There are millions of glucose test lancets used daily, to test the blood sugar levels of individuals with diabetes. I use them daily.

They are used in hospitals – where several incidents have occurred of disease transmission caused by a careless, probably criminally irresponsible, failure to use a new needle or lancet for each patient and to sanitise the lancet holder between patients – and widely used in the community, by every patient with insulin-dependent diabetes and many others with Type II diabetes controlled by drugs and/or diet.

How to dispose of these lancets? In hospitals and other healthcare premises, it should be a straightforward issue of dropping them into a sharps bin immediately after use. At home, matters are less easy. We might hope that insulin-injecting diabetics have been given a sharps bin for their used needles and insulin pens, and the blood test lancets can be placed into these. For others, the change of a GP issuing a sharps bin alongside a blood testing kit are rather slim, if not impossible. And, of course, no straightforward procedure for disposal once a bin has been filled.

Four primary school children in Tasmania have cause a health scare after pricking each other with a needle from a glucose testing kit.

The children at a school in the Derwent Valley, northwest of Hobart, underwent infection tests as a precaution after the needlestick incident on 9 May. “The incident involved four primary school students who used one or more needles from a diabetic test kit to prick each other,” Tasmania’s acting director of public health Dr Mark Veitch said in a statement.

The risk is perhaps small, but not so small as to be discounted and these children will need follow-up over several months. The psychological impact, for the children and more so for their patents, cannot be overstated.

And kids will be kids. Strangely, a discarded needle can be in some way attractive and pierce inquisitive little fingers. That message must reach each and every user of hypodermic needles and blood testing lancets to ensure safe disposal at all times.

 

 

Nobody wants to fund collections of clinical waste from the community. Though some companies make a business out of ‘smalls’ it operates generally on small margins and yet is costly to the PCTs, and now their new era replacements, and to Local Authorities.

Some GP surgeries will receive properly packaged sharps, though often failing to provide on prescription those sharps bins that diabetics will should use. Likewise, some high street pharmacists will accept used needles, as do some hospitals as part of their commitment to outpatient support from diabetic clinics and the like.

It the latter case, patients may take their boxed needles at the next outpatient visit, or drop them off at reception. This creates its own problems since the receptionist will not be able to issue by prescription a new sharps bin, creating problems of continuity. In every case, the diversity of options makes administration and funding something of a nightmare.

The US is far behind, since until recently used sharps have entered the trash in the absence of any better and more organised route for safe disposal. But that is changing. For most, the solution has been to prohibit disposal of sharps in household garbage, and to provide sharps safes in accessible locations, at the Police of fire station, at a local supermarket – in the Mall – or at the local County building.

Their are economies of scale. Most self-injecting patients, whether diabetic or others, and almost all IV drug users are sufficiently ambulant that there is no barrier to a visit to the local sharps disposal point. With a network of conveniently located and accessible disposal points, there are logistics advantages as well as savings in administration for funding arrangements. This might also capture some of those ‘private enterprise’ needles from IV drug users and those injecting bodybuilding steroids and tanning supplements that is now on the increase.

The advantages are many and obvious. Perhaps all that stands in the way of this improvement is predictable administrative inertia and public perception issues that can stimulate objections to needle safes placed in locations across the community.

But it seems a good idea, and far better than the present mish-mash arrangements that are many and varied, and subject to frequent change as if deliberately to confuse the service users.

 

 

Sounding more like a tale from some Transylvanian horror, Polish prosecutors say they are questioning a man suspected of burying body parts and other clinical (medical) wastes instead of delivering them for incineration.

A prosecutor in Chorzow, in southern Poland, Marta Zawada-Dybek said Friday that the man, identified as Marek M., has confessed to burying body parts, syringes, bandages and other waste on a plot of land that he owns.

His firm that has contracts with some 300 hospitals and private surgeries to professionally dispose of the waste. But he allegedly buried it rather than pay for its incineration, Zawada-Dybek said. The man’s two brothers work in the firm.

The man is already serving a 16-month prison term for dumping medical waste at a local refuse dump.

 

 

Needle with drop of bloodIreland has not been backward at making the most of EU laws and subsidies though it has now found itself in deep financial peril as a consequence.

But less advantageous though equally worthy EU legislation, to implement the requirements of Council Directive 2010/32/EU, has been surprisingly slow to implement in Ireland. Trade unions have claimed that the health of Irish healthcare workers has been put at risk by Ireland’s failure to implement an EU directive on the use of medical needles.

The Irish Congress of Trade Unions says member states were due to adopt the directive – the eve of International Nurses Day.

ICTU’s legal affairs officer Esther Lynch said needlestick injuries among healthcare workers were ‘notoriously’ unreported – and that workers were injured anywhere between 1,000 and 6,000 times a year. ICTU has called on jobs minister Richard Bruton to implement Irish laws, giving legal effect to the EU directive, without delay.

“The Health & Safety Committee of Congress is recommending the establishment of Needlestick & Sharps injury prevention committees to oversee the implementation of the Directive,” Lynch said.

“These committees should include representatives from all levels, employers and unions including health and safety representatives, occupational health, risk management, purchasing, housekeeping, infection control, employee education and training.”

With a number of high profile sharps injury claims from Ireland in recent months, this is perhaps rather surprising. Hopefully, the lack of formal legislation will not stop healthcare providers from doing the right thing and purchasing safety sharps without delay.

 

 

 

In many parts of the world, the treatment of clinical (medical) wastes amounts to little more than open burning with incineration using modern technology having all of the relevant emission control technologies.

This open burning, on surface beds or in burn pits has a profound effect on air quality but until now the impact on soils has not been tested. In a new study from Nigeria by Ephraim, Akpan and Obiajunwa (Investigation of soils affected by burnt hospital wastes in Nigeria using PIXE. http://www.springerplus.com/content/pdf/2193-1801-2-208.pdf) studied the fate of burnt hospital waste and its effect on agricultural soil.

Eleven elements – Si, Cl, K, Ca, Ti, V, Cr, Mn, Fe, Zr and Pb were detected at an elevated concentration when compared with the control. Perhaps not surprisingly, the highest concentrations were obtained for Fe. Moderate enrichment factors for Si, K, Ca, Ti, Cr and Zr were obtained. The level and the fate of these elements especially Cl and Pb is of serious environmental and health concern owing to the fact that there are intensive subsistence agricultural practices at and near the sites of the study. A future investigation to quantify dioxin and furan that is associated with the geochemistry of Cl is essential owing to the toxicity of these compounds.

These are important observations with great relevance to public health implications from this previously unquantified level of soil contamination. When used for agriculture, as an enrichment, the presence of this diversity of contaminating metals may result in uptake into and contamination of subsequent food products, with potentially long-term effects on health and well-being.

 

 

There has been an increasing tendency in recent years to downplay the risks of acquiring bloodborne virus infection. Statistics are quoted, showing that in general the risks of acquiring a bloodborne virus infection are:

  • for HIV transmission after a percutaneous exposure approximately 0.3%
  • for HBV transmission 6 to 30%,
  • and for HCV transmission is approximately 1.8%

 

Easy stats and generally low numbers. Reinforcing the message that the risks might be small is the fortunately exceptionally low incidence of reported cases of seroconversion, and an understanding that the risks may be higher with a deep wound, with a large bore hollow needle, with a needle heaving contaminated with fresh blood, with a needle used only moments before with a patient who had a high viral load. Added to this are reassuring messages of the value of immediate first air – making the wound bleed and washing it thoroughly with soap and water – or seeking immediate medical advice and, if appropriate, of taking post-exposure prophylactic (PEP) drugs to prevent HIV and a big jab in the buttock to protect against Hepatitis B. And then, all will be hunky dory!

But of course that isn’t quite so straightforward. Not everyone will receive that immediate first aid from an infectious diseases specialist who can properly manage subsequent PEP and follow-up. Others may be fobbed off and sent away from A&E for just a ‘trivial’ wound without thought for the impact and implications.

Others may simply fob off a small scratch or blood splash to already broken skin or to the eyes, dismissing that splash inoculation as simply a nuisance without recognition of the significant infection risks that it may carry. And how to manage the post-injury follow-up in the information is incomplete; if the needle had been discarded and the period between use and injury is not known; if the needle user cannot be identified?

Since a high proportion of IV drug users are Hepatitis C positive the risks must be heightened, but evidence from albeit a handful of reports are that assessment in A&E is inadequate and even if you can progress past the first triage assessment and see a junior doctor few such sharps injuries are recognised as potentially serious enough to warrant immediate referral to a specialist.

That immediate referral is now mandated by EU Council Directive 2010/32/EU for health service employees but as yet there is no evidence for similar standards for non-healthcare employees such as waste handlers and local authority staff who are being fobbed off with possibly inadequate treatment.

The implications may be profound.

We are increasingly aware of the often severe and profound psychological impact of sharps or needlestick injury† that has been in the news recently after a scientific investigation of this problem but which has been discussed many times over the years on the Clinical Waste Discussion Forum (check using the search system and browse the archive files). This too requires care in the immediate management and follow-up of sharps injuries and other blood and bloodstained body fluid exposures. Those who may be at risk by virtue of their employment must be trained properly and adequately briefed to ‘make a fuss’ for prompt specialist treatment in exposure does occur.

The various criteria and conditions of exposure or injury noted above can heighten or reduce the risk profile of any individual sharps injury event. So it is with considerable concern to read a recent case report from Brazil:

Brum MCB, Filho FFD, Yates ZB, Viana MCV,  Chaves EBM. HIV seroconversion in a health care worker who underwent postexposure prophylaxis following needlestick injury. American Journal of Infection Control 2013; 41: 471-2

They describe a case of HIV seroconversion in a health care worker who underwent PEP after accidental HIV exposure in Brazil. In December 2007 a nursing assistant aged 42 years working in an infectious disease unit experienced a thumb injury while performing a hemoglucotest. The health care worker wore a latex glove during the procedure yet was injured while collecting the test device, the lancet of which had not been completely enclosed and was left on the table after the procedure. The percutaneous injury on the surface of the thumb caused slight bleeding that was immediately washed.

Leaving aside the possibility of drug resistance of this particular strain of HIV, which was a possibility but was not proven by laboratory testing, this worker had PEP initiated within 2 hours of injury, maintained for 28 days. However, 4 months after exposure the worker was diagnosed with HIV infection.

There are several levels of concern. Not least is the observation that injury was caused by a lancet, a thin cutting spike intended to draw just a drop of blood from a finger prick for blood sugar testing. No hollow bore needle, and no deep injury – lancets are designed to prevent deep injury no matter how hard you try. These circumstances would, almost certainly, screen out a sharps injury victim from almost every sharps injury management protocol.

 

† Green B, Griffiths EC. Psychiatric consequences of needlestick injury. Occupational Medicine 2013; 63: 183–8

 

 

It is widely understood that laboratory wastes will be, or should be, autoclaved locally before removal for disposal. It stems from a statement by Chris Collins that “nothing should leave the laboratory unless it has been autoclaved” which appeared in the Howie Report and subsequent safety-related publication  in the mid- to late-80s.

But this aspirational quote never worked. Few laboratories then had sufficient autoclave capacity to achieve this and still few can fulfil this goal.

Some selectivity is practices, with laboratory cultures from microbiology labs autoclaved where possible – and thus not universally – while wastes from other laboratory disciplines are not treated. Continue reading “Laboratory wastes” »

Needle with drop of bloodSharps or needlestick injury carries with it, in some circumstances, a predictable risk of bloodborne virus infection. The statistics, from which risk can be calculated, are well known and relate to the “average” used hollow bore needle used in clinical practise, and sharps injuries occurring during or soon after use.

There are many additional variables including the time between use of the needle and its involvement in a sharps injury, the amount of blood that it contains, the bore of the needle and depth of injury, the immune status of the victim, post-injury care, the virus concentrations in the blood if any, the time interval between injury and post-exposure prophylaxis if this is indicated, and probably other factors of which we know very little.

But we must not close our minds to the possibility that sharps-related infections are limited to HIV, Hepatitis B and Hepatitis C infections. Other infections can and do occur. In fact, the diversity of infections that have been reported is substantial though the list is bolstered by many individual laboratory acquired infections that arise as, one must hope, a one-off occurrence. Continue reading “Non-BBV infections after needlestick injury” »

Sharps injury is depressingly common but should be preventable. Less easy to prevent is a blood splash that can unexpectedly contaminate the face and eyes – eye in particular are a potent and often unrecognised route for infection.

Several approaches are possible to prevent sharps injury through the use of passive engineered safety sharps, good sharps safety practice including safe disposal, and safe management of BS EN ISO 23907 2012 compliant sharps bins at the point of use and as the pass along the disposal chain.

But not so at Huddersfield Royal Infirmary where some idiot placed a used and part-blood-filled syringe on top of a sharps bin that really should have been in a safe location well away from inquisitive children.

The parents now face a significant worry throughout and beyond a period of precautionary treatment, blood tests etc for the little lad, and hopefully a successful complain to the heath regulators, HSE and anyone else who will take real action to make sure that those responsible are properly reprimanded. If the culprit(s) can be identified I think it appropriate that the conduct committee of their professional body should be invited to investigate, with expulsion if appropriately found.

Huddersfield Royal Infirmary medical director  David Wise said: ‘This is unacceptable and should never have happened and for  that we apologise to the family.

‘We have reviewed the environment on the unit  and are issuing a reminder to all staff that sharps boxes must be kept in a safe  location to make  sure that this does not happen to anyone else.’

But that’s just not good enough. Placement of sharps into a sharps bin is a perfectly reasonably safety precaution and those who are so lax in syringe disposal should face severe professional reprimand and/or regulatory action. The more fundamental issue of placement of the sharps bin, out of reach of children is too a well-recognised issue and should not be a new concept but part of established and quite routine practice. Failure is a matter for the regulator.

Read more: http://www.dailymail.co.uk/news/article-2318186/Toddler-blood-mouth-syringe-doctors-waiting-room.html

 

There seem to be plenty of tattooists in the UK but perhaps that really isn’t enough to go around, or they are too expensive.

As a – very poor – alternative, it seems that many illegal tattooists are in operation, unregistered and thus unsupervised. The great risk is of bloodborne virus (BBV) infection, and pyogenic infection of those brave enough to have a tattoo.

http://www.bbc.co.uk/news/uk-22320300

But it is the bloodborne virus risk that is our primary concern, since that extends beyond the process of tattooing and may continue as sharps wastes are disposed. The unregistered and unlicensed operation implies a failure to adhere to required standards of hygiene, and therefore to standards of waste management also. Is it likely that an unlicensed tattoo outfit would bother with safe sharps disposal into a suitable sharps bin? Continue reading “Bloodborne virus warning over illegal tattooists” »

A heroin-using grandfather who stuffed a used syringe into a supermarket loaf of bread that was later bought by an unsuspecting mother has been jailed for a year.

The woman discovered the needle – which had  been stuck through the middle of the loaf by 62-year-old David Rodgers – after  she used the bread to make her 10-year-old son a chicken sandwich for his school  lunchbox, Manchester Crown Court heard.

Rodgers, from Weaste, who was traced by a  speck of his blood left inside the syringe, had contaminated the loaf in a  branch of Tesco Extra in Salford last December.

He claimed to be ‘deeply remorseful’ when he  appeared in the dock to answer charges of contaminating or interfering with  goods with intent to cause public alarm or anxiety in a rare  case.

The needle he concealed in the loaf was found  to contain no infectious diseases.

 

Read more: http://www.dailymail.co.uk/news/article-2312071/Grandfather-jailed-year-putting-used-syringe-loaf-bread-used-mother-make-sons-school-lunch.html#ixzz2RfwqTRlT

Once again, this week (22nd to 28th April 2013) is the highlight of the Marine Conservation Society’s fight against marine litter with the Big Beach Clean-up.

Over 110 beaches across the UK and Ireland are going to see volunteers coming together to do a beach clean and litter survey which will highlight the issues of beach litter around our coastlines.

http://www.mcsuk.org/foreverfish/index.php

Hosted by your local M&S store team – and all credit to Marks and Sparks for their sponsorship of this valuable quarterly event [let's hope they bring some of their lovely sandwiches] - the beach clean and survey will last a couple of hours, leaving the rest of the day free for you to enjoy the beach. Continue reading “This septic isle?” »

In a landmark case involving reversal of a no liability finding for needlestick injury that occurred in a Queensland holiday apartment the circumstances of injury, and the legal wrangles, send shivers down the spine.

Wright v KB Nut Holdings Pty Ltd [2013] QCA 66

The Queensland Court of Appeal has held a hotel manager liable for a needlestick injury that a guest sustained while staying in a short-term rental apartment, reversing the original decision of no liability.

The trial judge had not been satisfied that a more competent cleaner or system of cleaning would have led to the discovery of the needle (which was in the crease of a stairwell and was dislodged by the guest when she was cleaning the apartment). He did not consider it reasonable to expect an apartment manager or cleaner to search and discover a concealed needle.

The Court of Appeal reversed this decision, finding that:

    1. it is likely a cleaner using normal skill, diligence and equipment would have detected the needle;
    2. it was probable that the needle was obscured from the guest’s vision as a direct result of the unclean state in which the apartment was handed over to her;
    3. the hotel manager knew or should have known of the risk of injury; and
    4. the build-up of ‘filth’ in the apartment increased the risk that dangerous objects would not be seen until after they were stood on or touched, which may have been with bare feet or hands.

The hotel manager was ordered to pay compensation of $494,759.38, plus interest.

This decision confirms the importance that rental property owners need to place on implementing thorough systems of regular cleaning and inspections.

Quite right too. But isn’t it a warning also, that if you arrive at a rental apartment or hotel room, the immediate response when finding it dirty is to walk back out again and go somewhere else – its not your job to get down and clean it!

And of course, we wish the injured guest well, with the medical and psychological implications of that sharps injury.  AS$494,759.38 (about £330.000) should help.

 

 

The press are today full of comment about hospital hotels, a new – at least new to the UK – initiative to use hotels as a half-way house for patients not quiet well enough to go home but good enough to move be moved out of a hospital ward.

It’s an idea predictably popular with Government and with the Department of Health since it frees much-needed hospital beds and todays news reports presumably represent a concerted political manoeuvre to test the waters of public opinion.

Hospital hotel transfers have been used in several countries already, most notably in Scandinavia, though an early trial at UCH London resulted in the unexpected and particularly embarrassing death of a patient while billeted at the local hotel. Continue reading “Hospital hotels?” »

Yahoo Answers is not something that I recommend, though no doubt it has its uses and many people find it particularly useful. When I’m teaching, I instruct students in no uncertain terms that written work drawn from Yahoo Answers or from Wikipedia score zero marks – it’s lazy and of a poor is non-existent standard – and may irritate me sufficiently to impact on future marks!

But Yahoo Answers does have a following, and today I visited it for the first time ever. The item that caught my eye was a question, posed by someone from the South West, that I will reproduce in full here:

How to address a carer burning clinical waste in the garden? Continue reading “What would you do?” »

Some time has passed since this paper by Green and Griffiths was published. Unsurprisingly, the professional journals and magazines, and the trades union RCN are up in arms about the impact to nurses, and separately to surgeons and physicians. Quite right too.

But the paper, which investigated the psychological welfare of 17 individuals having sharps injury. Only 5 of these five (29%) were in “the health sector (nurses and paramedics)” while the remainder fell into a category of ‘other occupations’ which involved police officers, porters, cleaners, a builder, a manager and one unemployed person.

Of the 3 brief case individual reports included in the paper, only 1 was a healthcare worker. This lady was injured while working in an accident and emergency department. Perhaps a nurse, or possibly a support worker/cleaner, we are not told, the lady was emptying a clinic bin and was replacing a bag when a needle, which had been incorrectly disposed of, pierced her leg. The remaining 2 cases involved a coach driver and postal worker respectively.

Leaving aside the serious issue of a healthcare professional incorrectly placing a used needle into a soft-walled clinical waste sack, the occupations of those involved in this sharps injury series requires further consideration. With so much noised from the medical and nursing professions, about the risks and impact of sharps injury that they may face, it seems that it is the ancillary worker and others who are at real risk.

We at Blenkharn Environmental and at the Clinical Waste Discussion Forum and are doing all we can to highlight the risks of waste handlers and ancillary and support staff. Perhaps the waste and services sectors simply have no voice. At least, they could shout a little louder.

“While Tanzania’s leading health facility, the  Dar-es-Salaam Muhimbili National Hospital (MNH) boasts of having a well-managed system for disposing infectious medical waste, The Citizen on Saturday has discovered that the situation elsewhere in the country is rather appalling.

“Environmental health experts have confided to this newspaper that most of the lower level health facilities are grappling with poorly managed systems of handling the dangerous garbage, posing serious environmental and human health risks as a consequence.

‘’Hospital waste management is still a big problem in the country to date’’ Prof Samuel Manyele confirmed this week – which is about three years after he published a series of studies that exposed poor health care waste management in Tanzania. Continue reading “Clinical waste management in Tanzania” »

An independent inquiry has been demanded after radioactive waste was wrongly disposed of at Ninewells Hospital.

Two weeks ago, a sharps bin containing radioactive waste was wrongly placed in a yellow clinical waste container. The radioactive material, which officials have stressed was not dangerous, was then sent out with the other clinical waste, against the conditions of the hospital’s site licence for the use of radioactive material.

The sharps bin containing radioactive waste was placed for uplift by janitors at stairwell 6, level 7 near the small lift in the laboratory block. This stairwell area temporarily holds all of the laboratory waste containers for level 7 until work on the freight lift is completed. An unknown person placed this waste in one of the yellow clinical waste containers, despite the waste being clearly labelled as radioactive.

[Stairwell?  A temporary holding site for wastes?  What about the fire regs?] Continue reading “Radioactive sharps bin contamination at Ninewells” »

Pupils of the Mandal Praja Parishad primary school at Achayyapeta have found some new “toys” to play with. During the recess and after school , the boys and girls run to the garbage dumps less than 350 meters away and search and pick up used injection syringes and IV fluid sets and start playing by filling them up with water.

Their parents, mostly away from the village rearing sheep or working on fields, are genuinely worried about the children contracting diseases. For the villagers, who are fighting all out to stop the Anakapalle Municipality from dumping the town’s garbage in their village, the threat to their children’s health appears to be the immediate major problem even as they wait for the High Court to give them a favourable verdict. The medical waste is part of garbage forcibly dumped on a site allotted to the municipality as a dumping yard on March 20 after chasing away the protesting villagers and arresting 20 of them.

more at http://www.thehindu.com/news/cities/Visakhapatnam/students-play-with-medical-waste-at-achayyapeta/article4609569.ece

 

“London’s Evening Standard reports that medical (clinical) waste including syringes, blood-filled tubes and pig snouts is being dumped on the pavement by Harley Street firms.

“Westminster council today issued a public safety alert as it accused a “handful” of clinics of failing to dispose of potentially hazardous waste safely.

“It came after council street wardens on routine patrols in the area discovered plastic refuse bags whose sides were punctured by used syringes.

“Other discoveries included a sack of pig heads – apparently used by medics to practise on, due to similarities between pig skin and human skin – and bags of used drips, vials of medicine and bloodied tissues.

“Two firms have already been successfully prosecuted and five others are being investigated by the council, with one due in court later this month in what has been a growing problem since the start of the year.

http://www.standard.co.uk/news/london/scandal-of-dumped-harley-street-medical-waste-8564308.html

 

Westminster Council has a deserved reputation for tough dealing with waste and other issues, so its no surprise that these civil enforcement fines have been imposed, and prosecutions have followed. Presumably, the issue was that wastes were presented at the wrong time, since sooner or later it would have to be left on the curtilage for collection. In Harley Street and surrounding street there are no gardens and front doors open almost directly to the pavement so there can be no question about where the wastes were placed, only when.

The picture, reproduced from the Evening Standard, is confusing. Why red bags? Why syringes – and we might assume needles also, in waste sacks. But if the needles had been separated, why breach now universal safety rules to dismount needles instead of placing them intact into a sharps bin? And why so many pig snouts, commonly used for basic surgical training when there is no training establishment in the area?

 

 

Regulators and those who follow on their every word continue to be exercised by the question of pharmaceutical residues from clinical wastes. Of course, bulk pharmaceutical wastes from the pharmacy department or drug manufacturing facilities must be managed with great care and their disposal must be properly controlled. There is, however, great confusion between this and the trace residues that might be present in soft clinical wastes and even in sharps bins filled with empty, or near entry, syringes.tablets and capsules

A recent conversation with colleagues in the US brought this issue once more to the fore. The proposal was that there exists serious environmental impact from empty syringes and the occasional tablet of IV bag in an orange (red) sack.

Taking this further, the conversation turned to the problem of scavenging of drug residues from clinical waste. When asked, that too was an environmental hazard since those drugs would end up in the environment, without control or proper disposal and treatment. The response perhaps bears repetition here:

 

Have you really swallowed the tale about the dire impact of drug residues from clinical wastes endangering the environment? That a few pharmaceuticals misappropriated from some insecure or unscrupulous waste management facility might precipitate environmental disaster? Or that outflows from domestic sewerage and/or solid wastes into which unwanted prescription drugs have been tipped will change the world?

Though it is no reason to ignore these sources completely, the impact is, without doubt, infinitesimally small when compared with excretion of the administered dose.

We cannot dispute that what goes in will come out, and actually quite quickly. On average, in excess of 95% of the administered dose of any drug is excreted unchanged, with some varying amount and range of metabolites. Half-lives change but most drugs begin to be excreted within a matter of hours and a single dose is usually eliminated within 24-36 hours.

We pass that into sewerage systems designed by Victorians to remove biological hazards but not pharmaceuticals. Yet when we find drug residues in natural water sources we get over-excited about a few street drugs and ignore the obvious.

Wastewater treatment processes are being considered for some hospitals, to reduce the burden of drug residues in their outflow. Quite right. But just why is this being done? Many regulators are taking the rather myopic view that this because hospitals are poor at segregation of pharmaceutical wastes. Yet they ignore completely, or simply cannot comprehend, that those same hospitals are full of patients receiving medications, defecating daily and urinating several times each day thus contributing a massive drug load to the sewer that conventional wastewater treatments cannot address. We make it worse still. Hospital staff are not immune from the need for drug treatments, from a simple cold remedy or painkiller, through to hormone-based contraceptives. And still regulators and those who hang on their words bang a drum for what are effectively the most minute contributions to the global environmental burden of pharmaceuticals, their metabolites and their degradation products.

To broaden the rather gloomy horizon still further, this is not restricted only to prescription pharmaceuticals but to OTC products also, though at least in the UK, and it seems elsewhere too, regulators cannot stretch their mind to this even greater pool of potential environmental contaminants but only to those prescription medicines defined by law and thus satisfying a naïve, or is it brainless, tick box mentality. Cleaning agents too, which though not considered in the same classes as pharmaceuticals share many similarities in biological and ecological impacts, in addition to more direct eco-toxicities.

Improvement in community wastewater treatment facilities may be advantageous, and particularly for outflows deriving from hospital ‘hotspots’. However, let’s not place blame squarely on the Victorian sewage treatment facility since globally many are lacking this basic public health resource and have to rely on cess pits, soak-aways or worse.

If that seems like a dipartite situation separating the have’s and have not’s, consider the veterinary and agricultural (livestock) use of pharmaceuticals . Globally, this is massive. It is largely unspoken as many developing countries use increasing but often undeclared amounts of drug additives to increase profitability in the global food markets.

At least some of us have the option to use a toilet. In the animal kingdom, mans intervention in the intensive livestock industries has not changed the inevitability of excretion directly to land.

Make your own mid up.

There should be concern about drug residues in the environment. When we stop over-prescribing, and curtail the sales of PTC (non-prescription) products, when we make arrangements for the collection of unwanted pharmaceuticals from households, when we stop passing out thousands of tonnes of pharmaceutical residues in urine, and start treating wastewaters accordingly, then there will be some significant reduction in the level of drug residue found in natural waters. The contribution from clinical wastes, and from drug litter, is infinitesimally small and regulators would do well to consider the science, and the logic, of the situation and divert their collective attention to the heart of the problem instead of making mischief around the periphery where their interventions will make little if any difference.

 

 

INeedle with drop of bloodn a House of Lords debate on 14 March 2013, Lord Turnburg asked the Government “what is their policy on testing for HIV in patients lacking capacity to give consent following a needlestick injury to a healthcare worker”.

It’s an important question, since source testing can shape the early decisions to administer potent but toxic and unpleasant anti-HIV drugs to the injured person.

The reply, from Earl Howe (Parliamentary Under Secretary of State (Quality), Health; Conservative) was that “Where a person lacks capacity to consent their rights are protected by the Mental Capacity Act 2005, which determines that decisions on behalf of such a person have to be made in their best interests.

The department’s view is that both the taking of samples and the testing of samples previously obtained from a patient who lacks capacity to consent are therefore acts that may only be undertaken if they are in the best interests of the patient. This would include testing a patient for a serious communicable disease such as HIV following a needlestick injury to a healthcare worker.

The department’s view is that determining whether it is in the best interests of a patient who lacks capacity to take and test samples for the purpose of determining what treatment, if any, to offer a healthcare worker with a needlestick injury is a stringent test to pass. It involves assessment of the individual circumstances of the patient on a case-by-case basis.”

That’s a tough call, and one that might be better answered by the Government rather than the patient’s carers. A policy would help, rather than a fudge answer that expects the healthcare team to interpret complex legal matters – in haste – in the knowledge that it may come back and bite them in later High Court action. For the needlestick ‘victim’ that offers no solace.

Neither too does it offer anything to the injured waste handler working as a hospital ancillary and support worker, in the waste management sector or for a Local Authority. For them, a needlestick injury will always be the same result – do we assume the worst and embark on a long and difficult course of ant-HIV medications since the source patient on whom the needle was used, or the user who discarded the needle, will always be unknown.

The Government might have helped with a straightforward yes or no, but regrettably the law is almost never that simple. But for those in eh waste management sectors, the opportunity will not arise anyway. The source is unknown.

On every post-exposure treatment algorithm, this places the injured person in the highest risk category. Other factors are involved such as the likely age of the needle, was it a deep wound from a large hollow bore needle – but did you stop to find out? – but this involves always something of a terrible gamble.

A gamble with a life. Make sure that its not yours or one of your workforce.

 

 

It’s the bane of many waste treatment facilities. Blue spun (non-woven) polypropylene wrap often ties its way around the best of shredders causing many hold-ups and some equipment damage during shredding of autoclave floc, and in automated feed systems for autoclaves, augers, microwave and incinerator plant.

Used for surgical drapes, the wrapper for sterile instrument packs, and for many single use disposable gowns used in theatre, radiology, in laboratories, and as the now universal disposable replacement for bed curtains that are found on every hospital ward, the material might be ideal for material recovery if separated effectively.

A new resource recovery service promises to do just that, but only for non-contaminated wrap. Strangely identifying itself as an environmentally aware non-profit .org organisation but nonetheless a limited company, Alternative To Landfill Ltd aims to be at the fore front of the recycling industry, concentrating on the recovery of waste for reuse, recycling and seeks alternatives for material that would otherwise end up in landfill sites.

Good for them. We are of like mind and would be happy to support their ideals. However, restricting the operation to accept only non-contaminated material is a serious drawback. Clearly aiming for the lower fruits, and avoiding the regulatory framework that might conflate operations that may then include wastes considered more accurately as clinical wastes, the problems that this may cause make the business model difficult to accept.

Chosen waste volumes must be low, especially since source segregation will permit recovery of non-contaminated feedstock for this operation only from the largest and most dedicated environmentally-aware surgical centres. They may be found centred around only the larger conurbations, leaving the logistics operation to bring together sufficient waste for a cost-efficient operation looking a little thin.

And of course, there is the thorny problem of source segregation. Will it be good enough? Will an item of miscellaneous plastic make a difference, or some stray sheets of paper? Probably not. But the ‘what if’ of contamination with some contaminated or bloodstained material is more difficult to predict.

How much contamination is necessary to define a contaminated load?

What about the contamination that is not visible? How hard should we look, among a skip full of compressed wrappers?

And once identified as contaminated, will the entire batch comprising multiple collections be rejected? And what becomes of that rejected material, since rejection must accept reclassification as clinical waste, consequentially bearing a high cost for disposal.

Mush spun or non-woven polypropylene drape and gown material finds its way to clinical waste treatment, and quite rightly so. The recovery of this fraction from autoclaved clinical wastes, after sterilisation and either before or after shredding, would be a major advance.

The developments of  Alternative To Landfill Ltd are an important step forward and, at least in theory, looks to be of value though there are practical and operational matters of concern that may impact upon profitability and overall success. It’s a good idea, and if the regulatory framework permitted should be extended to seek the development of technologies to capture other non-woven wastes from ATT treatment floc.

 

 

 

A second Lanarkshire hospital has been slammed over stained mattresses and the unsafe use of sharps disposal bins.

Monklands Hospital in Airdrie was the subject of an unannounced inspection by the Healthcare Environment Inspectorate (HEI) during which six of nine mattresses inspected were found to be damaged or stained.

In the news recently when a foetus was found in a clinical waste bin, Monklands hospital had a HEI visit in January, when inspectors also discovered that lids on sharps disposal bins were not always used and found one large sharps bin sitting on a trolley at knee height, without the lid properly fitted. Also, sharps bins awaiting disposal were being kept on a ward, not in a locked area.

It is the second time Monklands has been warned over how it handles sharps, following an inspection in January last year.

And it comes less than two months after an inspection of Hairmyres Hospital in East Kilbride, in which inspectors also found stained mattresses and problems with the way sharps were handled.

The HEI issued five requirements as a result of the latest inspection of Monklands. The first two called for an effective mattress audit system and the implementation of standard precautions in handling sharps. The others relate to infection control. The report found that, overall, “the hospital was clean and well maintained”.

Of course, clean and well maintained does not go hand-in-hand with sloppy sharps management, especially when this is more that an isolated incident suggesting systemic failures in sharps safety management.

If I had been inspecting, I would have been demanding data on sharps injuries and reported near misses, including reports from waste management contractors, cleaning companies and laundry services of sharps discarded inappropriately.

Overall, these problems, of inappropriate storage of filled sharps bins that may relate more to shortage of porters that sharps mismanagement are not uncommon and might be seen in many hospitals. Few are really beyond criticism and all can do better. It is, perhaps more appropriate to consider these as a flag for further and more detailed investigation in order to identify those centres at which there are real issues that impact directly on safety.

In such cases, when serious and potentially dangerous performance is observed, the health regulator should liaise with HSE to ensure that where necessary an improvement notice is issued, with prosecution is warranted for the most serious failures.

 

 

 

 

Various items of clinical waste, predominantly used sharps, can be found on the streets of London. But today’s news report from the BBC is of a placenta found by London dog walker – perhaps more likely found by the dog than the walker – on a footpath near Tooting Bec Athletics Track, south London.

Police are now concerned that a vulnerable woman has given birth and may require medical assistance. Police believe the tub was partially buried before being unearthed by an animal, and is up to 2 weeks old.

http://www.bbc.co.uk/news/uk-21985948

The issue of waste disposal may seem rather trite in circumstances where we might opine of a woman, alone and frightened, seeking to conceal a birth. But equally is the persistent trend toward retention of a placenta after delivery – is it part of the earth mother thing? - where mothers ask to keep the placenta, to bury in the garden or elsewhere as if completing the earthly circle. Others like to eat it, consuming its nutrients as a paté or sautéed with some garden herbs, butter and garlic!

So, is this a tragic story of a concealed birth, and possibly of infanticide? Or some idiot mother who wanted to go with the flow and keep her placenta, but was then stuck when it started to decay? In the latter case, there are disposal issues, and possibly accusations of littering that might offend many but serve its purpose by dissuading others from doing likewise.

 

 

A 12 year old Sunbury, Australia, girl faces an anxious wait after falling onto a discarded needle.

The girl slipped and fell playing in a park near Gibbons St Sunbury, cutting her arm on the hidden needle. She did not tell parents until later, when the arm became sore and swollen and they got medical help.

“I remember running towards the slide when I slipped and fell, landing on my left arm,” she said.

“I felt a sharp pain … and saw the needle, which I picked up and put in the bin.

“I wasn’t very happy about it at the time but I was too scared to tell my parents in case they blamed me.”

Her angry father has hit out at whoever discarded the needle, labelling it “irresponsible and dangerous”.

http://www.heraldsun.com.au/leader/north/agonising-wait-for-12-year-old-sunbury-girl-after-she-fell-on-a-discarded-needle/story-fnglenug-1226605528310

Understandably, this is the cause for great distress, for the child and her parents and family. Not just today, but for the many months of follow-up that will follow, and possibly beyond. The impact is profound, and we wish them well.

Regrettably, stories like this are not uncommon. They serve to highlight the considerable risks from discarded needles, that seem far more common in recreational areas than elsewhere.

 

File:Coat of arms of Shetland.jpgNHS Shetland is launching an investigation after a Vidlin resident found a medical waste bag in the ditch near her home last week.

The bag was labelled NHS Grampian and bore a hazard symbol. The lady finding it was understandably angry that nearly a week later the bag was still there.

It was labelled ‘path­ology dept.’ and ‘cytology unit’ on it and ‘clinical biochemistry/hae­ma­tology’ and ‘danger of infection’ in big letters.

After something of a run-around between NHS Grampian, Orkney, the Gilbert Bain Hospital there were promises that it would be removed, and some uncertainty whether it was a sample bag or a clinical waste bag.

With what seems to be an attitude of deny it first, then investigate, the official response was that it was a sample bag of the type that might be sent by post – not that that is permitted by Royal Mail so I guess that was bunkum. Moreover, the lady reporting the find said it was “about the size of a pillowcase”, and a waste sack comes to mind rather than something fallen of the back of the Postie’s bicycle!

http://www.shetlandtimes.co.uk/2013/03/22/health-service-investigation-after-bag-full-of-medical-waste-found-in-ditch

 

But it’s Shetland. There is some wild weather and it’s not impossible that a stray bag blew away from an insecure location. Then again, it may have been a laboratory sample bag, however unlikely. But that too should not have been blowing across the island.

It’s not the end of the world, is it. At least not until someone takes the trouble to report it, gets a whole lot of bullshit in return, and it takes days to deal with the problem.

 

 

UK postal restrictions forbid the packaging and shipment of small quantities of sharps to some distant disposal centre, even when packages in a sealed ISO-compliant sharps container and suitably impervious outer wrapper.

That creates a problem for many community-based sharps users who must package their used insulin syringes and take these to a co-operating high street pharmacy, to a GP surgery of to the local hospital. Since funding for this additional waste stream is often overlooked and does not flow equitably from the PCT patients are often left to struggle to find someone who will take their sharps waste.

Let’s not fool ourselves into believing that in the US they have it right, since in may States the management of sharps from domestic users is simply appalling. However, some States and cities do operate or permit a sharps by post service. These seem to operate well, with no reported incidents. They must save money, and make life easier for all.

So, why not in the UK? The official answer if to blame Europe, which forbids shipment of bio-hazardous materials by post.

But in the UK, the NHS Bowel Cancer Screening Programme, operates nationally to invite all over-60s to send 3 tiny samples of faeces to a central testing lab. All for the very best of reasons, and repeated through advancing age, the programme seeks to identify those who warrant further and more detailed investigation for the detection of early, and very much treatable, bowel cancer.

How does it work? Just 3 smears of faeces on a set of test cards folded into a paper envelope. With name and dates etc clearly marked, these are placed into a simply unpadded plastic pre-paid envelope and sent 1st class letter post to the lab.

If this is permissible under UK (or European) postal regulations then why not the shipment of suitable sealed  and packaged small sharps bins for personal use?

Is there a hygiene risk? A risk of spillage, perhaps of faeces, or of sharps penetration though an ISO-compliant bin? Is the welfare or health & safety of postal workers in jeopardy? Is there some de minimis scale of bio-hazardous materials, and do thousands of faecal smears fall below the line?

It seems, regrettably, that we have looked at Post Office regulations and talked our way out of a perfectly good method for disposal of small numbers of used sharps that might arise from trustworthy and competent patients who might otherwise struggle to dispose of their used sharps.

What a great shame that is.

 

As the archive files of the Clinical Waste Discussion Forum will attest, several years before the start of the move toward introduction of engineered safety sharps I took a sceptical view of the protection that they might afford. IMG_0161Not for sharps users, the clinicians, nurses and scientists who might wield a syringe and needle to draw blood or administer an injection, but for those working as ancillary and support staff, and waste handlers, who might be exposed to used sharps as they pass along the disposal chain.

So sure was I that the potential reduction in injury would be manifest in fewer sharps injury events in ancillary and waste handlers that I placed a small wager with a colleague. It was will deep regret that I have been able to collect on that wager - a modest lunch – having seen the evidence of sustained carelessness in sharps disposal.

Has that claim really come true?

needleGlSharps incidents and sharps injuries to waste handlers have reduced only where mechanisation and bulk handling of carts, as opposed to manual handling of individual clinical waste bags and sharps bins, reduces opportunity for direct contact. Even where this has been possible, waste containers are still managed by hand as they are removed from wards and clinics, generally by cleaners and other ancillary workers who might have access to latex gloves or a pair of Marigolds but who will never have the benefit of sharps-safe gloves.

Safety engineered sharps come in tow distinct types, passive devices that activate automatically, usually via a spring-loaded retraction mechanism, and active devices that need some positive action by the user to flip a shield over the exposed needle.

My hypothesis was that a) since the passive devices are more complex they will be more expensive, b) financial constraints will see many Trusts choose the cheaper active devices, and that c) careless failures to engage the safety features of those active safety sharps who result in many of these devices discarded without activation. This would result in no protection for those encountering the needle during its journey through the disposal chain. To make matters worse, would those who can’t manage activation of the sharps safety feature be so concerned to dispose of the used sharps with the required care, or would these unprotected sharps be found in an overfilled sharps bin, in a waste sack or in the soiled lined on its way to the hospital laundry?

A new research paper from France (Needlestick injury rates according to different types of safety-engineered devices: results of a French multicenter study. Infection Control and Hospital Epidemiology 2010; 31(4):402-7 DOI: 10.1086/651301 makes depressing reading. The authors objective was to evaluate the incidence of needlestick injuries (NSIs) among different models of safety-engineered devices (SEDs) automatic, semiautomatic, and manually activated safety) in healthcare settings. This was done by a multicenter survey involving no less that sixty-one hospitals in France, conducted from January 2005 to December 2006, examining all prospectively documented SED-related NSIs reported by healthcare workers to their occupational medicine departments. Participating hospitals were asked retrospectively to report the types, brands, and number of SEDs purchased, in order to estimate SED-specific rates of NSI.

More than 22 million SEDs were purchased during the study period, and a total of 453 SED-related NSIs were documented. The mean overall frequency of NSIs was 2.05 injuries per 100,000 SEDs purchased. Device-specific NSI rates were compared using Poisson approximation. The 95% confidence interval was used to define statistical significance. Passive (fully automatic) devices were associated with the lowest NSI incidence rate.

Among active devices, those with a semiautomatic safety feature were significantly more effective than those with a manually activated toppling shield, which in turn were significantly more effective than those with a manually activated sliding shield (p<0.001, Chi² test). The same gradient of SED efficacy was observed when the type of healthcare procedure was taken into account.

The authors conclude that passive SEDs, devices that do not require any action on the part of the user, are most effective for NSI prevention.

So perhaps we should expect that passive devices should be the gold standard safety-engineered device, for the protection of sharps users and inevitably therefore for the protection of ancillary and waste handlers.

And who else should we consider? Insulin-dependent diabetics not using insulin pens and IV drug users are particular problems since neither group is being offered safety-engineered sharps of any kind.

The devices look and feel differently and it takes some instruction and practice to use them effectively. For diabetics, that will involve a hugely complex and costly program of instruction – even if it takes just 2 minutes per patient that necessitates a hospital visit or GP appointment.

And for IV drug users, the probability for manual activation of a safety device after shooting up are probably small and possibly so small as to be negligible. For those clearing discarded sharps, the huge risk of injury and infection thus remains unchanged. There would (could?) be further advantages, since fully automatic and tamper-proof passive safety sharps are effectively single use only. This would eliminate needle sharing with a major impact on disease transmission rates among this vulnerable group.

Politics and public opinion will get in the way. Will it be accepted that IV drug users should be provided with expensive safety sharps? Would it be acceptable that they are trained in shooting-up? Should public money be spent in support of this group, even if there might be additional gains to society for reduced disease transmission rates though less needle sharing, and protection for those in the public sector who are tasked to clear discarded drug litter? The vociferous moral majority may well say no; there is considerable evidence for this with similar proposed public health interventions, for the creating of safe and accessible injection rooms that are provided in some other countries, or even the placement of secure sharps bins in high risk hot spots.

None of this bodes well for the safety of ancillary and waste handlers.

 

 

The Department of Resources Recycling and Recovery (CalRecycle) is offering grants in the form of sharps waste containers and/or kiosks, which CalRecycle will purchase and distribute to Approved California Local Jurisdictions (Approved Jurisdictions). The Sharps Grant Project (Sharps Grant), offered under the auspices of the Household Hazardous Waste (HHW) Grant Program, is a one-time grant to assist in the support of a safe, convenient and cost-effective infrastructure for collecting and disposing of home-generated sharps waste. Eligible jurisdictions must have direct responsibility for Household Hazardous Solid Waste Management and have established HHW sharps waste collection and public education programs or be able to demonstrate that they are in the process of implementing both this year. Local jurisdictions must distribute the sharps containers obtained through this grant to sharps users. All kiosks and sharps containers obtained through this grant must directly benefit public health and safety.

This one-time Sharps Grant Project (FY 2011/12) is now available. Please access the Guidelines and Instructions at: http://www.calrecycle.ca.gov/HomeHazWaste/Grants/SharpsFY1112/default.htm

 

So, what about sponsored sharps bins?  With the growing problem of IV drug abuse and the many areas blighted by discarded needles there can be little doubt, and there is much evidence to confirm, that thoughtfully placed sharps bins in parks and gardens, in public toilets, and in other areas where IV drug users congregate will be used by many with a corresponding reduction in discarded needles. Though a primary concern must be the reduction in opportunities for sharps injury, the added advantage is to prevent extensive needle sharing and thereby the burden of Hepatitis C and other infections infection.

Though the moral majority may complain, this is in almost every respect a win-win situation.

So why not sponsor bins, and perhaps the service that goes with it?  Roll it into contracts for clinical waste or more general hygiene services across a local authority area. Use it as a sweetener for future contract negotiations – but don’t describe it like that! Every way, it seems a winner, and may be a useful test bed for newer sharps containers and secure sharps collection devices.

Remember, you heard it first on the Clinical Waste Discussion Forum.

And let’s go further. The outside surface of a sharps bin is wasted space and might be used to carry advertising material alongside statutory markings. No, not eat at Joe’s Café, but something more useful such as a guide to source segregation of wastes, perhaps a reiteration of basic sharps safety guidance, of spillage management, or of hand hygiene?

 

With much evidence that suitable placed reminder messages reinforce the rules and standards of basic training and make a real difference in performance, this too seems like a win-win situation.

Remember, you heard this first on the Clinical Waste Discussion Forum too!