursing staff, swabs were taken of the interior nose, hand, uniform cuff, pager, shoe, and cell phone. At each of the nursing sites, countertop, computer mouse, phone handle, chair, and main corridor floor, hot water, and cold water handles were swabbed. The study protocol specified a total of 12,392 samples between January 2013 and January 2014. The aim of this work is to better understand how the hospital environment itself contributes to infection rates and to come up with ways to design or improve environments to help minimize those rates. Each environment has a unique microbial signature, depending on geography, building materials, air handling systems, and the activities and human population within the built environment. Differences between patient population, and whether duration of stay makes a difference, as well as the following factors: •

The number of patients to a ward.

•

The influence of medical and healthcare personnel on the microbiome.

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How microbial communities change over time.

•

‘Natural’ microbial communities vs. those introduced by patients or staff.

Although the University of Chicago Microbiome Project findings have not been published in a peer reviewed journal to date, the researchers noted signs that a hospital environment is largely shaped by the humans within it, and the way people interact fosters the exchange of bacteria. In particular, they noted that the incidence of Staphylococcus, Streptococcus, and Corynebacterium increased after the hospital opened. Meanwhile, the incidence of the Pseudomonas bacteria, which can cause bladder, wound, and lung infections, decreased. The Hospital Microbiome Project represents the first formal, systematic analysis of the source, presence, and development of either pathogenic or non-pathogenic microbial reservoirs in hospital environments. Building science technology used in the study includes sensors for light intensity and relative humidity, bioaerosol samplers, differential pressure sensors, beam-break people counters and CO2 gas analyzers.

News Briefs

Safe Drug Disposal Ordinance Passes in Contra Costa County

www.medicalwastetechnology.com

artinez, CA – The Contra Costa County Board of Supervisors recently passed a Safe Drug Disposal Ordinance requiring medication manufacturers to create a stewardship organization that will offer convenient drop-off locations throughout unincorporated areas of the county for safe disposal of unwanted, expired, and unused medications. Convenient locations include pharmacies and hospitals. This is the eighth Safe Drug Disposal Ordinance adopted in the Bay Area and the 13th in the nation. Safe Drug Disposal ordinances have gained significant interest from government agencies and non-government organizations because they provide a wide public benefit. Wastewater agencies have collaborated on this issue with clean water advocates because proper disposal of medications means cleaner waterways for fish and wildlife and increased quality of drinking water. “It’s our job to be strong stewards for the environment,” said Roger Bailey, General Manager of Central Contra Costa Sanitary District (Central San), which operates 13 customer-funded medication drop-off bins in Contra Costa County and has been a strong advocate for this ordinance. “This ordinance helps better protect public health and the environment,” Bailey said. Central San and six wastewater agencies, including City of Richmond’s Water Resource Recovery Department, Delta Diablo, Dublin San Ramon Services District, Ironhouse Sanitary District, Mt. View Sanitary District, and West County Wastewater District, provided strong east, west and central county support of the ordinance. “The ordinance will require more medication disposal bins and increase community education, both important steps in reducing access to potentially dangerous and addictive medications in Contra Costa County,” said April Rovero, Executive Director of the National Coalition Against Prescription Drug Abuse. Key Elements of the Ordinance include: 1. The ordinance places responsibility on medication manufacturers to be a solution in helping reduce medications entering local waterways. 2. The new drop-off bins will accept all medications, including overthe-counter drugs. 3. Medication manufacturers are subject to penalties if they fail to comply with the ordinance.

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Opposition Squelches Proposed Medical Waste Plant in Kentucky

arter County, KY – According to a DailyIndependent.com article, residents in the northeast corner of Kentucky have won a fight against the construction of a facility that would have treated and compacted medical waste. The Boyd County-based Medical Waste Services, LLC made an application to the state for a low-level biomedical waste treatment and transfer station. The Kentucky Energy and Environmental Cabinet is the agency that approves such permits. After heated public meetings and a strong opposition campaign, however, the company withdrew its permit application. Medical Waste Services had purchased a 100-acre parcel near a major highway, and had drawn up plans for an 80-by-60-foot metal barn-like building. The facility, which would have been located about 1,200 feet away from the closest neighbor would have accepted mailed-in medical waste such as insulin needles and absorbent materials, such as those used in surgeries, but no pathological material, such as skin tissue or organs was to be treated. Chief neighborhood concerns were related to odors, truck traffic and noise. The company explained proposed delivery schedules and communicated its intent to acquire a $60,000 state-of-the-art vacuum autoclave system to process the waste. After the state application was withdrawn, local officials were unsure whether the project was on hold or terminated. The facility would have employed six to eight people.

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spring 2017

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Consumer’s Union Report Takes Issue with Inspection Lapses in CA Hospitals

acramento, CA – Consumer’s Union is calling attention to public health administration problems, which it says are contributing to high rates of healthcare associated infection (HAI) rates at a number of California hospitals, reports Consumers Union. Consumers Union, the nonprofit policy and mobilization division of Consumer Reports, has taken issue with hospital inspection backlogs and communication disconnects at the California Department of Public Health (CDPH). Under California law, hospitals must report the rates of certain patient infections to CDPH, which discloses this information to the public through its Healthcare Associated Infections Program. Consumer’s Union has found fault with CDPH’s bureaucracy, warning that the agency itself is hindering effective prevention and control of superbugs such as Methicillinresistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff). One striking problem is that inspectors in CDPH’s enforcement branch, the Licensing and Certification Program (L&CP), do not receive data on infection rates information in a timely manner. Without access to the infection data prior to inspections or when investigating complaints, L&CP inspectors cannot move quickly enough to protect patients, according to the watchdog group. In its review of three years of CDPH infection data (2013, 2014, and 2015), Consumer’s Union found that nearly 60 percent of the state’s acute care hospitals had significantly higher infection rates compared to other 2017 hEshospitals News in at least one type of infection (MRSA, c. difficile, California or surgical infections). CDPH maintains a “firewall” between the two programs, based on the belief that sharing the information with inspectors would interfere with the HAI Program’s efforts to get hospitals to voluntarily improve infection

control. Meanwhile, a number of California hospitals with some of the worst infection rates have gone uninspected for as long as five years. Consumers Union’s analysis is part of an administrative petition the group filed in January with CDPH. The petition calls on the agency to share the infection data it collects with state inspectors as soon as it is reported, to prioritize inspections of the worst performing hospitals if they haven’t been reviewed in the past three years, and to use its enforcement authority to require hospitals to improve infection control. In 2015, 159 hospitals had significantly high infection rates in at least one type of infection reported to CDPH. Many hospitals had significantly high infection rates in multiple types of infections over multiple years. For that same year, CDPH disclosed that 19,847 patient infections were acquired in California hospitals. This figure is considered to represent a fraction of actual cases because not all infection types are reported. CDPH has previously estimated that 72,000-87,000 hospital patients get infected every year and that 7,500-9,000 of them die during their hospitalization. California law requires that acute care hospitals are inspected every three years. Consumer’s Union found that 131 California acute care hospitals have not been inspected in the past five years, and 80 of those hospitals have reported infection rates that are significantly higher than other facilities. In addition to closing the gap on data sharing with inspectors, Consumers Union’s petition calls on CDPH to adopt a policy requiring inspectors to investigate the infection prevention practices of hospitals reporting significantly high infection rates, and urges the agency to subject hospitals to higher fines and penalties if they have a history of failing to comply with infection prevention measures and jeopardizing patients.

Read more online at www.HealthcareEnvironmentalSolutions.com

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England’s C. diff Cases Decline 80 Percent Since 2006

xford, England – Results of an Oxford University and Public Health England study show an 80 percent decline in cases of Clostridium difficile infections since 2006, according to a paper published in The Lancet. The research paper, “Effects of control interventions on Clostridium difficile infection in England: an observational study,” investigated overreliance on fluoroquinolone and cephalosporin for C. difficile infections. In 2003, the UK Department of Health launched a three-year study on the use of antibiotics, called “The Hospital Pharmacy Initiative.” The aim of the 12M£ ($19M US) program was to monitor and encourage prudent use of antimicrobials by chief pharmacists with the goals of cutting costs and reducing antibiotic resistance. In the mid-to-late 2000s, English hospitals were dealing with record levels of C. diff infections – 50,000 in 2007 alone and hundreds of deaths. That public health crisis led to a reduction in the use of cephalosporin antibiotics, clindamycin, fluoroquinolones, carbapenems, and aminopenicillin, as well as the implementation of hospital acquired infection (HAI) prevention policies and practices that included “deep cleaning” of entire wards. The Oxford study’s lead investigator Derrick Crook PhD, was a hospital epidemiologist at the time of the outbreaks. In 2013, Crook and his colleagues used gene sequencing to learn what could be behind the steady increase in C. diff cases. Their findings indicated that more than 80 percent of the C difficile cases were not being transmitted between patients. Simultaneously, they identified four strains of antibiotic-resistant bacteria that were being widely treated with quinolones. Further study with 4000 isolates showed that reduced use of fluoroquinolone correlated with lower incidence of the four C. diff strains. There was no change in the quinolone-treated populations. Looking at a wider sampling of data, using antibiotic prescriptions from 1998 to 2013, the researchers saw a direct correlation between the disappearance of fluoroquinolone-resistant strains and the drop in fluoroquinolone treatment. The study’s findings are particularly relevant in the U.S. where quinolones are first line drugs used to treat C. diff. Brad Spellberg, MD, an infectious disease specialist at University of Southern California urges a change in prescription policies at the national level. Fluoroquinolones should be reserved for broad-spectrum gramnegative infections, which tend to be more resistant and harmful to humans, and should be used for less harmful gram-positive infections only when other options can’t be used, Spellberg said in a Center for Disease Research and Policy article.

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Tank Holding Acquires Division from Agri Plastics in Canada

ank Holding Corp., North America’s largest rotational molder, which includes major polyethylene tank manufacturers, Norwesco and Snyder Industries, has acquired Agri Plastics’, Material Handling Division. Agri Plastic’s Material Handling Division manufactures a broad product line of bulk containers designed to transport and store a wide array of materials for many industries, ranging from food processing to recycling. “The products manufactured by Agri Plastic’s Material Handling Division are an attractive addition to some of our existing product lines, and represent an opportunity to further expand our sales channels into new and existing markets”, said Tom O’Connell, Co-CEO of TH Corp. and President of Snyder Industries. Besides specializing in plastic tanks for the storage, transportation, and processing of bulk liquids, Tank Holding Corp. also manufactures many other proprietary products, including DOT approved transport containers for hazardous materials, medical waste and refuse containers, insulated containers, and specialty pallets. spring 2017

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New UK Study Sheds Light on What Makes Antibiotics Successful

New Treatment Method Prevents Recurrent C. difficile Infections

ondon, England – Study findings published in the journal, Nature Scientific Reports, show could lead to a new weapon in the arsenal against “superbugs.” University of College London researchers first observed the cellular changes caused by bacterial infections. Next, they tested four different antibiotics -- vancomycin, oritavancin, ristomycin and chloroeremomycin – to see what happened when the drugs encountered those changes. Using sensitive equipment and mathematical models, the scientists were able to interpret the force with which the antibiotics attacked the infected cells. The experiment is hoped to help spur chemistry enhancements to make the drugs more efficient. “Antibiotics work in different ways, but they all need to bind to bacterial cells in order to kill them,” explained lead author Dr. Joseph Ndieyira (UCL Medicine). “Antibiotics have ‘keys’ that fit ‘locks’ on bacterial cell surfaces, allowing them to latch on. When a bacterium becomes resistant to a drug, it effectively changes the locks so the key won’t fit any more. Incredibly, we found that certain antibiotics can still ‘force’ the lock, allowing them to bind to and kill resistant bacteria because they are able to push hard enough. In fact, some of them were so strong they tore the door off its hinges, killing the bacteria instantly!” According to Dr. Ndieyira, the study’s mathematical model could be used to screen promising new antibiotics, identifying which new drugs can kill bacteria by using “brute force.” The research was primarily funded by the Engineering and Physical Sciences Research Council (EPSRC), with additional support from UCL, the European Union and the National Institute for Health Research University College London Hospitals Biomedical Research Centre.

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eeds, England – Findings of clinical trials published in New England Journal of Medicine show that a new type of drug treatment for Clostridium difficile (C. diff) can help cut recurrent infections by 37 percent. The study, conducted by a team of University of Leeds microbiologists, involved clinical trials with 2,655 adults across over 300 hospitals in 30 countries worldwide. All the participants had primary or recurrent C. diff infections and were receiving metronidazole, vancomycin or fidaxomicin. The patients were administered two different human monoclonal antibodies (Actoxumab and bezlotoxumab) along with standard antibiotic treatment for C. diff and the results were compared. Monoclonal antibodies are created in laboratory by fusing myeloma cells with mouse spleen cells and immunizing them with a desired antigen. Actoxumab and bezlotoxumab are human monoclonal antibodies that fight C. difficile toxins A and B, respectively. Two double-blind, randomized, placebo-controlled phase three trials used the following methodology: •

a single dose of (another human monocalonal antibody) actoxumab - a single dose of bezlotoxumab (10mg per kilogram of body weight)

•

a single dose of bezlotoxumab plus actotoxumab (10mg per kg of body weight)

•

a placebo (saline)

After initial cure of their C.diff, the patients were then followed up for 12 weeks to see how many developed another C.diff infection. •

In the actoxumab group, 26% developed another C.diff infection

•

In the bezlotoxumab group, 17% developed another C.diff infection

•

In the bezlotoxumab/actotoxumab group, 15% developed another C.diff infection

•

In the placebo group, 27% developed another C.diff infection.

Among participants receiving antibiotic treatment for primary or recurrent C. difficile infection, bezlotoxumab was associated with a substantially lower rate of recurrent infection than placebo and had a safety profile similar to that of placebo. The addition of actoxumab did not improve efficacy. Lead investigator, Mark Wilcox, Professor of Microbiology at the University of Leeds said, “The studies showed that bezlotoxumab was particularly effective in those patients with risk factors for poor outcome, including older age, immunocompromise, and severe infection.” The study was funded by Merck.

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News Briefs

Understanding of Human Immune Component Points to New CRE Treatments

ritish scientists with the National Institutes of Health who investigated a particular Klebsiella bacteria believe that human antibodies may provide an alternative for fighting antibioticresistant Klebsiella infections. The NIH study involved introducing a modified antibody to destroy K. pneumoniae sequence type 258 (ST258). The bacterium is a CarbapenemResistant Enterobacteriaceae (CRE) organism that accounts for about 10 percent of all hospital-acquired infections in the United States and kills nearly half of people who become sick with bloodstream infections. CRE is classified as an urgent threat by the Centers for Disease Control and Prevention (CDC). The scientists introduced a modified antibody to human serum and mice infected with ST258. They observed that a component of the mammalian immune system called the “complement system” plays a role in destroying ST258. The complement system includes nine proteins (C1-9) that help protect against bacterial infections, a process aided by antibodies. Blood depleted of antibodies and/or the complement system had a significantly reduced ability to kill antibiotic-resistant ST258 bacteria, the scientists found. According to the CDC, “Klebsiella bacteria can be spread through person-to-person contact (for example, from patient to patient via the contaminated hands of healthcare personnel, or other persons) or, less commonly, by contamination of the environment. The bacteria are not spread through the air. Patients whose care requires devices such as ventilators (breathing machines) or intravenous (vein) catheters, and patients who are taking long courses of certain antibiotics are most at risk for Klebsiella infections. Healthy people usually do not get Klebsiella infections. The research is hoped to lead to the development of novel treatment strategies. Scientists at NIH’s National Institute of Allergy and Infectious Diseases (NIAID) led the study with collaborators from New Jersey Medical School-Rutgers University.

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Scientists Identify Cytotoxins Present in “Flesh-eating Disease” Infections

ouston, TX – Study findings published in the American Journal of Pathology point to two important cytotoxins present in severe infections of Streptococcus pyogenes (S. pyogenes) a discovery that may one day lead to a targeted vaccine. A team of Houston Methodist Research Institute scientists has linked the cytotoxins, NADase (SPN) and streptolysin O (SLO), to S. pyogenes, a Group A streptococcus (GAS) bacteria. If it overwhelms the body’s immune system, S. pyogenes can multiply and cause tissue necrosis, commonly referred to as “flesh-eating” infection. Lead investigator James M. Musser, MD, PhD and chairman of the hospital’s Department of Pathology and Genomic Medicine, said that both SPN and SLO are present in severe and fatal S. pyogenes infections. If one or the other is missing, evidence has shown that the body’s white blood cells are engaged and fighting the infection, making it more easily treatable with antibiotics. According to the Centers for Disease Control and Prevention, approximately 700 to 1,100 cases of necrotizing fasciitis caused by Group A streptococcus have occurred yearly since 2010. Although the disease primarily affects the very young and old and those with underlying chronic conditions, it may also develop in healthy individuals. Transmission occurs person-to-person, typically through a break in the skin.

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spring 2017

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EPA Waste Handling and Management Strategy: Changes in Store for Retailers

ashington, D.C. – In its latest action toward revising waste handling regulations under the federal Resource Conservation and Recovery Act (RCRA), the Environmental Protection Agency (EPA) is moving toward easing some of the biggest compliance challenges faced by retailers. Although the EPA review of the RCRA’s effects on retailers began nearly a decade ago, a 2011 executive order propelled the agency to take bigger strides in understanding the retail sector. Specifically, the Executive Order asked the agency to review the RCRA and consider how the Act could be “modified, streamlined, expanded, or repealed so as to make the agency’s regulatory program more effective or less burdensome in achieving the regulatory objectives.” The agency followed through by communicating its intent to more fully consider the retail sector in its approaches to issuing new guidance, policies, and rules on hazardous waste management, reverse distribution and other practices impacted by RCRA. In 2014, the EPA officially acknowledged problems faced by retailers with regard to hazardous waste classifications and disposal logistics, the unpredictability of waste generation due to customer returns and market variables, and difficulties in training a constantly changing workforce. Last September, the EPA issued its Strategy for Addressing the Retail Sector under RCRA’s Regulatory Framework. The document, which is a result of agency studies, and input from stakeholders and regulatory reviews, clarifies hazardous waste classification, handling and collection, exemptions for certain types of waste, rules for reverse distributors, large quantity and episodic waste generators and physical buffer requirements.

Medical Waste Washed Ashore on Palm Beach Raises Concerns

alm Beach, FL – Palm Beach tourists and local citizens have reported to authorities an increase in medical waste on the beach here, according to a PalmBeachDailyNews.com article. A beach-cleaning group, Friends of Palm Beach, thinks there’s medical waste on the beaches this year. They have been finding needles and blood collection tubes every day this winter, the group’s leader, Diane Buhler told the Daily News. State and local officials have been unable to place blame directly on any one source. When sewage treatment overflow is not the issue, medical waste can come from offshore. Buhler told Palm Beach Daily News that labels link some of the waste to Haiti, the Dominican Republic and other islands in the West Indies. She also suspects cruise ship waste being dumped in international waters several miles off the Florida coast. Buhler says the Friends of Palm Beach team delivers medical waste to Palm Beach FireRescue stations. According to USAID, the federal governmental agency that has been providing post-earthquake assistance in Haiti, medical waste is frequently left untreated, and waste is often dumped into open pits with incinerators in disrepair. Eric Call, director of Palm Beach County Parks and Recreation, confirmed to the Daily News that passing ships discard medical waste and it eventually washes ashore. Long stretches of public beach, such as those that come under county jurisdiction tend to have more deposits of all kinds of waste, including the medical variety. Meanwhile, the state administers a variety of educational programs and outreach to teach residents, drugstore employees and others how to properly dispose of needles, blood and other medical waste.

Product/Equipment Profiles VERTISA Introduces Plug and Play Technology Solution for Treating Medical Waste

E R T I S A (MedicalWasteTechnology. com) introduces a new Plug and Play advanced technology solution for in-situ treatment of medical waste. PROMED AXL comes in three different sizes that allows labs, clinics and hospitals to treat 20, 30 or 50 Kg per hour, converting medical waste to ordinary waste in 20 to 45 minute treatment cycles. The system sterilizes and shreds on the same vessel. It has its own computerized control panel and its own efficient electric generator system. The shredding system has grinder discs and dual axis rotations that changes directions automatically to avoid jams, and it comes with its own integrated odor control system. Our system, when installed, occupies a space of 2 x 2 x 2 meters. It is also available inside a 20f integrated container. The VERTISA, PROMED AXL is a very efficient, low cost operating system, revolutionizing the medical waste industry with all its custom‑made pre and post shredding technology! For more information contact VERTISA at (407) 852-8277 or visit www.MedicalWasteTechnology.com.

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spring 2017

New Proximity Self-Disinfecting Hospital Cabinets

roximity Systems, Inc., in partnership with UV Partners, recently announced Classic SD and Embrace SD, two new lines of self-disinfecting (SD) cabinets designed to reduce the transmission of infection pathogens in healthcare environments. The new Proximity SD cabinets, are designed to reduce bioburden on hospital surfaces around the clock, independent of human intervention. Proximity’s wall-mounted workstations, strategically placed in patient rooms, ER’s, ICU’s and other frequented areas, make sure data is always at caregivers’ fingertips. In-room cabinets and workstations save time and effort, allowing hospital staff to focus energy on what is important – providing the best care to their patients. The Proximity SD cabinets incorporate UV-C light technology from UV-Angel, providers of UV-C light disinfecting products, and software that allows hospitals to automatically eradicate superbugs multiple times a day. With the Proximity SD cabinet, hospitals and staff benefit from cleaning processes that are: programmable, aware, safe and traceable. For more information on Proximity Systems, visit www.proximitysystems.com.

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VOL. XIII NO. 1

spring 2017