HomeMy WebLinkAboutBoard of Health October 19 19991
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
WHATCOM COUNTY COUNCIL
Board of Health
October 19, 1999
The meeting was called to order at 12:30 p.m. by Council Chair Marlene
Dawson in the Council Chambers, 311 Grand Avenue, Bellingham, Washington.
Also Present: Absent:
Connie Hoag Kathy Sutter
Barbara Brenner
Tom Brown
L. Ward Nelson
Robert Imhof
INTRODUCTION
Chuck Benjamin, Health and Human Services Director, introduced members
of the Health and Human Services Department staff, members of the Public Health
Advisory Board (PHAB), members of the Medical Waste Task Force (MWTF), and
members of the public.
BIOMEDICAL WASTE TASK FORCE RECOMMENDATIONS
(Imhof arrived at 12:35 p.m.)
Dr. Mary Ellen Shields, Public Health Advisory Board Member, stated a great
deal of time and effort and consideration has been put into the recommendations.
The medical waste task force met twice a week for several months. They have
recommendations. She named and thanked the Task Force members. Eighteen
recommendations, which were forwarded to the Advisory Board, came from the
Task Force. Consensus was met on 13 of the 18 recommendations. The Task
Force forwarded differing opinions on the five recommendations that were not
reached by consensus. The Public Health Advisory Board adopted without change
12 of the 18 recommendations. One recommendation was adopted with only minor
clarifications. Regarding the five recommendations not approved, the Advisory
Board carefully reviewed all opinions and then made their own recommendations.
They included the differing opinions in their report. Management of medical waste
is an important issue. Washington State is one of the few that does not have
statewide regulations on medical waste. It is essential in developing clear local
regulations.
RECOMMENDATIONS AS CONSENT ITEMS
Benjamin distributed the recommendations and recommended that the Board
of Health act on the twelve items as a consent agenda. Those are
recommendations one through six, nine through eleven, fourteen, fifteen, and
eighteen. These are consensus items from both the MWTF and the PHAB.
Board of Health, 10/19/99, Page 1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
Nelson moved to approve all twelve items.
Hoag moved to withdraw item numbers four and fourteen from the consent
agenda.
Motion to approve items one through three, five, six, nine through eleven,
fifteen, and eighteen carried unanimously.
RECOMMENDATION NUMBER FOUR - PACKAGING OF BIOMEDICAL
WASTE
Hoag read recommendation number four regarding the packaging of medical
waste. She questioned whether this regulation is already law because these are
technical standards of the State Department of Transportation (DOT). Benjamin
stated he believed they are.
Regina Delahunt, Health and Human Services Environmental Health Manager,
stated they are currently required to meet the standards if the waste is transported.
Recommendation number four addresses the on -site generation of waste. State
regulations might not cover small waste, even if transported.
Imhof moved approval of item number four.
Motion carried unanimously.
Nelson stated he wanted to discuss recommendation ten regarding
commercial transportation of biomedical waste. He read the recommendation into
the record. He questioned whether DOT does this activity. Delahunt stated it is a
DOT regulation. They should enforce the transportation, but they do not because of
lack of staff. This was discussed at length by the MWTF. They wanted additional
assurance within the community that someone was looking at the vehicles.
Nelson questioned whether the County would increase its staffing to do the
inspections. Delahunt stated there are less than a dozen vehicles that transport
waste to the facility. It wouldn't be much of an increase in staff hours. They could
also potentially charge the transporter a fee for inspection.
Benjamin questioned whether it applies to medical waste haulers not going to
treatment facilities. Delahunt stated they won't stop a hauler on the road. They
inspect the transportation at the facility.
Nelson stated it would be an on -site inspection. He questioned whether they
would do the on -site inspection only at the time the Health Department would be
there doing a site inspection. Delahunt stated they would inspect them periodically,
once or twice during the year.
Board of Health, 10/19/99, Page 2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
Nelson asked if they would have to have the spill kit that DOT requires.
Delahunt stated they would.
Nelson asked if they would have to have the lining that guarantees the
integrity that DOT also requires. Delahunt stated they would.
Nelson questioned whether they would have to operate in a clean and safe
manner. He asked whether 'clean and safe manner' refers to standards. Delahunt
stated those would be subjective standards. Based on these recommendations,
they will have to write regulations. Those things will be addressed specifically in
the regulations.
Nelson asked if it would require additional staffing. Delahunt stated it would
require additional staffing hours.
Hoag stated the County could recoup the fees.
Dawson stated the Health Department will inspect the haulers at the site
when the Health Department is on -site already doing site inspections.
Nelson questioned whether the County would notify the haulers. Delahunt
stated they would be notified and required to register their vehicles with the Health
and Human Services Department, who will then know how many vehicles are
coming. They'll have a list of those vehicles.
Nelson asked if the haulers pay a fee to the DOT. Delahunt stated they
must.
Imhof suggested the County could request the DOT to keep a better eye on
those trucks.
Nelson suggested the County could also contract with the DOT to take over
inspection of the vehicles. Delahunt stated this regulation would not be for a
complete DOT inspection.
Nelson asked how much DOT collects. Delahunt stated she didn't know.
Other counties have a similar provision.
Nelson stated he would support it, but questions need to be answered to find
out if they would be double - penalizing the haulers because the DOT isn't doing their
job.
Nelson moved to recommend that administration work with DOT to recoup a
portion of what DOT charges to do the inspection. Benjamin stated developing
regulations is recommendation one.
Hoag stated they could add a footnote to recommendation 18 to work with
state agencies to recoup funds as appropriate.
Board of Health, 10/19/99, Page 3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
Nelson withdrew his motion regarding number ten.
The Board of Health concurred to direct administration to recoup funds as
appropriate. Benjamin stated they would accept that as direction from the Board.
RECOMMENDATION NUMBER FOURTEEN -RULES GOVERNING A
TREATMENT FACILITY
Hoag needed an explanation of Recommendation fourteen, item (2). She
asked about a six log biological spore reduction. Delahunt stated there are spore
strips that are placed in the autoclave. They have a known number of bacterial
spores on the strip, which is one million. The autoclave process has to kill all the
spores on the strip. The strips are sent to a lab, after being autoclaved, and are
incubated to ensure the spoors were killed. A log six reduction is more than is
required in many states, and is the sterilization level for medical instruments. They
use a spore that is very difficult to kill under these conditions. This is the spore
that is used as the standard for sterilization.
Dawson stated the packages that go in are quite thick. Delahunt stated they
devised a complicated method for packaging the spore strips.
Benjamin offered to do a presentation on the validation testing.
Hoag questioned what was being accomplished by item (2). They want to
make sure the waste is not infectious when it comes out of the sterilization process.
She questioned whether they would regularly put test strips in with each batch and,
if so, are the test strips packaged similarly to the rest of the waste going in.
Michele Jenkins, Health and Human Services Environmental Health Specialist,
stated that before the facility could start up, they went through the rigorous
validation process to create a worst case scenario. Once established, the facility
does a weekly spore test. She described the validation test procedure and the
weekly spore tests.
Dr. Greg Stern, Whatcom County Health Officer, stated that with a large
volume of waste, there would be a question of how sure they are the waste is not
infectious. They set up a scenario in which spore strips were placed in insulated
environments. They also placed spore strips in a way that they would be used for
routine testing. During the validation testing, they compared the insulated test
with the stick and tube tests.
Jenkins stated they placed paper thermometers to measure the maximum
temperature of each location of the spore strips.
Stern stated they correlated the spore kill with a local temperature, and also
measuring pressure and temperature for the entire container. They did this in
multiple sites. They looked specifically for cold spots. When they finished the
Board of Health, 10/19/99, Page 4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
testing, before they authorized the commercial runs, they were convinced the
autoclave process was effective in decontaminating the waste. They would use the
weekly test to validate that it is continuing to be effective.
Hoag asked if the validation testing established the protocols. Stern stated
that was correct. They used the time and pressure readings, the biological testing,
and temperature readings. They were satisfied the treatment was effective.
Jenkins stated they put their own spore strips in the autoclave. The facility
also put their strips in. They were sent to different labs. The results were the
same.
Hoag stated the information from the State Department of Health (DOH) said
double bagging in plastic insulates the waste. She asked why the spore strip isn't
going into a double insulated plastic bag. Stern stated it is to avoid unnecessary
worker exposure. They went through the intensive validation stage and are
comfortable that the temperature, time, and pressure were adequate for treating
the waste. The spore strips provide an additional biological indicator that the
process is effective. They validated that the process is effective. This is an ongoing
extra test that would pick up a problem, but they wouldn't anticipate a problem if
they are meeting the same conditions that occurred during the validation testing.
Jenkins stated this is the standard nationwide. All facilities go through a
validation procedure. Afterwards, there is a routine weekly test.
Stern stated the temperatures melt the plastic bags. With all the insulation,
they were seeing if there was a problem in terms of heat penetrating those
environments.
Brenner stated she supported the recommendation. There is one disease
that she knows of that has become more common, Creutzfeldt -Jakob disease.
Autoclaving will not kill those bugs. Even if level six does work, she has
documentation it will not be killed by autoclaving. Level six does not take into
account compaction and overloading of an autoclave. She was not comfortable that
there will be surprise inspections. According to workers at the facility, there has
never been a surprise inspection. This is an improvement from what they have,
which is why she supported the recommendation. Medical instruments have to be
thrown out because they cannot be sterilized from Creutzfeldt -Jakob disease.
Hoag also questioned item (3) and whether the qualified person is an
impartial person or someone from the facility. Delahunt stated that is something
they would need to clarify in the regulation.
Brenner stated she understood it would be someone from the Health
Department. Delahunt stated the Health Department would not be qualified to
inspect the equipment. They could contract with someone to do it.
Imhof moved approval of recommendation.
Board of Health, 10/19/99, Page 5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
Dawson asked how they send the spore strips back to the lab. Delahunt
stated they go through the mail. They are pathological, not disease causing.
Motion to approve carried unanimously.
RECOMMENDATION NUMBER EIGHT- SHARPS EDUCATION
Benjamin asked the Board of Health to consider recommendation number
eight, regarding sharps education. The PHAB changed the Task Force
recommendation to include wording about residential sharps. That is appropriate
because health care providers are held to the bloodborne pathogen laws. They
already have internal training. However, the residential component of the
community doesn't have that training.
Brown asked if this includes a method to educate people with diabetes.
Delahunt stated recommendation number nine is to establish a drop site for citizens
to dispose of residential sharps.
Brown asked if that could be picked up with the residential garbage in a
special container.
Nelson stated that he spoke with Sanitary Service Company (SSC). At
certain times, they won't pick it up. This recommendation didn't discuss that. They
can't make it more difficult and costly. The County needs to work with the
residential waste haulers.
Brenner stated the Task Force discussed that. Disposable needles are being
developed that are retractable. They will not be that much more expensive in the
future. That is the direction they are going.
Nelson stated someone with diabetes will use the needles two or three times,
and will not invest in the retractable needles.
Hoag asked if they are going to educate school children, which isn't a
residential use. Dr. Stern stated it is addressed in public outreach on bloodborne
infection. This specifically addresses medical waste. They are separate issues.
Hoag asked if there is sharps education available to the kids. Benjamin
suggested they go back and look at the curriculum the Health Department and the
schools are using.
Hoag moved to approve the Public Health Advisory Board recommendation
number eight.
Nelson stated he thinks of a particular disposal container when he hears the
term 'sharps.' Stern clarified that 'sharps' refers to devices such as needles,
Board of Health, 10/19/99, Page 6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
lancets, scalpels, or contaminated broken glass. 'Sharps containers' refers to the
container used to dispose of the sharps.
Nelson moved to amend to clarify that they are approving the PHAB
recommendation.
Motion carried unanimously.
RECOMMENDATION NUMBER SEVEN - SHARPS TREATMENT AND
COMPACTION
Benjamin introduced recommendation number seven. The PHAB added a
sentence regarding the location of where sharps can be compacted.
Imhof moved to approve the PHAB recommendation number seven.
Brenner stated the Task Force's minority position originally didn't want to see
any compaction unless there was a way to render them non - injurious. She
questioned whether the PHAB recommendation agrees with the minority position.
Stern stated the PHAB language refers to on -site compaction rather than
compaction at a transfer station or landfill.
Brenner stated the language says they can be compacted provided they have
been processed in a manner that renders them non - injurious. That tells her the
sharp cannot puncture.
Hoag stated that the way it is written, it is not limited to on -site compaction.
Stern stated the way he understood it, sharps should not be disposed of
without treatment, and they shouldn't be compacted before they are treated. After
treatment, they could be compacted at a transfer station or landfill. This would
allow, after autoclaving, to put them in a compactor.
(Clerk's Note; End of tape one, side A.)
Stern continued to state the concern was that treated compacted sharps
could still cause puncture injuries. The sites where it would be most likely that
someone would get stuck would be prior to arriving at a transfer station. If
someone was treating sharps in their office, they would have to grind them up or
melt them down before putting them in a dumpster.
Brenner stated that is not what the recommended language says. One of the
things the MWTF discussed was about the possibility of someone at a landfill being
stuck with a sharp. The language doesn't address that concern. Stern stated the
idea was to separate the differing degrees of risk of injury at different stages of
transportation. The high -risk area was prior to disposal at the transfer station. The
Advisory Board recognized that the risk of needle stick injuries at a landfill was low
because they are mechanized.
Board of Health, 10/19/99, Page 7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
Brenner stated the language includes the final destination of the sharp.
Delahunt stated the recommendation isn't worded in a way that reflects the PHAB
intention. Their rationale was that compaction at a transfer station or landfill
should be allowed because it is under controlled conditions and workers are trained
in precautions to use when handling waste and to avoid injury.
Brenner stated she read it and agreed, but they don't contradict. She asked
what they meant by non - injurious. Delahunt stated that refers to treatment on -site
at a doctor's office. The PHAB believed that, at that point after treatment, they
should be rendered non - injurious if they are going to be dumped in a dumpster.
Hoag recommended that the language be amended, "...transfer or landfill.
Compaction will be allowed of on -site, after treatment,..." that would distinguish
between the intent. Stern stated that was the intent of the Advisory Board.
Hoag asked how they are dealing with needles in landfills and how someone
would know when they get stuck that they won't get infected. Stern stated they
don't know, however people aren't walking around landfills. It is a mechanized
operation. The municipal waste and treated medical waste is compacted into the
containers. The containers are trucked to the landfill. The entire unit is tipped into
the fill. People are not exposed. Avoiding those injuries is part of the training for
working in these areas.
Hoag moved to amend the language as she stated above.
Brown stated the word non - injurious doesn't mean that one can't get injured
by being stuck, but one won't get contaminated. Stern stated the treatment
prevents infection. The injury with sharps will be a puncture or a cut. Rendering
the sharps non - injurious means melting it down or grinding it. If treated in an
office, it has to be melted or ground down. The other part was to allow compaction
of the treated waste. The other issue with being stuck with the treated sharp. If
stuck, one has to be treated as if it was infected.
Brenner stated she didn't support the word change. They are still talking
about waste workers. If they are concerned about one waste worker hauling
regular dumpsters, then they should be equally concerned about waste workers
hauling infectious waste. There should not be compaction. It would be just as easy
for anyone generating sharps to keep him or her separate. There isn't much to
compact when doing only sharps. There shouldn't be compaction because they
would still expose people.
Imhof stated if they have been treated and rendered sterile, and then
compacted and made non - injurious.
Brenner stated that would be fine, if they are ground up. That isn't what
they are saying, though. They are saying they don't have to be made non - injurious
unless they are treated on -site at a doctor's office. Stern stated treated medical
Board of Health, 10/19/99, Page 8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
waste now is mixed with the municipal solid waste and trucked with the municipal
solid waste. If they require that all sharps not be compacted at any point in that
path, then they would require a separate transportation path to the landfill, where
they would have to be segregated from all other waste. Otherwise, they would be
compacted at some point. The other alternative was to require that all sharps be
ground or incinerated. For facilities that choose to autoclave, they would have to
make sure all sharps were only treated by incineration or ground.
Hoag asked what is involved in rendering the sharps non - injurious. Stern
stated they would have to be segregated from other medical waste and either
melted or ground. Another option would be to imbed them in plastic.
Hoag stated she didn't want to incinerate the sharps. She asked what they
are requiring the on -site medical professionals to do to make them non - injurious.
Stern stated they are requiring them to grind or incinerate the sharps.
Delahunt stated that wouldn't be a viable option onsite.
Hoag asked if there is currently anything being done to render the sharps
non - injurious. Delahunt stated there are some sharps containers that compact the
sharps, but it is not common on -site treatment technology.
Brenner stated sharps could go in a sharps container. When they haul the
medical waste, there are different types of containers for different facilities and for
different operations. If there were sharps containers that are kept separate and
could not be compacted, then they just wouldn't be on that part of the stream.
Stern stated they might be on the same train or track, but in separate cars. They
would have to be segregated all the way along.
Brown stated they would be compacted at the landfill.
(Imhof left the meeting at 1:30 p.m.)
Hoag restated her motion.
Motion carried 4 -1 with Brenner opposed.
Dawson moved to approve recommendation number seven as amended.
Motion carried unanimously.
RECOMMENDATION NUMBER TWELVE
Benjamin read recommendation number twelve from the PHAB into the
record. The MWTF recommendation basically said the same thing, except it also
required treatment of level two stocks and cultures.
Board of Health, 10/19/99, Page 9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
Hoag read about level three being treated onsite according to the plan filed
with the Health and Human Services Department. She asked if that plan would
guarantee that they would be non - infectious. Delahunt stated the substitute
wording from the PHAB accomplishes the same thing. The plan of operation filed
with the Health and Human Services Department would require that it would be
non - infections.
Hoag asked where they would find the regulation that makes them non-
infectious. Benjamin stated that is in the plan of operation they approve.
Stern stated the Center for Disease Control (CDC) guidelines state that it
needs to be rendered non - infectious.
Hoag asked the level of tuberculosis (TB). Stern stated it is level three.
Hoag asked about the MWTF recommendation that the bio- safety level 2 be
treated with an Environmental Protection Agency (EPA) designated tuberculicidal
disinfectant. Stern stated that wasn't to treat tuberculosis. It is similar to Lysol, a
phenol- containing disinfectant. It will kill TB, but they wouldn't consider that
complete treatment. Adding a disinfectant is not the same as autoclaving or
incineration. When hospitals routinely throw out cultures of pathogens that are
thought to be more dangerous, then they will add a tuberculicidal disinfectant to
the petri dish before tossing it in for treatment. It is a pre- treatment.
Brenner stated she was concerned about watering this down. The person
who made the motion for level two and above was the expert on infectious diseases
that sat on the MWTF. Some level two cultures can be fatal. The intent of doing
this is to address worries if the waste was not properly handled. If regulating level
two cultures is not enforceable, then it would be more unenforceable to make sure
people separate out level two and level three cultures. All stocks and cultures
should be treated on site. That was a recommendation in the Senate Sub-
committee. A year ago, the Health Department supported that all stocks and
cultures be treated on -site and asked that the effective date be the year 2000
instead of 2001. The Board of Health would be creating more problems by
separating out different stocks and cultures, rather than requiring that all stocks
and cultures to be treated at laboratories prior to transportation.
Dawson agreed.
Nelson asked about the Hepatitis B transmission survival rate in the
environment. Stern stated the infection mechanism involves sharps exposures.
One consideration with separating levels two and three is the method of
transmission. Stocks and cultures are about growing pathogens and having a
higher concentration of the bacteria or virus.
Nelson asked about salmonella. Stern stated salmonella would be grown
from stool cultures. It will not be a respiratory transmission. The municipal solid
waste is full of salmonella from chicken skins. It is everywhere. The effect of
Board of Health, 10/19/99, Page 10
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
minimizing salmonella in a medical waste stream is going to be a drop in the bucket
compared to the salmonella load in the municipal waste stream.
Nelson asked if the remaining type two diseases would include swabs for
colds and streptococcus. Stern stated streptococcus is considered a class two.
Nelson stated they would then have to treat all those items. Stern stated
they would also have to treat all urinary samples, which are normal bacterial bugs.
Nelson stated there would be an increased cost associated with that
treatment. He asked if there has been any indication of transmission of type two
diseases through medical waste. Stern stated the only documented transmission
from infected medical waste was tuberculosis, which is a class 3 disease. He was
not aware of medical waste transmission for any other pathogens.
Brenner stated Hepatitis B is not as contagious as streptococcus, which is
extremely contagious. They do find it in regular solid waste. That has been an
argument used by the industry all along. The problem is that the concentrations
are greater in infectious waste. This regulation has only to do with laboratories.
They already have the set -up to do this. It is just a question of whether they do it
all, or spend more time, which costs more money, to separate out which they will
do and which they won't. If there is a risk of infection from the stocks and cultures,
then it will be more costly to separate them out.
Nelson asked how they would separate them out. Stern stated stocks and
cultures apply to labs. The question is whether all of these have the same risk to
the workers or the public. The MWTF looked at those issues. The PHAB felt that
the question was whether they should require all stocks and cultures or separate
out the most dangerous ones and assume proper handling, training, and packaging
address the safety. The PHAB opinion was that for level two and below, proper
handling and packaging would allow transport for treatment off -site.
Hoag asked for information about what constitutes level two and three,
specifically about the skin - eating bacteria. Stern stated that disease was
streptococcus, so it would be a level two disease. It has to do with the effects of
the infection on the particular host as opposed to it being more contagious to other
streptococcus.
Hoag asked if antibiotic resistance has to do with the level designation.
Stern stated antibiotic resistance has to do with treatment, but not with infection.
The categories are still based on how the bugs are spread, not how they are
treated.
Hoag stated that something that cannot be treated should be of concern.
Stern stated the PHAB wasn't saying there was no risk associated with level two
materials. The issue was whether proper handling, packaging, and training are
adequate to protect workers. These are the same bugs that are being handled by
health care, laboratory technicians, and people working in the community now. The
Board of Health, 10/19/99, Page 11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
issue is whether it is safe to package those materials and send them off -site for
treatment without having a significant increase in risk to the workers of the public.
The PHAB felt the training and regulations would protect workers. It wasn't
necessary for the extra cost and regulation of all the sites.
Brenner stated she specifically asked at the MWTF meeting if this was just for
labs. This was the first she heard about doctors having to treat urine samples. She
moved to amend the MWTF recommendation to say, "All locally laboratory
generated stocks and cultures known or suspected to be bio- safety level two or
three sheuld shall be pre- treated on -site in accordance..." That would take care of
the concern about the doctor's having small materials on site.
Stern stated that any doctor's office that is growing a culture is regulated as
F7F1:1
Brenner stated level two only has to be done with prudent activities. It is not
a big deal to include level two.
Brown stated that if they are going to make level two something that has to
be treated, then everyone should have to treat it.
Benjamin stated this would be a local regulation only for local labs. Any
medical waste coming in would not be regulated.
Brenner stated that wasn't accurate. Recommendation 16 says that anything
coming into the County has to be packaged and pre- treated the same as local
material. Benjamin stated that they would be placing another level of regulation on
laboratories that they don't have jurisdiction over. That could be challenged.
Brenner stated that came up in the MWTF meeting. They said it is up to the
treatment facilities to make these their regulations. If it is legal, it should be done.
Hoag asked for clarification on the language at the end of the MWTF
recommendation 12. She questioned whether "can be" should say, "should be."
Delahunt stated the intent was to require it.
Brenner stated the intent was to do this rather than being treated with the
autoclave. Stern stated they were talking about pre- treatment, as opposed to
treatment.
Hoag suggested, "level two organisms can be initially treated with a EPA -
designated..." Stern stated this was based on the previous CDC recommendations
that allow for level three organisms to be treated off -site. The requirement was
that all local stocks and cultures of level two or three would be required to have
pre- treatment on site, in accordance with a plan of operation. That plan of
operation would require full treatment of level three bugs, so the Lysol wouldn't be
sufficient for TB. The plan of operation could allow for Lysol treatment of level two
bugs.
Board of Health, 10/19/99, Page 12
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
Hoag stated she wanted to retain that language. They would be increasing
risk to more common bugs that are more resistant. The idea of treating them
before they are shipped off makes sense. Stern stated it brings up an
implementation question. They can require that all waste coming into the County
for treatment follow the rules. Inspection for compliance would be difficult.
Hoag stated that if one was shipping to Whatcom County and not following
the regulations, then one would be breaking the law. Delahunt stated she didn't
know who would be responsible. They have generators in Canada. The County
doesn't have any regulatory authority over them. They only have authority over
the facility here.
Stern stated it is more of a question about enforcement.
Hoag stated exposure and levels of risk to the public and whether or not they
will be able to enforce this on the Canadians is not the issue. The issue is whether
the County is treating the waste generated in the County to a level that minimizes
the risk for the County's public and waste handling workers. That is what she
wanted answered. Regarding level two, she was uncomfortable having the
disinfectant requirement removed. Stern stated the PHAB and members of the
MWTF asked whether the extra step was required. There was an agreement to add
that step. There is still a question of whether the safety is protected by the
packaging, training, and handling requirements.
Hoag stated she was not confident with that. They've had those
requirements all this time, even when the workers were infected with tuberculosis.
She wanted the language proposed by the Task Force.
Nelson stated the workers didn't get the tuberculosis in that fashion. He
understood the safety concern for all levels of bacterium. Cost - effectiveness is also
an issue. He asked how cost - effective this was. He wanted to be assured of what
the risk factor is. When he asked that question regarding type two bacterium in
handling the medical waste stream, there is no risk because there are no incidents.
They had an incident with type three bacteria, which is handled in the same
fashion. He asked what they would gain by this.
Brenner stated the MWTF asked that question of the CDC person and national
expert Wayne Turnberg. They say it is a moving target and virtually impossible to
track. It was by accident that they found out those workers were infected from
handling infectious waste. The management said the workers brought it into the
facility but there were three different strains. They did the DNA tracking which
identified the source of infection. The other diseases are not done with DNA
tracking. They have no idea who is getting sick and when. They can't say there is
no risk. There is a risk. The workers were infected because the materials were not
treated before they came. Stocks and cultures have the most intensive amounts of
the diseases. It is prudent. It is just as much work to separate the level two and
Board of Health, 10/19/99, Page 13
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
level three diseases. The issue of whether or not it was constitutional bothered her.
She could not believe they are not allowed to set their standard.
Brown asked if the Lysol treatment was the same Lysol that could be
purchased at the store. Stern stated it is that type of a disinfectant with phenols
that are considered tuberculicidal. It is not necessarily Lysol.
Brown stated it doesn't take that much of an effort to do this. He asked if all
they would have to do would be to put them in a container with a dose of Lysol.
Stern stated that is all.
Hoag asked if St. Joseph's hospital is already doing this. Stern stated they
are not doing it on all materials. They are using discretion in determining which
materials to pre- treat.
Hoag stated she was surprised to find out there have not been any studies
done to track contamination of workers.
Nelson asked why one would do a study if there is no indication of a need for
a study.
Brenner restated her motion, "All locally laboratory generated stocks and
cultures known or suspected to be bio- safety level two or three should shall be pre-
treated on -site in accordance..."
Motion to amend failed 2 -3 with Hoag and Brenner in favor.
Nelson moved the PHAB recommendation number 12.
Motion carried unanimously.
(Brown left the meeting at 2 :03 p.m.)
(Clerk's Note: End of tape one, side B.)
TOBACCO ORDINANCE
Hoag stated there is a substitute proposed ordinance.
Brenner moved to accept the introduction of the substitute ordinance.
Dr. Chris Covert - Bowles proposed an amendment regarding signage near
schools.
Brenner moved to approve the amendment.
Motion carried unanimously.
Board of Health, 10/19/99, Page 14
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
Motion to accept the substitute as amended.
Motion carried unanimously.
BIOMEDICAL WASTE TASK FORCE RECOMMENDATIONS (continued)
RECOMMENDATION NUMBER THIRTEEN -ON -SITE VS. OFF -SITE
TREATMENT
Benjamin continued with recommendation number 13. The PHAB adopted
the MWTF non - consensus recommendation unchanged. He read the
recommendation into the record.
Hoag asked if there was a volume or bio- safety limit. Stern stated those
issues are dealt with in the other regulations. This was a way to allow the transport
to an off -site facility, rather than requiring all waste to be treated on -site. Not
including this recommendation would require that all medical waste to be treated
on -site.
Hoag stated they should look at some sort of filter regarding the type of
waste being generated. She questioned whether medical waste is rated like stocks
and cultures are. Delahunt stated there is not a rating system. Within medical
waste, stocks and cultures are recognized as being the most dangerous.
Stern stated the rating only has to do with the laboratory work.
Brenner stated two members of the MWTF wanted isolation waste and
untreated sharps to be treated on -site. Rationale number two from the PHAB says
that local generators would be held to a different standard than other generators.
Twice now this rationale has been used, and it goes against recommendation
number 16, and is prejudicial. She agreed she was in the minority and it didn't go
through the MWTF, so she would not push to change it. The background for it
should be consistent.
Hoag stated that rationale was a weak one. It is not the point, unless it is an
undue burden and would put them out of business. Anytime they are trying to
make things safe, it is going to take extra time and effort, which will cost more. As
a result, the community will be better protected. The comment before that says
that the DOT inspections are adequate to protect the community, but the DOT
inspections are not routinely conducted due to a lack of staffing. Materials that are
particularly hazardous should be treated on -site.
Hoag moved to include respiratory isolation waste, "With the exception of
respiratory isolation waste and stocks and cultures, which are discussed separately
- biomedical waste should be allowed to be transported off -site for treatment."
Board of Health, 10/19/99, Page 15
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
Brenner stated she agreed with the amendment. It isn't just about being
held to a different standard, which wouldn't be true if they pass recommendation
16. Regarding incurring increased costs, the MWTF came to two different
companies that make on -site treatment options. They brought data that showed
their treatment options are less expensive than trucking the waste to remote
locations for treatment. It isn't fair to say it would incur increased costs. One of
the MWTF members is also on the PHAB. The PHAB had the information about the
costs. The language is prejudicial and doesn't belong.
Stern stated the only item he could think of as being of specific concern
would be the respiratory canisters. There is other isolation waste and would include
people in nursing homes. Anything used in respiratory isolation would be part of
the waste.
Nelson gave an example of someone with an infection being isolated at
home. He questioned whether that person would have to have a treatment. Sterr
stated it would be for someone under medical supervision with a home health
agency, in a nursing home, or in a hospital and in a designated respiratory
isolation. The waste would have to be treated on site. There would have to be an
autoclave or incinerator on site. That is what they would be requiring by not being
able to transport the material off -site.
Hoag stated this is for people in isolation, not for people in a home.
Stern stated he could put someone in respiratory isolation in their home if
they have TB. If a patient doesn't need a nursing home to be treated, it would be
better to keep the patient at home rather than exposing a large number of people.
Brenner stated this is all new stuff that was not discussed before. She
wanted more answers before they continue this. She asked about level four
agents. Stern stated that if there was a level four virus, the military would be here.
There are only two labs in the country that work with level four agents.
Brenner asked about respiratory isolation waste treatment and whether the
waste generated from someone isolated at home could go in the regular garbage.
Stern stated it can now go in the regular garbage. At this point, it is not regulated.
If they do not define medical waste to include pulmonary suction canisters, then
they would not be regulated by any of these rules because they are using the
definition of the Washington Administrative Code for medical waste. By expanding
that, they are including pulmonary suction canisters so they are covered in the
regulations. The question is how they need to be treated. They have medical
waste in general. They've broken out stocks and cultures, sharps, and now the
respiratory isolation waste. The question is the relative risk from that waste and
whether it needs special handling compared to general medical waste. The issue is
whether there is a significant risk to workers in the public from packaging,
transport, and treatment. If it requires on -site treatment, then some of the sites
will be nursing homes and home health care.
Board of Health, 10/19/99, Page 16
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
Brenner stated the Task Force declared a minimum amount in poundage.
Home health care would not generate that much waste. Delahunt stated the 50
pound limit was to determine whether or not they would require a license for
transportation.
Hoag stated she was concerned because there was recent news about
antibiotic resistant strains of TB that are incubating in prisons in Russia and are
beginning to show up in the United States. Because they know this is coming,
according to the CDC, they should address this. It is a big deal and they should be
handling it in the proper way. She didn't want to cause unnecessary regulation or
undue burdens, but she also wanted to be as protective as they can. She asked if
treatment was something that someone could easily do at home. Stern stated that,
if it was possible to reduce the risk by adding Lysol to a canister and shipping it out
for treatment, that regulation may make sense. He recommended that they have
more information before requiring all respiratory isolation waste be treated on site.
Onsite treatment wasn't the recommendation of the advisory board, so he didn't
have any background information supporting that position. It is important to
quantitate the risks as much as possible. He agreed that the drug- resistant
tuberculosis is a major concern. He was unsure whether requiring in -home
treatment of respiratory isolation waste would do much to address that risk.
Hoag stated she wanted more information on it, and it wasn't a consensus
item. They shouldn't be adopting this at this point. They need more information.
Nelson stated that they couldn't adopt the entire thing if they don't adopt
item 13. They need to get questions answered. He looked at the information and
was comfortable with the plan and the recommendations of the Public Health
Advisory Board.
Delahunt recommended that the Board of Health give a directive to the staff
to look at the question of the respiratory isolation waste. When they bring draft
regulations forward, the answers and information will be available.
Nelson stated they still have to approve this by the County Council.
Hoag suggested they adopt the rest of the recommendations, and then
request that this item be brought back with more information.
Nelson and Dawson agreed.
Hoag withdrew her motion.
Hoag questioned recommendation 17. She asked how they plan to
encourage biomedical waste generators to reduce the amount of biomedical waste
generated. Stern stated that was something that wasn't discussed a lot by the
MWTF. It was part of the Wisconsin state regulations. They had a waste volume
reduction component of their plan. That was brought up to add to the County plan.
The majority of the task force members thought there were enough economic
Board of Health, 10/19/99, Page 17
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
incentives not to inflate the volume of medical waste. It is more expensive to have
waste labeled as medical waste and have it hauled.
Hoag stated that argument was laid out in the rationale. She agreed with
the rationale. Stern stated the other thought was that, if they have reduced
volume there would be less waste being contaminated by infectious waste to deal
with and to worry about. He was not clear how that would be enforced.
Hoag stated she also agreed with the concern that, if they tried to reduce it,
they may end up with people putting medical waste into the regular waste stream.
Those are all legitimate concerns. She questioned how they were going to
encourage it. Stern stated it was a compromise between not addressing it at all
and saying they would encourage it without enforcing it.
Delahunt stated they don't really know at this point. She suggested that the
Board of Health might be able to suggest a program for them to implement.
Benjamin stated there are a number of avenues they could follow to
encourage people on the subject.
Hoag stated they removed recommendation 13 until they receive more
information, and moved to approve recommendations 16 and the PHAB version of
recommendation 17.
Motion carried unanimously.
PUBLIC SESSION
No one spoke.
ADJOURN
The meeting adjourned at 2:35 p.m.
Jill Nixon, Minutes Transcription
These minutes were approved by Council on January 11 , 2000.
ATTEST:
Dana Brown - Davis, Council Clerk
WHATCOM COUNTY COUNCIL
WHATCOM COUNTY, WASHINGTON
Marlene Dawson, Council Chair
Board of Health, 10/19/99, Page 18