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Robert Pocock and William King Townend Today, more and more healthcare service is delivered in non-hospital community settings, a trend which poses new challenges to agencies dealing with clinical and healthcare waste. Clinical waste is also generated by practitioners ranging from acupuncturists to veterinarians, and is a major issue in the development of strategies to minimize the healthcare burden created by increasing numbers of intravenous drug users. In the UK, progress is being made towards developing a multi-agency approach that will address all aspects of healthcare waste in a community setting. In the UK, the National Health Service (NHS) was introduced in 1947 as part of the collectivized reforms of welfare provision following the Second World War. Since then the NHS has withstood the various changes in political control for more than 50 years and, for many developing countries, it has been seen as a template for the management and delivery of professional healthcare treatment resting on the 'bedrock' of the general (acute) hospital. A changing environment for waste generation The improved management of clinical and other wastes from hospitals in recent years and the controlled environment and institutional setting of the hospital provides a firm management infrastructure onto which good waste management practices can be readily grafted. But increasingly within the past 5-10 years, a growing, significant and increasing proportion of healthcare waste is generated outside hospitals, taking place in a variety of community healthcare premises and private homes. This trend is set to accelerate as developments in health treatment technology mean more and more treatment can be delivered through 'day case' and short-stay surgery. Ongoing treatment, convalescence and disease management are then undertaken with the patient resident in community facilities (residential and nursing homes) or their own home. This technological change is reinforced by the policy changes embodied in the NHS reforms introduced in 2000. These mean, inter alia, a greater role for local GPs in minor surgery as the focus of the NHS moves away from 'secondary' (hospital) care towards a 'primary- care led' NHS. There is also a shift to treatment within people's own homes as 'care in the community' continues to develop as a preferred option to institutionalized care. This structural shift in healthcare away from large hospital institutions towards community and domestic settings is creating a concomitant shift in the location of waste generation. This increasingly occurs in an environment where waste management is largely unstructured and poorly regulated, where roles and responsibilities are ambiguous, and where good practice is ill-defined. Best practice entails segregation of healthcare waste Further aspects of wider social change compound the problem. In the UK and other western societies, the upsurge in intravenous drug use over the past decade has led to the generation of millions of used syringe needles (up to half are thought to be discarded to the local environment). On top of this, local non-NHS premises are expanding and offering services ranging from 'body modification' (piercings, tattoos), acupuncture and other natural therapies, to chiropody services and animal (veterinary) care. In each case 'healthcare wastes' are generated to greater or lesser degree in environments very different from the traditional hospital institution. In the community setting, a wide range of people - both professionals and non-professionals - are therefore involved in the generation and disposal of healthcare wastes. This includes householders who are exempt from the legal Duty of Care. The hazards, which are relatively transparent and well-defined in a hospital setting, are not so immediately apparent in the community. There are greater difficulties in targeting training and in the investigation of accidents and incidents involving waste disposal. All in all there is a risk that the improving standards of healthcare waste management in the UK could be significantly undermined by these changes. For this reason, the UK Chartered Institution of Wastes Management (CIWM) has asked its Healthcare Waste Special Interest Group (SIG) to review the problems and initiate multi-agency and inter-professional actions to tackle this growing threat. Cross-infection hazards The CIWM guidance document on managing and minimizing healthcare waste1 examines the microbiological hazards posed by community healthcare waste. As the document states, the means by which infection can be transmitted between people is not generally well understood by waste management operatives and the public. People do not generally appreciate that, before cross-infection can occur, it is necessary for intact skin to become pierced or injured, and then for the micro-organisms present in the waste to contact the damaged skin, conjunctiva or mucosa in sufficient numbers. The organisms also need to be sufficiently virulent to cause disease even if they have found a way of entering the body. The immune status and susceptibility of the individual also need to be considered. Many microbiologists believe the actual dangers of contracting an infection from healthcare waste are small and it is therefore important not to overstate the hazards. Used dressings, incontinence pads, sputum containers, urine and stoma bags could present a risk, especially if contaminated with blood. However, organisms recovered from these items such as Pseudomonas, Proteus, Staphylococcus aureus, Streptococcus, Faecalis and coliforms are found in normal human body flora and in the environment. They all have the potential to cause infection in susceptible individuals, but only in certain subscribed conditions and not in all circumstances. Clinical waste bags must now be transported in rigid containers There is general agreement that the following constitute a risk to the public health: used needles, syringes and sharps laboratory cultures and microbiological wastes selected infected waste (i.e. waste infected with grade 4 pathogens) animal waste and discarded materials from infected animals, including carcasses and bedding. The so-called 'Group E' healthcare waste (as defined by the Health and Safety Executive2) is not usually classed as a risk unless the waste contains infectious material. Group E waste includes items used to dispose of urine, faeces and other bodily fluids that do not already fall within the hazardous Group A. There are circumstances where it may be disposed of as normal household waste; for example, the majority of household tampons, sanitary towels and babies' nappies are treated as household waste. Factors that determine when Group E waste can be disposed of via the household waste stream include an absence of known infection and the proportion of Group E waste generated in relation to the amount of household waste. For practical purposes, the general rule is that if more than one third of a standard 90-litre sack Group E waste is generated each week, then a domiciliary clinical waste service should be used, as the ratio of Group E waste is then out of proportion to the usual amount of household waste. Waste generated outside hospitals The waste generated outside hospitals (viewed for the purpose of this article as in the community) can be split into that generated at premises operating as healthcare or related establishments, and that which is generated by householders in their own home. Areas within the community from which healthcare waste can arise include: nursing homes residential homes veterinary surgeries medical centres dental centres body piercing/tattooists childcare premises daycare premises private laboratories/research centres pharmacies funeral parlours the emergency services sexual health services substance misuse clinics first aid rooms in commercial/industrial premises In community healthcare premises, the range of waste is similar to that arising in hospitals, although human tissue is a less significant arising. Animal carcasses/tissue are generated as a waste by veterinary practices. The increase in home treatment and care-in-the-community means that increasingly significant amounts of healthcare waste are generated in an individual's own home. The range of waste is similar to that in community healthcare establishments, but may include other wastes similar to that from hospitals (e.g. home dialysis). Much of the lower risk waste (e.g. incontinence waste) is usually not treated as healthcare waste and can safely be disposed of in the normal domestic waste steam. Healthcare in these circumstances may be administered in a number of ways: by healthcare professionals with community nursing qualifications by other professionals such as chiropodists by healthcare professionals working in an outreach capacity from an acute hospital by carers who may or may not hold National Vocational Qualifications (NVQs) in care (this type of care in the home is usually classed as social care and may or may not take place alongside healthcare) by family carers, with or without the help of the personnel above by any one or a combination of the above with patients also accessing facilities at daycare or respite facilities It is evident that a wide range of professional, voluntary and personal care workers and private individuals can be significant handlers of community healthcare wastes. Unlike workers in the hospital setting, their activities are largely unsupervised, are at best under loose line management, and are vulnerable to involuntary error both by commission and omission. Estimating community healthcare waste Estimates of the production of healthcare waste are generally poor but improving,3 but those for waste from the community are few and of limited accuracy. Table 1 shows UK data for the production of clinical waste from sources other than health authorities; the data are the latest officially released but are 10 years old and do not show all producers of clinical waste, let alone other non-clinical community healthcare wastes. 'Many microbiologists believe the actual dangers of contracting an infection from healthcare waste are small, so it is important not to overstate the hazards' Waste management in community healthcare In community healthcare establishments, waste is typically segregated by designating separate containers/sacks for the different HSE waste groups.2 There may be specific containers for pharmaceutical wastes, incontinence wastes, swabs and dressings, as well as sharps boxes. Containers are usually provided on a unit exchange basis by the healthcare waste companies carrying out collection, with the replacement of full containers with clean ones or the provision of fresh sacks. Due to the relatively low generation rates, containers are often in use throughout the period before the next collection date, and storage is generally not an issue. The interval between collections can vary from a matter of days up to several weeks, or even 1-2 months. In the case of sharps and pharmaceutical waste, intervals can be as long as 3-6 months, with service on demand rather than a fixed frequency. Waste is normally collected by private contractors, although some local authorities also offer specialist collection services provided they have the consent of the waste disposal authority. A number of authorities allow lower risk wastes (e.g. incontinence pads) to be disposed of via the domestic waste stream. TABLE 1. Clinical wastes from selected sources other than health authorities and NHS premises. Source: DTI, 19974 Establishment Tonnes per annum Independent hospitals 4,900 GPs and dentists 20,000 Nursing homes 11,400 Private residential homes 33,300 Blood transfusion centres 400 Home treatment 24,500 Funeral directors 150 Embalmers and mortuaries 900 Other miscellaneous sources 12,500 Veterinary practices 19,500 Research centres 23,000 Farm/equine centres 2,500 DUMP campaigns (unwanted medicines) 250 Total 153,300 Segregation of waste arising in the home is also governed largely by the way in which it is collected. Lower risk wastes are often not segregated and are frequently disposed of in the domestic waste stream. Higher risk wastes are usually segregated for separate removal in containers provided by the organization responsible for waste collection. Local authorities have a duty to collect household waste but, in the case of clinical waste, they have to be specifically requested to do so and they can make a charge. Arrangements vary across the country for the collection of healthcare wastes from household premises; there are good examples of local authority waste collections but arrangements often have to be made through Health Trusts due to the absence of a council service. Local authorities that do collect healthcare waste separately do not usually charge for the service. Community healthcare waste in Edinburgh A recent case study by Rayner5 aimed to estimate the total amount of community healthcare waste in Edinburgh. In this study, community sources included all healthcare activities except those conducted in NHS Trusts (independent hospitals were included). A total of 11 different types of establishment were surveyed and information was gathered about eight types of clinical waste: soiled dressings, blood, etc. (including incontinence pads, etc.) incontinence wastes (Sanpro) microbiological cultures/pathology wastes special wastes (highly infectious wastes and dental amalgam) human tissue wastes prescription-only medicines cytotoxic drugs used sharps The questionnaire sent to care providers relied on the producer to identify what was and what was not clinical waste. Sanpro waste was included within the questionnaire as a separate waste category. The following types of establishment were surveyed: NHS Trusts nursing homes veterinary surgeons residential homes children's homes tattooists chiropodists acupuncturists dental surgeons funeral directors blood services daycare centres GP surgeries unknown Mailing lists were obtained from various sources including Lothian Health Board, Edinburgh Council, the British Veterinary Association and Yellow Pages. An average response rate of 23% was estimated. Table 2 shows the total amount of waste produced by waste type. The questionnaire asked the respondent to state the number of bags, bins or boxes produced and the average weight of each container. An estimate of the total weight per waste type was calculated by multiplying the total number of containers per year by the average weight per container. TABLE 2. Total amount of each community healthcare waste type produced (kg/year). Source: Rayner, 20005 Waste type Amount (kg/year) Blood, soiled dressings, swabs, etc. 33,134 Sanpro waste 142,772< /td> Pathology waste 289 Special waste (including dental amalgam) 36 Human and animal tissue 20,700 Prescription-only medicines 108 Cytotoxic waste 106 Used sharps 1,712 From these data, Rayner estimated that the total amount of community clinical waste produced in Edinburgh in one year was over 1800 tonnes. This figure is likely to be an overestimate of that strictly defined as clinical as much of the waste consigned as clinical waste in the survey was mixed clinical/non-clinical. Sanpro waste was produced in the largest quantity; over three times more Sanpro waste was produced than blood-soiled waste. The amount of human/animal tissue produced was significant and came mainly from veterinary practices. Most local authorities provide storage receptacles and replace clinical waste bags on a one-for-one basis. Some local authorities offer a collection service for sharps boxes. Where wastes are generated in the home by visiting medical staff (e.g. from nurses administering injections, changing dressings or obtaining blood specimens), then those carrying out the treatment are responsible for ensuring that the used dressings, needle and syringes are disposed of safely. Community nurses should therefore carry sharps boxes and clear arrangements must be in place to ensure that clinical waste can be disposed of within the law. This is the responsibility of the employer, although the extent to which this is currently appreciated by primary care trusts (PCTs) is unknown. Inappropriate disposal of community healthcare wastes is not uncommon and, although waste disposed of in this way is usually of low risk to the public, it is nevertheless illegal. A very real risk is posed where used needles or medicines are disposed of in this way. To combat this risk the CIWM guidance document1 advises: providing consistent clear guidance for individuals in the community involved in healthcare waste risk assessment educating all concerned about the actual risks involved (including the public) delivering education at a correct and understandable level ensuring easy access to a clinical waste service (if required) developing clear policies and protocols to be followed in the event of accidental spillages or injury having clear lines of accountability for the provision of facilities in landlord-tenant situations Drug-related waste and litter One of the areas causing most concern both to professionals in waste management and the general public is the hazard posed by waste relating to intravenous drug injection. This mostly centres on the presence of 'sharps' (hypodermic needles and syringes), although there may be additional hazards from the associated 'paraphernalia' of injecting use, and from other forms of substance misuse such as butane gas containers, glue and solvents. Over the past 5-10 years, concern about transmission of HIV and other diseases such as Hepatitis B caused through intravenous drug users (IDUs) sharing 'works' (injecting devices), has led to a 'harm minimization' approach to healthcare. In the UK, this centres first and foremost on helping IDUs reduce the levels of self-risk. Strong health messages against needle sharing are promoted and these are coupled with policies to distribute needles to IDUs with relatively few questions asked. Needle distribution is organized in the UK through 'needle exchange schemes' (NESs) operating in selected community pharmacies, community drug prevention teams and other primary healthcare outlets. The principle of the NES is to encourage users to bring back used sharps when collecting new supplies, but the return of sharps is not a prerequisite to supply. The scheme is not a 'closed loop', since this is seen by drug workers as potentially creating an obstacle to their primary aim of eliminating the use of shared needles through the ready availability of clean 'works'. Scheme operators audit supply and return data, but there is no formal national collation of statistics. Individual return rates are poorly estimated because used needles are often returned in containers such as drinks cans where the numbers returned are not readily visible; users may even add material such as pebbles to the can so that 'feel and shake gives the impression that more needles have been returned. Moreover genuine return rates vary and, as users can get supplies from various outlets, the issued sharps are not always returned to their point of origin. Thus, there is no presumption that a 1:1 return rate should have to apply to each NES. Overall, the schemes are thought to recover little more than half the needles issued.6 'Overall, needle exchange schemes are thought to recover little more than half the needles issued' From the perspective of the waste manager, this practice has caused controversy. Some might argue that NES providers are abdicating a 'duty of care' by issuing needles without ensuring or requiring their safe disposal. For health educators, on the other hand, the general IDU lifestyle is chaotic and placing such a requirement on the user would be unrealistic and counterproductive to the primary objective of harm minimization. The 'supply and return' principle being followed in the UK is one of three basic approaches identified in an international review published in 1998.7 The other two approaches involve placing used syringes in common household containers (cans, bottles) which are then placed in the municipal waste stream, and placing used needles in collection boxes sited in public places. Both these alternative schemes create waste management risks: there is a risk to refuse handling operatives if the containers fracture or are crushed, or are handled in materials recovery plant, and the publicly accessible deposit containers may be vandalized or raided resulting in acute localized littering. The relative merits of the supply and return system are therefore clear. Clearing waste from drug abuse. Source: Stephen Didsbury, London Borough of Bexley 'Even within the US, a wide range of practices operates between states and there appears to be no nationally accepted model of best practice' The position in the UK is compared and contrasted to that operating in the US in a paper published in 2002.8 The authors discuss the US Syringe Exchange Programs (SEPs), which are the equivalent of the UK NESs. They highlight the fact that possession of syringes is a criminal offence in many states and that IDUs place themselves at risk of prosecution by storing and returning syringes. The paper's main findings are that, even within the US, a wide range of practices operates between states and that there appears to be no nationally - let alone internationally - accepted model of best practice. In the UK, the CIWM has attempted to initiate inter-agency working to explore the problem in more detail. At a preliminary meeting held in April 2003, CIWM members met officials from three Government departments: the Department for Environment, Food and Rural Affairs (Defra has overall responsibility for municipal waste management), the Department of Health (DoH oversees drug care programmes for IDUs), and the Home Office. Incineration of healthcare waste must take place in high-temperature facilities. Photo: Pat Shirreff-Thomas, ABIPP ARPS In view of the close link between substance misuse and drug-related crime, the Home Office was the lead department. The Home Office's prime focus is to reduce the criminal, social and economic impacts of substance misuse and its responsibilities include the leadership and resourcing of local Drug Action Teams (DATs). While DATs have a partnership role associated with the wider health benefits of better drug education and treatment, it was evident from the meeting that drug-related litter is not a major feature of the concerns addressed from day-to-day by local DATs. At the meeting, DoH clarified its departmental position, which is to promote drug treatment and support for substance misusers, with a particular focus on harm minimization. This means ensuring the ready availability of clean needles to eliminate, as far as possible, the dangerous practice of sharing needles. While the principle of returning used needles was advocated, the primary clinical concern was to ensure injecting users had easy and unfettered access to clean needles. While Defra holds the brief for problems associated with street litter, and has received a useful report from the environmental charity ENCAMS on drug-related litter, it has no clear input to local DAT strategies or to national policy on drug treatment. DATs are local but it was not clear during the meeting how far local authority cleansing services are integrated into local DAT work. The principal outcomes of the meeting were that: the three main Government departments were meeting for the first time in the same room to talk about this issue CIWM was usefully represented both from the street cleansing and healthcare waste perspective healthcare professionals and practitioners were central to the issue and would also need to be represented in future little systematic information was available on the scope and scale of the problem nationwide no documents appeared to be available that described current practice in co-ordinating local efforts to minimize drug-related litter and there was no evidence base from which to determine or recommend 'best practice' baseline audit research and multi-agency trial schemes would appear to offer a helpful way forward The issue of used sharps in community health-care wastes extends to the legitimate (prescribed) injecting such as that practised by some diabetics. Not all pharmacies that supply insulin and needles operate a needle collection scheme; similarly, GP practices are under no obligation to receive the needles prescribed for treating diabetes. The recent UK health reforms have resulted in a series of national guidelines - called National Service Frameworks (NSFs) - for treating major health conditions. Current discussions on the NSF for treating diabetes have proved contentious as there is no mention of any requirement for diabetics prescribed insulin by injection to be offered free provision for safe needle return; this omission is despite strong lobbying by the Infection Control Nurses Association. While the NSF provides a vehicle for introducing a solution, the stumbling block remains the issue of which 'arm' of national or local government should be responsible for providing it in practice. Suitable containers should be used for discarded sharps. Photo: Steve Judge, Grundon The experience of attempting to progress this initiative has highlighted the vast diversity of agencies and different professional perspectives that need to be brought together to tackle this specific area of community healthcare waste. As well as the three Government departments, the potential list of participants includes: Local Government Association (representing UK local authorities) HSE National Needle Exchange Forum (co-ordinating NES good practice) Chief Police Officers Association British Diabetics Association Centre for Pharmacy Practice/Royal Pharmaceutical Society Infection Control Nurses Association health professionals within community drug teams officials from local authorities with a particular interest or experience International progress on healthcare waste The World Health Organization's Healthcare Waste Working Group recently published draft guidance on the preferred methods for the safe management of waste generated at primary healthcare centres (PHCs) in economically developing countries.9 The main tool within this guidance consists of five decision trees to assist users in identifying appropriate waste management methods. The Healthcare Waste Working Group's decision trees guide the choices according to important local conditions linked to the safety of workers and the public in terms of the management of healthcare wastes. The WHO guidance consists of the following parts: A typical community collection vehicle. Source: Stephen Didsbury basic information on risks basic elements for safe healthcare waste management parameters to assess before selecting options decision trees to assist the selection of options technical annexes describing selected options 'The latest WHO guidance highlights a further global recognition of the primary healthcare setting as a vital and neglected source of healthcare waste arisings.' The guidance can also be used to evaluate current practices in healthcare waste management. More detailed sources of information on handling and storage practices, technical options for the treatment and disposal of wastes, training and personal protection, and assessment are included in appendices. This latest guidance highlights a further global recognition of the primary care setting as a vital and neglected source of healthcare waste arisings. CIWM's Community Healthcare Wastes Programme In light of the issues raised in this article, the CIWM Healthcare Waste SIG is undertaking a comprehensive and investigative review of the problems in community healthcare waste management and current responsibilities and practices. The aim is to facilitate inter-professional discussions and to identify and promote action to improve current standards. The following 18-month programme of activity is proposed: A scoping discussion of the CIWM Healthcare Wastes SIG along with other professional groups and CIWM SIGs (as appropriate) to identify the main problems, starting with three key priorities: Duty of Care: who holds responsibility? PCTs: what new management arrangements are needed? Local authorities: what are the roles and boundaries of responsibility? In community healthcare premises, the range of waste is similar to that arising in hospitals, although human tissue is a less significant arising. However, animal carcasses/tissue are generated as a waste by veterinary practices A workshop to discuss the key issues and to draw up an agenda of priority concerns to be addressed in the review Work with the Environment Agency and other research data sources such as NHS Estates on developing a best estimate of current quantities and sources of arisings of community healthcare wastes in the UK Identify areas where specific research is required and facilitate this research being undertaken Delegate to its members, a review of practices and desirable changes and improvements within specific themes including: microbiological criteria and risk assessment management practices within residential and nursing homes guidance to nurses, health visitors, midwives and other community healthcare support workers management practices within PCT-led premises including dentists, vets and pharmacies as well as GP surgeries management practices within private community-based facilities such as chiropodists, tattooists and body-modification clinics management practices within local authorities on healthcare waste collection and drug-related litter the role and practices of the waste and hygiene management industries in community healthcare waste management the role and practices of the healthcare supply industries in helping to develop a comprehensive cradle-to-grave supply chain community healthcare waste management strategy existing guidance from within the many professions handling or responsible for the production of community healthcare wastes transferable practices and expertise from overseas and opportunities for skill transfer from the UK Hold a major review conference in 2004 including reporting and workshops covering the above in alliance with associated other professions Draft a report detailing current practice and recommendations for improvement within the framework of a comprehensive 'community healthcare waste management strategy' linked to the national waste strategies and the new waste strategy for the NHS Hold a consultation on these recommendations and produce a targeted guidance and reference document together with proposals for a comprehensive healthcare waste management strategy for the UK Although led by the UK's principal waste management professional institution, the work of the CIWM Healthcare Wastes SIG is being undertaken in partnership with a full range of professional and industry organizations. As shown by the specific problem of drug-related litter highlighted above, it is evident that progress in waste management will only be achieved through action that includes and represents the interests of all stakeholders who may influence future policy and practice in community healthcare waste management. References Chartered Institution of Wastes Management (CIWM). Healthcare waste management and minimization - a guidance document. 2000. Health and Safety Executive (HSE). Safe disposal of clinical waste. ISBN 072762492-7. 2001. Pocock, R. L. 'From Segregation to Minimization - New Steps Forward in Healthcare Waste Management', Wastes Management, May 2000. Department of Trade and Industry (DTI), 'Competitiveness of the UK Waste Management Industry', DTI, London, 1997. Rayner, W. 'Community Clinical Waste in Scotland', Wastes Management, May 2000. Robinson, S. 'The Management of Drug Related Litter'. Paper to CIWM Spring Workshop, Coventry, 30 January 2003. Macalino, G.E., Springer, K.E., Rahman, Z.S. et al. 'Community-based Programs for Safe Disposal of Used Needles and Syringes, Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology, 18 (Suppl 1). 1998. Turnberg, W.L. and Jones, T.S. 'Community Syringe Collection and Disposal Policies in 16 States'. Journal of the American Pharmaceutical Association ent to the, 42 (6) Suppl 2. November/December 2002. World Health Organization (WHO). Decision-making guide for managing healthcare waste from primary healthcare centres (draft). 2003.   DR ROBERT POCOCK is Chief Executive of MEL Research Limited and Chair of the CIWM Healthcare Wastes Special Interest Group. WILLIAM KING TOWNEND is an international environmental consultant and Chair of the ISWA working group on healthcare waste. e-mail: R.Pocock@m-e-l.co.uk townend@williamking.freeserve.co.uk