Missouri

Infectious
Medical Waste

Background Information
Infectious Medical Waste Definitions
Regulation of Infectious Medical Waste
Handling, Treatment and Management of Infectious Medical Waste
OSHA Regulations
Contacts
More Information

Background Information

Medical waste differs from hazardous waste. Hazardous waste is regulated by the US EPA (and related state rules) under the Resource Conservation and Recovery Act. Medical waste is not covered federal environmental laws or US EPA regulations (with the exception of a medical waste that also meets the definition of hazardous waste). Rather, medical waste is mostly controlled by state law and associated regulations. In addition to state environmental agency laws/rules, aspects of medical waste management are also controlled by the Occupational Safety & Health Administration (federal and/or state) and Department of Transportation (federal and state).

Each of our 50 states have developed rules and implemented regulations for medical waste. The state rules vary to some extent, including terminology. Depending on which state you live in, you may hear the terms regulated medical waste, biohazardous waste or infectious medical waste. In most cases, these terms all refer to the same thing: that portion of the medical waste stream that may be contaminated by blood, body fluids or other potentially infectious materials, thus posing a significant risk of transmitting infection.

Most states have regulations covering packaging, storage, and transportation of medical waste. Some states require health care facilities to register and/or obtain a permit. State rules may also cover the development of contingency plans, on-site treatment, training, waste tracking, recordkeeping, and reporting.

In most states, the environmental protection agency is primarily responsible for developing and enforcing regulations for medical waste management and disposal. Although in some states, the department of health may play an important role or even serve as the primary regulatory agency. Where both agencies are involved, typically the department of health is responsible for on-site management and the environmental agency is responsible for transportation and disposal.

OSHA, whether it is the U.S. Department of Labor Occupational Safety & Health Administration or an OSHA state program (24 states operate their own program), regulates several aspects of medical waste, including management of sharps, requirements for containers that hold or store medical waste, labeling of medical waste bags/containers, and employee training. These standards are designed to protect healthcare workers from the risk of exposure to bloodborne pathogens. However, they also help to systematically manage wastes, which benefit the public and environment.

Regulated medical waste is defined by the US Department of Transportation as a hazardous material. DOT rules mostly apply to transporters rather than healthcare facilities; although, knowledge of these rules is important because of the liability associated with shipping waste off-site.

Infectious Medical Waste Definitions

Infectious medical waste (IMW) is waste capable of producing an infectious disease because it contains pathogens of sufficient virulence and quantity so that exposure to the waste by a susceptible human host could result in an infectious disease.  These wastes include isolation wastes, cultures and stocks of etiologic agents, blood and blood products, pathological wastes, other contaminated wastes from surgery and autopsy, contaminated laboratory wastes, sharps, dialysis unit wastes, discarded biological materials known or suspected to be infectious; provided, however, infectious waste does not include waste treated to MDNR specifications.

An Infectious medical waste generator is any single office (doctor’s office, dentist’s office, and the like) or facility (hospital, nursing home, mortuary, and the like), whose act or process first causes an infectious waste.  A small quantity generator (SQG) of infectious waste is defined as a generator of 100 kilograms (approximately 220 pounds) or less of infectious waste per month.  A transfer station permitted as an infectious waste processing facility becomes the generator when the infectious waste is transported for further processing.

Infectious medical waste includes the following wastes:

• Isolation wastes generated by patients who have communicable diseases which are capable of being transmitted to others via those wastes.
• Contaminated surgical, dialysis and laboratory wastes generated by surgery, dialysis and laboratory departments in the process of caring for patients who have communicable diseases which are capable of being transmitted to others via those wastes.
• Cultures and stocks of infectious agents and associated biologicals when discarded because of the high concentrations of pathogenic organisms typically present in these materials.
• Blood and blood products including serum, plasma and other components known or suspected to be contaminated with a transmissible infectious agent.  An exception is that the term “blood products” does not include patient care waste such as bandages or disposable gowns that are lightly soiled with blood or other body fluids, unless such wastes are soiled to the extent that the generator of the wastes determines that they should be managed as infectious wastes.
• Pathology wastes including tissues, organs, body parts and body fluids that are removed during surgery and autopsy.  All such wastes must be considered infectious waste and include are animal carcasses, body parts and bedding from animals contaminated with infectious agents capable of being transmitted to a human host.
• Sharps including hypodermic needles, syringes and scalpel blades.  Broken glass or other sharp items that have come in contact with material considered infectious by definition are also included.

Regulation of Infectious Medical Waste

Infectious waste in Missouri is regulated as a non-hazardous solid waste under the Missouri Waste Management Law.  Missouri law charges the Missouri Department of Natural Resources (MDNR) and the Missouri Department of Health (MDOH) with the responsibility for regulation of infectious waste management:

• MDOH is responsible for regulating the on-site management of infectious waste by Missouri hospitals defining wastes which are considered infectious when produced by small quantity generators. 
• MDNR is responsible for regulating all other aspects of infectious waste management, including permit requirements, transportation, packaging, etc.

In addition, to these state regulations there are some federal Occupational Safety and Health Administration (OSHA) rules that apply to infectious medical waste.  Missouri is one of 26 states covered entirely by the federal OSHA program.  OSHA rules impact several aspects of infectious medical waste, including management of sharps, requirements for containers that hold or store IMW, labeling of IMW bags/containers, and employee training.  These requirements can be found in the HERC OSHA Standards for Regulated Waste section.

Anyone generating infectious waste must be aware of the requirements for infectious waste management.  Included in the requirements are the following major points:

• All infectious waste must be treated before disposal in Missouri, except waste generated at individual residence.
• All sharps must be packaged in a rigid, leak proof and puncture-resistant container prior to transport and all treated and untreated sharps must be similarly packaged before disposal. 
• If infectious medical waste is going to be transported to a permitted treatment facility, the generator must prepare a tracking document that will accompany the waste.
• All treated waste must be certified as having been treated prior to disposal in a landfill in Missouri.  The certification must be provided to both the hauler and the landfill.
• The only requirement for infectious waste generated at an individual residence is that it be packaged in rigid, leak proof and puncture-resistant containers prior to disposal with regular household waste. 

Missouri regulatory agencies set waste minimization and pollution prevention as the first priority for managing wastes (i.e., maximum feasible reduction of the total volume of IMW generated; the reduction of the toxicity of the IMW, or both).  Practices that are considered waste minimization and pollution prevention include recycling, source separation, product substitution, and the use of less toxic materials.  Missouri regulatory agencies prefer that all IMW generators consider performing a waste minimization and pollution prevention assessment for their facility.

Handling, Treatment and
Management of Infectious Medical Waste

Packaging of Infectious Medical Waste

Prior to transport, all infectious medical waste must be placed in rigid or semi-rigid, leak-resistant containers clearly marked with the universal biohazard symbol prominently displayed and labeled Infectious Waste or Biohazard Waste and sealed.  All containers must be closed in such a manner as to completely contain all waste and the outside of the container must be kept free of contamination.  Leak-resistant containers are defined as containers that are closable with a tight fitting lid and are leak proof on the bottom and sides.

Transportation of Untreated Infectious Waste

Unless a healthcare facility is a small quantity generator (SQG), untreated infectious medical waste can only be transported from the healthcare facility by transporters who are licensed by the Missouri Department of Natural Resources (MDNR).

An SQG has three options for transportation:

• The generator may transport the properly packaged waste using its own employees and vehicles, provided the vehicles are closed and secure.
• If the SQG chooses not to transport its own waste, the waste must be transported by an infectious waste transporter licensed in Missouri for the transportation of infectious waste.
• In addition, untreated sharps may be transported for the treatment by the United States Postal Service, as long as the Postal Service requirements (39CFR111) are followed.

If the waste is transported off the premises of the generator, it must be taken to a permitted infectious waste processing facility, a hospital approved by both the MDNR and MDOH to accept such waste, or out of the state.  A tracking document must be prepared by the generator, which accompanies the waste during transport.

Tracking Documents

The generator of infectious waste that is to be transported to a permitted infectious waste processing facility must prepare tracking documents which must include:

• name, mailing address, location and telephone number of the generator,
• name and address of the designated facility which is permitted to process the waste,
• name and address and Missouri Transporter identification number of the transporter’s company, if other than the generator,
• quantity of waste to be transported,
• name and signature block for the transporter, and
• name and signature block for the receiving facility.

The healthcare facility retains one copy of the tracking document and gives the transporter the remaining copies.  Within 35 days after the date that a waste shipment is received by a processing facility, the processing facility must send a final copy of the tracking document back to the generator.

Treatment of Infectious Waste

The following treatment technologies are approved for the treatment of infectious waste by permitted facilities:

• Incineration; and
• Steam sterilization.

Chemical sterilization and other types of treatment may be approved by the department on a case-by-case basis.

Disposal of Infectious Waste

• All sharps shall be packaged in rigid, leak-resistant and puncture-resistant containers and sealed prior to disposal.
• Infectious waste treated to render it innocuous may be disposed as a solid waste provided the treater certifies to the transporter, if other than the generator, and certifies to the sanitary landfill operator or processing facility operator that the waste has been rendered innocuous.
• Incinerator residue from a permitted infectious waste processing facility shall be considered to be a special waste and handled accordingly.

On-Site Treatment

Healthcare facilities generating infectious waste may choose to treat that waste on site to render it innocuous and dispose of it as solid waste.  Such on-site treatment of infectious waste does not require a permit or approval from the MDNR, except that on-site incineration will require a permit from the Missouri Department of Natural Resources (MDNR) Air Pollution Control Program or from a local air pollution control agency. Some treatment methods may result in the discharge of liquids and may be regulated by the MDNR Water Pollution Control Program or the local sanitary sewer district.

Hospitals choosing to treat infectious waste on site must comply with the requirements of the Missouri Department of Health (MDOH). Acceptable methods for on-site treatment include incineration, steam sterilization (autoclave) and chemical treatment.

For chemical treatment of sharps, the MDOH recommends the use of one part common household chlorine bleach mixed with nine parts water. This solution should be poured into the container of sharps and allowed to remain for approximately thirty (30) minutes. The solution must then be carefully poured off so that free liquid does not remain in the container. The solution may be disposed of in the sanitary sewer system. The sharps container must then be sealed prior to disposal.

Off-Site Treatment

Infectious waste transported off the premises of the healthcare facility must be taken to a permitted infectious waste processing facility (for example, a transfer station, incinerator or steam sterilizing facility permitted to accept infectious waste), or to a hospital approved by both the MDNR and the MDOH to accept the waste or out of Missouri.

In order for a hospital to be approved to accept infectious waste from small quantity generators (SQG's), the hospital must submit a request for approval to both MDNR and MDOH. Requirements for such requests are specified in 10 CSR 80-7.010 and 19 CSR 30-20.020. Hospitals may contact the Solid Waste Management Program and the MDOH - Bureau of Hospital Licensing for information about the approval process.