Medical waste: how to protect yourself and your patients?

Alexander Litus, d . M.Sc., Head of the Department of Dermatovenerology, National Medical Academy of Postgraduate Education named after P. L. Shupik

Andrey Kraplya, head of the scientific and advisory department, disinfectionist (Kiev)

Background

The issue of the dangers of medical waste was first raised in Europe at the end of the first half of the last century. In the period from 1930 to 1939, medical institutes in Germany and Switzerland independently conducted studies of hospital garbage in order to identify residual bacterial flora in it, which could serve as a secondary source of infection of patients and medical personnel with various infectious diseases. Then the very first methods of disposal of medical waste (chemical disinfection, thermal disposal) and general provisions for handling them were proposed. At the same time, special requirements were developed to protect medical personnel and patients.

After World War II, the public again returned to discussing the dangers of medical waste. Larger studies have been carried out on the contents of medical waste, its dangers, and the possibilities of various methods of disposal.

In the Soviet Union, such studies have been carried out since the late 40s. In the period from 1960 to 1963, systematic studies of the state of the problem of medical waste management were carried out on the basis of the largest Moscow clinics. As a result, the USSR Ministry of Health developed and implemented requirements for the collection, temporary storage, transportation and disposal of medical waste. Particular attention was paid to the protection of patients and medical personnel.

In 1979, the World Health Organization (WHO) classified medical waste as highly hazardous. The Basel Convention in 1992 identified 45 types of hazardous waste, the list of which is headed by clinical waste. The presence of infectious materials, radioactive components, and toxic substances (mercury, heavy metals, etc.) in medical waste puts it at a higher level of danger in environmental, sanitary and hygienic terms compared to household waste. Therefore, medical waste poses a real threat – both to the staff of medical institutions and to the general population.

How dangerous is medical waste?

The activities of any medical and preventive institution are accompanied by the generation of waste that has varying degrees of epidemiological and environmental danger - depending on its morphological, chemical composition and the degree of contamination with biological agents. Medical waste is considered a direct and indirect risk factor for infectious and non-infectious diseases due to possible contamination of the environment (water, air, soil, food, etc.), intra-hospital environment and potentially poses an epidemiological hazard. They differ significantly in their characteristics from other types of waste (for example, household or industrial) and require special attention. They contain a danger to humans, due primarily to the constant presence in their composition of pathogens of various infectious diseases, toxic, and often radioactive substances. If, for example, 1 g of household waste contains 0.1–1 billion microorganisms, then in medical waste this number increases to 200–300 billion. In addition, the survival time of pathogenic microorganisms in them is quite long.

Published results of an analysis of the microbiological picture of waste from medical institutions show that most often they are sown:

• bacteria of the genus Staphylococcus (30.7% of cases);
• coli bacteria (26.7%);
• non-fermenting gram-negative bacteria represented by pseudomonas aeruginosa (21.3%);
• gram-positive spore rods bac. cereus, clostridium perfringens (14.7%);
• in the remaining 6.6% of samples, other microorganisms were isolated - both in monocultures and in associations with those already mentioned.

These microorganisms are found in more than 30% of medical waste disposed of in city landfills. They are able not only to maintain their viability for a long time, but also to reproduce on environmental objects.

According to the World Health Organization (WHO, August 2004), some types of waste from health care pose a major risk to human health. Such waste, which includes hazardous infectious materials, sharps, substrates and human body parts, accounts for 15% to 25% of all waste generated from health care.

The situation in Ukraine

In recent years, requirements from environmental authorities for medical institutions regarding waste management have become more stringent. In Ukraine, regulatory documents containing the classification of waste from medical institutions (HCI) according to the degree of their toxicological, epidemiological and radiation hazard are still being worked out. In 2007, the draft State Sanitary Regulations and Regulations “Rules of Conduct with Waste from Health Care Institutions” was published. This document, depending on the degree of epidemiological, toxicological and radiation hazard, as well as to introduce effective waste sorting in order to reduce the amount of those that require special treatment and disposal methods, provides for the division of all waste from medical institutions into three groups: safe , hazardous and especially hazardous waste.

Safe waste includes:

• waste that does not differ in composition from household waste and does not come into contact with biological fluids of patients and infectious patients;
• food waste from all departments of medical institutions, except for infectious diseases (including dermatovenerological and phthisiological institutions);
• furniture, equipment, faulty or outdated medical and laboratory equipment that does not contain toxic elements;
• uninfected paper and packaging, construction waste and waste from the territories of medical institutions.

Hazardous waste consists of:

• used medical products (including sharp objects - needles, syringes, scalpels and their blades, glass slides, ampoules, empty test tubes, broken glassware, vasofixes, feathers, pipettes, lancets, etc.);
• pharmaceutical waste (medicines that have expired);
• solvents, chemicals, expired disinfectants, fixing solutions;
• batteries, items, devices and equipment containing heavy metals;
• radioactive waste (materials that contain or are contaminated with radioisotopes).

Particularly hazardous wastes include:

• discarded materials or equipment contaminated with blood and blood products, other biological fluids or excrement of patients;
• anatomical waste (tissues, organs, body parts, placenta, embryos, etc.) of patients;
• waste from patients who underwent hemodialysis (dialysis equipment - tubes, filters);
• waste that contains blood and biological fluids of people or animals, as well as blood containers, sheets, underwear, aprons, gloves, lab coats contaminated with blood);
• laboratory waste (microbiological cultures and strains that contain any live pathogens artificially grown in significant quantities, as well as laboratory dishes and equipment for their transfer, remnants of culture media, infected remains of experimental animals, their excrement and garbage from laboratories where experiments were carried out or research);
• cytotoxic pharmaceutical waste;
• pharmaceutical waste that requires special accounting (contains narcotic drugs, psychotropic substances and precursors, potent drugs).

Depending on the type and group of waste, different requirements are put forward for its collection, disinfection, processing, storage, transportation and disposal.

It is prohibited to mix waste from different groups at the stages of collection, storage, disinfection, transportation and disposal. Separate collection of waste should be carried out taking into account the types and groups of waste by personnel whose activities lead to their formation (nurse, doctor, laboratory assistant, etc.), near the source of their direct formation (in the ward, operating room, laboratory, etc.) in order to isolation of waste and eliminating the need for re-sorting, which is associated with the risk of injury and infection.

Waste collection should be carried out as close as possible to the places of its generation - in separate special containers that are visually clearly distinguishable (by color and/or marking). In each room (ward, operating room, procedure room, manipulation room, etc.) containers (containers/bags) must be installed for the types of waste that are generated there (according to the classification).

Danger at the tip of the needle

Injection needles and syringes pose a particular danger, since improper handling after use can cause injury and occupational illness to medical personnel, or lead to their reuse. Health care workers are often at risk of being injured by needles, during which contamination occurs with a small but very dangerous amount of blood, which can lead to infection with HIV, hepatitis B and C viruses, and other blood-borne infections. Accidental needle sticks by medical workers most often occur when putting a cap on a needle before and after an injection, or when the rules for disposing of syringes and needles are not followed.

According to WHO estimates, in 2000 the following people became infected as a result of syringe reuse alone:

• 21 million people with hepatitis B virus (HBV) (32% of all new infections);
• 2 million people with hepatitis C virus (HCV) (40% of all new infections);
• 260 thousand people have HIV (5% of all new infections).

Cosmetology and dermatovenereology clinics operating on the basis of licenses for medical practice are fully classified as medical and preventive institutions, which means they must strictly comply with all requirements for ensuring the epidemiological safety of their activities. A significant proportion of medical, cosmetic and diagnostic procedures and manipulations are associated with damage to the skin and mucous membranes from piercing and cutting medical products. The most widely used include, for example: elimination of wrinkles by injection of drugs based on botulinum toxin, contouring with implants based on hyaluronic acid, autolipofilling (transplantation of one’s own adipose tissue), blepharoplasty, transconjunctival blepharoplasty, mesotherapy, liposuction, hair transplantation, treatment of hyperhidrosis with botulinum toxin injections, blood sampling for diagnostic studies and many others. All these manipulations are associated with the generation of medical waste, among which, first of all, it is necessary to note injection needles and syringes, as well as dressings, tampons and napkins contaminated with blood and other biological substrates.

Rules for handling medical waste

The first step in Ukraine to regulate the management of medical waste was the introduction of the “Instructions on the collection, disinfection, storage and delivery of used disposable medical products made from plastic masses” (Order of the Ministry of Health of Ukraine dated October 22, 1993 No. 223). Certain provisions for handling used injection needles and syringes are also set out in other, more recent instructions and methodological documents of the Ministry of Health of Ukraine.

Safe injection practices ensure the safety of patients, medical personnel, and the community at large.

Summarizing domestic and foreign experience, recommendations for the safe handling of used injection needles and syringes can be reduced to the implementation of ten basic rules.

Rule #1

Each patient must be considered as potentially infected , including HIV and other blood-borne infections! Therefore, used syringes are hazardous or extremely hazardous waste from healthcare facilities due to their contamination with infected or potentially infected biological fluids.

Rule #2

Single-use injection syringes are not allowed to be reused for injections and are subject to mandatory disinfection by chemical or physical methods.

Rule #3

Disinfection of used injection needles and syringes by chemical method is carried out separately in two special containers, closed with lids and filled with a pre-prepared disinfectant solution. Containers must be marked as follows: “Container for disinfecting needles” and “Container for disinfecting syringes.” A needle remover can be used as a container for disinfecting needles if it is filled with a disinfectant solution. The needle remover is a hard, puncture-proof, disposable plastic container that has a lid with a specially configured hole suitable for removing needles from syringes of different diameters. The container for disinfecting syringes must be equipped with a perforated tray and pressure.

Rule #4

After the injection (manipulation), the medical worker, without covering the needle with a cap, draws a disinfectant solution into the syringe using a piston from a container for disinfecting syringes. Then the medical worker disconnects the needle from the syringe in one of the ways that eliminates the possibility of injury from the needle , depending on the availability of special devices in the medical institution (for example, a needle remover or a needle cutter with an integrated puncture-proof container for needles, etc.).

Rule #5

After disconnecting the needle , the syringe body with the piston should be placed in a container for disinfecting syringes , which is filled with a solution of a disinfectant, and the required exposure time specified in the guidelines for the use of the product used should be maintained. After the end of the exposure, the disinfectant solution is released from the syringe body using a piston, after which the disinfected pistons and syringe bodies are placed in a bag or disposable container with markings corresponding to the class of medical waste. The container (bag, container), after filling 3/4 of its volume, is packaged and stored in a room for temporary storage of medical waste for the purpose of subsequent transportation to the place of destruction or disposal.

When the needle stripper is filled to 3/4 of the volume with needles and the required disinfection exposure time is observed, which is counted from the moment the last needle is immersed in the solution, the solution is carefully drained, the container is closed with a lid, placed in a mini-container marked corresponding to the class of medical waste, and stored in room for temporary storage of medical waste.

Rule #6

If there are no special devices and devices in the medical institution, separation of the needle from the syringe should be carried out only after disinfection of the syringe with the needle. For disinfection, the disinfectant solution is drawn through a needle into the syringe and the syringe with the needle is immersed in a container for disinfecting syringes with a disinfectant solution for the required exposure time. After the disinfection time has expired, the needle is separated from the syringe using tweezers and placed in a solid package (a puncture-proof sealed container for single use). The disinfectant solution is released from the syringes by pressing on the piston, after which they are placed in a bag or disposable container with markings corresponding to the class of medical waste. The container (bag, container), after filling 3/4 of its volume, is packaged, placed in a mini-container marked according to the class of medical waste, and stored in a room for temporary storage of medical waste.

Rule #7

To disinfect needles and single-use injection syringes , disinfectants that have a certificate of state registration in Ukraine and guidelines for their use are used. The concentration of the working solution of the disinfectant and the exposure time are determined in accordance with the guidelines for its use, taking into account the regime effective against pathogens of infectious diseases that the healthcare institution is focused on, and the regimes recommended for the disinfection of medical devices for viral infections.

The frequency of replacing the solution in containers is determined according to the guidelines for the use of a disinfectant. The container for storing the disinfectant solution must indicate its name, concentration, purpose and date of preparation (for ready-to-use products approved for repeated use, indicate the start date of use).

Rule #8

The most well-known and accessible method of physical disinfection of single-use injection syringes is the method of disinfection with saturated water vapor in steam sterilizers (autoclaves). When using this disinfection method, the syringe bodies and pistons are placed in a special, vapor-permeable, disposable bag that is resistant to high temperatures and intended for sterilization of medical products. After filling the bag with syringes without needles to 3/4 of the volume, it is sealed and placed in an autoclave and kept at a temperature of 132°C for 20 minutes in order to destroy them (change their appearance and lose their consumer properties). It is preferable to carry out disinfection in a steam sterilizer (autoclave) specially designated for this purpose. Needle strippers (containers of needle cutters) with removed non-disinfected needles, after filling them to 3/4 of the volume, are closed with a lid and placed in an autoclave, having previously opened the covers of the needle strippers (needle cutters) so that steam can penetrate inside the container. After the disinfection cycle, the needle removers (needle cutters) are tightly closed with lids (sealed). Syringes without needles, located in a vapor-permeable bag, are packaged in a disposable outer bag intended for collecting waste with markings corresponding to the hazard class, sealed and delivered to the temporary waste storage room (in a mini-container).

Rule #9

Medical workers disinfecting single-use injection syringes draw up a disinfection report for the entire batch of used syringes accumulated over a certain period and prepared for delivery to specialized organizations that have the right to work (handle) with hazardous (medical) waste (the form of the report is determined by the mentioned above “Instructions on the collection, disinfection, storage and delivery of used disposable medical products made from plastic masses”).

Rule #10

Security measures. The employee who collects and disinfects waste and seals it must work in special clothing, a gauze mask (respirator) and rubber gloves . Transportation of all types of waste outside the medical institution is carried out only in disposable packaging after it has been sealed.

Not allowed:

• use soft disposable packaging to collect sharp medical instruments and other sharp objects;
• pour hazardous and especially hazardous waste from one container to another;
• compact any waste by hand;
• collect waste without gloves.

If an employee receives an injury while handling waste that is potentially dangerous in terms of infection (an injection, a cut that breaks the integrity of the skin and/or mucous membranes), it is necessary to take appropriate emergency preventive measures. At the personnel workplace there should be a first aid kit for injuries.

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To summarize, we consider it necessary to once again emphasize that medical waste poses a serious danger to the staff of medical institutions, patients, and the environment and requires special handling. Moreover, this danger is increasing due to the progressive trend of increasing the amount of medical waste. Most important issues of medical waste management require further urgent legislative regulation.

First published: Les Nouvelles Esthetiques Ukraine, No. 4 (68), 2011